Pediatric Idiopathic Chylopericardium: A Case Managed with Thoracoscopic Window Pericardiotomy.

Idiopathic chylopericardium (CP) in the pediatric population is a rare entity with very few reported cases and is characterized by the accumulation of chyle in the pericardial cavity. There are no guidelines for the management of this rare entity. The present study reports a case of idiopathic CP in an infant and our experience of managing it by pericardial window creation using VATS and a multidisciplinary approach providing the optimum care for the child.

Acute Scrotum in Children: A Retrospective Study of Cases With Review of Literature.

BACKGROUND: Testicular pain or swelling, often referred to as acute scrotum, can have a number of causes and presentations. Testicular torsion is an emergency condition requiring early diagnosis and surgery to salvage the involved testis in order to preserve testicular fertility. The study is aimed to know the incidence, aetiology, and management of acute scrotal conditions with a particular focus on testicular torsion. Epididymorchitis, trauma, and scrotal cellulitis are other causes of acute scrotum which are managed conservatively after proper investigations. MATERIAL AND METHODS:  The authors retrospectively reviewed 10-year epidemiological data of all children age under 14 years admitted to the tertiary care hospital with the diagnosis of acute scrotum. Data were collected about the clinical history, physical examination, biochemical investigations, Doppler ultrasound, and management done. RESULTS:  133 children aged between 0 days and 14 years (mean age, 7.5 years) were found to have acute scrotum out of which 67 (50.37%) patients had epididymitis, 54 (40.60%) patients presented with Torsion testis, three (2.25%) had torsion of testicular appendages, eight (6.01%) had scrotal cellulitis and one (0.75%) presented with a strangulated hernia. Due to late presentation, testis could be salvaged in only eight of the 54 patients with torsion testis. The testicular loss was seen more in bigger children and those with signs of infection in blood reports and colour Doppler showing no blood flow in the testis. CONCLUSION:  The study results indicate that non-recognition of the severity of paediatric acute scrotum results in late presentation leading to testicular loss. Timely diagnosis will require sensitization of the parents, primary care providers, and paediatricians for this grave condition which leads to permanent testicular loss.

Laparoscopic-Assisted Modified Posterior Sagittal Anorectoplasty for Rectobulbar Urethral Fistula of Anorectal Malformation: A Prospective Study.

Introduction: Laparoscopic anorectoplasty (LAARP) is useful for the management of rectoprostatic urethral fistula (RPUF), due to easier rectal mobilization, avoidance of posterior sagittal muscular incision, and shorter hospital stay. However, its role in rectobulbar urethral fistula (RBUF) is still debated as there is a chance of urethral diverticulum (UD), due to incomplete dissection. Laparoscopy-assisted modified posterior sagittal anorectoplasty (LAMPSARP) utilizes advantages of LAARP combined with fistula dissection using small sagittal incision preserving puborectalis. The present study compares the results of LAMPSARP with LAARP for correction of RBUF associated with anorectal malformations (ARMs). Materials and Methods: All male ARM with RBUF presenting in a tertiary center in Central India (January 2014-January 2016) were included. Low male ARM, RPUF, rectovesical fistula, and congenital pouch colon were excluded. They were randomized into LAARP and LAMPSARP groups. Complications were assessed in terms of anal stenosis, mucosal prolapse, and UD. Kelly's scoring and Krickenbeck scoring were used to assess continence, and visible anal cosmesis scale (VACS) was used to assess wanal cosmesis. Results were statistically analyzed using a comparison of means and 2 × 2 contingency tables. Results: Fifty-six colostomized patients with RBUF (26 LAARP, 30 LAMPSARP) were included. Mean operative duration in the LAARP group and LAMPSARP group was 42 ± 10 min and 56 ± 12 min, respectively (P < 0.0001). On mean follow-up of 4.5 years, mucosal prolapse (53.9%) and UD (15.38%) were significantly higher in LAARP group, while anal stenosis was similar. All three, Kelly's score, Krickenbeck score, and VACS, were better (P < 0.05) in the LAMPSARP group. Conclusion: Laparoscopy-assisted modified posterior sagittal approach is better for RBUF and offers better surgical outcome.

