Reverse Gastric Tube Esophagoplasty with and without Lower Esophageal Stump Wrap - Comparison of Outcome.

Aim and Objectives: The aim of the study is to compare the outcome in children born with long-gap esophageal atresia following reverse gastric tube esophagoplasty (RGTE) with or without the lower esophageal stump as a "fundoplication" wrap. Materials and Methods: All children who underwent RGTE between 2008 and 2018 were retrospectively analyzed. Patients in whom the lower esophagus (LE) had been excised as is done routinely in RGTE (Group 1) were compared with those where the LE was wrapped partially or completely around the intraabdominal neo-esophagus (Group 2). Both vagal nerves were preserved to the extent possible. Complications and final outcome, including weight and height centiles were assessed. Follow-up upper gastrointestinal contrast study and reflux scans were studied. Results: Nineteen patients (mean age: 15.78 ± 5.02 months [range 10-30 months] at RGTE) were studied; nine in Group 1 and ten in Group 2. Both groups had similar early postoperative complications as well as the requirement of dilatation for anastomotic stricture. Dysphagia for solids was noticed in two patients with complete lower esophageal wrap (n = 4), one requiring removal. More patients in Group 2 had absent reflux (n = 7) compared to Group 1 (n = 3) (P = 0.118). At a mean follow-up period of 45.75 ± 18.77 months (14-84 months), Group 2 children reached better height and weight percentiles compared to Group 1. Conclusion: We have described a novel method of using the LE as a "fundoplication" wrap following RGTE. Vagi should be preserved. Those with complete esophageal wrap may develop dysphagia to solids and this is, therefore, not recommended. Lower esophageal wrap patients appeared to have a better outcome in terms of growth and less reflux.

Trends in Referral Pattern of Antenatally Diagnosed Surgical Abnormalities in a Tertiary Care Center in North India.

AIM: Pregnant women with antenatally diagnosed surgical abnormalities of the fetus are often referred for pediatric surgical consultation for likely outcome and prognosis. In this study, we analyzed the gestational age at referral to see the benefits of the same in decision-making and also looked for any change in trends of referral pattern over a period with the increasing availability of ultrasonography (USG). MATERIALS AND METHODS: Records of pregnant women referred for antenatal counselling over an eight year period were analyzed. This was an observational study conducted in the Pediatric surgery outpatient department of a tertiary care centre from 2008-2015. All pregnant women referred for antenatal counseling were included, with the diagnosis of fetal abnormalities being based on USG. Abnormalities were classified by system involved. Comparison of data before and after the year 2012 was done to look for change in trends. Patients with poor prognostic outcome were further analyzed. RESULTS: A total of 1211 women were analyzed, with 490 (40.7%) presenting between 2008 and 2011 and 719 (59.3%) between 2012 and 2015. Overall, in those with likely poor prognostic outcome (n = 482), 189 (39.2%) patients presented at <20 weeks gestation, 106 (22%) between 21 and 24 weeks gestation, and 187 (38.8%) after 24 weeks of gestation. Genitourinary abnormalities (n = 220; 46%) accounted for the most common poor prognostic outcome group in all gestational ages. CONCLUSION: Nearly two-thirds (61%) of the patients with poor outcome were referred after 20 weeks of gestation, i.e., beyond the permissible time for termination. Fetal sonography expertise between 16 and 20 weeks should be improved as a priority by the government in peripheral centers.

Scrotal Migration of Tubing: An Unusual Complication after Ventriculo-peritoneal Shunt.

Scrotal migration of peritoneal end of ventriculo-peritoneal (VP) shunt into the patent processus vaginalis (PPV) is a rare complication. Its exact incidence is not mentioned in the literature till date. This may be because of the rarity of this complication, and also because all previous articles related to the complication were case reports. We, in our series, had an incidence of 0.9%. This prospective study has been conducted on 437 patients in the age group of 1 month-3 years who underwent VP shunt for hydrocephalus over a period of 5 years from 2007 to 2011. The incidence of a hernia manifesting after shunt insertion has been reported to be around 16.8%. The average age of patients at the time of insertion of the shunt was 27.25 months (3-48 months). All our patients presented with swollen right sided scrotum after an average of 4 months (3-5 months) after shunt insertion. Shunt migration was more common on the right which is consistent with the incidence of hernias in children. The proper management of such cases includes repositioning of the catheter with the proper closure of the PPV. Usually, shunt revision is not required. We discuss the etiology, treatment and preventive measures of this rare entity.

Giant Duplication Cyst Presenting as a Discharging Umbilicus.

