Spectrum of paediatric blunt abdominal trauma in a tertiary care hospital in India.

Aim: To study the profile of paediatric blunt abdominal trauma and to assess the correlation of grade of injury with the outcome. Materials and Methods: It is a prospective observational study from January 2015 to December 2020. Children below 12 years with blunt abdominal trauma were included. Patient demographic data, treatment given and the final outcome were recorded. All patients were followed up for a minimum of 6 months to maximum 5 years. Results: A total of 68 patients were included in the study. Fall from height was the most common mode of injury (62%) followed by road traffic accidents (35%) and the other causes included in the miscellaneous group (hit by animal and fall of heavy object on the abdomen; 3%). Most commonly injured organ was liver (n = 28, 41%) followed by spleen (n = 18, 26%) and kidney (n = 15, 22%). Other injuries were bowel perforations (jejunal [n = 4], ileal [n = 1] and large bowel [n = 1]; 9%), pancreaticoduodenal (n = 5, 7%), urinary bladder (n = 3, 4%), abdominal vascular injury (iliac vein-1, inferior vena cava-1;3%), adrenal haematoma (n = 2,3%) and common bile duct (CBD) injury (n = 1, 1%). More than one organ injury was seen in 13 cases (19%). Non-operative management was successful in 84% (n = 27) and laparotomy was done in 16% (n = 11). Most of the patients sustained Grade IV injury (n = 36, 53%) and majority of the patients (n = 60, 88%) had good outcome without any long-term complications. Conclusion: Profile of paediatric blunt abdominal trauma include solid organ injuries such as liver, spleen, kidney, pancreas, adrenal gland and others like bowel injury, CBD, urinary bladder and abdominal vascular injury. The grade of injury does not correlate with the outcome in a higher grade of injury and these children had good outcome.

Anorectal Malformations in Male Monozygotic Twins and Review of Literature.

Anorectal malformations (ARMs) are one of the common congenital gastrointestinal malformations with a prevalence of 0.2-0.6/1000 live births. There are only a few reported cases of familial ARMs in literature suggesting different patterns of inheritance. Among them, isolated ARMs in monozygotic twins are quite rare with significant male preponderance. Most of these ARMs are either of intermediate or low anomaly type. We reported two pairs of male monozygotic isolated ARMs from a tertiary care hospital in India and reviewed the literature in details adding to the total of nine pairs of twins till date.

Musculoskeletal and Esthetic Complications after Neonatal Thoracotomy: Revisited.

Aim: The aim is to study the complications of neonatal thoracotomy and its preventive measures. Methods: We retrospectively reviewed 53 neonates who underwent thoracotomy from January 2017 to December 2019 for a period of 3 years. Patient demographic data, primary disease for which they underwent thoracotomy, postoperative complications (immediate and delayed) during follow-up were documented. Results: During 3-year period, 53 neonates underwent thoracotomy for various surgical pathologies. The indications were esophageal atresia with tracheoesophageal fistula (n = 49), eventration of diaphragm (n = 3), congenital lobar emphysema of left upper lobe of lung (n = 1). Most of them were right posterolateral thoracotomies (n = 48, 90.56%) and left posterolateral thoracotomy was done in only 5 cases (9.43%). Associated anomalies were seen in 22 cases, such as cardiac (n = 19), renal (n = 4) and gastrointestinal (n = 5). Associated comorbidities seen in 14 cases; preterm (n = 4), low birth weight (n = 13), delayed presentation (n = 6). Early postoperative complications such as pneumonia (34%, n = 18) and wound infection (11.3%, n = 6) were noted. Delayed complications include musculoskeletal abnormalities (n = 19, 35.8%) and esthetic complications such as asymmetry of chest (5.6%). Conclusion: Neonatal thoracotomy is associated with complications such as pneumonia, wound infections, and musculoskeletal abnormalities such as asymmetry of chest and scoliosis. These can be prevented by adequate postoperative pain relief, muscle-sparing thoracotomies, avoiding tight closures, and nerve injuries. Long-term follow-up is required because these complications may manifest later on also. Early detection and institution of physiotherapy may help.

Complications and Management of Retained Double-J Stents in Children During the Coronavirus Disease-2019 Pandemic.