A 10-Year Study of the Outcome of Wilms' Tumor in Central India and Identifying Practice Gaps.

Introduction: Despite remarkable improvement in Wilms' tumor (WT) survival in Western world, sub-optimal outcome in resource-constrained settings is influenced by late presentation, larger size, and poor access to treatment. This prompted us to study the outcome at a tertiary care center and to identify the global and local practice gaps. Materials and Methods: A retrospective, observational study of WT was conducted from October 2009 to September 2019 at a tertiary care setting. Following the National Wilms' Tumor Study Group protocol, an upfront nephrectomy (unilateral resectable tumors) and preoperative chemotherapy (large/unresectable Stage I-III) were followed. The records were reviewed for demographics, stage, preoperative chemotherapy, predictive factors, and outcome. Survival curves were plotted by the Kaplan-Meier method, and analysis was performed using the SPSS software version 16. Results: One hundred and fifty-six children were included, median age was 4.1 years, with a male predominance. The most common stages of the presentation were II (40.4%) and III (34.6%). An upfront surgery was done in 27.6%, while remaining received preoperative chemotherapy. The median follow-up was 22 months, and the events included relapse in 46 (29.48%) and death in 54 (34.61%). The mean survival time was 45.7 (95% confidence interval [CI], 41.08-50.30). The 2-year overall survival was 65.38% (95% CI, 59-73), and the 2-year event-free survival was 36% (95% CI, 32-41). On comparison of the impact of preoperative chemotherapy, the survival estimates in Stages I-III and relapse rate were statistically similar, tumor size reduced significantly, and tumor spill was significantly lower (P < 0.05). Conclusion: WT is associated with late presentation, sub-optimal survival, and higher relapse in our setting associated with practice gaps related to the management including practice violations.

Impact of "Lateralizing" the Sigmoid Colostomy on Port Ergonomics in Laparoscopic Anorectoplasty for High Anorectal Malformations.

INTRODUCTION: The high-type anorectal malformations (ARM) are conventionally managed by an initial left iliac fossa sigmoid colostomy, followed by laparoscopic anorectoplasty (LARP). Such a stoma occupies left half of the infraumbilical region and hinders the LARP ergonomics, leading to the surgeon's discomfort. We studied the outcome and impact of "lateralizing" (shifting laterally in the abdominal wall) the colostomy on port ergonomics. MATERIALS AND METHODS: This prospective study was conducted in the pediatric surgery unit of a medical college in central India between March 2014 and June 2017 in two parts. In the first part of the study, neonates with high ARM were block randomized in two groups: conventional colostomy (CC) in left iliac fossa and lateral colostomy (LC, laterally placed abdominal colostomy). Outcomes of colostomy were compared among these two groups. In the second part of the study, 40 consecutive infants from both types of colostomy groups underwent ergonomic comparison and assessment of the surgeon's discomfort during LARP (CC-LARP and LC-LARP). Standard statistical tests were used for comparison. RESULTS: In the first part of the study, 203 ARM cases were included in this study; 100 underwent CC and 103 underwent LC. Colostomy prolapse, excoriation, reversed stoma, and short distal limb were significantly higher in the CC group. In the second part of the study, the LC-LARP group showed many significant advantages over the CC-LARP group, including less peri-stomal adhesions, better vision, shorter operative time, and better ergonomics (better manipulation, elevation, and azimuth angles). The LC-LARP also significantly reduced the surgeon's discomfort. CONCLUSION: Lateralization of high-sigmoid colostomy should be preferred over left iliac fossa sigmoid colostomy for ARM, as it improves the port ergonomics and reduces the surgeon's discomfort for second stage LARP.

Comparison of 3D vs 2D laparoscopic-assisted anorectal pull-through (LAARP) for high anorectal malformations in children.