Alimentary tract duplication cysts are rare congenital anomalies, most commonly located in the ileum, but may present anywhere from mouth to anus.Clinically, they may be asymptomatic, incidentally diagnosed or may present with obstruction, volvulus, intussusception or gastrointestinal bleed. Here we report a case of a one year old male child presenting in gasping state and shock. Despite the initial strong suspicion of Meckel's diverticulum and tubercular abdomen, the final diagnosis remained elusive till exploratory laparotomy was performed which revealed a duplication cyst of ileum with perforation into the umbilicus. Duplication cyst should always be kept as a differential diagnosis so that early intervention can help in better management.

Pediatric Rhabdomyosarcoma in India: A Single-center Experience.

OBJECTIVE: Analyze the profile and outcome of children with rhabdomyosarcoma from a pediatric-oncology unit. DESIGN: Retrospective analysis of case records over 23 years (1990-2012). SETTING: Government-run, tertiary-care, university hospital in Northern India. PARTICIPANTS: 159 children (<12-years) with a diagnosis of rhabdomyosarcoma were enrolled. The median age was 4 years; 13% were infants. MAIN OUTCOME MEASURE: Five-year event free survival. RESULTS: The median symptom interval was 2-months. Head and neck region was the most frequent site (44%), followed by tumors in the extremity (15.7%). The majority (67%) of the tumors were located at 'unfavorable' sites; 68% were >5 cm in size. The most frequent (58%) pathological subtype was embryonal. Treatment was based on the 'Intergroup Rhabdomyosarcoma Study (IRS) Group' risk-stratification. 33% were 'low-risk' children, 11% were 'high-risk'. Treatment-refusal (18%) and abandonment (33%) were major impediments. The median ± SE five-year event free survival of those taking treatment was 43.6 ± 6%. CONCLUSION: Large sized tumors, tumors at unfavorable locations, and treatment refusal/abandonment contributed to inferior outcome in children with rhabdomyosarcoma.

Solitary Peutz-Jeghers Polyp of Jejunum: A Rare Cause of Childhood Intussusception.

An extremely rare case of solitary jejunal Peutz-Jeghers polyp causing intussusception in an 8-year-old boy is reported. The polyp was excised by laparoscopic-assisted surgery. This appears to be only the fourth and the youngest patient with such a polyp reported in the indexed English language literature.

Kawasaki Disease Presenting as Acute Intestinal Obstruction.

Kawasaki disease (KD) is an acute febrile illness of childhood associated with vasculitis of medium-sized arteries especially the coronary arteries. Typical clinical features involving the skin, mucous surfaces, etc., occur sequentially over a few days. We report a rare presentation of KD as a surgical abdomen in a 2-year-old boy. Awareness of this presentation is important as it can otherwise lead to a delay in starting potentially life-saving intervention like intravenous immunoglobulins for cardiac complications kept cryptic by the manifest acute abdomen.

Childhood parathyroid adenoma: a rare but important cause of nephrolithiasis.

Primary hyperparathyroidism is very rare in children and adolescents. The management of a 12-year-old boy with renal calculi due to parathyroid adenoma is discussed. The single tumor after localization with sestamibi scintigraphy and SPECT-CT scan was excised with amelioration of symptoms. The case is reported due to the rarity of the disease and successful unilateral exploration. The association with hypopigmented areas of skin has also not been previously reported in literature.

Pyeloplasty for hydronephrosis: Issues of double J stent versus nephrostomy tube as drainage technique.

AIMS: To compare the efficacy, complications, cost analysis and hospital stay between two methods of drainage of the kidney: double J (DJ) stent versus nephrostomy tube following open pyeloplasty for ureteropelvic junction obstruction hydronephrosis. PATIENTS AND METHODS: This was a prospective randomized study of 20 patients in each group over 14 months. Pre and post-operative (3 months) function and drainage were assessed by ethylenedicysteine scan and intravenous urogram. RESULTS: Both groups showed similar good improvement in function and drainage. Nephrostomy group had significantly longer hospital stay (P < 0.001) but incurred less cost. Complications with nephrostomy included tube breakage (n = 1) and urine leak after tube removal (n = 2). DJ stents were associated with stent migration (n = 4), increased frequency of micturition (n = 9), dysuria (n = 4) and urinary tract infection (n = 1). CONCLUSION: Both methods of drainage did not interfere with improvement after pyeloplasty. Minor complications were more with DJ stent (P = 0.0003). Although overall cost of treatment was more with stents, they reduced length of hospital stay. Optimal length of stent is essential to reduce complications secondary to migration and bladder irritation.

Risk of surgical site infection in paediatric herniotomies without any prophylactic antibiotics: A preliminary experience.

