Single piece artificial urinary sphincter for secondary incontinence following successful repair of post traumatic urethral injury.

Post traumatic urethral injury is uncommon in children. The management of this condition is dependent on the severity of injury. Initial suprapubic cystostomy with delayed repair is the conventional treatment. Successful reconstruction of urethral injury may be followed by urethral stricture, incontinence, impotence, and retrograde ejaculation. Successful repair of post traumatic urethral injury followed by secondary incontinence in children has not been well addressed in literature. We report the management of one such child, with satisfactory outcome with implantation of a new model of single piece artificial urinary sphincter in the bulbar urethra by perineal approach.

Extrahepatic portal hypertension: quality of life and somatic growth after surgery.

AIM: This study was carried out in order to determine whether children with extrahepatic portal hypertension show any improvement in growth parameters and quality of life after elective surgery. PATIENTS AND METHODS: All patients with extrahepatic portal hypertension who underwent surgery between April 1999 and March 2002 were studied prospectively. Height and weight before and after surgery were converted into Z scores for comparison. The quality of life was assessed by changes in scholastic ability, physical activity, social interaction, and economic effects on the family. RESULTS: At the end of a minimum follow-up period of 1 year, of the 30 children, 50 % and 76 % showed improvement in weight and height Z scores, respectively, compared to their scores while on medical management. Z scores below - 2 SD for weight and height were seen in 57 % and 37 % of patients prior to surgery, and only in 40 % and 20 %, respectively at the end of follow-up, which ranged from 1 - 4 years. The improvement in height and weight was more in those who had undergone splenectomy with either devascularization or central splenorenal shunt compared to those who had undergone side-to-side lienorenal shunt without splenectomy. The children, who had dropped out of school while on medical management, either rejoined school or attended vocational courses after surgery. There was an improvement in school performance and physical activity in 85 % of the children. Improvement in personality was seen in 73 % of the affected patients. The cost incurred for surgery was one-third of the amount spent while on medical management. CONCLUSIONS: Growth parameters improved significantly in children after surgical intervention for portal hypertension. Overall improvement in scholastic abilities, physical activity, and social interaction was noted in a majority of the patients. As a one-time procedure in a developing country, surgery is also more cost effective.

Early postoperative feeding and outcome in neonates.

OBJECTIVES: The results of neonatal surgery in the Western world have rapidly improved over the past three decades. Early nutrition support is thought to be one of the key factors. We used transgastric, transanastomotic feeding jejunostomy tubes in every infant undergoing upper gastrointestinal surgery when the expected period of fasting has exceeded 7 d. METHODS: Newborns with duodenal atresia, malrotation, and jejunal atresia were treated consecutively between November 1998 and November 1999. We analyzed the outcome of such a practice. There were 17 consecutive babies recruited into the study. Ten babies had duodenal atresia, one associated with esophageal atresia and tracheo-esophageal fistula, six had malrotation, and one had jejunal atresia. The weights of the babies varied between 1.2 and 3.78 kg (mean = 2.1 kg) and they were referred between the ages of 1 and 23 d. Three babies were younger than 32 wk of gestation and weighed less than 1.5 kg; all had multiple bowel atresia, including one with associated pyloric atresia. None of these three survived. Enteral feeding was started by postoperative day 2 in 14 cases. Period of feeding varied between 3 and 20 d, with a mean of 10.4 d in the surviving babies. Three of the tubes had minor mechanical complications. RESULTS: The weight loss or gain during the period of hospitalization was not significant (P = 0.3) Breast milk was the most common nutrient. Thirteen of the 14 babies weighing more than 1.5 kg were discharged and are being followed; the remaining baby died from neonatal septicemia. Excellent results can be obtained with aggressive enteral nutrition support in newborns undergoing upper intestinal surgery. CONCLUSIONS: Transgastric, transanastomotic feeding jejunostomy was well tolerated by the newborns and is preferable to parenteral nutrition.

Management of accessory hepatic ducts in choledochal cysts.

This report describes the surgical management of 2 children with fusiform choledochal cysts who had accessory hepatic ducts (AHD) identified during excisional surgery for fusiform choledochal cysts (CC). Two children presenting with a triad of recurrent jaundice, fever, and abdominal pain were investigated and found to have type 1 choledochal cyst. Preoperative imaging and intraoperative cholangiography missed the AHD in both cases. In one of the patients, the main and the accessory ducts were separated by the right hepatic artery. In both the patients the accessory ducts were reconstructed successfully into a Roux loop along with the main common hepatic duct. Follow-up studies showed no evidence of biliary tract obstruction or atrophic changes in the liver. There was satisfactory uptake and drainage on hepatic scintigraphy. During excision of CC, AHD may be encountered. These may be missed on preoperative imaging. AHD may have a close relationship with neighboring vascular structures in the porta. Accessory hepatic ducts should be anticipated, identified, and reimplanted into the Roux loop during excisional surgery.

Anorectal malformation with malrotation of gut.

Infants with anorectal anomaly have a high risk of having other congenital anomalies, but associated gastrointestinal tract anomalies are quite rare. Malrotation of gut is rarely associated with anorectal anomaly. We report two such cases of anorectal malformation with malrotation of gut. The high index of suspicion, diagnostic difficulty and surgical management with avoidance of appendicectomy in these neonates is discussed.

Prospective analysis of renal function and somatic growth in neonatal posterior urethral valves.