INTRODUCTION: The limitation of two-dimensional (2D) laparoscopic techniques includes lack of stereoscopic vision and depth perception which can affect surgical performance, physical and mental comfort of the operating surgeon. 3D laparoscopic surgery is popular in adults; however, its application and experience in the pediatric age group have been limited. We did a comparison of 2D and 3D laparoscopic-assisted anorectal pull-through (LAARP) in male high anorectal malformations (ARM). MATERIAL AND METHOD: This prospective cohort study included male children diagnosed with high anorectal malformation (recto-prostatic urethral fistula) who underwent LAARP in infancy after a neonatal colostomy between November 2019 to March 2020. The patients were randomized into a 2D group or 3D group at a 1:1 ratio. Patient demographics and operative/postoperative parameters were recorded. The effect of 3D laparoscopy was assessed in terms of laparoscopy visual parameters (image quality, depth perception, hand-eye coordination, and precision), physical discomfort (5-point Likert scale), and mental strain (State-Trait Anxiety Inventory scale). The statistical tests were performed on SPSS version 16. RESULTS: The demographics of both groups, 20 (patients in each), were similar. There was a significant reduction of laparoscopy execution time, physical discomfort (for eye, hand and wrist strain), and overall mental strain in the 3D group. There were similar complications, blood loss, and hospital stay, and no open conversion in two groups. CONCLUSION: 3D LAARP is feasible and safe in the surgical treatment of ARM in children. Further studies with assessment by more than one observer are needed to investigate the wider application of 3D in pediatric surgery.

Needs-driven skill training for surgical residents: our first experience in a low-/middle-income country.

Traditional Halstead teaching, which is time- and opportunity-dependent, has often been replaced by 'boot' camps which involve expensive modules and are usually a grand one-time event. This does not suit the complex teaching and learning needs of low- and middle-income countries (LMICs). We studied the impact of a needs-driven surgical training course implemented instead. The course was taken by 17 first-year residents of surgery, and included a pre-course knowledge assessment test, pre-test skills assessment, as well as post-test assessment and feedback impressions.Mean post-test scores improved significantly (P < 0.05) in all eight skills areas, though only 7 (44.11%) scored ≥80% in tests after the course, but all 17 in theoretical and clinical skills. There was strong agreement over all six points that the needs-driven course was of benefit. Our short and intensive needs-driven skills video training course for surgical residents fills the gap in skills development for general surgery residents.

Transperineal Intracath Meconiolysis and Evacuation Technique of "Distended" Bowel Evacuation for One-Stage Laparoscopic Anorectoplasty for High Anorectal Malformations in Males.

Introduction: One-stage anorectoplasty provides maximum potential for "normal" defecation reflexes right at birth and avoids complications and problems of colostomy. One-stage laparoscopic anorectoplasty (OSLARP) for rectourinary fistula (RUF) is restricted by distended bowel obscuring the working space for laparoscopy. This study describes transperineal intracath meconiolysis and evacuation (TIME) technique for OSLARP in the treatment of RUF in neonates. Materials and Technique: High male anorectal malformation (ARM) admitted from January 2016 to March 2019 were included in the study. Diagnosis of level of ARM was made on the basis of invertogram. Patient presenting with lethal comorbidities were excluded who underwent colostomy. The technique involved placement of a 16G intracath in the perineum through the site of future neo-anus, which was identified using muscle stimulator. Meconiolysis and evacuation was done using warm saline and 2% N-acetyl. The creation of enough abdominal space was achieved after evacuation and two working instruments were placed in paraumbilical positions. The laparoscopic dissection and division of fistula was done as followed in standard laparoscopic anorectoplasty. Results: Seventeen patients were selected for TIME technique but on laparoscopy 2 patients had severe necrotizing enterocolitis hence they underwent laparoscopy-assisted high sigmoid colostomy. Fifteen patients underwent OSLARP successfully. Mean weight was 2.5 ± 0.4 kg, mean gestational age was 36 ± 5 weeks, and mean age of presentation was 3.5 ± 1 days after birth. The TIME technique was successful decompressing bowel in all the patients. Out of 15 patients of OSLARP, 14 had rectoprostatic urethral fistula and 1 had rectovesical fistula. Mean total operative duration of OSLARP was 46 ± 15 minutes. Patients who could be followed for 3 years had good results in terms of continence and bowel movements. Discussion: TIME technique is a very simple and effective way to overcome the problem of associated colonic distention in neonatal one-stage laparoscopic anoplasty.

