A Critical Appraisal of Clinicopathological, Imaging, and GeneXpert Profiles of Surgical Referrals with Pediatric Abdominal Tuberculosis.

Aim: To study the clinicopathological, imaging, and GeneXpert profiles of surgical referrals with abdominal tuberculosis (TB) and to compare the utility of GeneXpert versus conventional diagnostic armamentarium. Materials and Methods: This cohort study which was conducted over a study period of 8 years (2011-18) included seventy-seven children operated with a provisional diagnosis of abdominal TB and those who had either histological (n = 58; 75.3%) or GeneXpert (n = 9) confirmation or had miliary tubercles on exploration with supportive clinical and imaging findings (n = 17; 22.1%). GeneXpert testing was added to the diagnostic armamentarium only in the latter half of the study (2016-18, n = 31). Demographic details, symptomatology, prior antitubercular treatment, GeneXpert positivity, imaging, operative, and histological findings were recorded and analyzed using mean, standard deviation, and range for continuous variables and proportion for categorical variables. Results: Perforation peritonitis (n = 26; 33.8%) and unrelieved obstruction (n = 51; 66.2%) were the main surgical indications. The mean age at presentation was 9.5 ± 3.6 years with a distinct female preponderance. The presence of right lower abdomen lump (n = 23; 29.9%), alternate diarrhea and constipation (n = 34; 44.1%), tubercular toxemia (n = 38; 49.4%), positive history of contact (n = 20; 25.9%), tuberculin positivity (n = 38; 49.4%), fibrocavitary pulmonary lesion (5.2%), clumped bowel loops with pulled-up cecum (n = 23; 29.9%), septated ascites (n = 17), mesenteric lymphadenopathy and omental thickening (n:18; 23.4% each) were the supportive tell-tale signs of the disease. The hallmark of pathological diagnosis was caseous necrosis with epithelioid granulomas (n = 43; 55.8%), nongranulomatous caseation (n = 15; 19.5%), and acid-fast bacilli positivity in 27.3% of patients. GeneXpert was positive in only nine patients with an overall sensitivity of 29% as compared to 75.3% for histopathology. Conclusion: Bacteriological and histological confirmation of the disease eluded us in a significant proportion of patients, requiring a very high index of clinical suspicion to clinch the diagnosis. The current version of GeneXpert has low sensitivity in diagnosing pediatric abdominal TB.

Supernumerary Remnant Vas Deferens Like Wolffian-Derivatives in a Young Child With Abdominal Cocoon Syndrome-A Clinicopathological Novelty.

The abdominal cocoon syndrome is a rare cause of recurring intestinal obstruction in children. It refers to encasement of the small bowel by a fibrocollagenous membrane forming a cocoon. We report a nine year old male presenting with abdominal pain, distension, bilious vomiting and inability to pass stool and flatus for two days. In view of a persistently increasing bilious nasogastric output, an urgent exploratory laparotomy was performed. The small bowel loops were matted together forming a cocoon densely adherent to the parietal peritoneum with supra-colic fibrous bands. The bands histologically displayed multiple ductal remnants with epithelium resembling that of ductus deferens. These structures showed immunopositivity for pan-cytokeratin and basal CD10.Workup for tuberculosis and other etiological causes was unremarkable. This is the first documented case of abdominal cocoon in a pediatric subject associated with supernumerary wolffian remnants.

Mammary Fibrocystic Change in a Pre-Pubertal child- A Case Report with a Histopathological Perspective.

BACKGROUND: Fibrocystic change in the breast is one of the entities under the spectrum of benign breast disease. It occurs primarily in females of the reproductive age group. Though the exact etiology is unknown, estrogen-progesterone imbalance is possibly one of the causative factors. Its occurrence in the pediatric age group is infrequent and is hitherto unreported in the pre-pubertal age group. Case report: We present the case of a 2-year-old female presenting with an ill -defined lump approximately 4 cm in diameter, with an unremarkable hormonal status for the age. Histopathology revealed fibrocystic change in the resected tissue. Conclusion: Fibrocystic breast change in children may represent an exaggeration of the normal developmental involution process.

Comparison of leakage test and ultrasound imaging to validate ProSeal supraglottic airway device placement.

