Isolated Penile Injury in Boys: Accident, Negligence, or Abuse?

AIM: The aim of the study was to highlight the etiology, spectrum of presentation, and management of isolated penile trauma in boys. METHODS: A retrospective review of boys treated for isolated penile trauma between January 2015 and June 2019 at a tertiary-level hospital. RESULTS: Nine children were admitted over 4½ years. Etiology: The mechanism of penile injury (PI) was penile hair tourniquet (n = 5), postcircumcision (n = 2), dog bite (n = 1), and scald injury (n = 1). Extent of injury includes complete urethral transection at corona (n = 4); loss of urethral plate in a case of hypospadias (n = 1); complete loss of glans (n = 1); penile transection at corona (n = 1); total penile amputation (n = 1); and deep partial-thickness burns of penile shaft and adjacent suprapubic skin (n = 1). Management: One patient absconded. The remaining patients were managed as follows: calibration of urethral meatus (n = 1); penile burn was managed with dressing and antibiotics; coring of glans with urethral end-end anastomoses (n = 4); Bettocchi's quadrangular lower abdominal flap phalloplasty (n = 1); and Bracka's staged urethroplasty (n = 1). Complications include wound infection following trauma (n = 4), postsurgical infection (n = 3), urethrocutaneous fistula (n = 2), and reapplication of penile hair tourniquet (n = 1). CONCLUSION: Isolated PI in boys is not uncommon. Most are preventable if the parents are apprized and watchful. The clinician should also be vigilant regarding child maltreatment. A staged approach tailored to the type of injury provides a satisfactory outcome.

Bracka Urethroplasty with Buccal Mucosa Graft: Ergonomic Management of Penile Skin Dartos in the First Stage to Facilitate Second-stage Neourethral Coverage.

AIMS: The aim of the study was to report a new technique of ergonomic penile skin-dartos management during buccal mucosa graft (BMG) to provide adequate penile skin-dartos for neourethral coverage at the time of second-stage tubularization. MATERIALS AND METHODS: Ten proximal hypospadias with severe chordee underwent first-stage surgery with a new technique. An incision along the urethral plate margin and preputial edge was used to split inner prepuce off preputial dartos and penile degloving leaving inner prepuce attached to corona. Urethral plate was divided into the subfascial plane. Penile dartos was bisected in the dorsal midline. Distal half of penile skin-dartos bifurcated and joined to inner preputial edges. Mobilized and lateralized penile skin-dartos was sutured flanking edges of BMG. The second-stage tubularization after 6 months provided neourethral double dartos coverage with eccentric suture lines. RESULTS: Adequate dartos for neourethral coverage during second-stage tubularization was available in all. Subcoronal urethrocutaneous fistula occurred in one that was repaired. CONCLUSIONS: Ergonomic management of inner-preputial skin and ventral transfer of penile skin-dartos helps in providing neourethral coverage during subsequent second-stage tubularization to minimize the occurrence of complications.

The wandering ventriculoperitoneal shunt and the scope of its salvage.

PURPOSE: Distal shunt tube migration following ventriculoperitoneal (VP) shunt placement in children is mostly managed by an initial shunt diversion/removal and subsequent replacement. Lately, shunt salvage is being used as an alternative in certain conditions. We have focused on the situations where one can consider or disregard shunt salvage in such cases. METHOD: A retrospective study of children treated for distal shunt migration following VP shunt placement between January 2013 and December 2019. RESULT: Seventeen children were managed for over 7 years. These included cutaneous extrusions (n = 4), hollow viscus perforation (n = 6), inguinal hernias (n = 5), and umbilical extrusion (n = 2). The surgical treatment varied from a cutaneous wound closure (with a tube in situ), temporary external shunt diversion, and laparotomy with shunt reposition into the peritoneal cavity. Shunt salvage was possible in three cases, whereas in 2 cases even though shunt salvage was possible, it was not feasible due to a short residual shunt length. CONCLUSION: VP shunt salvage is possible in certain cases of distal shunt migration with a functional uninfected shunt. Small cutaneous extrusions can be covered by a local skin flap. Also, one should consider the residual intraperitoneal shunt length before its salvage in small children.

