Hyponatremia among Postoperative Children Administered with Hypotonic Fluids in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Hypotonic solutions in postoperative children may cause hyponatremia. Considering humidity and temperatures in India, this study was conducted to find out the prevalence of hyponatremia among postoperative children who were administered with hypotonic solutions in a tertiary care hospital. METHODS: A descriptive cross-sectional study was conducted at a tertiary care hospital. Ethical approval was taken from the institutional review board of Christian Medical College, Vellore, India (Reference number: 9177). Children aged less than 15 years undergoing elective surgery, requiring fasting for more than 12 hours post-operatively with normal preoperative electrolytes and renal functions were included. Hypotonic fluids were administered following existent protocol. Electrolytes were repeated immediate postoperatively and at 12-24 hours. Data was entered into and analyzed using the Statistical Package for the Social Sciences version 18.0. Point estimate at 90% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Among 109 participants, hyponatremia in the postoperative period was seen in 53 (48.6%) (40.7-56.5 at 90% Confidence Interval) children. Hyponatremia was found in the immediate postoperative period in 10 (9.2%) children. All received Ringer Lactate as maintenance intra-operatively and none were severe enough to need correction. In the 12-24-hour sample, 43 (39.41%) had hyponatremia and none in severe category. CONCLUSIONS: Asymptomatic hyponatremia was noted in normal children planned for elective surgery. Among children managed with the existing institutional perioperative (hypotonic) fluid management protocol, subclinical postoperative hyponatremia within 12-24 hours of surgery was noted in a significant proportion, which was more in the hot and warm months in tropics. There are grounds for switching to isotonic fluids for perioperative management.

Testicular Volume in a Cohort of Prepubertal Indian Children.

CONTEXT: There are orchidometer-based testicular volume nomograms for Indian children; however, accurate and reliable values measured by ultrasound are lacking. AIMS: The aim of this study was to (1) measure the testicular volumes of boys from birth to 8 years and generate reference values and (2) to identify factors if any that may influence variation in testicular volumes. SETTINGS AND DESIGN: This was a prospective observational study conducted on 320 children in the Department of Pediatric Surgery, Christian Medical College, Vellore, India. SUBJECTS AND METHODS: A total of 320 boys without any genital abnormalities were studied. The testes were scanned using a linear transducer, and the length, width, and depth of each testis were recorded. Testicular volume was calculated using Lambert's equation - length × width × depth × 0.71. STATISTICAL ANALYSIS USED: Mean testicular volumes and standard deviation for every year of age were calculated. The centile values for testicular volume were computed using R software. RESULTS: Age-specific nomogram of each testis was created separately. Interobserver variability of the measurement was shown to be up to 0.3 ml. No difference was demonstrated in the testicular volumes between the right and left testis. No correlation was found between body weight and body mass index with testicular volume. From the data on differences in size between the two sides, a volume differential index of 27% corresponds to the 95th centile. CONCLUSIONS: Reference values have been created for testicular volumes in prepubertal Indian children that could be used to assess the effects of disease and surgical interventions in this age group.

Laparoscopic cholangiogram in biliary atresia: a refinement in the gallbladder hitch technique.

INTRODUCTION: The study describes a refinement in the gallbladder hitch stitch and assesses the value of the laparoscopic cholangiogram in children with suspected biliary atresia. METHODS: Twenty children with neonatal jaundice and no drainage as shown on the HIDA scan underwent a diagnostic laparoscopy through an umbilical 5 mm port. A 3 mm laparoscopic needle holder inserted through a 3.5 mm port to the left of the umbilicus was used to hitch the gallbladder to the abdominal wall. The stylet of a large bore 16F IV cannula then was used to penetrate the gallbladder to perform the laparoscopic cholangiogram. RESULTS: There was no need for conversion in all 20 children by this technique. Patent biliary anatomy was demonstrated in 11 children (11/20). These children had no further procedures. In 3 (3/20) children, the common bile duct was demonstrated, while the hepatic ducts were not. These children had a laparotomy for Kasai procedure after an open cholangiogram with a vascular bulldog clamp on the CBD confirmed the finding. Six (6/20) had no demonstrable patency; 3 had it confirmed when the abdomen was opened for the Kasai procedure; only those proceeding to Kasai portoenterostomy (3 hepatic duct atresia, 3 complete biliary atresias) had an epidural catheter placed by the anesthetist. The remaining 3 had no further procedure performed due to the advanced nodular liver with ascites and evidence of portal hypertension. CONCLUSION: The findings of laparoscopic cholangiogram were confirmed in all six children who underwent laparotomy for Kasai procedure. The laparoscopic cholangiogram using gallbladder hitch reliably demonstrates a patent biliary system (11/11) and was valuable in avoiding further invasive procedures in 70% (14/20) of babies.

