Early feeding in pediatric patients following stoma closure in a resource limited environment.

BACKGROUND: Establishment of enteral nutrition is necessary after intestinal surgery. In resource-strained environments, it can be critical. This study examined the effect of early feeding in pediatric patients undergoing stoma closure in a country with mid-level socioeconomic indices. METHODS: With parenteral consent and ethics board approval, patients were prospectively enrolled in early feeding (Group 1), starting feeds 24h post-operation with a protocol driven increase. They were compared with similar patients managed without a specific protocol over the 12 months prior (Group 2). RESULTS: There were 31 patients in each group with similar mean age and weight. The mean first sustained feed was achieved at 28.5 ± 4.4 h* in Group 1 vs. 153.8 ± 28.6 h in Group 2. Full feeds were achieved within 62.3 ± 19.2 h* vs. 196.0 ± 40.5 h in Group 1 and 2, respectively. Mean hospital stay was 7.2 days* in Group 1 vs. 9.4 days in Group 2. A reduction in postoperative fever and wound infections was observed in Group 1 (*p<0.05). CONCLUSION: Early enteral feeding after elective bowel anastomosis is well tolerated in children and results in shorter hospital stay and fewer complications.

Umbilical signs of peritoneal tuberculosis in children.

OBJECTIVES: To report the observation of involvement of the umbilicus with alteration of its morphology in association with peritoneal tuberculosis. METHODS: This is a retrospective observational case series of abdominal tuberculosis (ATB) in children, treated in the department of pediatric surgery of a tertiary-care children's hospital in the period from January 2004 through April 2010. RESULTS: Out of a total of 38 cases of ATB in children, 22(57.9%) were of the peritoneal type, 14(36.8%) were of the intestinal type, and 2(5.3%) involved the mesenteric lymph nodes. Of the patients manifesting with peritoneal tuberculosis, 11 cases (50%) had involvement of the umbilicus with changes in the umbilical shape and appearance. In seven cases the umbilicus was found retracted and transversely oriented (a slit-like "smiling" appearance) with loss of the umbilical hollow. In two cases there was puckering of the umbilicus. Other findings included umbilical erythema with inflammation in one patient and a fecal fistula at the umbilicus in another patient. While seven cases responded to treatment with antituberculous therapy (ATT), four cases underwent surgery (two laparotomy and two laparoscopy). Findings were similar in all four patients, consisting of adhered dilated bowel loops studded with tubercles which also covered the parietal peritoneum and the falciform ligament. All four cases responded to postoperative ATT. CONCLUSIONS: Morphological changes of the umbilicus can provide an additional clue to the diagnosis of peritoneal tuberculosis in children.

Combination of N-(4-hydroxyphenyl) retinamide and genistein increased apoptosis in neuroblastoma SK-N-BE2 and SH-SY5Y xenografts.

Neuroblastoma is the childhood malignancy that mainly occurs in adrenal glands and is found also in the neck, chest, abdomen, and pelvis. New therapeutic strategies are urgently needed for successful treatment of this pediatric cancer. In this investigation, we examined efficacy of the retinoid N-(4-hydroxyphenyl) retinamide (4-HPR) and the isoflavonoid genistein (GST) alone and also in combination for controlling the growth of human malignant neuroblastoma SK-N-BE2 and SH-SY5Y xenografts in nude mice. Combination of 4-HPR and GST significantly reduced tumor volume in vivo due to overwhelming apoptosis in both neuroblastoma xenografts. Time-dependently, combination of 4-HPR and GST caused reduction in body weight, tumor weight, and tumor volume. Combination of 4-HPR and GST increased Bax:Bcl-2 ratio, mitochondrial release of Smac, downregulation of baculovirus inhibitor-of-apoptosis repeat containing (BIRC) proteins including BIRC-2 and BIRC-3, and activation of caspase-3 and apoptosis inducing factor (AIF). Further, downregulation of nuclear factor-kappa B (NF-kappaB), vascular endothelial growth factor (VEGF), and fibroblast growth factor 2 (FGF2) was also detected. In situ immunofluorescent labelings of tumor sections showed overexpression of calpain, caspase-12, and caspase-3, and also AIF in the course of apoptosis. Combination therapy increased apoptosis in the xenografts but did not induce kidney and liver toxicities in the animals. Results demonstrated that combination of 4-HPR and GST induced multiple molecular mechanisms for apoptosis and thus could be highly effective for inhibiting growth of malignant neuroblastoma in preclinical animal models.