Laparoscopic suture-less herniotomy using tissue-sealing device for paediatric hydrocele.

Introduction: Laparoscopic herniotomy (LH) for hydrocele is an accepted procedure and provides advantages of contralateral diagnosis and repair with the same incisions. The suturing of patent processus vaginalis is associated with various complications. We describe suture-less herniotomy using tissue-sealing device for LH of hydrocele in children. Materials and Methods: The study was carried out on a prospective group of 21 children presenting with hydrocele after 1 year age over a period of 2 years. All infants with hydrocele and complicated hydroceles were excluded. The technique involved peritoneal incision and sealing of hydrocele sac with tissue-sealing device. Results: A total of 21 patients (28 hydroceles) were operated. The age ranged from 1 year to 14 years (mean age, 4 years). Ten right, 4 left and 7 bilateral hydroceles (2 diagnosed on laparoscopy) were operated. Operative time ranged from 15 to 32 min, with a mean time of 18 min. All patients were discharged after a hospital stay of 12 h. No recurrences were observed during the follow-up period. One patient had persistent hydrocele for 4 months which resolved spontaneously. Conclusion: The laparoscopic suture-less herniotomy for paediatric hydrocele is a safe, secure and easy procedure which can reduce suture and suturing-related complications following LH in hydroceles.

Laparoscopic hybrid pyloromyotomy for infantile hypertrophic pyloric stenosis: A simplified technique.

INTRODUCTION: Laparoscopic pyloromyotomy (LP) for the treatment of infantile hypertrophic pyloric has advantage of smaller incisions, faster recovery, reduction in wound-related complications and better cosmesis. Various laparoscopic knives and spreaders have been used for LP, but they do not provide the depth and tissue perception as in open surgery. We describe the laparoscopic hybrid pyloromyotomy (LHP) which makes procedure simple and safe without the requirement of any special instrument. MATERIALS AND METHODS: This retrospective and prospective comparative study was conducted over a period of 4.5 years in a tertiary teaching hospital in central India. All patients with infantile hypertrophic pyloric stenosis diagnosed on the basis of clinical history, examination and ultrasonography were included in the study. Retrospective data of three-port conventional LP (CLP) using monopolar diathermy hook for incision was used as control group against prospective data of 25 patients undergoing LHP. After a proper layout, LHP was done using one umbilical optical port, right paraumbilical grasper of holding the pyloric olive and an epigastric incision for hybrid pyloromyotomy using 11 no blade and blunt-tipped mosquito artery forceps. RESULTS: Prospective group of LHP included 25 patients which were compared with a retrospective group of CLP consisting of 25 patients. On comparison of two groups, it was found that LHP reduces operative duration significantly. The outcome in terms of complications and recovery was comparable in two groups. None of the patients developed recurrence and required any redo surgery. CONCLUSION: LHP is a simplified approach which is easy to learn and teach, improves safety and accuracy of the procedure.

Per-operative modified rigid cholangioscopy for removal of intrahepatic stones associated with choledochal cyst in children.

INTRODUCTION: Choledochal cyst (CDC) is often associated with intrahepatic stones (IHSs) in children which necessitate their removal during excision. The endoscopic equipment needed for their clearance such as paediatric flexible cholangioscope and other advanced modalities are not freely available in resource-poor setups. We describe per-operative modified rigid cholangioscopy using rigid paediatric cystoscope for stone removal during open CDC excision. METHODS: All children with CDC presenting with IHSs between January 2015 and December 2017 were included in the present study. IHSs were diagnosed by ultrasound/magnetic resonance cholangiopancreatography (MRCP). In these patients, after cyst excision by open technique, a 9 Fr paediatric cystoscope with 4 Fr working channel was inserted into the common hepatic duct for visualisation and clearance of stones from (intrahepatic bile ducts). Follow-up was done using liver function tests, ultrasound and MRCP (if needed). Patients underwent three monthly liver function test and ultrasound and if needed MRCP. RESULTS: Six cases of CDC presenting with IHS were managed, and one case with post-R-en-Y IHS was treated with this technique. Rigid paediatric cystoscope with working channel and forceps was used. All cases were successfully managed, and one case was found to have intrahepatic duct stenosis was dilated. CONCLUSION: Per-operative rigid endoscopy using paediatric cystoscope is an easily available tool in most of the setups for the management of IHS associated with CDC in children.

