Neuroendoscopic management of hydrocephalus and associated intracranial lesions

To document the experience of intraventricular neuroendoscopy in the diagnosis and management of intracranial lesions causing hydrocephalus as well as endoscopic third ventriculostomy [ETV] in treating hydrocephalus. Descriptive case series. Department of Neurosurgery, Peoples University of Medical and Health Sciences Nawabshah, from January 2009 to June 2011. Patients of hydrocephalus associated with intracranial lesions were enrolled. Lesions were resected using endoscopic approach or by microsurgical technique. Extra-axial lesions causing obstructive hydrocephalus were managed with microsurgical resection and ETV. Endoscopic third ventriculostomy was performed for persistent hydrocephalus. The study population consisted of 20 patients [13 males - 65% and 7 females - 35%]. The age ranged from 6 months to 70 year with the mean age of 21.6 year. Colloid cysts [n=2] and cystic craniopharyngioma [n=1] in third ventricle were completely excised. Third ventricular ependymoma was partially excised and referred for radiotherapy. Hydrocephalus was treated by ETV in 10 cases [50%], complete resection of the intraventricular lesions in 3 [15%] cases and ventriculoperitoneal [VP] shunt placement in 7 [35%] cases. VP shunt was avoided in 13 [65%] cases. ETV is an effective method of treating hydrocephalus associated with intracranial lesions. Intra-cranial extra-axial lesions can be effectively managed with microsurgical method. Intraventricular lesions can be resected or biopsied with neuroendoscopy providing a better minimal access with good illumination. VP shunt can be avoided in most of the cases.

Pattern and outcome of admissions to neonatal unit of tertiary care hospital Nawabshah

To determine the number, disease pattern and outcome of admitted patients in neonatal unit of tertiary care hospital Nawabshah. Retrospective, descriptive study. This study was conducted at NICU pediatrics ward People's Medical College Hospital, People's University of Medical and Health Sciences for women, Nawabshah, Sindh from 1[st] January 2010 to 31[st] December 2010. Data was retrieved from file record regarding sex, gestational age [term and preterm], reason for admission and outcome [discharge, expired]. 2584 neonates were admitted during study period, among them 1776 [68.73%] were males and 808 [31.27%] were females, majority of patient 1657 [64.12%] were admitted during first 24 hours with the clinical diagnosis of birth asphyxia, 489 [15.85%] having neonatal sepsis, 312 [10.67%] because of prematurity, 117 [8.63%] admissions were due to neonatal jaundice and 19 [0.73%] having various conditions like hydrocephalus associated with meningomyelocele, prune belly syndrome, down syndrome, Icthyosis, HDN and TORCH infection. Birth asphysia, Pre-maturity, neonatal infection, neonatal jaundice were the main causes of neonatal admissions. Regular antenatal visits and timely referral to tertiary care hospitals will hopefully result in better outcome

Peadiatric tracheostomy: an experience in Tertiary Care Hospital

Tracheostomy is the surgical procedure originally described in 1[st] century BC. It is the life saving procedure when performed with appropriate indications and surgical technique. Tracheostomy in the pediatric population is a particularly hazardous procedure. Retrospective chart review This study was conducted at the Peoples University of Medical and Health Sciences Hospital Nawabshah between 2004 to 2008. Retrospective review of pediatric tracheostomy done in emergency or elective procedure under general anesthesia or local anesthesia was under taken. Name, age, indications, time of decanulation and follow up were evaluated. 31 Pediatric patients had tracheostomies within study period. There were 19 males and 12 females. Age range was 2 months to 10 years. The most common indication of tracheostomy was upper respiratory tract obstruction due to traumatic causes [54.83%]. 83.87% tracheostomies were done in emergency while 16.12% as elective procedure under general anesthesia or local anesthesia. Complications were encountered in 32.25%of patients. Most frequent complication was granulation tissue formation in the area around stoma [30%]. Complication rate was high in patients below 2 years of age [63%] and in patients having emergency tracheostomy [73.9%]. Decanulation was successfully done in all alive patients [87%]. Overall mortality rate was 12.9%. There was no tracheostomy related mortality. The indications for pediatric tracheostomy are changed from airway obstruction due to infection to trauma. Complication rate of tracheostomy is higher in younger age groups. Mortality and outcome of these patients depends primarily on underlying medical condition of the patient, otherwise pediatric tracheostomy is safe when performed in tertiary hospital settings

