Implantable Venous Access Devices in Pediatric Malignancies - Institutional Experience in a Developing Nation.

BACKGROUND: Implantable venous access devices (IVAD) are preferred over long term external catheters in children due to less infection rates and better patient compliance in pediatric malignancies. Use of IVAD is a routine practice in developed part of the world. However it needs more emphasis for its widespread use in developing nation in order to improve the quality of care in children with malignancy. AIMS AND OBJECTIVES: We aimed at analyzing the outcome of IVAD in pediatric malignancies in a tertiary care set up of developing nation. Our objective is to enlighten the importance and feasibility of IVAD in childhood malignancies with review of literature. MATERIALS AND METHODS: There were 152 children who underwent IVAD insertion in the study period. The parameters analyzed were indications, patient demography, size of the port, laterality of insertion, method of access to internal jugular vein (IJV), duration of surgery, time for access, complications, indication for removal and the parental satisfaction. RESULTS: Mean age was 48 months. 112/152 patients had hematological malignancies. Right sided IJV was used by default in 97.4% patients, while remaining 2.6% had their left IJV cannulated. Open venotomy was used in 14 cases and 138 underwent ultrasound guided IJV access. The position of the catheter was reconfirmed in the X-ray, 6-8 hours after surgery. 149/152 ports were accessed 12 hours after surgery, whereas remaining 3 had a delay in access for 24 hours. Post operative complications were divided into early and late. 141 ports were removed after completion of chemotherapy, 4 were removed due to complications. 93 of parents gave the response as "satisfied". CONCLUSION: With proper training and expertise, insertion and care of IVAD is safe in pediatric malignancies without significant complications.

Institutional experience with laparoscopic-assisted anorectal pull-through in a series of 17 cases: A retrospective analysis.

AIMS: To retrospectively analyse the results of laparoscopically-assisted anorectal pull-through (LAARP) for high anorectal malformation (ARM) in male children in our institution. MATERIALS AND METHODS: We analysed the hospital records of patients who had undergone LAARP from October 2010 to December 2015 in terms of age, operative time, length of hospital stay and post-operative complications. RESULTS: Of 17 cases, 13 (76%) were in 6-12 months age group, whereas rest of them were in 12-18 months age group. The recto-prostatic urethral fistula was encountered in 82% (n = 14) of patients and rectovesical type in two cases (12%). The mean operative time was 132 min with mean length of hospital stay being 4 days. Rectal mucosal prolapse was the most common complication noted. CONCLUSIONS: LAARP is a feasible approach to male children with high ARMs with less post-operative morbidity.

Isolated Ileal Pancreatic Heterotopia Causing Intussusception with Gangrene.

Isolated ileal heterotopic pancreatic tissue as a lead point of intussusception in children is extremely rare. We report a 6-month-old female with ileoileal intussusception and a 4-year-old female with ileocolic intussusception both associated with gangrene. A review of literature suggests a higher prevalence of gangrene probably secondary to the pancreatic exocrine tissue.

Laparoscopic management of gastric volvulus, diaphragmatic eventration and wandering spleen in a child.

Gastric volvulus (GV) and wandering spleen (WS) associated with eventration of diaphragm share a common pathological cause of absence or laxity of intraperitoneal ligaments. We herein report a rare case of a 13-year-old child presenting with an acute GV, WS, diaphragmatic eventration and an ectopic ascended kidney managed with a laparoscopic approach.

Urethral duplication in a 1 year old: a rare case report.

An 8-month-old male child presented with the complaint of two separate urinary streams from the penis. The child had no complaints of incontinence or recurrent UTI (urinary tract infection). Initial diagnosis of urethrocutaneous fistula was made and proceeded to micturating cystourethrography (MCU) and found to be having a urethral duplication. The duplicated urethra was excised and accessory urethra closed. Postoperatively, the child was followed up for 1 year and had no complaints of recurrence or incontinence. Through this case report, we learn about different classification systems and types of urethral duplication and their associated anomalies, and mode of management, which is mainly surgical. Further, management should be individualised to each patient based on their complaints and intraoperative findings.

Rare cause of extravasation from implantable venous access device.