Laparoscopic 'steering wheel' derotation technique for midgut volvulus in children with intestinal malrotation.

INTRODUCTION: Since the first description by William Ladd, the Ladd's procedure has been the surgery of choice for the correction of malrotation. The laparoscopic Ladd's procedure is becoming popular with the advent of minimal access surgery and is described in the literature. Various techniques of the Ladd's procedure have been described but none of them describes the stepwise technique for derotation of volvulus which is the most difficult and confusing part of the surgery. We describe 'steering wheel' technique for easy derotation of volvulus associated with malrotation. METHOD: A total of 62 patients were diagnosed to have an intestinal malrotation between 2010 and 2017. All cases which had complete non-rotation with a midgut volvulus were reviewed. Out of these, 48 patients were operated with open technique and 14 patients were subjected to the laparoscopic correction. TECHNIQUE: Using three-port technique, stepwise derotation of volvulus is done which simulates the rotation of steering of car at an acute turn and has been described in four simple steps. This technique also stresses the importance of the release of Ladd's band before derotation. RESULTS: Of 62 patients diagnosed with malrotation, 14 (22.6%) patients underwent the laparoscopic Ladd's procedure. The mean age was 26 + 8 months, mean weight was 10 + 2 kg and included eight males (57%) and six females (43%). There was only one (7.14%) conversion to open technique, due to a huge dilatation of duodenum causing difficulty in dissection in a patient with malrotation without volvulus. The laparoscopic Ladd's procedure took an average time of 70 ± 15 min. CONCLUSION: The laparoscopic 'steering wheel' derotation technique is easy and provides a stepwise description of the laparoscopic derotation of volvulus associated with malrotation in children.

Effects of glargine insulin on glycemic control in patients with diabetes mellitus type II undergoing off-pump coronary artery bypass graft.

BACKGROUND: The prevalence of diabetes mellitus in patients requiring coronary artery bypass grafting (CABG) is noticeably high (20%-30%). These patients have inferior perioperative outcome, reduced long-term survival, and high risk of recurrent episodes of angina. To improve perioperative outcome surgical unit defined satisfactory glycemic control is desired during this period. Hence, the aim of our study is to compare the efficacy of glargine insulin combination with continuous human insulin infusion for perioperative glycemic control in patients with diabetes undergoing CABG. MATERIALS AND METHODS: Fifty Patients, who were posted for off-pump CABG with diabetes mellitus type II, were randomized in two group, Group I normal saline + human insulin infusion during the perioperative period, Group II (glargine group): Glargine + human insulin infusion during perioperative period. RESULTS: During surgery and in the postoperative period, random blood sugar and human insulin requirement are significantly higher in control group than glargine group. Other infection, step-up antibiotics, intensive care unit (ICU) stay, and hospital stay were significantly higher in control groups in postoperative period. CONCLUSION: Our study results suggest that glargine effectively manages blood glucose level with significantly greater control over postoperative morbidity.

Single-incision trocar-less endoscopic management of giant liver hydatid cyst in children.