Pneumonostomy in the Surgical Management of Hydatid Cyst of the Lung.

Background Pneumonostomy in the surgical treatment of bilateral hydatid cyst of the lung(HCL) was described by Anand et al. This study presents the comparative long-term results of pneumonostomy for simple and complicated HCL. Methods and Patients The pneumonostomy technique was applied to both open and minimally invasive operations. The cyst was opened, endocyst removed, and any bronchial openings closed. The pericyst was closed over a 20-French Malecot tube, which was exteriorized and connected to an underwater seal. The tube was removed after 3 weeks by which time a well-established tract had formed. Hospital records of 26 children with 30 HCL who underwent pneumonostomy between 2001 and 2014 were reviewed and followed up. Patients were analyzed in two groups:group1 comprised uncomplicated and group2 complicated HCL. There was a statistically significant difference in the age at presentation in the two groups. The groups were comparable with respect to presenting symptoms, sex ratio, and side or size of cyst. Results Six(20%) children with surgical complications were graded by Clavien-Dindo classification. Three(10%) children qualified as grade 1 and did not require pharmacologic or surgical therapy. Three(10%) children had grade 3 complications; two developed empyema and one pneumothorax. There were no prolonged air leaks. Children with complicated cysts did not require longer hospitalization. Follow-up was possible in 80.76% of the children. The mean duration of follow-up was 21.3 months (interquartile range, 5-63 months). There were no postoperative recurrences or disease-related mortality. Conclusion Pneumonostomy is a safe and effective technique for dealing with the residual cavity in large complicated cysts and bilateral HCL.

Clinical profile and management options of children with congenital esophageal stenosis: A single center experience.

AIM: The aim of the study is to review 7 patients with congenital esophageal stenosis treated in our institution from a diagnostic and therapeutic point of view. MATERIALS AND METHODS: This is a retrospective cohort study of 7 patients treated in Christian Medical College, Vellore from 2008 to 2014. The data were analyzed with regards to age at onset of symptoms, investigative findings, age at definitive treatment, pathology, modalities of treatment, and outcomes. RESULTS: Symptoms started within the 1(st) year of life in all children with a median age of 4 months. The time of delay in diagnosis ranged from 8 months to 81 months with a mean period of 37 months. About 6 patients had a lower esophageal stenosis and 1 patient had a mid-esophageal stenosis. About 4 of the 7 children underwent endoscopic balloon dilatation from elsewhere, with 2 of the above 4 undergoing a myotomy for a wrongly diagnosed achalasia. The number of dilatations ranged from 2 to 7 with a mean of 4 dilatations. Resection of the stenotic segment with end to end anastomosis was employed in 6 of the 7 patients, and a transverse colon interpositioning was done in 1 patient. An antireflux procedure was performed in one patient. Histopathological examination of the resected specimen revealed tracheobronchial remnant in 3 patients, fibromuscular thickening in 3 patients, and membranous web in 1 patient. Postoperatively, 2 of the 7 patients had asymptomatic gastroesophageal reflux and 1 patient had postoperative stricture requiring one session of endoscopic balloon dilatation. The mean follow-up period was 42 months (range 18-72 months). At the time of the last follow-up, all 7 patients were able to eat solid food, and none of the children were found to have symptoms suggestive of obstruction or gastroesophageal reflux. There was a statistically significant increase in the weight for age after the operation. CONCLUSION: Congenital esophageal stenosis is rare and often confused with other causes of esophageal obstruction. Although endoscopic balloon dilatation offers an effective temporary relief, we feel that definitive surgery is curative. Long-term results following definitive surgery have been good, especially with respect to symptoms and weight gain.

An assessment of quality of life of operated cases of esophageal atresia in the community.

AIMS: To evaluate the outcome of the operated children of esophageal atresia (EA) focusing on their early and late morbidity and mortality and quality of life (QoL) of survivors. SETTINGS AND DESIGN: A cross-sectional follow-up with retrospective analysis of available medical and surgical records of children who underwent repair for EA. MATERIALS AND METHODS: The medical records of the children who underwent repair for EA during the period from 2000 to 2011 at the Christian Medical College Hospital, Vellore, were collected retrospectively. Patients with parents were invited to visit the hospital for follow-up and nutritional status, digestive and respiratory symptoms, status of associated anomalies and QoL assessment of children done. QoL assessment was done using the PedsQL™ 4.0 generic core scales questionnaire comprising 4 scale scores: physical, emotional, social functioning, and school functioning. Mean scores are calculated based on a 5-point response scale for each item and transformed to a 0-100 scale with a higher score representing better QoL. STATISTICAL ANALYSIS USED: Statistical Package for Social Sciences (SPSS) version 16 using Chi-square or Fisher's exact test. RESULTS: Of 79 patients operated during the said period, there were 10 deaths and a total of 69 (87%) children survived. Of the 66 patients available for follow-up, we interviewed 30 parents and children while for the remaining 36 children, out-patients charts were reviewed retrospectively. Mean follow-up duration was 3.56 years. The height and weight for age measurement showed 47% and 56% of children respectively as below the 5(th) percentile. Main problems faced by operated EA children were of the respiratory (26%) and gastroesophageal (36%) tracts. In spite of the mentioned problems faced, the overall QoL of this group appeared good. In 23 of 30 patients, who answered PedsQL™, more than 70% had scores >85 out of 100 in QoL scoring. CONCLUSIONS: While survivals of the children born with EA have improved, these children still face nutritional, respiratory, and gastroesophageal problems during their early childhood. In spite of this, the overall QoL of this patient group appears good.