The colovesical fistula in congenital pouch colon: a histologic study.

PURPOSE: The aim of this study was to perform a detailed histopathologic examination of the terminal colonic pouch and the colovesical fistula (CVF) excised during surgical management of male patients with the more severe forms (types I/II) of congenital pouch colon (CPC) associated with anorectal agenesis. METHODS: From January 2005 to December 2006, 25 male patients with types I/II CPC underwent abdominal exploration with dissection of the terminal portion of the colonic pouch and associated CVF till the bladder, division-ligation of the fistula, and excision of the colonic pouch. In 6 of the 25 patients, a complete dissection of the fistula to the bladder was possible, and in them, the terminal portion of the colonic pouch and the CVF were subjected to detailed histopathologic examination. The 6 patients included 3 newborns in whom this surgery was performed as a primary procedure, and 3 patients aged 3 months, 15 months, and 2 years, respectively, in whom a window colostomy of the pouch had earlier been performed. After due processing, multiple sections from the specimens were stained using the routine H&E method and examined under the microscope under different magnifications. RESULTS: In 4 specimens, the epithelial lining of the CVF consisted of transitional stratified epithelium with underlying anal/urethral glands. In 2 specimens, obtained from patients 15 months and 2 years old, respectively, the lining was of nonkeratinizing, stratified squamous epithelium. Other findings included aganglionosis in the muscle layers (n = 2), submucosal and subserosal fibrosis (n = 1), and thickening of muscle layers in the fistulous portion, suggestive of the presence of an internal sphincter (n = 2). CONCLUSIONS: The CVF in patients with types I/II CPC shows histologic features of the normal anorectal canal.

Choledochal cysts in infancy and childhood.

OBJECTIVE: To study the clinical presentation, management and results of treatment of 41 consecutive cases of choledochal cyst (CC) managed from 1999 to 2006. METHODS: The age of the patients ranged from 20 days to 11 years. Eleven cases were 1 year or less in age (infantile group) and 30 patients were more than 1 year old (classical pediatric group). Children less than 1 year old presented with jaundice (72%), hepatomegaly (54%) and clay-colored stools (63%); whereas those above one year in age presented with pain (83.3%) and jaundice (47.6%). Three cases had biliary perforation with localized or generalized biliary peritonitis. Ultrasonography (US) diagnosed/suggested CC in all 41 patients, however, contrast-enhanced computed tomographic (CECT) scan (n=12), radionuclide DISIDA scan (n=5) and magnetic resonance cholangiopancreatogram (MRCP) (n=3) also contributed to the diagnosis. 19 patients, including 4 from the 'infantile' group, had significant dilatation of intrahepatic biliary ducts. RESULTS: Nine patients from the 'infantile' group had cystic type I CC (type Ic), while 2 patients had fusiform dilatation of the common bile duct (type If disease). In contrast, 21 of the older patients had type If disease while 9 had type Ic disease. Operative management included primary complete excision of the cyst with a Roux-en-Y hepaticodochojejunostomy (HDJ) (n=32), Lilly's modification of submucosal resection with a HDJ (n=8) and cyst excision with a hepaticodochoduodenostomy (HDD) (n=1). All 3 patients with biliary perforation had primary excision of the CC with a HDJ. Unusual operative findings included accessory hepatic ducts (n=2), anteriorly placed common or right hepatic arteries (n=3) and partially or completely blocked proximal extrahepatic bile ducts (n=3). There were 2 postoperative deaths, one had cirrhotic liver disease with portal hypertension, the other had deep icterus with poor general condition. Both patients succumbed to overwhelming sepsis. One patient required reexploration and refashioning of the HDJ for biliary leak. Short-term follow-up was satisfactory in all 39 patients. CONCLUSION: Infants with CC constitute a distinct group with regard to clinical presentation and the pathological should be kept in mind while evaluating neonates and infants with cholestatic jaundice and older children with recurrent abdominal pain. Primary excision of the cyst with a HDJ provides satisfactory results in the management of the vast majority of cases of CC including those in infants, massive CC and in the presence of biliary perforation and peritonitis.