INTRODUCTION: Laparoscopic management of giant hydatid cyst has limitations such as spillage, poor control, difficulties in suctioning the contents through special ports which are not easily available, difficulty in the obliteration of residual cavity and recurrence. We describe single-incision trocar-less endoscopic (SITE) technique which simplifies enucleation and management of residual cavity. METHOD: Inclusion criteria for these cases were patients having single uncomplicated giant hydatid cyst >5 cm present at the surface of the liver and palpable on clinical examination. The cysts which were <5 cm, multiple, deep-seated and impalpable were excluded from the study. TECHNIQUE: An incision of 1 cm is marked over the site of the maximum bulge and deepened to open peritoneum, cyst is held with two stay sutures, injection of scolicidal agent and aspiration is done and suction of the cyst content is done. After suction of the contents, 5 mm telescope is inserted, and the cyst cavity is inspected, clearance and cyst procedure is done. RESULTS: In 6 years, 62 cases of giant hydatid cyst fulfilling the inclusion criteria and were taken for SITE technique. SITE was successful in all patients and none needed a conversion. Twenty-nine (46.77%) underwent omentopexy and three (4.83%) underwent SITE capitonnage. There was post-operative biliary leak in one (0.016%) patient who underwent capitonnage, which was managed by prolonged drainage which resolved in 10 days. Mean operative duration was 52 min (30 min to 85 min). Mean follow-up was for 18 months (12-36 months). One (0.016%) patient had cyst recurrence. DISCUSSION: SITE has advantages of endoscopic clearance and does not require special ports which are expensive, technically difficult to use and often unavailable. It allows controlled handling, effective suction and easier management of bile communication. SITE can be a preferred procedure for endoscopic management of giant liver hydatid cysts. CONCLUSION: SITE management of giant liver hydatid cyst seems to be a reliable treatment modality as it is minimally invasive, efficient, easy to perform and effective.

Management of a case of double aortic arch with tracheal compression complicated with postoperative tracheal restenosis.

Tracheal stenosis in association with the double aortic arch (DAA) is uncommon; however, it carries a high risk of morbidity, mortality, and restenosis. Although surgery is the mainstay of managing a case of the DAA with tracheal stenosis, management of tracheal restenosis requires a multidisciplinary approach. In this case report, we present our successful experience in managing a child of DAA with tracheal stenosis who developed tracheal restenosis after sliding tracheoplasty of trachea.

Elective nasal continuous positive airway pressure to support respiration after prolonged ventilation in infants after congenital cardiac surgery.

BACKGROUND: We sought to compare the effectiveness of oxygen (O2) treatment administered by an O2 mask and nasal continuous positive airway pressure (NCPAP) in infants after congenital cardiac surgery. METHODS: In this retrospective observational study, 54 infants undergoing corrective cardiac surgery were enrolled. According to the anesthesiologist's preference, the patients ventilated for more than 48 h were either put on NCPAP or O2 mask immediately after extubation. From pre-extubation to 24 h after treatment, arterial blood gas and hemodynamic data were measured. RESULTS: After 24 h of NCPAP institution, the patients showed a significant improvement in oxygenation compared to O2 mask group. Respiratory rate (per minute) decreased from 31.67 ± 4.55 to 24.31 ± 3.69 (P < 0.0001), PO2 (mmHg) increased from 112.12 ± 22.83 to 185.74 ± 14.81 (P < 0.0001), and PCO2 (mmHg) decreased from 42.88 ± 5.01 to 37.00 ± 7.22 (P < 0.0076) in patients on NCPAP. In this group, mean pediatric cardiac surgical Intensive Care Unit (PCSICU) stay was 4.72 ± 1.60 days, with only 2 (11.11%) patients requiring re-intubation. CONCLUSION: NCPAP can be used safely and effectively in infants undergoing congenital cardiac surgery to improve oxygenation/ventilation. It also reduces the work of breathing, PCSICU stay, and may reduce the likelihood of re-intubation.

Invasive pericardial hydatid cyst: Excision of multiple huge cysts.

Cardiac hydatid cyst is rare even in endemic countries, and poses a therapeutic challenge due to varying presentation and unpredictable pre-, peri-, and postoperative complications. We herein present a case of multiple, multifocal, huge pericardial hydatid cyst, with invasion into the left ventricle and main pulmonary artery in a young male patient, presented with atypical chest pain.

Early laparoscopic management of appendicular mass in children: Still a taboo, or time for a change in surgical philosophy?