Intussusception after Rotavirus Vaccine Introduction in India.

BACKGROUND: A three-dose, oral rotavirus vaccine (Rotavac) was introduced in the universal immunization program in India in 2016. A prelicensure trial involving 6799 infants was not large enough to detect a small increased risk of intussusception. Postmarketing surveillance data would be useful in assessing whether the risk of intussusception would be similar to the risk seen with different rotavirus vaccines used in other countries. METHODS: We conducted a multicenter, hospital-based, active surveillance study at 27 hospitals in India. Infants meeting the Brighton level 1 criteria of radiologic or surgical confirmation of intussusception were enrolled, and rotavirus vaccination was ascertained by means of vaccination records. The relative incidence (incidence during the risk window vs. all other times) of intussusception among infants 28 to 365 days of age within risk windows of 1 to 7 days, 8 to 21 days, and 1 to 21 days after vaccination was evaluated by means of a self-controlled case-series analysis. For a subgroup of patients, a matched case-control analysis was performed, with matching for age, sex, and location. RESULTS: From April 2016 through June 2019, a total of 970 infants with intussusception were enrolled, and 589 infants who were 28 to 365 days of age were included in the self-controlled case-series analysis. The relative incidence of intussusception after the first dose was 0.83 (95% confidence interval [CI], 0.00 to 3.00) in the 1-to-7-day risk window and 0.35 (95% CI, 0.00 to 1.09) in the 8-to-21-day risk window. Similar results were observed after the second dose (relative incidence, 0.86 [95% CI, 0.20 to 2.15] and 1.23 [95% CI, 0.60 to 2.10] in the respective risk windows) and after the third dose (relative incidence, 1.65 [95% CI, 0.82 to 2.64] and 1.08 [95% CI, 0.69 to 1.73], respectively). No increase in intussusception risk was found in the case-control analysis. CONCLUSIONS: The rotavirus vaccine produced in India that we evaluated was not associated with intussusception in Indian infants. (Funded by the Bill and Melinda Gates Foundation and others.).

Intussusception in children aged under two years in India: Retrospective surveillance at nineteen tertiary care hospitals.

OBJECTIVE: Intussusception has been linked with rotavirus vaccine (RVV) as a rare adverse reaction. In view of limited background data on intussusception in India and in preparation for RVV introduction, a surveillance network was established to document the epidemiology of intussusception cases in Indian children. METHODS: Intussusception in children 2-23 months were documented at 19 nationally representative sentinel hospitals through a retrospective surveillance for 69 months (July 2010 to March 2016). For each case clinical, hospital course, treatment and outcome data were collected. RESULTS: Among the 1588 intussusception cases, 54.5% were from South India and 66.3% were boys. The median age was 8 months (IQR 6, 12) with 34.6% aged 2-6 months. Seasonal variation with higher cases were documented during March-June period. The most common symptoms and signs were vomiting (63.4%), bloody stool (49.1%), abdominal pain (46.9%) and excessive crying (42.8%). The classical triad (vomiting, abdominal pain, and blood in stools) was observed in 25.6% cases. 96.4% cases were diagnosed by ultrasound with ileocolic location as the commonest (85.3%). Management was done by reduction (50.8%) and surgery (41.1%) and only 1% of the patients' died. 91.1% cases met Brighton criteria level 1 and 3.3% Level 2. Between 2010 and 2015, the case load and case ratio increased across all regions. CONCLUSION: Intussusception cases have occurred in children across all parts of the country, with low case fatality in the settings studied. The progressive rise cases could indicate an increasing awareness and availability of diagnostic facilities.

Evaluation of nebulized N-acetyl cysteine in outcome of esophageal atresia with tracheoesophegeal fistula.