Congenital cystic adenomatoid malformation associated with ipsilateral eventration of the diaphragm.

A two-month-old girl was operated for a left-sided eventration of the diaphragm. At surgery, a mass representing an extralobar pulmonary sequestration (EPS) was found inferior to the left lobe of the lung and was excised. Histopathological examination of the resected specimen showed presence of a type II congenital cystic adenomatoid malformation (CCAM) within it. A review of the relevant literature is presented.

Congenital pouch colon: follow-up and functional results after definitive surgery.

PURPOSE: In this study, functional results with regard to fecal continence levels and other parameters were studied in 22 patients with congenital pouch colon associated with anorectal agenesis (CPC) more than 3 years old who had undergone definitive pull-through surgery 1 to 13 years earlier. An attempt was made to formulate treatment protocols for management of fecal incontinence and other problems associated with CPC. METHODS: The study sample consisted of 14 males and 8 females. Three of the 8 female patients had had a cloacal malformation. The medical records of the patients were scrutinized and they were classified into 4 subtypes based on the length of normal colon proximal to the colonic pouch. The patients were further categorized into 3 groups based on the terminal bowel that had been pulled-through, namely, the ileum or colon proximal to the colonic pouch or a tubularized segment of the colonic pouch. The somatic growth of the patients was studied. Clinical assessment of fecal continence was performed by the Kelly and the Kiesewetter and Chang scoring systems. A computed tomographic scan of the pelvis with a barium enema was performed to assess the terminal bowel and its placement as well as the bony and muscular anatomy of the pelvis. The urinary system was assessed by a clinical history as well as by abdominal ultrasound and a micturating cystourethrogram. Various treatment modalities including dietary modifications, drugs, and enemas were instituted in patients with poor continence levels, and the response to treatment studied. RESULTS: Thirteen patients (59.2%), all with an ileal pull-through, had height and weight less than 50% of that expected for their ages. Overall fecal continence was "poor" in 17 patients and "fair" in only 5 patients. Patients with pull-through of either ileum or normal colon often had very frequent passage of liquid or semisolid stools, whereas the 4 patients with pull-through of tubularized colon had infrequent passage of semisolid stools with abdominal distension and bloating. One of these 4 patients had massive colonic redilatation necessitating surgical correction. Mucosal prolapse and perineal excoriations were frequent findings. Ultrasonography and micturating cystourethrogram showed hydroureteronephrosis and vesicoureteric reflux in 5 patients. Radiologic assessment revealed that there were no significant sacral abnormalities and the striated sphincteric musculature was well developed, although the levator ani was thinner than normal in 15 patients (68%). The bowel was very well placed in the sphincteric complex in 19 patients (86%). In 7 of the 13 patients who had pull-through of normal ileum or colon, some improvement in continence levels was seen 3 to 6 months after institution of dietary measures, loperamide, and saline-water enemas. Two of 3 patients with pull-through of tubularized colon improved to some extent with colonic washouts alone. Overall, quality of life was poor in the 22 patients. CONCLUSIONS: Despite the fact that the sacrum is usually normal, the sphincteric musculature well developed, and the terminal bowel well placed without any anal strictures, long-term prognosis with regard to fecal continence, growth and development, and quality of life appears to be dismal for all subtypes of CPC, irrespective of the type of definitive surgery performed. Corrective measures also appear to be of limited value. Various newer management modalities for management of fecal incontinence may be considered, but in several patients a permanent abdominal stoma may be a more practical solution.