INTRODUCTION: Early appendicectomy has been found to be a safe and better alternative for management of appendicular mass in various studies in adults, while very few studies report such advantages in the paediatric population. We conducted this study to assess the safety, efficacy and need of early laparoscopic appendicectomy (ELA) in child patients with appendicular mass. MATERIALS AND METHODS: All patients with appendicular mass who underwent ELA at our institute between September 2011 and August 2014 were retrospectively reviewed. Appendicular mass was defined as a right iliac fossa mass in a case of acute appendicitis, diagnosed by clinical, laboratory and radiological evaluation, and palpation under anaesthesia, the patient being subjected to laparoscopic treatment. RESULTS: Forty-eight (48) patients were confirmed to have appendicular mass intraoperatively and were included in the analysis. There were 30 males and 18 females, with ages ranging 7-13 years (mean 9 years). In the present study, appendicular complications included appendicular abscess (62.5%), gangrenous appendicitis (25%), sloughed-out appendix (8.33%) and appendicular perforation (4.16%). The average operative time was 72 min (range 45-93 min). One case (1.92%) required conversion to open procedure due to failure of identification of the appendicular base of a sloughed-out appendix. Post-operative complications were found in 4 (7.69%) patients, of whom 3 (5.76%) had minor wound infection at the umbilical port site and 1 (1.92%) had post-operative pelvic abscess, which was managed with percutaneous aspiration. DISCUSSION: ELA avoids misdiagnosis, treats complicated appendicitis at its outset, and avoids complications and/or failure of non-operative treatment of a potentially lethal, diseased appendix. This approach is associated with minimal complications in experienced hands and is a safe and feasible option in children with appendicular mass.

Prevalence and Predictors of Metabolic Syndrome in Young Asymptomatic Gujarati Population.

Background. Metabolic syndrome is a cluster of risk factors leading to the development of atherosclerotic cardiovascular diseases. We aimed to evaluate the prevalence of metabolic syndrome (MS) and its predictors in young and apparently healthy Gujarati individuals. Methods. This population based cross-sectional study involved a total of 1500 healthy adults of 20-40 years of age. Demographic details and clinical data such as body mass index (BMI), waist circumference (WC), and blood pressure were measured along with the estimations of lipoprotein (a), total cholesterol (TC), triglyceride (TG), total lipid, LDL/HDL ratio, TC/HDL ratio, and fasting blood glucose (FBS). Results. Overall in young Gujarati population (20-40 years) prevalence rates of MS were 16.0% (male: 21.5%; female: 10.8%) where the metabolic abnormalities increased with advanced age as 9.56% of the young population (20-30 years) had MS, in contrast to the 24.57% in the old (31-40 years). Odds ratio analysis had indicated BMI (1.120; 95% CI: 1.077-1.163; P < 0.0001) as the strongest risk factor for MS closely followed by advancing age (1.100; 95% CI: 1.061-1.139; P < 0.0001) levels. Conclusion. Prevalence of metabolic syndrome in young Gujarati population reinforces the need for early life style intervention and awareness programs in this ethnic group.

Subcutaneoscopic excision of external angular dermoid cyst in children without conspicuous scarring.

INTRODUCTION: External angular dermoid cysts are benign lesions that are excised through an incision over the eyebrow. This leaves a visible scar that may not be cosmetically acceptable. Herein, we describe a minimally invasive subcutaneoscopic technique that involves placing incisions above the hairline to avoid scarring on the face. MATERIAL AND SURGICAL TECHNIQUE: This is a retrospective review of three consecutive cases of dermoid cysts. Each patient underwent subcutaneoscopic excision between March 2012 and September 2012. With the patient under general anesthesia, a 6-mm incision was made on the scalp above the hairline. After a wide subcutaneous tunnel was created, a 5-mm port with a 30° telescope was placed for an optical port. Insufflation was done with CO2 at pressure of 8 mmHg and flow rate of 1 L/min. Two para-optical stab incisions were used to insert a 3-mm Maryland dissector and a 3-mm hook for dissection. The cyst was excised and removed through one of the ports. DISCUSSION: All three cases underwent successful subcutaneoscopic excision without the need for conversion. The mean operative time was 42 min. There were no complications, and all patients had excellent cosmesis. Subcutaneoscopic excision of dermoid cyst is a technically feasible procedure in pediatric patients, as demonstrated by our three cases. It provides excellent cosmesis and avoids scarring on the face.