BACKGROUND: Different studies underline the use of pre-operative antibiotic prophylaxis in clean surgeries like herniotomy and inguinal orchiopexy. But, the meta-analyses do not recommend nor discard the use of prophylactic pre-operative antibiotics. The scarcity of controlled clinical trials in paediatric population further vitiates the matter. This study assessed the difference in the rate of early post-operative wound infection cases in children who received single dose of pre-operative antibiotics and children who did not receive antibiotics after inguinal herniotomy and orchiopexy. MATERIALS AND METHODS: This randomised prospective study was conducted in Paediatric Surgery department of PGIMER Chandigarh. Out of 251 patients, 112 patients were randomised to the case group and 139 were ascribed to the control group. The patients in control group were given a standard regimen of single dose of intravenous antibiotic at the time of induction followed by 3-4 days of oral antibiotic. Case group patients underwent the surgical procedure in similar manner with no antibiotic either at the time of induction or post-operatively. RESULTS: The incidence of surgical site infection in case group was 3.73 % and that in control group was 2.22%. The observed difference in the incidence of surgical site infection was statistically insignificant (P value = 0.7027). The overall infection rate in case and control group was 2.89%. CONCLUSIONS: Our preliminary experience suggests that there is no statistically significant difference in the proportion of early post-operative wound infection between the patients who received single dose of pre-operative antibiotics and the patients who received no antibiotics after inguinal herniotomy and orchiopexy. The risk of surgical site infection in paediatric heriotomies does not increase even if the child's weight is less than his/her expected weight for age.

Vesicoureteral reflux: Endoscopic therapy and impact on health related quality of life.

AIM: To evaluate the health related quality of life (HRQOL) after endoscopic injection treatment for vesico ureteral reflux (VUR) in children. MATERIALS AND METHODS: Fifty four children received treatment and were prospectively evaluated for their quality of life scores, according to resolution of reflux on cystograms and status of renal scars. RESULTS: Of the 81 refluxing units, 72 (89%) had resolution of reflux whereas 9 (11%) did not resolve. The total average QOL was higher for the patients in the resolved group as compared to the non resolved group. Comparison of pre and post procedure renal DMSA scans in 44 patients showed status quo in 26, regression of scars in six, progression in two and formation of new scars in 6. The total increase in HRQOL was highest in regression group (67.91), and lowest in progression group (36.45). CONCLUSIONS: Successful endoscopic treatment of VUR is associated with improved quality of life, as indicated by higher HRQOL scores in the resolved group.

Isolated cystic cervical oesophageal duplication: a rare congenital anomaly.

Oesophageal duplication is a rare congenital anomaly. The cystic form is the usual presentation of the duplication, found predominantly in the lower third. Less than 20 cases of isolated cystic oesophageal duplication in the cervical region have been reported till date in the English literature. We are reporting this case because of its rarity.

Position of a sigmoid colon in right iliac fossa in children: A retrospective study.

AIM: The aim was to identify the position of sigmoid colon in children and discuss its clinical significance. MATERIALS AND METHODS: Ninety-one contrast enema studies were retrospectively evaluated and the position of sigmoid colon categorized as below: Left lower quadrant, right lower quadrant, midline, and indeterminate. RESULTS: The position of sigmoid colon in the right lower quadrant, left lower quadrant, midline, and indeterminate was 32 (35.16%), 33 (36.26%), 12 (13.19%), and 14 (15.38%), respectively. There was no statistically significant difference in mean age (P = 0.87) or gender prevalence (P = 0.49) for different positions of the sigmoid colon. CONCLUSION: The sigmoid colon occupies the right lower quadrant in a large number of children. Awareness of this finding is of crucial importance in correct interpretation of abdominal radiographs in the emergency room.

Meckel's diverticulum in infants and children; technetium-99m pertechnetate scintigraphy and clinical findings.

Meckel's diverticulum (MD) is the most common congenital gastrointestinal anomaly. About 50% of diverticulae contain ectopic gastric mucosa. Gastric mucosal secretions can cause peptic ulceration resulting in pain, bleeding and perforation. Technetium-99m ((99m)Tc) pertechnetate scintigraphy is helpful in diagnosing ectopic gastric mucosa. We have conducted a retrospective analysis of scintigraphic data of 107 pediatric patients, 28 females and 79 males, their age ranging from 5 days to 11 years who referred to us for a query diagnosis of MD. Our results have shown that the most frequent presenting symptom was bleeding per rectum. Twenty-one cases of the 107 were positive for functioning gastric tissue indicating MD (19.62%). Maximum clustering of positive cases was at the age group of 1-2 years (11 cases i.e. 52.38%). The site of the ectopic activity was mainly at the umbilical quatrum in 11 cases (52.4%). Two patients were lost to follow-up and hence surgery could not be performed. The remaining 19 cases were subjected to surgical intervention and 16 were found to be positive for MD. The scintiscan was true positive in 84.2%. Our findings were in agreement with those of other authors. In conclusion, in pediatric patients (99m)Tc-pertechnetate scintigraphy is by 84.2% true positive for gastric mucosa, indicating MD.