Endovascular Popliteal Artery Aneurysm Repair Using an "Off-Label" Abdominal Endograft Limb-Module with Nitinol-Ring Structure: A Single Centre Experience.

PURPOSE: To evaluate endovascular popliteal artery aneurysm repair using a an "off-label" abdominal endograft limb-module with nitinol-ring structure. MATERIALS AND METHODS: Retrospective observational study of 14 popliteal artery aneurysms in 12 male patients (mean age 76 years and median ASA grade 3) treated electively using the Anaconda™ endograft limb (Terumo Aortic) at a single teaching hospital. Eight limbs were treated percutaneously and 6 limbs required surgical arterial exposure. The mean popliteal artery aneurysm diameter treated was 3.6 cm (range 2.1-5.3 cm). Stent-graft diameters and lengths used were 10-15 and 60-140 mm, respectively. The median covered stented length was 218 mm (range 160-270 mm) and median duration of follow-up was 3.7 years. Outcomes assessed included technically successful aneurysm exclusion, primary patency, re-intervention and survival. RESULTS: All patients had successful stent-graft deployment and aneurysm exclusion, with no early complications or mortality at 30 days. Primary stent-graft patency at 1, 3 and 4 years was 93%, 75%, and 64%. By 8 years, patency had declined with 29% (2/14) stent-grafts patent. 7/14 limbs occluded; 3 underwent re-intervention (2 surgical, 1 endovascular). There were no deaths related to the procedure. Freedom from re-intervention and survival at 1/5 years was 93%/84% and 93%/67%, respectively. CONCLUSION: The Anaconda™ endograft limb for endovascular popliteal artery aneurysm repair offers good mid-term patency and acceptable long-term patency up to 4 years when compared with other grafts and open surgery. It may be considered in older comorbid patients unfit for surgery and can be performed percutaneously under local anaesthesia when anatomically feasible.

Prenatal diagnosis of biliary atresia: A case series.

BACKGROUND: Biliary atresia is a progressive disease presenting with jaundice, and is the most common indication for liver transplantation in the pediatric population. Prenatal series have yielded conflicting results concerning a possible association between BA and prenatal nonvisualization of the gallbladder. AIMS: This retrospective case series was performed to assess the association between biliary atresia, prenatal nonvisualization of the gallbladder and other sonographic signs. STUDY DESIGN/SUBJECTS: We identified biliary atresia patients who underwent a Kasai procedure by a single pediatric surgeon and/or follow up by a single pediatric gastroenterologist. Axial plane images and/or video recordings were scrutinized for sonographic signs of biliary atresia on the second trimester anomaly scan. OUTCOME MEASURES: Proportion of biliary atresia cases with prenatal sonographic signs. RESULTS: Twenty five charts of children with biliary and high quality prenatal images were retrieved. 6/25 (24%) of cases analyzed had prenatal nonvisualization of the gallbladder or a small gallbladder on the prenatal scan. Two cases had biliary atresia splenic malformation syndrome. None of the cases had additional sonographic markers of biliary atresia. CONCLUSIONS: Our study suggests that in addition to the well-established embryonic and cystic forms, an additional type can be suspected prenatally, which is characterized by prenatal nonvisualization of the gallbladder in the second trimester. This provides additional evidence that some cases of BA are of fetal rather than perinatal onset and may have important implications for prenatal diagnosis, for counseling and for research of the disease's etiology and pathophysiology.

The large loop excision of the transformation zone cut or blend thermal artefact study: a randomized controlled trial.

The objective of this randomized controlled trial was to determine whether the pure cut setting results in less thermal artefact than the traditional blend setting when performing a large loop excision of the transformation zone (LLETZ). Forty-nine consenting women were randomized to undergo an LLETZ procedure using either the pure cut or the blend setting. Two histopathologists, who were blind to the randomization, examined the specimens and then graded and measured the degree of thermal artefact. No significant difference was noted at the epithelial margin. At the deep stromal margins, in the blend group, the mean thickness of thermal artefact was 0.382 mm (95% CI, 0.350-0.414) and in the cut group 0.325 mm (95% CI, 0.297-0.353). This was statistically significant. No significant difference was detected in terms of grading of thermal artefact, the presence of dysplasia at the specimen margins, or in positive follow-up smears. Although there was less thermal artefact at the deep stromal margin, cautery at this margin does not generally interfere with pathological assessment of the specimen and the pure cut setting does not produce a clinically significant decrease in the degree of thermal artefact.

Circumcision : A Time to Rethink.