BACKGROUND AND AIMS: To validate the placement of ProSeal supraglottic airway device using ultrasound (USG) with leakage test in adult population of both sexes. MATERIAL AND METHODS: This single-arm observational study was conducted on 80 American Society of Anesthesiology (ASA) I-III patients, undergoing elective surgery under general anesthesia with ProSeal supraglottic airway device. Leakage pressure test was conducted in all cases. The position of the ProSeal laryngeal mask airway (LMA) was assessed by USG in the pharyngeal, laryngeal, and the cranial-caudal axis plane. The fiberoptic examination was done to confirm the position of ProSeal if the seal pressure was <27 cm H2O, to confirm suboptimal placement. The position of the ProSeal in the three USG planes was allocated a predetermined score. This score was compared with the leakage test to determine the strength of the correlation, sensitivity, and specificity for predicting a need for reinsertion. RESULTS: Leakage seal pressure was recorded as <27 cm H2O in 6 (7.5%) patients and fiberoptic bronchoscopy was done in these cases to determine the need for reinsertion. ProSeal was reinserted in 5 (6.25%) cases. Patients with a composite ultrasound score of 0-1 required ProSeal reinsertion while those with a score of 2-3 did not require reinsertion. Seventy-one patients had seal pressure >27 cm H2O and a score of 3. USG examination is comparable with leakage test in predicting the requirement of reinsertion (P = 0.003) and a score of 19 equating 0-1 predicted the need for reinsertion with a sensitivity and specificity of 80% and 100%, respectively. CONCLUSION: USG is comparable with the leakage test for confirmation of ProSeal placement.

Correlation of Antenatal Ultrasound Parameters with the Postnatal Outcome of Bilateral Fetal Hydronephrosis.

AIM: To determine the role of antenatal parameters in predicting the outcome of bilateral fetal hydronephrosis. METHODOLOGY: Total 50 antenatal women with bilateral antenatal fetal hydronephrosis (ANH) were included. On ultrasound, amount of liquor, kidney size, pelvic anteroposterior diameter, degree of caliectasis, bladder size, and thickness were observed at 28 and 32 weeks of gestation. For 3 months post-delivery, the babies were evaluated in terms of ultrasound renal parameters, serum creatinine levels, and need for surgery. RESULTS: The mean gestational age at delivery was 37.4 ± 1.7. All babies were alive at birth, 48 were alive after 3 months. Surgery was done in 10/50 cases; cystoscopic fulguration was the most common procedure. There was a resolution of bilateral ANH in 27/50 cases, in 5/50 cases there was pylectasis with normal serum creatinine, and in 18/50 cases there was adverse outcome. Most of the parameters had better sensitivity and specificity at 32 weeks than at 28 weeks. At 32-week gestation, the renal pylectasis between 10 and 15 mm had the highest sensitivity (88.9%), and the presence of caliectasis had the highest specificity (90.6%) for adverse outcome. CONCLUSION: Resolution of hydronephrosis took place in the majority of cases, and there was an adverse outcome in only one-third of them. Renal caliectasis was the best marker for the prediction of adverse outcome.

Novel insights into the histology of jejunoileal atresia and its therapeutic implications.

AIM: To study the histology of resected specimens of jejunoileal atresia (JIA) and to explore its probable therapeutic implications. METHODS: Biopsies were taken from the resected specimens of 32 patients of JIA. Sections were taken at the atretic ends and successively at every 5 cm in resected proximal bowel. They were stained for light microscopy and immunohistochemistry for CD117 (Interstitial cell of Cajal), α smooth muscle antibody (SMA), neuron filament protein (NFP) and calretinin. Histological findings on light microscopy and immune reactivity intensity for NFP, calretinin and α-SMA were recorded. Time taken to achieve full enteral nutrition (FEN; defined as attainment of oral feeds at 100 ml/kg/day without any intravenous fluid supplementation) was recorded and correlated with CD117 count by non-parametric Spearman rank correlation coefficient. RESULTS: Light microscopy failed to detect any abnormality in majority (n = 27, 84%) of JIA specimens. Mucosal ulceration (7.8%), submucosal inflammatory cells (8%), focal muscle thinning (2.5%), decreased ganglion cells and nerve fibers (3.8%) were noted on light microscopy. However all of them had normal α SMA, calretinin and NFP immunoreactivity. Mean ICC counts at proximal and distal atretic segment were 6.56 ±â€¯3.79 and 8.37 ±â€¯3.21 per HPF respectively. Serial sections in proximal dilated segment did not reveal any definite or well demarcated increase in ICC counts. CD117 counts at the proximal cut end of atresia was less than 6 per high power field (hpf) in 15 patients (46.8%) while at the site of anastomosis a count of more than 6/hpf was observed in 73% patients. There was no direct correlation of ICC counts with attainment of FEN. CONCLUSION: Absence of major morphological abnormalities in the proximal dilated bowel contradicts the findings of earlier studies on histology of JIA in smaller cohorts. Our observations reiterate that bowel plication rather than massive bowel resection should be the preferred management in babies with JIA. LEVEL OF EVIDENCE: Prognosis study (Level II).