Background: Double-J (DJ) stents were commonly used for internal drainage after major reconstructive procedures or in cases of obstruction and ureteral injuries. They should be removed or changed within the stipulated time; otherwise, they can lead to various complications such as stent occlusion, migration, breakage, encrustation, stone formation at either end of the stent, and entanglement of the two stents if bilateral stenting was done. The present study focuses on the complications and the management due to delay in the removal of the DJ stents due to the coronavirus disease-2019 pandemic. Materials and Methods: This is a cross-sectional study over a period of 9 months. Children <12 years were included in the study. The patients' demographic data, indication for DJ stenting, time gap between DJ stenting and removal, complication with delay in DJ stent removal, and its management were recorded. Indwelling duration for >4 months was considered a delay in removal. All patients were followed up for 3 months. Results: A total of 10 patients were included in the study. Encrustation, proximal migration, distal migration, knotting of the stent, and entanglement of the bilateral stents in the bladder were observed. These complications were managed by various endourological procedures such as ureteroscopy, percutaneous nephroscopic, and cystoscopic removal. During follow-up, all patients were symptom-free. Conclusion: Prolonged indwelling stents can cause various complications. Endourological procedures are an essential armamentarium for a pediatric surgeon to manage these complications. Proper patient counseling regarding indwelling stents and maintaining stent registry and sending automatic messages and e-mails to patients may prevent these complications.

Awareness of Medical Research among the Resident Doctors in a Tertiary Care Hospital in India.

Aim: The aim of this study was to study the awareness of medical research (MR) among resident doctors in a tertiary care hospital. Materials and Methods: This is a descriptive and cross-sectional study conducted for 30 days among the residents of paraclinical, surgical, and nonsurgical specialties, based on a customized self-prepared questionnaire. Convenience sampling was done. Undergraduates, interns, and faculty members were excluded from the study. Scoring was given from 1 to 10 based on their responses to the ten knowledge-based questions in the questionnaire. Data regarding the publication of research articles if any, obstacles in conducting research, and suggestions to improve the research awareness were recorded. Descriptive analysis of the data was done. Based on the scoring, they were divided into three groups: below average if the score is <5, average if the score is 5-7, and above average if the score is 8-10. Results: A total of 364 resident doctors were included in the study. They were divided into three groups which include paraclinical (n = 56, 15%), surgical (n = 132, 36%), and nonsurgical branches (n = 176, 48%). Scores for the three levels, i.e., below average, average, and above average were 0, 39% (n = 140), and 61% (n = 224), respectively. Forty-eight percent of participants had a publication. Obstacles for conducting the research included lack of time (55%), lack of interest (29%), lack of guidance (35%), and lack of material and teaching (45%). The majority (n = 300, 82%) suggested that conducting more interactive sessions or teaching programs may help in improving the awareness on research. Conclusions: Most of the resident doctors had a fair knowledge of MR but its application into practice was limited. Including research as a part of the medical curriculum, conducting educational programs or conferences oriented on research may improve the awareness about research.

Delayed presentation of anorectal malformations in a tertiary care hospital in India.

AIM: To study delayed presentation of ARMs, management and its effect on surgical and functional complications. METHODS: It is a retrospective study from March 2015 to March 2020. All the patients satisfying the criteria of delayed ARMs, i.e., presenting 7 days after birth were included. Information regarding type of ARM, mode of presentation, time of presentation, associated anomalies, management strategy, postoperative complications and functional outcome was noted. Minimum follow-up period was 6 months. RESULTS: Out of 102 patients with ARM, 44 patients presented late. Among the 44 patients, 9 were males and 35 were females. Associated comorbidities observed are low birth weight (n = 9) and preterm (n = 13). Associated anomalies observed were cardiac (n = 18), renal (n = 8), other gastrointestinal (n = 5) and skeletal (n = 1). (1) Male: rectourethral fistula-2 (staged repair), anal stenosis-3 (anoplasty) and anocutaneous fistula-4 (anoplasty). (2) Female: vestibular fistula: 15 (6 primary definitive surgery + 9 staged repair), ectopic anus: 3 (staged repair), anal stenosis: 2 (anoplasty), urogenital sinus: 4 (staged repair), H-type ARM: 8 (staged repair) and persistent cloaca: 3 (staged repair). Primary repair was done in 15 patients (34%), and staged repair was done in 29 patients (65.9%). Anoplasty was done in 9 patients, ASARP (modified tsuchida's procedure) in 8 patients and PSARP in 27 patients. Postoperative complications observed were constipation (n = 21, 47.7%), fecal incontinence (n = 12, 27.27%) with perianal excoriation in 2 patients, anal stenosis (n = 3, 6.8%) and rectal mucosal prolapse (n = 2, 4.5%) CONCLUSION: Delayed presentation of ARMs is not uncommon and is more common in females. Management is almost similar to those who present early. Those who present with chronic constipation and megarectum require staged repair. Complications were more frequent with delayed presentation. Hence, every newborn should have careful examination of perineum and screened for ARM to avoid possible morbidity and mortality.