AIM: To evaluate the role of nebulized N-acetyl cysteine (NAC) in liquefying the airway secretions and improving the outcome of patients of esophageal atresia with tracheoesophageal fistula (EA + TEF). METHODS: It was a non-randomized interventional study. Two milliliters of 10% NAC was given in a nebulized form (2:5 dilution, every six hourly) to patients of ET + TEF, along with regular suction of upper esophageal pouch. The group was compared with control, which comprised patients of EA + TEF receiving only saline nebulization. The consistency of the secretions was compared by hand held consistometer in unit of time (seconds) required to cross a predetermined distance along with gravity. RESULTS: Sixty patients were assessed. Of these, 30 patients were present in both groups. The study group showed significant (p = 0.01-0.0001) decrease in consistency of secretions from the control group after day 2 of NAC nebulization. Patients' discharge was significantly (p = 0.01) earlier in cases. There was no significant (p = 0.41) difference in mortality between the groups. No specific adverse effects were observed in the study group. CONCLUSION: It appears that nebulized NAC decreases the consistency of secretions in EA + TEF patients. It is interesting to note that the group of patients that received NAC was discharged earlier than the control group and had a higher survival rate than the control group. Whether this is directly attributable to the use of NAC is unknown. A prospective double-blinded randomized clinical trial is warranted to confirm these results. LEVEL OF EVIDENCE: Level II, prospective comparative study (non-randomized).

Study of Thoracoscopic Repair of Diaphragmatic Eventration in Children: A Case Series.

Background: To present a case series of children with eventration of diaphragm who underwent thoracoscopic repair highlighting the technical points and surgical modifications to prevent a recurrence. Settings and Design: This is an observational study of patients with diaphragmatic eventration admitted to a tertiary care institute. The study was designed following CARE guidelines endorsed by EQUATOR Network. Pediatric patients who had undergone thoracoscopic repair between January 2010 and March 2019 were included in the study. Materials and Methods: Age at surgery, gender, weight, site of the lesion, operating time, need for postoperative drain, and complications were assessed. Results: Twenty-six patients had thoracoscopic repair of the eventration of diaphragm. The male-female ratio was 12:1 and mean weight at the time of surgery was 6.3 kg (2.2-22 kg) with most patients having left side congenital diaphragmatic eventration (n = 21) as compared with the right side (n = 5). The average operating time was 66 minutes (37-144 minutes). Conclusions: Diaphragm plication by a thoracoscopic approach is safe and feasible in neonates and pediatric patients.

Meningocele tourniquet syndrome.

Tourniquet syndrome is a rare condition where a tourniquet applied to an appendage leads to an obstructed blood flow and subsequent ischemic injury. Meningomyelocele and meningocele are common birth defects, and involvement of meningocele in tourniquet syndrome is never mentioned in the literature. We managed a 10-day-old male child presenting with infected lumber meningocele with a tourniquet tied at its base. It is being presented with review of relevant literature.

Evaluation of Effect of Propranolol on Serum Vascular Endothelial Growth Factor and Tissue Inhibitor of Metalloproteinase-2 Levels in Infantile Hemangioma.

BACKGROUND: Infantile hemangioma is the most common tumor of infancy. Currently, propranolol is a preferred drug for treating hemangioma. The exact mechanism of action of propranolol is not known. In this study, we attempted to assess whether propranolol has any effect on vascular endothelial growth factor (VEGF) and tissue inhibitor of metalloproteinase-2 (TIMP-2) over a period of time, and if it is there, how long it affects it. MATERIALS AND METHODS: Propranolol was administered in the dosage of 2-3 mg/kg. The first serum sample was collected before starting the propranolol treatment. Thereafter, samples were collected at monthly intervals up to a total of six samples. The samples were assessed for TIMP-2 and VEGF using enzyme-linked immunosorbent assay kit. RESULTS: The duration of this study was from June 2016 to November 2017. The total number of patients in this study was 15. Thirteen patients responded to treatment. The mean age of patients was 7.1 months. The mean value of baseline VEGF was 0.234 ± 0.059 and that of TIMP-2 was 1.338 ± 0.679. As compared to baseline value, the P value was statistically not significant in any of sequential values. In category-wise analysis, apart from statistically significant value in the 6th month in excellent category and good response category in the 1st month, all other values did not reveal any significant change in VEGF analysis. The analysis of TIMP-2 revealed a significant change in the levels from Sample 2 to Sample 6 in the excellent response group; however, the levels did not show a specific trend either increasing or decreasing. CONCLUSION: Despite its beneficial action in regression of hemangioma, the exact mechanism is yet to be identified. The exact duration of treatment needs further evaluation.