A Pilot Study on Neonatal Surgical Mortality: A Multivariable Analysis of Predictors of Mortality in a Resource-Limited Setting.

PURPOSE: The aim of this research is to study the predictors of neonatal surgical mortality (NSM)-defined as in-hospital death or death within 30 days of neonatal surgery. MATERIALS AND METHODS: All neonates operated over the study period of 18 months were included to evaluate NSM. The evaluated preoperative and intraoperative variables were birth weight, gestation age, age at presentation, associated anomalies, site and duration of surgery, intraoperative blood loss, and temperature after surgery. Assessed postoperative variables included the need for vasopressors, postoperative ventilation, sepsis, reoperations, and time taken to achieve full enteral nutrition. Univariate and multivariate logistic regression was applied to find the predictors of mortality. RESULTS: Based on patient's final outcome, patients were divided into two groups (Group 1-survival, n = 100 and Group 2-mortality, n = 50). Incidence of NSM in this series was 33.33%. Factors identified as predictors of NSM were duration of surgery >120 min (P = 0.007, odds ratio [OR]: 9.76), need for prolonged ventilation (P = 0.037, OR: 5.77), requirement of high dose of vasopressors (P = 0.003, OR: 25.65) and reoperations (P = 0.031, OR: 7.16 (1.20-42.81). CONCLUSION: NSM was largely dependent on intraoperative stress factors and postoperative care. Neonatal surgery has a negligible margin of error and warrants expertize to minimize the duration of surgery and complications requiring reoperations. Based on our observations, we suggest a risk stratification score for neonatal surgery.

Minimal flow anesthesia can be initiated early with the use of higher fresh gas flow to facilitate desflurane "Wash-in".

BACKGROUND AND AIMS: More than 80% of delivered anesthetic gases get wasted at high fresh gas flows as they are vented out unused. Use of minimal flow anesthesia is associated with less waste anesthetic gas emission and environmental pollution. There is no approved or validated technique to initiate minimal flow anesthesia and simultaneously achieve denitrogenation of the breathing circuit. We studied the wash-in characteristics of desflurane, when delivered with 50% nitrous oxide, to reach a target end-tidal concentration at two different gas flow rates. MATERIAL AND METHODS: Patients were allocated randomly to two groups of 25 adults each. In Group A, with the vaporizer dial fixed at 4 vol %, after an initial fresh gas flow of 4 L/min was administered to wash-in of desflurane using the closed-circuit, with 50% N2O in O2, and in group B, 6 L/min was used. Minimal flow anesthesia, with 0.5 L/min, was initiated in both groups on attaining a target end-tidal desflurane concentration of 3.5 vol %. After initiation of desflurane delivery, the inspired/expired gas concentrations were noted every minute for 15 min. RESULTS: In Group A, the target desflurane end-tidal concentration was reached in 499.2 ± 68.6 s±, and in the Group B (P < 0.001), it was reached significantly faster in 314.4 ± 69.89 s. Denitrogenation of the circuit was adequate in both groups. CONCLUSION: Minimal flow anesthesia can be initiated, without any gas-volume deficit, in about 5 min with an initial fresh gas flow rate of 6 L/min and the vaporizer set at 4 vol%.

Predictors of upper tract damage in pediatric neurogenic bladder.