BACKGROUND: Circumcision is one of the most routinely done surgery world over but has no scientific basis to enforce it on all patients. Of late, the operation has been criticized, non-operative methods have been tried and operations preserving the skin of prepuce have been recommended. The presence of physiological phimosis, which is self-correcting by the age of 15 years in children, needs to be differentiated from the pathological variety. METHOD: The child population reporting to Surgery OPD was taken as sectional representative of the Indian communities and socioeconomic strata. A simple protocol was adapted to differentiate true phimosis from the physiological one and data collected. An observational study was done and data collected for last six years. RESULT: 566 children were referred to the hospital and only 212 were subjected to circumcision. Of these, 169 were cases of true phimosis, 7 had paraphimosis and the rest included 9 ritual circumcisions. CONCLUSION: The incidence in this study is much less as compared to the series from the west. Though rare, this simple surgery is often fraught with complications. A refined approach has been planned for referring cases and selection for surgery thereby reducing unnecessary referrals and circumcisions.

Omental infarction: an unusual cause of acute abdomen in children.

Acute abdomen is caused by a wide variety of etiologies, many of which require surgical intervention. Two boys were hospitalized for acute abdominal pain and low-grade fever. Physical examination revealed epigastric and right upper abdominal fullness, and laboratory studies showed elevated erythrocyte sedimentation rates, with normal leukocyte counts and coagulation profiles. Abdominal ultrasound and computerized tomography revealed pseudotumor in both cases. Symptomatic treatment and cefazolin were administered, and pain and fever subsided after 6 to 10 days. Pseudotumor due to omental infarction can present as acute abdomen in children. A high index of suspicion and the use of both ultrasonography and computerized tomography will help avoid unnecessary surgical intervention in such cases.

Umbilical granuloma: a new approach to an old problem.

Umbilical granuloma (UG) is the most common umbilical abnormality in neonates, causing inflammation and drainage. Most fail to epithelialize and persist for more than 2 months. The common treatment is application of a 75% silver nitrate stick, usually repeated two to three times over a number of clinic visits. Burns have been reported following spillage onto the surrounding tissues. During a 10-year period, 302 neonates were treated for UG using excision and application of absorbable hemostatic materials. Healing was uneventful in all cases, and no complications have been encountered to date. This technique is simple, safe, and inexpensive, and obviates the need for repeated outpatient visits.

Ascites following ventriculoperitoneal shunting in children with chiasmatic-hypothalamic glioma.

OBJECT: Optic pathway gliomas in children can involve the optic nerve, chiasm, and hypothalamus. This uncommon, slowly growing tumor can cause hydrocephalus, which usually requires placement of a ventriculoperitoneal (VP) shunt. Symptomatic ascites may occasionally develop as a complication of the VP shunt procedure. The purpose of this study was to assess the risk factors associated with CSF ascites in children with optic pathway gliomas. METHODS: Twenty-two children (ages 4 months to 20 years) with chiasmatic-hypothalamic optic gliomas participated in this study. Four children were diagnosed with a chiasmatic glioma, 7 with a hypothalamic glioma, and 11 with a glioma involving both the optic chiasm and hypothalamus. Twelve children (55%) developed hydrocephalus and required VP shunt placement. Of the 12 shunted children, 4 (33%) developed CSF ascites. The incidence of ascites was not associated with infection, tumor metastasis, or multiple shunt revisions. There was no correlation with the size of the tumor. All 4 children with ascites had tumor involving the optic chiasm or optic nerve. None of the 5 children with pure hypothalamic glioma who underwent VP shunt placement have developed ascites. Among the 7 children suffering from chiasmatic or optic nerve gliomas who developed hydrocephalus, the risk of developing ascites as a complication of VP shunt placement was 57% (4/7). Ventriculoatrial (VA) shunt was the treatment of choice for children with VP shunt-induced ascites. After placement of a VA shunt the ascites subsided. The children did not develop further complications. CONCLUSION: We conclude that glioma involving the optic chiasm or nerve is associated with a high risk of developing ascites following VP shunt placement. VA shunt may be the treatment of choice for children with chiasmatic or optic nerve gliomas who require a CSF diversion procedure.

The importance of early surgery in children with ulcerative colitis.