Oesophageal atresia -experience of 7 years with data evaluation

Study conducted for evaluation of Oesophageal atresia patients to assess the factors influencing the survival and outocme. Prospective analytical study. This study was conducted in dept. of Paediatric surgery at peoples medical college, Nawabshah from September 2001 to September 2008. A prospective analysis of 37 cases of Oesophageal Atresia [EA] was performed. In this study, 37 neonates were admitted with the diagnosis of EA with or without TEF. The data were collected retrospectively from hospital charts. The preoperative assessment of upper pouch was done with plain X-ray chest with 8 Fr Red Rubber catheter. The associated congenital anomalies were evaluated on the basis of careful examination, radiological and sonological investigations. The commonest type of Oesophageal Atresia was with distal Tracheoesophageal Fistula [TEF] in 32 cases [86.48%]. Associated anomalies were present in 50% patients, cardiac was commonest followed by gastrointestinal anomalies. Vacterl association was found in 6 [16.21%] cases. Prematurity, associated congenital anomalies, gap between esophageal ends and preoperative respiratory status were the significant factors affecting the survival. Primary extra pleural repair was the surgical approach in most of the patients except two with difficulty that change to intra pleural approach. Retro pleural drainage was used in 32 classical type 1 cases. Staged procedures were performed in 5 cases of isolated Oesophageal Atresia. Pneumonitis and sepsis were the most common early postoperative complications [30%]. Sepsis and cardio respiratory arrest were the most common causes of mortality 11 cases [18.91]. Oesophageal leak found in 3 cases, including 2 major and 1 minor leaks. Major leak followed by sepsis caused 1 Deaths. Survival as per Waterston criteria 85% in group A, 66.6% in group B and 20% in group C. factors affecting the survival of patients with Oesophageal Atresia are major or life-threatening associated anomalies, long gap, pneumonia and sepsis at presentation or that acquired during hospitalization and major leaks. The high incidence of low birth weight, delayed diagnosis, poor referral, low-socio economic status and lack of advanced neonatological back up are important contributory factors to poor outcome

Evaluation of the efficacy of Saccharomyces boulardii in children with acute diarrhea

To evaluate the efficacy of the yeast Saccharomyces boulardii [SB] as an antidiarrheal agent in 100 children with acute diarhoreal illness. Analytical observational study. Study was conducted From 1st April 2008 31st August 2008, 200 children 6 months to 12 years of age with acute watery diarrhea with duration of less than 07 days without history of fever or blood in stool or severe malnutrition admitted in Paediatric department PMCH were included in the study group. Evaluation of the results showed reduction in the number of stools and an improvement in their consistency in Saccharomyces boulardii group. After 48h and 96h children treated with Saccharomyces boulardii scored better than controls. It is concluded that in Saccharomyces boulardii group significantly more children recovered and normalized stools than controls without adverse reactions. It is concluded from our study that in infant and small children with acute diarrhea treatment with SB achieves significant reduction in the duration of diarrhea and number of stool even in the early period of SB preparation use. This yeast [SB] can be used as an adjunct to oral rehydration in treating acute diarrhea in children

Laparoscopic pyloromyotomy for hypertrophied pyloric stenosis - experience of 14 class

To share the first ever national experience about laparoscopic pyloromyotomy and its technical details. Descriptive study. Study conducted at private hospital at Nawabshah Sind from Sept. 2009 to Dec 2010, Hypertrophic pyloric stenosis is a common problem in pediatric surgery, Conventional management by the open extra mucosal pyloromyotomy has been the method of choice for many decades, Advanced, minimally invasive surgery also allows successful laparoscopic management of this entity, In this study 14 cases of laparoscopic pyloromyotomy, concentrating on technical details. Patients operated at some private hospital Nawabshah. 14 patients underwent laparoscopic pyloromyotomy with standard technique. Initial operating time was more of initial learning curve. The infants tolerated the operative procedure well. There was one conversion to the open method because of immaturity of patient and technical difficulty. Our experience suggests that laparoscopic pyloromyotomy can be a safe and efficient procedure, but during the learning phase, laparoscopy should be decided on a case-by-case basis and performed by an experienced laparoscopic surgeon. Careful selection of patients is helpful to increase confidence and operative comfort