Lumbosacral parasitic rachipagus twin.

A rare case of a newborn girl presenting with a mass representing an aborted parasitic twin attached to the back in the midline over the lumbosacral region (parasitic rachipagus) is reported. Rudimentary digits were attached to the mass, and in one area, the overlying skin resembled scrotal skin. A depression resembling an anal dimple was also present on the surface of the mass. Investigations showed a well-developed long bone and other small bones within the parasite, and sacral spina bifida in the autosite. Successful surgical excision of the parasitic mass was performed. A review of the literature pertaining to parasitic rachipagus twinning is presented.

Management of splenic abscess in children by percutaneous drainage.

BACKGROUND/PURPOSE: Isolated splenic abscesses are rare in pediatric patients. The recommended treatment in the literature has been in favor of splenectomy, although conservative treatment with splenic preservation is being increasingly reported. We report successful management of 4 pediatric patients with splenic abscess by needle aspirations and antibiotics. MATERIALS AND METHODS: Four children (aged 7-11 years; male-female, 3:1) were admitted in our institution with history of high-grade fever with chills, anorexia, left hypochondrial pain, and splenomegaly. One child was a known case of thalassemia, and one had a history of typhoid fever. The others did not have any predisposing condition. Ultrasonography (USG) and computed tomographic scan of the abdomen showed a solitary abscess in the spleen in 2 patients and multiple abscesses in the other 2. Ultrasonography-guided needle aspiration in 3 cases revealed purulent fluid, which, on culture, grew Escherichia coli in 1 case, Salmonella paratyphi A in 1 case, but sterile in 1 case. Blood culture was sterile in all the cases, but Widal's test was positive in 2 patients. Treatment protocol included USG-guided needle aspiration of pus along with intravenous ceftriaxone, metronidazole, and amikacin for 3 to 12 weeks. RESULTS: All 4 patients showed a good response to conservative treatment. Serial USG showed gradual resolution of abscess, and none was subjected to splenectomy. CONCLUSION: Isolated splenic abscess in children can be successfully treated with needle aspirations and intravenous antibiotics, thereby avoiding splenectomy.

Bilateral adrenal abscess in a neonate.

A 23-day-old male baby with a history of perinatal hypoxia presented with refusal of feeds and abdominal distension. The child had a right-sided cystic upper abdominal mass and features of neonatal septicemia. Abdominal ultrasound (US) and contrast-enhanced CT scan showed bilateral adrenal abscesses. Laparotomy with drainage of the abscesses successfully treated the condition. The literature on the subject is reviewed.

Advanced hepatoblastoma: successful liver resection following preoperative chemotherapy.

We present a case of advanced hepatobastoma in a 9-month-old child who was treated with chemotherapy (three cycles of PLADO regimen conisting of cisplatin and Adriamycin) followed by surgical excision (left lobectomy). At 1-year follow up, the is doing well and is disease-free.

Total gastric necrosis in a neonate.

Necrosis of the entire stomach is extremely rare in neonates. We report a case of total gastric necrosis in a full-term neonate. The possible pathophysiology, diagnostic features and therapeutic options for gastric necrosis in a newborn are discussed.

Embryonal rhabdomyosarcoma of the common bile duct.

A two-and half-year-old boy presented with a short history of fever, jaundice and abdominal distension. At laparotomy, a rhabdomyosarcoma (RMS) arising from the common bile duct (CBD) was found. The tumor including the CBD was successfully excised and a Roux-en-Y hepaticodochojejunostomy was performed. Postoperatively, the child received chemotherapy and is doing well on one-year follow-up the recent literature on the subject is reviewed.