Prevalence of Pancreato-Biliary Maljunction in Children with Choledochal Cyst - A Prospective Observational Study.

Background: Pancreatico-biliary maljunction (PBM) is often found to be associated with choledochal cysts (CCs). According to a European multicenter study, the prevalence of PBM in cases of CC is found to be 72.2%, however, there is no Indian study depicting the prevalence of PBM in Indian children with CCs, which is one of the main postulated factors in the etiopathogenesis of CC. In this study, we have attempted to observe prospectively the prevalence of PBM in children with CC and correlate this to its morphological and biochemical parameters. The association between the presence of PBM and histopathological findings such as epithelial changes of the mucosa of the CC, inflammation, metaplasia or dysplasia, and histopathology of the liver has also been evaluated. Materials and Methods: We carried out a single center, prospective observational study with a single arm study group. We prospectively selected all patients of CC admitted for surgery from November 2018 to October 2020. Data on biochemical, radiological, and histopathological parameters were collected and analyzed. Results: We included a total of 20 patients in our study. The mean age of the participants was 6.22 ± 4.32 years. Among them, 11 (55.0%) were male and 9 (45%) were female. Abdominal pain was the most common presenting complaint among our patients (75.0%) and had a significant association with the presence of a PBM (P = 0.001). In symptomatic children, the mean duration of symptoms was 4.50 ± 2.26 months for jaundice, 4.50 ± 1.98 months for abdominal distension, and 5.07 ± 2.02 months for abdominal pain. Among the 3 children with cholangitis, the mean number of episodes was 3.33 ± 2.08, with a median of four episodes. Fourteen (70.0%) of the children had type I a CC, 1 (5.0%) participant each for types I b, I c, II and IV a and 2 (10.0%) of them had type IV b cyst. The mean size of the cyst (cm) was 7.41 ± 3.03 with a median of 6.85 cm. Among the children, 9 (45%) showed the presence of PBM on magnetic resonance cholangiopancreatography (MRCP), with 7 (77.8%) showing Komi's C-P type and 2 (22.2%) showing Komi's PC type. The mean common channel length (mm) on MRCP was 8.11 ± 2.47 with a median length of 8.00 mm. The biochemical analysis of a bile fluid amylase and lipase is the functional indicator of the presence of a PBM. Histopathological examination showed the presence of ulceration in the walls of the CC in 10 (50.0%) of the specimens. There was a significant association of the presence of PBM and ulceration in the mucosa of the CC (P ≤ 0.001), with the median levels being the highest in the PBM present group. Conclusion: Abdominal pain is the most common complaint in a child with CC, and when present, it is significantly associated with the presence of a PBM. MRCP is the gold standard tool to detect CCs and find out the morphology of PBM. The prevalence of PBM in children with CC of 45% with a mean common channel length of 8.11 mm. The biochemical analysis of a bile amylase and lipase is the functional indicator of the presence of a PBM and there is a significant association of their higher levels and presence of PBM. The presence of chronic inflammation and microscopic ulcers is significant histologic parameters depicting the presence of a PBM.

Phimosis - Are we on right track?

Background: Phimosis, a common paediatric condition, is defined as the inability to retract the preputial skin behind the glans. Current practice shows there is some confusion among the paediatricians towards this common condition and in differentiating it from the more common physiological preputial adhesion; leading to frequent referrals to a paediatric surgeon or a general surgeon, which can be addressed by the parents and the child physicians themselves. Aim: To find out the awareness towards the management of phimosis among the paediatricians. Materials and Methods: A questionnaire on this topic was generated using 'Google Forms' and was circulated among junior and senior residents, faculty in various medical colleges and consultants in private practice all over India and their response was collected and analysed. Results: We received a total of 221 responses from all over India from paediatric medicine trainees and consultants. Among them, majority (48%) were senior residents. According to the survey participants, the most (46%) find inability to retract the prepuce as the major presenting complaint. A straight away reference to a paediatric surgeon was preferred by majority of paediatricians (62.9%), though most of them were aware of them were aware of physiological adhesions and conservative management (94.2%). There was a belief among 43% about counselling each and every patient presenting with phimosis for circumcision. Among the respondents, 60.2% advised ultrasound of kidneys, ureter, and bladder to their patients and believed that backpressure changes alter the management of the child. A urine routine examination was advised by 70.1% of participants, with 46.6% believing that the presence of urinary tract infection changes the management of phimosis. Waiting up to 1 year of age before going for surgery was advocated by 71.5%. A major proportion of respondents (76%) believed all cases of phimosis should be referred to a surgeon, only 58.8% would voluntarily follow them up. There is still a belief among 69.7% of participants that all cases of phimosis should be referred to a paediatric surgeon and only few of them, 5.4% feel referring only indicated cases. Conclusion: Physiological phimosis is a common condition which can be addressed by the paediatricians themselves. Awareness is to be increased among them, especially during the training period regarding the proper management of this common condition, avoiding unnecessary circumcisions.

Pedunculated cavernous lymphangioma of the newborn oral cavity.

Oral swellings and ulcers in neonates are a spectrum of diseases often creating a sense of anxiety among parents. Early detection, high index of suspicion, proper investigations, and prompt diagnosis can aid in accurate management of the same. Lymphangiomas are benign hamartomas which are basically malformed lymphatics do not drain into other lymphatics or veins and hence there is lymphatic accumulation and enlargement following cystically dilated spaces. We hereby present a rare case of a neonate born with a cystic mucosal swelling at the upper gingival sulcus since birth.