Giant Occipital Encephalocele - Challenges in Management.

INTRODUCTION: Giant occipital encephalocele (GOE) is a term used when the size of the OE is greater than or equal to the size of the head. It has been limited to case reports, with only sporadic exclusive series. This is a series of GOE managed at our center over time with emphasis on practical problems faced in management. MATERIALS AND METHODS: This was a retrospective observational study. The patients were evaluated for the age of presentation, sex, and head size. Any associated neural tube defect was also looked for. Imaging was used for associated brain anomalies and to plan the surgical procedure. The requirement of ventriculoperitoneal (VP) shunt was also assessed. RESULTS: During the study period of 7 years, 11 patients of GOE were admitted. Apart from one, all other patients were <1 year of age. Nine patients underwent surgical intervention, which included excision and repair of swelling with or without VP shunt placement. The content of the sac was only cerebrospinal fluid (CSF) in six patients and CSF and gliotic brain tissue in remaining patients. The attendants of two patients did not give consent for surgery and left against medical advice. CONCLUSION: GOE is an uncommon entity with limited information about management. Careful evaluation, proper imaging of patient, and care during intraoperative and postoperative periods with emphasis of factors determining the prognosis may provide satisfactory results.

Management Strategy of Meconium Ileus-Outcome Analysis.

BACKGROUND: Meconium ileus (MI) is defined as an intestinal obstruction caused by the impaction of inspissated meconium in the terminal ileum. In this study, we have evaluated the nonoperative management of patients of simple MI without fluoroscopic support -an important requisite of the Noblett's criteria. Besides this, surgical management in cases of failed conservative management and complicated MI was also assessed. MATERIALS AND METHODS: This was a retrospective observational study. Various clinical and radiological parameters were evaluated. Conservative management included the use of water-soluble contrast diatrizoate meglumine and diatrizoate sodium. In case of nonpassage of meconium in 24 h from first intervention, exploratory laparotomy with ileostomy was performed. All complicated MI underwent exploratory laparotomy with creation of stoma as and when needed. RESULTS: The duration of this study was 6½ years. Twenty-five neonates of MI were admitted. Of these, 22 had simple MI and remaining three had complicated MI. Eighteen neonates responded to the conservative management. In four neonates, who did not respond, exploratory laparotomy was performed. All three neonates having complicated MI underwent exploratory laparotomy. One patient expired in follow-up. CONCLUSION: MI is an important neonatal emergency, which needed immediate attention of a pediatric surgeon. Proper evaluation of the patient, careful application of principals of conservative management, and timely surgical intervention may fetch satisfactory results.

IschioPubic Osteotomy, A Simple and Effective Technique for Pelvic Ring Closure in Repair of Classic Exstrophy Bladder.

AIM: The aim of this study is to report the technique and outcome of ischiopubic (IP) osteotomy for pelvic ring closure in classic exstrophy bladder. METHODS: A total of 85 male classic exstrophies were selected based on trapezoid-shaped space between IP ramus on three-dimensional computed tomography pelvis. Using midline scroto-perineal approach, after bladder plate mobilization and radical corporal detachment; the pelvic surface of superior pubic ramus (SPR) was exposed. Above the obturator canal, H-shaped incision was made on periosteum of the SPR. The horizontal line of H was placed above the obturator canal. Rectangular periosteal flaps above and below the horizontal line was raised. In the subperiosteal plane, curved hemostats encircled the SPR that were divided using a bone drill. On the medial aspect of ischial tuberosity, a notch was created as hinge using a bone drill. Forks of bone holding forceps hooked the pubic bone and tightened for its midline approximation, lengthening of the SPR and inward rotation of IP ramus. Linea alba and pubic bones were approximated with interrupted Polygalactin sutures. RESULTS: Midline approximation of pubic bone and linea alba was possible in all. There was no injury to obturator nerve, vessels, or other structures . CONCLUSIONS: IP osteotomy is the safe and effective technique of pelvic ring closure in patients with specific pelvic configuration.

Ectopic Salivary Gland Cyst in the Neck: Association with Congenital Plunging Ranula.