Implantable venous access devices are routinely used, but they are not without complications. A 4-year-old male child with B cell acute lymphoblastic leukaemia was planned for chemotherapy. Chemo port was accessed through the right internal jugular vein. Check X-ray was done, which showed the correct placement of the catheter. Two months after chemo port insertion when the patient underwent chemotherapy, he developed a fever and he was started on intravenous antibiotics. On the next two admissions, the patient had a fever with chamber site oedema for which culture was done, which revealed Pseudomonas and Candida, which responded to antibiotic and antifungal therapies. In the successive admission, the patient had immediate local oedema on injecting chemotherapy. Exploration was done, which revealed chamber base perforation. It is an infrequent complication and has been reported in only three studies.

Health-related Quality of Life in Children with Congenital Hydrocephalus and the Parental Concern: An Analysis in a Developing Nation.

PURPOSE: To analyze quality of life of children operated for congenital hydrocephalus and the concern of parents in taking care of these children. METHODS: Thirty patients who underwent ventriculo-peritoneal shunt were randomly selected with minimum gap of 1 year between surgery and study. Canadian validated questionnaire was used. Overall health score (OHS) and parental concern score (PCS) were correlated with gender, family type and number of surgeries. RESULTS: Mean OHS was 159.43 which was summation of physical health (mean 45.76), social-emotional (mean 80.03) and cognitive health scores (mean 33.66). Mean OHS was 151.57 for males and 177.77 for females (p-value 0.233). Nuclear and joint families had mean OHS of 160.36 and 158.89 respectively (p-value 0.944). Those who underwent one surgery had mean OHS of 167.48 and PCS of 23.10 whereas mean OHS was 140.66 and PCS was 27.78 for those with multiple procedures. Mean PCS for males was 26.71 and for females was 19.33 (p-value 0.036 statistically significant). This was not statistically significant between nuclear (24.73) and joint families (24.26). CONCLUSIONS: Quality of life of survivors of hydrocephalus is reasonably good even in developing countries due to keen parental involvement irrespective of gender, family type and number of surgeries.

Dysphagia because of unilateral internal jugular vein phlebectasia in an infant.

Phlebectasia affecting the internal jugular vein is a rare cause of a benign neck swelling in children. They are mostly asymptomatic and therefore managed conservatively. Ligation of the vein and excision is usually avoided owing to the worry of raised intracranial pressure. We report a case of a large right internal jugular vein phlebectasia, causing dysphagia in a 7month old male child. Contrast enhanced computed tomography with 3-D reconstruction helped in pre-operative anatomical delineation, especially of the lower extent. It was excised through a cervico-thoracic approach with postoperative amelioration of symptoms. Contrary to expectation, the ectasia was not friable and was covered with a pseudocapsule of fibrofatty tissue, making excision easy.

Barriers to Pediatric Pain Management in Children Undergoing Surgery: A Survey of Health Care Providers.

The appropriate pain management in neonates and children is lacking. Factors that prevent the execution of proper pain relief vary from center to center. We studied the factors responsible for it in a surgical unit. We conducted a survey at a tertiary-level institute among the resident doctors and nursing staff by means of an informal questionnaire analyzing their basic knowledge. The questions pertained mainly to pain assessment, analgesic usage, role of opioids, and formal training, and the responses so obtained were analyzed under these four headings. Seventy-three percent (22/30) of the residents and 74% (26/35) of the nursing staff knew about pain assessment scoring system in pediatric patients. However, assessment of pain in emergency cases was always done by only 6.6% of the residents. Effect of analgesia on severity of pain was never recorded by 33% (10/30) of the residents. Eighty-six percent (26/30) of the residents and 91% (32/35) of the nursing staff had adequate knowledge about analgesic dosage and interval for routine use. Ten of the 30 (33%) residents believed that analgesic administration in an acute abdomen, before definitive diagnosis, will always mask the symptoms. During a minor procedure, 56% (17/30) of the residents always used analgesia. Only 3.3% (1/30) of residents and 2.8% (1/35) of the nursing staff had received a structured training for pain management. Although, 93% (28/30) of the residents claimed to know about the safety of use of opioids, only 46% (14/30) used them routinely as analgesics. Pain management in surgical neonates and children is often ignored. Lack of formal training, inadequate knowledge, and standard protocols are the barriers in our setup, which may in turn be due to overwhelming attention given to the surgical condition.