Outcome of endoscopic third ventriculostomy in hydrocephalus

To elucidate the outcome of endoscopic third ventriculostomy [ETV] in patients with hydrocephalus. Descriptive case series. Neurosurgery Department Peoples Medical College Nawabshah, from 1[st] January 2009 to 31[st] December 2009. Patients aged more than 2 years with hydrocephalus were included. Endoscope used with free hand technique and third ventriculostomy performed with Fogarty balloon. Success was defined with clinical improvement and radiological reduction in ventricular size. The study population consisted 19 patients with male preponderance 12 [63.15%] males and 7 [36.84%] females. Age ranged from 3 years to 55 years with mean age 20.8 years. Shunt conversion was done in 5 patients [26.31%]. The most common indication was tuberculous meningitis. Success rate was 68.41% [13 cases]. ETV is an alternative and effective method of treating hydrocephalus in patients with normal ventricular anatomy and thin membrane at the third ventricular floor. Patients with thick membrane and tuberculous meningitis and obscure anatomy had high failure rate

Per rectal bleeding in children

To find out different causes and management of bleeding per rectum in infants and children. Descriptive study. The study was conducted at various hospitals where authors worked, from January 2005 to December 2007. All children under 12 years of age presenting with a common symptom of bleeding per rectum were included. The data was reviewed for age, gender, clinical characteristics and management. In all cases CBC and in selective cases stool DR were done. Some patients were subjected to sigmoidoscopy. Rectal polyp and mucosal biopsy were sent for histopathology. The study included 80 patients, of whom 57 [71.25%] were boys and 23[28.75%] girls with male to female ratio of 2.5:1. The mean age at diagnosis was 6.31 years. Rectal polyps were the most common cause and found in 45[56.25%] children. Polyps were diagnosed with digital rectal examination and by sigmoidoscopy. Twenty one [26.25%] children were treated conservatively with the suspicion of infectious colitis. Non specific colitis [n=2], intusssusception [n=3], Meckel's diverticulum [n=1], ulcerative colitis[n=2] and anal fissure[n=2] were the other causes. Colorectal polyps are common cause of rectal bleeding in children. Proper physical examination including per rectal digital examination along with the endoscopy promotes both rapid and accurate diagnosis and the opportunity for immediate therapeutic measures

Pattern and frequency of cranio-spinal anomalies

To find out number and type of cranio-spinal anomalies and management given. Observational study. Department of Paediatric Surgery and Neurosurgery at Nawabshah Medical College Nawabshah, from January 2006 to December 2007. All patients with gross CNS anomalies were included in this study. Data related to type of anomaly, gender, age, location etc were recorded on a pre-designed proforma. Parents were counseled regarding prospects of survival, operative procedure and the quality of life. Genetic and family planning advice were given. Those who were considered candidate for surgery were investigated using ultrasound and CT scan according to the type of lesion. A total of sixty four patients were received during the study period. Males were in dominance [n - 40 62.5%] and most of them belonged to rural areas. Fifty two cases [81.25%] were operated and 12 cases [19.75%] were managed conservatively. The most common anomaly was isolated hydrocephalus [n-27] followed by menenigocle and myelomeningocele [n-17]. Both lesions combined found in 7 patients. None of the mothers had folic acid supplementation before conception. Patients with gross major CNS defects and associated with systemic problems do not need active surgical intervention. Patients with amenable neural tube defect and expected of adequate quality of life require operation after proper counseling. There is a need of public awareness of folic acid supplementation in the antenatal period and antenatal screening to detect anomalies

Brown-Sequard syndrome following firearm injury with a bullet lodged in the upper cervical canal

A case of stray bullet injury in a child is reported who presented with Brown-Sequard syndrome and CSF leak from the wound at the nape of neck. Patient was assessed by plain radiography and CT scans showing bullet lying in the cervical spinal canal under the C1 and C2 laminae. Laminectomy at C1/C2 level was done and bullet was carefully removed. Patient improved neurologically and CSF discharge stopped. The case report indicated the atypical neurological presentation and possibility of survival in high cervical spinal firearm injury

Transdiaphragmatic approach to thoracolumbar junction fractures

The purpose of this study is to share experience with transdiaphragmatic approach to thoracolumbar junctions for adequate exposure, decompression, reconstruction and fixation. Quasi-experimental study. Neurosurgery department Peoples Medical College Nawabshah, from January 1999 to December 2004. Patients with thoracolumbar junction fractures were being studied. Plain x-rays, CT scan, myelography or MRI were done for assessment and planning. Anterior approach by thoraco-phrenico-laparotomy was used for adequate decompression and stabilization with Webb Morley system. Males dominated. Adults and middle age groups suffered mostly. Neurological improvement was seen in 17 [47.2%] cases. Bony fusion was observed in 32 [88.9%] cases. Phrenotomy for anterior approach to thoracolumbar junction provides adequate exposure to facilitate decompression of the cord and instrumentation. Patients with partial neurological deficit improve well than with complete neurological deficit. Most of the patients improve by 1 grade on American spinal injury association [ASIA] scale