AIM: The present prospective study focuses on the effect of transurethral fulguration (TUF) and vesicostomy on the renal functions and somatic growth in posterior urethral valves (PUV). PATIENTS AND METHODS: 37 consecutive neonates were diagnosed and treated for PUV with vesicostomy (18 patients) and TUF (19 patients). Postoperative stable creatinine values, renal function and somatic growth were recorded. Standard anthropometric techniques and standard statistical methods were used to compute distance statistics for body weight and crown-heel length at age intervals of 3 months for the first year. OBSERVATIONS: The distance values of body weight and crown-heel length of these groups of children were less than the 5th percentile of the National Centre For Health Statistics (NCHS) and healthy Punjabi infants showing growth retardation in the first year of life. Pre- and postoperative mean serum creatinine of the fulguration group was 1.5 +/- 1.5 mg/dl and 0.8 +/- 0.3 mg/dl and for vesicostomy it was 2.4 +/- 2.2 mg/dl, and 0.9 +/- 0.7 mg/dl respectively. The babies of the fulguration group showed better growth attainments than the babies of the vesicostomy group at the end of one year. CONCLUSION: At the end of one year, babies of the fulguration group had a similar growth velocity compared to the vesicostomy group, though in general they showed retarded growth compared to healthy counterparts. The modality of treatment chosen did not seem to affect the renal functions or somatic growth in the short-term follow-up.

Helicobacter pylori infection in patients with perforated duodenal ulcer.

AIM: Perforation is the commonest complication of duodenal ulcer. Helicobacter pylori is found in 95% patients with duodenal ulcer. However, there is paucity of reports on prevalence of H. pylori infection in patients with duodenal ulcer perforation. We, therefore compared the incidence of H. pylori infection in patients with duodenal ulcer perforation with the incidence in patients having complicated duodenal ulcers and non-ulcer dyspepsia. PATIENTS AND METHODS: The study was conducted on 45 patients (complicated duodenal ulcer 15, duodenal ulcer perforation 15, non-ulcer dyspepsia 15). Per-operative punch antral biopsies were taken in patients with duodenal ulcer perforation whereas endoscopic punch biopsies of antrum were taken in patients with non-ulcer dyspepsia. The criteria for H. pylori positivity was i) growth of H. pylori on culture, ii) combination of rapid urease test (RUT) and Giemsa staining, combination of RUT and Gram stain being positive for H. pylori. RESULTS: While 9 of 15 cases with complicated duodenal ulcer, 7 of 15 cases with non-ulcer dyspepsia were positive for H. pylori, none of the patients with duodenal ulcer perforation tested positive for H. pylori (p < 0.000). All patients with perforated duodenal ulcer had histological gastritis (H. pylori -ve). Fourteen of 15 patients (9 H. pylori +ve, 5 H. pylori -ve) with complicated duodenal ulcer and 9 of 15 patients (7 H. pylori +ve) with non-ulcer dyspepsia had histological gastritis. CONCLUSION: Patients with duodenal ulcer perforation do not have H. pylori infection. H. pylori negative patients of duodenal ulcer may have more predilection for perforation.

Delivery systems for pediatric parenteral nutrition.

Delivery systems for parenteral nutrition have to be based on fundamental principles regarding venous access, choice of intravenous line, need for inline filters, infusion rate control and mode of packaging into "all in one" bags/two line/or the older three line system and, above all, the aseptic maintenance of this delivery system. Delivery systems need to be modified as per the available resources and hospital where they are to be used. Central venous access and handling of lines demand a high level of dedication and discipline, ideally left to a dedicated team of nurses and doctors. Staff training is the key factor in developing an efficient delivery system.

Management of anorectal malformation in neonates.

Anorectal malformations are one of the commonest anomalies in the new born. Major advances have been made in the last decade in operative techniques to reconstruct this abnormality. The final outcome in these babies is dependent on careful planning and operative intervention in the neonatal period. The purpose of this paper is to discuss the varied presentations of this anomaly, initial assessment and operative management with reference to our own experience.

Crohn's disease: disastrous consequences of late diagnosis.

Chronic and recurrent perianal abscess is an uncommon condition in children. Tuberculosis is thought to be the common etiology for such a presentation in India. We report a case of a child with colonic and perianal disease due to Crohn's disease and emphasize the disastrous complication due to delayed diagnosis.

Shah Waardenberg syndrome.

Intermittent or partial small bowel obstruction in a neonate may be a rare presentation of total aganglionosis. The presence of partial albinism and white forelock should alert the clinician to the possibility of associated Hirschsprung disease as a cause of bowel symptoms. Such a rare association has been called Shah Waardenberg syndrome and is being reported.

Minimal access surgery in children:a 5 year study.

Over a period of 5 years, we analyzed our data on outcome, feasibility, and safety of Minimal Access Surgery (MAS) in 211 children. The outcome was compared objectively with age matched controls with similar diagnosis undergoing open surgery over the same period. There was no significant difference between mortality, morbidity, re-exploration rates and analgesic requirement between MAS and open surgery. There was a significant difference in the length of stay in hospital, in favour of laparoscopic cholecystectomy, appendectomy, nephrectomy, splenectomy, surgery for intra-abdominal testis compared to open surgery but not for children undergoing surgery for appendicular perforation and intestinal pathology. All parents preferred the cosmetic outcome of minimal access surgery.