Bilateral high loop ureterostomy in the primary management of posterior urethral valves in a developing country.

Of 200 consecutive cases of posterior urethral valves (PUV) managed in a single institution, 26 underwent bilateral high loop ureterostomy (BU) as their first operative intervention. Indications for BU were persistently raised serum creatinine levels after bladder drainage, severe urosepsis, and urinary ascites, especially in a neonate or infant. After a median period of 1 year of diversion, the serum creatinine fell from a median value of 2.5 to 0.6 mg%. Twelve cases have been fully undiverted without deleterious effects (median serum creatinine level 0.5 mg%). Three patients died. Of the 14 renal units with documented persistent vesicoureteric reflux at the time of undiversion, only 1 has been reimplanted. One child has undergone bladder augmentation.

Pneumonostomy in the surgical management of bilateral hydatid cysts of the lung.

During the period 1994-1998, three patients with bilateral hydatid cysts of the lung (HCL) underwent operative removal of the cysts. In three of the six lungs operated upon the conventional technique was used: after removal of the cyst and suture closure of bronchial leaks, the chest was closed with an intercostal drainage tube. Two of these patients developed bronchopleural fistulae requiring rethoracotomy and prolonged hospital stays. The other three lungs were operated upon using the pneumonostomy technique: after excision of the cyst a separate catheter is fixed within the residual lung cavity and brought out through the adjacent chest wall, effectively marsupialising the residual cavity to the atmosphere. All these patients had an uneventful postoperative recovery. We conclude that the pneumonostomy technique is a very useful method of treating HCL surgically, especially when the cysts are bilateral and complicated.

Wilms' tumor presenting as Cushing's syndrome.

We report a 2-year-old boy presenting with Cushing's syndrome caused by a Wilms' tumor. This is the fifth such case reported in the English literature.

Achalasia cardia in infancy and childhood: an Indian experience.

Seven children with achalasia cardia, six of them infants, were seen over a 10-year period. In infantile achalasia, respiratory symptoms predominate and vomiting may easily be mistaken for gastroesophageal reflux (GER). Vomiting of uncurdled milk is characteristic of achalasia. Six children underwent esophagocardiomyotomy with good results in five. The procedure was transthoracic in two and transabdominal combined with an anterior fundoplication in the others. There was one post-operative death. Achalasia and alacrima were associated in two infants. One baby with this association also had a neurogenic bladder.

Recurrent parotid abscess formation 8 years after an episode of cancrum oris.

Recurrent parotid abscess formation as a consequence of isolated right parotid duct osteal stenosis was a very unusual sequela of successfully treated early cancrum oris. Interestingly, it manifested after an uneventful interval of 8 years and required a near-total conservative parotidectomy for cure.

Results of Wilms' tumour management in two tertiary-care hospitals in Asia.

In the period 1985-1995, 87 children underwent surgery for Wilms' tumour; 16 were lost to follow-up. Of the remaining children, 27 presented with stage I disease, 11 with stage II, 12 with stage III, 14 with stage IV, and 6 with stage V. One child was not staged. The histology was favourable Wilms' tumour in 44, anaplastic in 12, unclassified in 8, clear-cell sarcoma in 4, and rhabdoid tumour in 3. Although a total nephrectomy was generally performed, partial renal surgery was performed for 6 bilateral and 4 unilateral tumours, the latter including 2 fused kidneys. Preoperative chemotherapy was employed with benefit in massive tumours, tumour in fused kidneys, bilateral tumours, and preoperatively diagnosed inferior vena caval tumour thrombi. Postoperative chemotherapy, employed in all cases, consisted of actinomycin D and vincristine with the addition of adriamycin in anaplastic and advanced-stage tumours. Ten children underwent second-line chemotherapy for disease unresponsive to the above management, but only 1 of these is currently free of disease. Postoperative tumour-bed radiotherapy, used in selected cases, prevented local recurrence in stage I and II disease. However, 20% of stage I and II patients not receiving radiotherapy developed tumour-bed recurrence. Twenty-three children have died and 5 with advanced disease and incomplete follow-up are presumed to be dead. Nine children are currently on treatment; 34 have successfully completed treatment, the disease-free survival in stages I-V being 81%, 75%, 42%, 14%, and 50%, respectively. Overall disease-free survival was 69% for Wilms' tumour of favourable histology and 50% for anaplastic tumours. The 3 patients with rhabdoid tumours and 3 of 4 with clear-cell sarcomas have died. Wilms' tumour management in the developing world is compromised by cases lost to follow-up and late presentation with massive tumours and advanced stage. Preoperative chemotherapy is advantageous in a number of cases, and postoperative radiotherapy should be deployed more frequently.

Allopurinol reduces the severity of peritoneal adhesions in mice.

A study was designed to investigate the possibility of reducing peritoneal adhesion formation in mice by pretreatment with allopurinol. Allopurinol, at a dose of 35 mg/kg of body weight/d significantly reduced the severity of peritoneal adhesions (P < .001), and also the neutrophil response to ischemia (P < .05). Tissue myeloperoxidase activity at the site of ischemic injury was significantly lower in the allopurinol-treated mice at the end of 2 weeks (P < .001). However, xanthine oxidase was undetectable in both control and allopurinol-treated mice. These observations suggest that allopurinol reduces the severity of peritoneal adhesion formation in mice, possibly by reducing the neutrophil response to ischemia.

Primary peritonitis in children.

Thirty-one children with primary peritonitis were studied. Most of them had been healthy prior to the onset of peritonitis and only one had nephrotic syndrome. There were 27 girls and four boys. The predominant organism in girls was pneumococcus, and in boys staphylococcus. The causative organisms, identified in 27 children, were all Gram positive. Most of the children were between four and 10 years of age. The onset of their illness was sudden with fever, vomiting and abdominal pain. Since in recent years, primary pneumococcal peritonitis has been the commonest type of peritonitis in young girls, our earlier policy of routine laparotomy for peritonitis was given up and in girls aged between four and ten, an attempt at initial pre-operative diagnosis was made by Gram's staining of peritoneal aspirate or vaginal swab. If Gram positive peritonitis was diagnosed, early cases were treated with antibiotics alone and late cases with antibiotics and minilaparotomy for drainage of pus. There was one death. Morbidity and mortality were higher when the period without treatment exceeded one week. The contribution of pre-operative diagnosis by Gram's staining to the provision of optimum treatment is emphasized.

Duodenal ulcer in South Indian children.

Twenty-nine children with duodenal ulcer received treatment during an 18 year period. Twenty-five were followed over a period that ranged from 3 to 18 years; 53.8 percent of the patients who received medical treatment either had recurrence or persistence of ulcer symptoms during adolescence or adulthood. Two patients with acute bleeding ulcers have remained well after vagotomy and drainage procedures. Pyloric stenosis was the most common indication for surgical intervention and in all such cases the patients underwent truncal vagotomy and drainage procedures and continue to live without any symptoms, except one in whom anastomotic ulcer due to incomplete vagotomy has developed.

Results of Surgical Treatment of Carcinoma of the Penis.

A five-year follow-up of 133 patients treated surgically for carcinoma of the penis shows a 69% survival if the lymph nodes are not involved, and 33% survival if the lymph nodes arc involved. Clinically, in patients with operable disease, it is not possible to determine with accuracy whether the lymph nodes are invaded by tumour. The prognosis is not affected significantly by anaplasia of the growth, but is related to clinico-pathological spread. Local complications are recurrence, urethral stenosis, delayed wound healing of the groin dissection and lymphœdema.