Comparison of Dartos flap and spongioplasty in Snodgrass urethroplasty in distal penile hypospadias.

Background: Hypospadias surgery has been continuously evolving, although there is no single technique which can be said to be perfect and suitable for all types of hypospadias. Tubularized incised plate (TIP) urethroplasty (Snodgrass procedure) is presently the most common surgical procedure performed for distal penile hypospadias (DPH). The aim of this study was to compare the outcome of TIP urethroplasty using Dartos flap (DF) and spongioplasty as second layer in DPH. Methods: A total of 30 patients of DPH were repaired using TIP urethroplasty with DF or spongioplasty as second layer from January 2017 to June 2018. Out of 30 patients, TIP with DF was done in 15 patients (group A) and TIP with spongioplasty was done in the remaining 15 patients (group B). Preoperative mean age and weight were comparable in both groups. Postoperative complications, namely, postoperative edema, residual chordee, urethrocutaneous fistula (UCF), meatal stenosis and final cosmesis, were recorded. Results: In both groups, complications included postoperative edema (Gp A-1Gp B-1), residual chordee (Gp A-1, Gp B-1), UCF (Gp A-3, Gp B-4), meatal stenosis (Gp A-1, Gp B-5) and poor cosmesis (Gp A-3, Gp B-4). Wound infection was managed with appropriate antibiotics, and meatal stenosis responded to calibration in five patients.Although it seems that DF has a better outcome clinically, the difference between the two techniques was statistically not significant. Conclusion: DF as an additional cover to TIP is associated with an acceptable complication and has good cosmesis compared with spongioplasty; however, the difference is not statistically significant.

Pediatric Thoracoabdominal Trauma: Experience from a Tertiary Care Center.

AIM: The aim of this study is to assess the pattern and mode of thoracoabdominal trauma and anatomical organ involvement, type of management employed, and overall outcomes in the pediatric population. MATERIALS AND METHODS: A retrospective study conducted at a tertiary hospital over a period of 38 months with a total of 198 pediatric patients <12 years of age with a history of abdominal and chest trauma between July 2014 and September 2017 were reviewed. Case files of all pediatric patients were evaluated. Information regarding age, sex, mechanism of injury, site of injury, mode of injury, nature of the injury, definitive treatment required, whether conservative or surgical and outcome of patients was evaluated. site of injury, mode of injury, nature of the injury, definitive treatment required, whether conservative or surgical and outcome of patients was evaluated. RESULTS: A total of 198 patients of thoracoabdominal trauma patients were studied. The majority of pediatric thoracoabdominal trauma cases were observed in males (n = 128, 64.64%) and females comprise only 35.35% (n = 70). Fall was the most common mode of trauma (58.08%) followed by road traffic accidents (30.30%), thermal injuries (9.09%) assaults in order of decreasing trends. The abdomen was the most common anatomical site of the injury (45.95%) followed by combined thoracoabdominal trauma (32.32%) followed by thoracic trauma (21.71%). Among the thoracic trauma, the most common comprised the lung contusions (37.20%) followed by the lung laceration comprising (25.58%) and rib fractures comprised only 20.93%. Among the abdominal trauma, the most common organ of injury was the liver (36.26%) followed by splenic trauma in 19.78% of patients. Approximately, 85% of patients were managed conservatively, and only 15% required major surgical intervention in the form of laparotomy and repair of bowel perforation, thoracotomy and ligation of bleeding intercostal vessels, partial and total splenectomy, repair of the liver laceration, and nephrectomy for the patient of Grade 5 renal injury with expanding retroperitoneal hematoma. Three patients died, one of which was Grade 5 renal injury with expanding retroperitoneal hematoma, two others were cases of combined thoracoabdominal trauma with massive hemothorax and both liver and splenic injury. CONCLUSION: The study defines the pattern of thoracoabdominal trauma, mode of trauma, and the prevalence of different organs involved in both the chest and abdominal cavity. We concluded that main indications for performing an operative intervention included severe hemodynamic instability, pneumoperitoneum, massive pneumohemothorax with significant shift and definitive confirmation of oral contrast leak on computed tomography films. A detailed trauma registry in our set up seems important for managing pediatric thoracoabdominal trauma.