Congenital ranula is rare. We report a large, symptomatic, congenital plunging ranula associated with a salivary gland cyst in the neck. To the best of our knowledge, this is the first such reported case. Even though both the cysts had their origin from the sublingual gland, only the cervical cyst had a capsular covering. Herniation of a part of the immature sublingual gland anlage through a congenital mylohyoid defect, its separation, and subsequent maturation could explain this occurrence.

Bladder exstrophy: Comparison of anatomical bladder neck repair with innervation preserving sphincteroplasty versus Young-Dees-Leadbetter bladder neck reconstruction.

AIM: To evaluate the outcome of innervation preserving sphincteroplasty along with anatomical bladder neck reconstruction (IPS-ABNR) compared to classic Young-Dees-Leadbetter (YDL) bladder neck reconstruction in exstrophy with insufficient bladder capacity requiring detubularized-ileocystoplasty. MATERIALS AND METHODS: Sixteen male patients of exstrophy bladder who required ileocystoplasty from 2004 to 2010 were randomized into group A (n = 7) and group B (n = 9). After detubularized-ileocystoplasty with Mitrofanoff stoma and ureteric reimplantation in all, group A received YDL bladder neck repair while group B received IPS-ABNR repair through a midline scrotoperineal approach. Outcome measurement included operative and postoperative problems, continence, and upper tract status. RESULTS: In group A, two had incompetent bladder neck with gross incontinence, while four had a dry interval of more than 3 h without the ability of voiding per urethra. In group B, seven patients had dry interval of more than 3 h with an ability of urethral voiding and midstream holding in five. CONCLUSIONS: Exstrophy patients requiring augmentation cystoplasty and repaired with IPS-ABNR can achieve dynamic bladder outlet resistance with adequate leak point pressure and ability to void voluntarily with midstream holding capability. The children had the satisfaction of voiding per urethra with ability to stop in midstream similar to that in normal children.

Congenital lumbar hernia: 20 years' single centre experience.

AIM: Congenital lumbar hernia is an uncommon anomaly with only few cases reported in the English literature. This study was done to study the incidence, associated conditions, management and complications of congenital lumbar hernia repair in paediatric patients. METHODS: Retrospective study of all patients over a period of 20 years (January 1990 to January 2010) was analysed. RESULTS: A total of 18 patients (two bilateral hernias) were encountered in this series. All were in the age group of 1 day to 6 years. All the patients were operated by open technique. Primary repair was done in 14 patients and prosthetic meshplasty in two. Two patients could not be operated. The average follow-up period was 3 years. There was no follow-up loss in our study. There was no evidence of recurrence in this series. CONCLUSION: Up until now, the total number of cases is 68. The large size of hernia defect (>10 cm) may determine the use of prosthetic mesh repair. Proper surgical treatment, either primary repair or hernioplasty, provides adequate management of this condition.

Esophageal atresia associated with anorectal malformation: Is the outcome better after surgery in two stages in a limited resources scenario?

AIMS: To analyze whether outcome of neonates having esophageal atresia with or without tracheoesophageal fistula (EA±TEF) associated with anorectal malformation (ARM) can be improved by doing surgery in 2 stages. MATERIALS AND METHODS: A prospective study of neonates having both EA±TEF and ARM from 2004 to 2011. The patients with favorable parameters were operated in a single stage, whereas others underwent first-stage decompression surgery for ARM. Thereafter, once septicemia was under control and ventilator care available, second-stage surgery for EA±TEF was performed. RESULTS: Total 70 neonates (single stage = 20, 2 stages = 30, expired after colostomy = 9, only EA±TEF repair needed = 11) were enrolled. The admission rate for this association was 1 per 290. Forty-one percent (24/70) neonates had VACTERL association and 8.6% (6/70) neonates had multiple gastrointestinal atresias. Sepsis screen was positive in 71.4% (50/70). The survival was 45% (9/20) in neonates operated in a single stage and 53.3% (16/30) when operated in 2 stages (P = 0.04). Data analysis of 50 patients revealed that the survived neonates had significantly better birth weight, better gestational age, negative sepsis screen, no cardiac diseases, no pneumonia, and 2-stage surgery (P value 0.002, 0.003, 0.02, 0.02, 0.04, and 0.04, respectively). The day of presentation and abdominal distension had no significant effect (P value 0.06 and 0.06, respectively). This was further supported by stepwise logistic regression analysis. CONCLUSIONS: In a limited resources scenario, the survival rate of babies with this association can be improved by treating ARM first and then for EA±TEF in second stage, once mechanical ventilator care became available and sepsis was under control.