INTRODUCTION: Upper tract damage (UTD) is a life-threatening complication of neurogenic bladder (NB). Early identification of risk factors for UTD and institution of remedial measures may probably prevent UTD. The aim was to study the predictors of UTD in children 2 years or older with NB. METHOD: This cross-sectional, observational study over 2 years included 30 children. UTD was defined as serum creatinine of >1 mg/dL or society of fetal urology grade III-IV hydronephrosis or hydroureteronephrosis on ultrasonography or renal scars on 99mtechnetium dimercaptosuccinic scan or subnormal glomerular filtration rate (GFR) for age. The evaluated clinical variables were age at presentation, gender, palpable bladder lump, and recurrent urinary tract infection (UTI). Bladder wall thickness (BWT), grade and laterality of vesicoureteric reflux (VUR), status of the bladder neck, post-void residue (PVR), and level and type of intraspinal lesions were also noted. Urodynamic studies were performed for functional bladder assessment. A p-value <0.05 identified the risk factors. RESULTS: UTD was detected in 15 (50%) with serum creatinine >1 mg% (2, 6%), SFU III-IV (11, 36%), renal scars (12, 40%), and subnormal GFR in (2, 6%) patients. Clinical risk factors for UTD were delayed presentation (p = 0.034), palpable bladder lump (p ≤ 0.001; OR 38.5; CI 5.6-262.5), and recurrent UTI (p = 0.033, OR 4.125, CI 0.913-18.630). The presence of significant PVR, trabeculated bladder, spin-top urethra, and bilateral VUR were identified as radiological risk factors for UTD. Mean BWT in patients with and without UTD was 4.69 ± 1.78 mm and 2.91 ± 1.08 mm respectively. BWT predictive of UTD was 3.05 mm (Figure). The mean detrusor leak point pressure (DLPP) did not vary significantly in those with and without UTD (36.82 ± 14.74 and 29.09 ± 10.44 cmH2O, respectively), yet 75% patients with DLPP > 40 cmH2O had UTD (p = 0.038, OR 5.4, CI 0.84-34.84). DLPP <40 cmH2O was associated with UTD in 35% patients. DISCUSSION: The incidence of UTD in this series is in accordance with that reported with expectant management (40%) and is much higher than the 17% stated with proactive management. A limitation of this study is the small number of patients and heterogeneous clinical diagnosis. CONCLUSION: Delayed presentation with palpable bladder lump, recurrent UTI, increased BWT, bilateral VUR, increased PVR, and DLPP > 40 cm H2O were identified as potential risk factors for UTD. This study highlights the significance of BWT as a predictor of UTD in NB.

Pediatric Penile and Glans Anthropometry Nomograms: An Aid in Hypospadias Management.

OBJECTIVE: To establish pediatric penile and glans anthropometry nomograms. This may be used as a reference model for penile assessment while managing hypospadias. PATIENTS AND METHODS: Between October 2012 and September 2013, 263 boys of varying ages (0-16 years) were included in the study. Those with genetic, endocrine disorders, having genital anomaly, undescended testis, neonates, and infants with a nonretractile prepuce, with multiple congenital anomalies and refusal to take part in the study were excluded. Evaluated outcome variables were stretched penile length, glans circumference (GC) at coronal sulcus, glans diameter at coronal sulcus (Gdcl), mid glans diameter, and ventral glans length. Glans ratios were generated by dividing Gdcl by GC. Data were expressed as mean, median, and standard deviation. Correlation between age and variables was evaluated using nonparametric Spearman's rank correlation coefficient. RESULTS: The patients were divided in six age groups, namely 0-1 (n = 61), 1-3 (n = 37), 3-5 (n = 36), 5-7 (n = 36), 7-12 (n = 45), and >12 years (n = 48). Gdcl was the maximum transverse glans diameter and based on it small glans size varied widely from 8.9 to 35.04 mm for various age groups. Although glans anthropometry showed age-related changes, glans ratio remained relatively constant between 0.49 and 0.53 (mean: 0.5 ± 0.051, r = 0.29). All the variables except glans ratio showed a significant positive correlation with age (r = 0.954-0.98, P < 0.01). CONCLUSION: Penile anthropometry nomograms provide a reference model for hypospadias. This may aid in (a) objective preoperative assessment of glans size (b) patient selection for preoperative hormonal stimulation (c) provides a yardstick for postoperative cosmesis.

Congenital pouch colon in girls: Genitourinary abnormalities and their management.