Epidemiology of Pediatric Trauma and its Pattern in Urban India: A Tertiary Care Hospital-Based Experience.

AIM: To assess the epidemiology, pattern, and outcome of trauma in pediatric population. MATERIALS AND METHODS: A total of 1148 pediatric patients below 15 years of age presenting in the emergency department of our hospital were studied over a period of 3 years. The patients were categorized into four age groups of <1 year, 1-5 years, 6-10 years, and 11-15 years. The data were compared regarding mode of trauma, type of injury, place of injury among different age groups and both sexes. RESULTS: The majority of the pediatric trauma cases were seen in males 69.86%, (n = 802) and females comprised only 30.13% (n = 346). Road traffic accident (RTA) was the most common mode of trauma in male children, i.e. 59.47% (n = 477) followed by fall injuries, i.e. 29.42% (n = 236). In females, fall was the most common mode of trauma, i.e. 52.31% (n = 181) followed by RTA (36.70%, n = 127). Fall injuries occurred mostly at homes. Among RTA, hit by vehicle on road while playing was most common followed by passenger accidents on two wheelers, followed by hit by vehicle while walking to school. Among fall, fall while playing at home was the most common. Out of total 1148 patients, 304 (26.48%) comprised the polytrauma cases (involvement of more than two organ systems), followed by abdominal/pelvic trauma (20.99%, n = 241), followed by head/face trauma (19.86%, n = 228). Out of total 1148 patients admitted over a period of 36 months, 64 died (5.57%). 75 (6.5%) patients had some kind of residual deformity or disability. CONCLUSION: The high incidence of pediatric trauma on roads and falls indicate the need for more supervision during playing and identification of specific risk factors for these injuries in our setting. This study shows that these epidemiological parameters could be a useful tool to identify burden and research priorities for specific type of injuries. A comprehensive trauma registry in our set up seems to be important for formulating policies to reduce pediatric trauma burden.

Omphalocele major with absent lower limb.

A newborn delivered by Caesarian section presented with an absent anterior abdominal wall and visible bowel loops and liver. The defect was covered by a thin membrane. The patient had associated absent left lower limb and right foot fusion defect. The patient was haemodynamically stable; general condition was average. No genito-urinary abnormality was detected. The anal opening was present normally, and the patient passed meconium immediately after birth. A diagnosis of omphalocele major with amelia was made. The patient was initially managed by topical application of povidone-iodine for eschar formation and epithelisation of the sac. The patient was discharged after 1 week with advice for regular follow-up.

Infantile hypertrophic pyloric stenosis in twins.

Infantile hypertrophic pyloric stenosis (IHPS) is a common surgical cause of vomiting, which requires surgery in infant. There is the complete or partial obstruction of pylorus due to hypertrophy of circular muscle of the pylorus leading gastric outlet obstruction. The occurrence of IHPS in dizygotic twins is rarer and the theory of genetic origin alone does not explain it. Recent literature points to the association of bottle feeding in singletons to be a major aetiological factor for this condition. Here, we present a rare case of dizygotic twins who were bottle-fed and were affected with IHPS. We review the literature and focus on the question of whether this condition in twins supports a genetic or environmental origin of IHPS.

Intraoral teratoma in a newborn presenting as severe respiratory distress.

A new born female presented to us immediately after birth with mass protruding from the mouth, with severe respiratory distress and was immediately intubated. Antenatal ultrasonography did not reveal any abnormality. On examination, a non-pulsatile, multilobulated, 4 cm×5 cm sized mass of variable consistency was seen originating from the palate with no other associated congenital anomaly. CT showed a large heterogeneous mass arising from the hard palate with few hyperdense calcific areas with no intracranial extension. Mass was excised completely. Histopathological examination showed features of mature teratoma.

A rare case of isolated complete diphallia and review of the literature.

A 3-year-old boy presented with complaints of abnormal genitalia. On examination, there was penile duplication with two completely separate phalluses, unequal in size, one with hypospadias and the other with meatus at the tip of the glans. Voiding cystourethrography revealed a normal sized single bladder but two urethras with no associated vesicoureteral reflux.