Osteolytic torcular lesion

Torcular lesion encroach supratentorial and infratentorial compartments saddling or invading the big sinuses leading to torrential bleeding, which may need repair with venous or arterial graft. A case is, hereby, reported that presented with headache and an occipital swelling. CT scan showed torcular osteolytic tumor extending out beneath the scalp and into the posterior cranial fossa and causing fourth ventricular blockage. It needed two-stage surgery for complete excision. All the big venous sinuses near the lesion were protected. The dural gap was filled with fascia lata graft. Histopathology report revealed as malignant tumor of bony origin

Experience with spinal instrumentation for tuberculosis spine at PMCH Nawabshah

Spinal column is the common site of skeletal tuberculosis. Anteriorly there are three varieties: Paradiscal, Centrosomatic and Anterior Longitudinal. Extra-osseous involvement causes paravertebral abscess, epidural abscess or involvement of ligaments. The purpose of this study is to identify the frequency, presenting features, diagnostic tests and outcome of decompression and stabilization of tuberculous spondylitis. This study was conducted in Peoples Medical College, Nawabshah. All cases of spinal tuberculosis treated surgically were included. Admission criteria for these patients were advanced form of spinal tuberculosis, presenting with progressive deformity, neurological deficit, intractable pain, large paraspinal abscess or posterior element involvement. Over a period of 5 years, we had operated upon 248 cases of tuberculous spondylitis. Females dominated [1.91 times]. Bulk of series belonged to younger age group less than 40 years. Majorities of them had pain, neurological deficit and gibbus deformity. Surgery was performed to decompress the cord, apply a bony strut graft and stabilize with instrumentation. Thoracic region was commonly involved. Anterior approach was preferred because most of times anterior elements were involved. Webb Morley instrumentation system was used in majority of cases from D4 to L4. At the end of 6 months postoperatively pain relief was observed in 94.9% and neurological [motor] improvement in 92.2% cases. In this series we have observed that in our part of the world tuberculosis of spine is commonly seen in females and younger age group. Anterior decompression and stabilization is helpful in segmental rigid fixation of spine, pain relief deformity correction and early neurological recovery

Sacrococcygeal teratoma in infants and children review of 17 cases

Sacrococcygeal teratoma a congenital tumor, may present at birth or at later in childhood. Altman's type 1 and 2 are most commonly seen while type 3 and 4 are rare. Sacrococcygeal teratoma may be benign with mature tissue and malignant with immature elements. Apart from surgery, adjuvant chemotherapy and radiotherapy may be needed in few cases. This Study conducted retrospectively to examine spectrum of 17 cases of sacrococcygeal teratoma received in infancy and childhood in the dept: of pediatric surgery People's Medical College Nawabshah from 2001 to 2005. Female predominance found. Most of patients underwent through classical inverted chevron incision except two, which require abdomino-sacral approach. Benign histology found in 15 cases and two had malignant pathology, which required chemotherapy. In 2 years follow-up no recurrence found. From our study we found most of lesions were benign. Combined approach usually required in Altman's type 3, and early presentation always revealed benign pathology

Empyema thoracits in children: results of tube thoracostomy and decortication

Empyema thoracis is a common surgical complication of pneumonia. Various modes of treatment are described for the management of this condition. This study describes results of different modes of management of empyema thoracis. During a period of one year, 25 patients of post pneumonic empyema thoracis were managed at the Department of Paediatric Surgery at National Institute of Child Health [NICH], Karachi. There were 11 male and 14 female patients. Majority of patients [56%] was under five years of age. Tube thoracostomy resulted in expansion of lungs in 12 cases [Group I], while decortication was performed in 13 patients [Group II]. Lobectomy was performed in one case. Complications were noted in: a] patients who presented late with organized stage, b] patients in whom air leaks persisted for longer duration and c] in whom lung expansion was also delayed. One patient in this series died. At follow-up asymmetry of chest wall was noted in 5 patients of Group II. The hospital stay of Group I patients on average was 11.8 days in comparison to Group II where it was 31.3 days. The postdecortication stay average was 14 days. Tube thoracostomy in early stage of disease results in expansion of lung in most of the cases. Decortication is well tolerated in children and procedure related complications are few, therefore, decortication should not be delayed if no or partial response is observed in patients with tube thoracostomy