Comparison of clinical outcome and anal manometry following laparoscopic-assisted anorectoplasty and posterior sagittal anorectoplasty in patients with high and intermediate anorectal malformation: A randomised controlled trial.

Introduction: High and intermediate types of anorectal malformations (ARMs) may be managed by either open posterior sagittal anorectoplasty (PSARP) or by laparoscopic-assisted anorectoplasty (LAARP). Most of the literature favours one approach over the other based on retrospective analysis. We performed this study with the aim to compare the short-term outcomes of both procedures. Materials and Methods: All paediatric patients with high and intermediate ARM were enrolled and randomised into two groups: open PSARP group and LAARP group. Outcome parameters such as faecal continence using Kelly's scoring system, anal manometric parameters and post-operative complications were compared between the groups. Results: A total of 16 patients were included with equal distribution in the open PSARP and LAARP group. Patient's variables were comparable in both the groups. Five patients developed immediate post-operative complications, three in the LAARP and two in the open group. The mean Kelly's score was 3.63 ± 1.6 versus 2.57 ± 1.9 (P = 0.132) for LAARP and PSARP group, respectively. The mean resting pressure was 34.71 ± 6.26 cm of H2O and 35 ± 6.16 cm of H2O (P = 0.384) in LAARP and open group, respectively. Rectoanal inhibitory reflex was demonstrated in 6/7 patients in LAARP group and 5/7 patients in open group. Conclusion: Faecal continence in patients undergoing either of the procedure is comparable. However, wound-related complications are lesser in LAARP procedure.

Neuroblastoma: Application of International Neuroblastoma Pathology Classification on fine needle aspiration cytology smears.

Background: Neuroblastoma (NB) is the fourth most common tumor of childhood. There is a paucity of literature on its subtyping of cytology and prognostic utility. Aims: We aimed to study the cytopathological features of NB on the aspirated material, subtype it, and assess the role of International Neuroblastoma Pathology Classification (INPC) classification on cytology smears in the preoperative prognosis of NB. Materials and Methods: Fifteen cases of NB reported on fine-needle aspiration cytology (FNAC) in the past 3 years were included. Detailed clinical, radiological, and cytological features were noted. Smears were assessed for characteristics such as cellularity, neuroblasts (cytoplasmic, nuclear details), rosettes, neuropil, Schwann cells, fibroblasts, calcification, and necrosis. Afterward, cases were categorized as undifferentiated (UD), poorly differentiated (PD), and differentiating (D) subtypes. Mitotic-karyorrhectic index (MKI) was calculated and correlated with histopathology. Follow-up was done to date. Results: The age ranged from 19 days to 10 years with an M: F ratio of 3:1. Twelve cases were retroperitoneal, two cervical, and one mediastinal. Metastatic disease was seen in six cases, one to the cervical, four to the bone marrow, and two to the scalp. The International Neuroblastoma Risk Group (INRG) staging system was available in all cases, out of which three were in stage L1, six in stage L2, four in stage M, and two in stage Ms. On cytology, four cases were differentiating NB, five PD NB, and six UD NB. The MKI was high (>4%) in 80% of UD, intermediate (2-4%) in 100% of PD, and low (<2%) in 75% of D cases. MKI corroborated in both histology and cytology, except in one case. Conclusion: NB can be subtyped on cytology on the basis of characteristics of neuroblasts, presence of neutrophils, rosettes, and necrosis. UD NB has a high MKI and is associated with a poor prognosis. A preoperative comprehensive reporting of NB on cytology can be very useful in guiding appropriate chemotherapy with some increment in survival. However, larger studies are needed to validate the calculation of MKI on FNA smears.

Evaluation of Risk Factors Affecting Outcome in Outborn Surgical Neonates.

BACKGROUND: Mortality in surgical neonates contributes to neonatal mortality rates. The study was conceptualized to study clinical and nonclinical factors affecting mortality in surgical neonates so that timely intervention could result in improved survival of the neonates. MATERIALS AND METHODS: The study was initiated after approval from the institutional ethics committee and included 120 surgical neonates over a period of 18 months after obtaining consent from the parents/caregivers. Predesigned pro forma was used to record the details of antenatal care received, place of birth, travel history, maternal education and gestational age, and clinical condition at the time of admission. Values of biochemical tests such as serum electrolytes, serum creatinine, and arterial blood gasses were recorded. The need of inotrope support, blood or blood product transfusion, and postoperative ventilator support and intensive care unit (ICU) care was recorded. The results of the two groups, i.e., survivals and mortality, were compared. Outcome was recorded as mortality at 30 days or earlier. RESULTS: Irrespective of the surgical condition, the survival rate was significantly better in those babies who weighed more than 2.5 kg at the time of admission, had capillary refill time of <3 s, had serum ionized calcium levels more than 1 mmol/L, and did not require inotropes, blood or blood product transfusion, and postoperative ICU care and ventilator support. The place of birth, educational status of the mother, gestational age, and distance traveled for care had no statistically significant effect on survival. CONCLUSION: There is a statistically significant correlation between the survival of the babies who weighed more than 2.5 kg and are more physiologically preserved at the time of admission. Mortality rates can be decreased by timely interventions to reduce the need of inotropes, blood or blood products, and ICU care and ventilator support during their postoperative recovery.

Benign vascular anomalies: A transition from morphological to etiological classification.

The International Society for the Study of Vascular Anomalies (ISSVA) devised a multidisciplinary etiopathogenesis based approach to classify benign vascular anomalies into tumors and malformations. This classification scheme has major therapeutic and prognostic implications as treatment modalities differ for both the categories. Inappropriate usage of the term "hemangioma" for etiopathogenetically distinct entities is commonly seen in clinical practice leading to delivery of incorrect treatment to the patients. We aimed to study the histomorphological and immunohistochemical features of benign vascular anomalies for their precise histopathological classification. A total of 48 cases diagnosed over a period of 3.5 years were reviewed and reclassified into vascular tumors and malformations based on ISSVA classification and prototypical histopathological features. Biopsies were reviewed based on 5 histopathological criteria viz. endothelial morphology, mitotic activity, intralesional nerve bundles, intralesional inflammation, and prominent vessel type. A panel of GLUT-1, WT-1, and Ki-67 was performed in each case. Seven cases of infantile hemangioma, 4 cases each of non-involuting congenital hemangioma and pyogenic granuloma, and 33 cases of vascular malformations were diagnosed. Endothelial cell morphology (p < 0.001), mitotic activity (p < 0.001), and intralesional nerve bundles (p < 0.001) were found to be statistically significant in differentiating hemangioma from malformations. GLUT-1 (p < 0.001) and Ki-67 labeling index (p < 0.001) were useful to distinguish infantile hemangioma from vascular malformations. To conclude, the ISSVA classification of benign vascular anomalies can be reliably done on histopathology. However, every case must be interpreted in the light of clinical and radiological features.