BACKGROUND: Ulcerative colitis begins in early childhood in 4% of cases. Medical therapy is non-specific, and as many as 70% of children will ultimately require surgery. The dynamic growth, physical and psychological changes that characterize childhood are severely compromised by the complications of ulcerative colitis and its therapy. OBJECTIVE: To review the outcome of children undergoing early surgery for ulcerative colitis at a tertiary medical center in Israel. METHODS: A retrospective review was conducted of all children operated on following failure of medical therapy for ulcerative colitis during a 5 year period. RESULTS: Eleven children underwent a J-pouch procedure with ileo-anal anastomosis in one to three stages. Postoperative complications included recurrent pouchitis in 5 patients, intestinal obstruction in 3, fistula with incontinence in one, stricture in one, and wound infection in 4. Follow-up revealed that most of the patients have three to four soft bowel movements daily. All currently enjoy normal physical activities and a rich social life. CONCLUSIONS: The quality of life in children with ulcerative colitis was markedly improved following J-pouch surgery. This procedure was not associated with major complications. We recommend early surgery as an alternative to aggressive medical therapy in children with this disease.

Decision-making in pediatric varicocele surgery: use of color Doppler ultrasound.

Although varicoceles are common in adolescence, the indications for surgery as well as the procedure of choice are controversial. We have evaluated the use of color Doppler ultrasound (CDUS) as an objective tool in the assessment of such patients in a 5-year prospective study for determination of varicocele size, venous flow patterns, testicular volume, and resistance index. A high ligation was performed only when reverse blood flow was demonstrable in the varicocele during a Valsalva maneuver, and a low approach when this finding was absent. Twenty-six boys underwent low ligation and 53 high ligation based on the findings of CDUS. The incidence of recurrence (3.8%) was lower than that encountered by the same surgical team prior to introduction of CDUS (20.5%) (P = 0.004). These results are even more striking when contrasted with published recurrence rates of 12% to 15% (P = 0.015 to 0.003). Thus, CDUS proved to be a useful tool in selecting the proper surgical approach for varicocele in adolescence. The incidence of recurrence was significantly reduced following the introduction of this procedure.

The role of ultrasound in the diagnosis of stitch granulomas following paediatric herniotomy.

OBJECTIVE: To study the role of US in the diagnosis of stitch granulomas following paediatric herniotomy. MATERIALS AND METHODS: A retrospective 10-year study of herniotomies performed by a paediatric surgical service. RESULTS: Twenty children developed stitch granulomas following herniotomy. In all cases, silk sutures had been used in the repair. Masses appeared 1-10 years following surgery and were demonstrated by preoperative US in 17 patients, by CT alone in 1 patient and by both CT and US in 2 patients. CONCLUSIONS: US is an accurate and cost-effective method for evaluating stitch granulomas following herniotomy in children. The procedure is also valuable in marking the position of these foreign bodies prior to removal.

[Atypical infantile hypertrophic pyloric stenosis].

Infantile hypertrophic pyloric stenosis (IHPS) is the most common reason for nonbilious vomiting in infants. Its cause is unknown. Hypertrophy of pyloric muscle can progress after birth and reach complete gastric outlet obstruction. Usually symptoms start after the age of 3 weeks. In the past diagnosis was based on history of projectile, nonbilious vomiting and palpation of a pyloric mass. Greater awareness of IHPS and increased use of imaging modalities, mainly abdominal ultrasonography, have resulted in a change in the clinical condition at presentation. The length of illness before admission has decreased and weight loss, dehydration and metabolic abnormalities have become less common. We describe an atypical clinical manifestation of IHPS: bilious vomiting. This atypical presentation may be due to earlier diagnosis.

Duplications of the gastrointestinal tract.

BACKGROUND: Gastrointestinal duplications are rare, benign congenital lesions that may occur at any location along the alimentary tract and generally require surgical intervention. Presenting symptoms may be quite varied even among patients with the same anomaly. OBJECTIVE: To review the clinical presentation of gastrointestinal duplications and present our experience with such lesions over the past decade. METHODS: The records of all patients treated for gastrointestinal duplications at a tertiary hospital during 1987 through 1996 were collected, and relevant published literature reviewed. RESULTS: In the nine patients with gastrointestinal duplications, six were in the small bowel and one each in the cecum, colon and esophagus. Presenting clinical features were varied and often subtle. Perinatal ultrasonography, radioscintography and computerized tomography were useful in some cases, while in others the correct diagnosis was established only at surgery. CONCLUSIONS: Alimentary tract duplications are uncommon, and may present as solid or cystic tumors, intussusception, perforation or gastrointestinal bleeding. A high index of suspicion is required when dealing with such cases. Appropriate investigations, including imaging techniques, should be directed toward adequate and planned surgery.