Six-year retrospective analysis of colonic perforation in neonates and infants: single centre experience.

BACKGROUND: Developing countries at tertiary referral centre. This study analysed the aetiology of colonic perforation (CP) in neonates and infants. MATERIALS AND METHODS: Retrospective analyses of 60 CP cases (presented from May 2005 to May 2011) were done. RESULTS: The mean age at presentation was 8.33 ± 0.11 days (range, 2-110 days). The aetiology were Hirschsprung's disease (HD), necrotising enterocolitis (NEC) and idiopathic perforation in 78.33% (47/60), 6.67% (4/60) and 15% (9/60), respectively. There were 210 patients with histopathologically proven HD; 22.38% (47/210) cases of HD had CP. Most common site of perforation was mid-transverse colon (74%, 35/47) in HD patients. All HD-associated mid-transverse colonic, caecal, appendicular and ascending colon perforations (except one caecal perforation) had aganglionic recto-sigmoid region and ganglionic perforation site. Features of enterocolitis were not found in any HD patients. Two patients (3.33%) died due to sepsis. CONCLUSIONS: There was a high rate of primary HD-associated colonic perforation in this study. Colonic perforation may the initial presenting condition in HD disease. We advocate colonic biopsy to rule out HD in any neonate presenting with primary colonic perforation.

Retrospective analysis of paediatric achalasia in India: single centre experience.

BACKGROUND: Developing countries at tertiary referral centre. The aim of this study was to share our experience of paediatric achalasia in Indian scenario. MATERIALS AND METHODS: This was a retrospective analysis of children <16 years, operated for achalasia at our centre, from December 1998 to December 2011. RESULTS: Total 40 patients (mean age 39 ± 4.29 months), including 1 patient of megaesophagus were operated over 13 years of period; 17 patients (associated congenital H-type tracheoesophageal fistula in one patient, non- responders/ lost follow-up for minimum of 3 years in 16 patients) were excluded from the study. The response rate of parents in follow-up was 60.0%. Mean symptoms duration was 27.88 ± 2 months. Most common symptoms were regurgitation and failure to thrive (78.2%). Mean symptom scoring in follow-up after 3 year was 1 ± 0.7 compared to 5 ± 0.51 at the time of admission (P < 0.012). One infant expired (mediastenitis), one developed adhesive intestinal obstruction and one needed posterior re-myotomy (for megaesophagus). There were no treatment failures in mean follow-up of 40.2 ± 5.07 months. CONCLUSIONS: Cardiomyotomy with partial fundoplication is the best modality of treatment for paediatric achalasia cardia, even from parents' perspective.

Chronic cervical lymphadenopathy in children: Role of ultrasonography.

AIM: To assess the usefulness of ultrasonography in the differentiation of causes of chronic cervical lymphadenopathy in children. MATERIALS AND METHODS: Children with palpable cervical lymph nodes were included. An ultrasonographic examination was performed to delineate multiple lymph nodes, irregular margins, tendency towards fusion, internal echos, the presence of strong echoes and echogenic thin layer. RESULTS: The total number of patients was 120. Echogenic thin layer and strong internal echoes were specific for tuberculosis. Long axis to short axis (L/S) ratio was more than 2 in most of the tubercular nodes (85.71%). Hilus was present in 50 (73.53%) tubercular lymphadenitis, 12 (40%) lymphoma and 10 (62.5%) cases with metastatic lymph nodes. Hypoechoic center was present in 60 (88.24%) tubercular lymphadenitis cases followed by 62.5% metastatic and 60% malignant lymphoma cases. CONCLUSIONS: Ultrasonography is a non-invasive tool for lymph nodal evaluation in children. It may be used to differentiate cervical lymphadenopathy with different etiologies in children. When correlated clinically, it may avoid biopsy in a patient.