AIMS: To discuss the assessment and management of genitourinary (GU) tract abnormalities in 21 girls with Types I-III congenital pouch colon (CPC), studied over a period of 10 years. MATERIALS AND METHODS: Assessment included clinical and radiological assessment, examination under anesthesia (EUA), endoscopy of the lower GU tract, and evaluation of the surgical findings, operative procedures for the GU anomalies, and the results of management. RESULTS: Initial examination of the external genitalia showed a "clover-leaf" appearance (n = 6) and a single perineal opening (n = 6). In 9 patients, the openings of the urethra and double vagina were seen, of which a vestibular fistula was seen in 5 and an anterior perineal fistula in 1. Seventeen patients (81%) had urinary incontinence (UI) - partial in 10, and complete in 7. Renal function tests, X-ray sacrum, and abdominal US were normal in all patients. Micturating cystourethrogram (n = 9) showed a wide, bladder neck incompetence (BNI) with reduced bladder capacity in seven patients. EUA and endoscopy revealed a septate vagina in all patients and the urethral opening at a "high" position (n = 14) or at a relatively normal or "low" position (n = 7). In 8 patients, the intervaginal septum was thick and fleshy. Endoscopy showed a short, wide urethra, an open incompetent bladder neck, poorly developed trigone, and reduced bladder capacity in the patients with UI. The fistula from the colonic pouch opened in the proximal urethra (n = 4), high in the vestibule (n = 3), low in the vestibule (n = 8), perineum just posterior to the vestibule (n = 1), and undetermined (n = 5). Vaginoscopy (n = 8) showed normal cervices in all and cervical mucus in 4 patients. The subtypes of CPC were Type I CPC (n = 4), Type II CPC (n = 16), and Type III CPC (n = 1). All 21 patients had uterus didelphys. In four patients with UI, during tubular colorraphy, a segment of the colonic pouch was preserved for later bladder augmentation if required. A Young-Dees bladder-neck repair (BNR) was performed in four older girls for treatment of UI, with marked improvement in urinary continence in two girls, some improvement in one girl with complete urinary incontinence, and minimal improvement in one child. Division of the intervaginal septum was performed in three girls. CONCLUSIONS: GU abnormalities in girls with CPC need to be assessed and managed by a tailored protocol. UI is frequent, and its correction may require BNR. A segment of the colonic pouch can be preserved for possible future bladder augmentation. All girls have a septate vagina, often widely separated, and uterus didelphys. Gynecologic assessment and monitoring is required throughout adult life. Considering the wide opening of the vestibule, surgical management of the urogenital component by division of the intervaginal septum and if required, the vagino-fistula septum on each side results in a normal or a hypospadiac urethral opening and an adequate vaginal inlet.

Vesical preservation in patients with late bladder exstrophy referral: histological insights into functional outcome.

PURPOSE: We evaluated bladder growth after combined bladder and epispadias repair in children 5 years or older, and correlated the histological findings with final surgical outcomes. MATERIALS AND METHODS: We prospectively evaluated 8 late bladder exstrophy referrals from a series of 26 patients treated during a 5-year period. Evaluated outcome measures were bladder capacity (expressed as percentage of expected bladder capacity for age), upper tracts status, continence and histological findings (collagen-to-smooth muscle ratio and type III-to-total collagen ratio). Data were analyzed using nonparametric Spearman rank correlation coefficient and Mann-Whitney U test. RESULTS: Mean age at combined bladder and epispadias repair was 8.9 years. Volitional voiding with a mean ± SD bladder capacity of 90 ± 7.48 ml was achieved in all patients except 1 with a suprapubic fistula. However, mean ± SD bladder capacity was 33.1% ± 7.47% of expected bladder capacity, and was inversely proportional to age at surgery. Mean ± SD compliance and pressure specific bladder volume less than 20 cm H2O were 13.86 ± 4.97 ml/cm H2O and 69.29 ± 18.07 ml, respectively. Two patients had nonobstructive hydroureteronephrosis with bilateral polar scarring. Mean ± SD collagen-to-smooth muscle and type III-to-total collagen ratios were 2.96 ± 1.062 and 0.4 ± 0.106, respectively. The latter showed a significant negative correlation to bladder compliance (p = 0.025). CONCLUSIONS: Successful anatomical closure stimulates bladder growth, even in cases of late referral. However, due to histological alterations, these bladders are poorly distensible and noncompliant. Thus, to have an acceptable functional outcome with preserved upper tracts, augmentation cystoplasty is needed in cases of late referral.

Endodermal sinus tumor of vagina posing a diagnostic challenge and managed by chemotherapy and novel posterior sagittal surgical approach: lessons learned.

Vaginal germ cell tumor (GCT) is a rare gynecological malignancy with no more than 100 reported cases in the international medical literature. It is an unusual, but an important, cause of premenarchal vaginal bleeding in a child. This article describes a 2-year-old child with vaginal GCT, initially misdiagnosed as rhabdomyosarcoma (on imprint smear cytology) and then as clear cell adenocarcinoma. The authors highlight the salient differentiating clinical, radiological and histological features to prevent misdiagnosis in future. The report emphasizes the need for increased awareness and screening for vaginal GCT by estimation of serum α-fetoprotein levels, in all patients with premenarchal vaginal bleeds, to prevent inadvertent operative interventions.