Enteric duplication in children: Experience from a tertiary center in South India.

BACKGROUND: Enteric duplications (EDs) are rare aberrations of the embryonic gut. This study was undertaken to define the clinical characteristics and management challenges of this unusual entity in the Indian population. MATERIALS AND METHODS: Hospital records of 35 children with 38 ED operated between 2003 and 2014 were analyzed and followed up. RESULTS: The median age at presentation was 285 days (range 1-day to 16 years) with male preponderance (71%). Small bowel duplications were the most common (44%), and thoracoabdominal duplications were seen in 8% children compared to 2% in the literature. The median duration of symptoms was 18 days (interquartile range [IQR] 3-210 days). Associated anomalies were seen in 49% children with vertebral and spinal anomalies being the most common. Ultrasonogram (US) was done in 83% children and had a sensitivity of 55%. In the presence of a gastrointestinal bleed, Technetium(99m) pertechnetate scintigraphy scan had a positive predictive value of 80%. Thirty-five lesions were completely removed. Mucosectomy was done in two children, and one total colonic duplication was left in situ after providing adequate internal drainage. There was no postoperative mortality. The follow-up was possible in 66% children. CONCLUSIONS: EDs are uncommon and have varied, nonspecific symptoms. Thoracoabdominal duplications are more common in the Indian population. The US is a good screening tool but requires a high index of suspicion where complete excision is not possible; the provision of adequate internal drainage is an acceptable alternative. The long-term prognosis of children with ED depends on the extent of physiological disturbance due to associated anomalies.

The Effect of Entonox, Play Therapy and a Combination on Pain Relief in Children: A Randomized Controlled Trial.

Pediatric pain is often undertreated/neglected due to time constraints, difficulties in timing of oral analgesics, fear of side effects of opioids and anxiolytics, and apprehension of additional pain in the use of local anesthetic injections. In this study, the researcher was prompted to choose rapidly acting interventions that were low dose and allowed the child to stay alert, suitable for a quick discharge. The purpose of this study was to evaluate the effects of Entonox, play therapy, and a combination to relieve procedural pain in children aged 4-15 years. The study was designed as a randomized controlled trial; the subjects were divided into four groups using a sequential allocation plan from 123 total subjects. Group A received Entonox, Group B received play therapy, Group C received both Entonox and play therapy, and Group D received existing standard interventions. The study was vetted by the departmental study review committee. The pain level was assessed using FLACC scale for children aged 4-9 years and the Wong Bakers Faces Pain Scale for children aged 10-15 years; scores ranged from 0 to 10. All the data were analyzed using SPSS 16.0 with descriptive statistics and, inferential statistics. The mean pain scores were as follows: Entonox group, 2.87; Play therapy group, 4; combination group, 3; and control group, 5.87. When statistical testing was applied, a significant reduction in the pain score in all the three experimental groups when compared to the control group was found (p = .002), but not in the pain score among the three experimental groups (p = .350). The findings of this study indicated that all three interventions were effective in lowering pain scores when compared to the control group. Play therapy is as potent as Entonox in relieving procedural pain, though there was no additive effect on pain relief when play therapy and Entonox were combined. A protocol for age-related choice between play therapy and Entonox administration was introduced as a standing order in the Pediatric Surgery department for acute procedural pain relief.

Bowel vaginoplasty in children and young women: an institutional experience with 55 patients.

INTRODUCTION AND HYPOTHESIS: Absence of a vagina owing to congenital Mullerian defects or other acquired causes requires reconstruction of the female genital passage. We present our experience using various bowel segments. METHODS: Bowel vaginoplasty was performed in 55 patients from January 2004 through May 2014 for cervicovaginal atresia (20), Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome (20), distal vaginal atresia (8), cloaca (2), cervical atresia (1), complex urogenital sinus (1), transverse vaginal septum (1), rhabdomyosarcoma of the vagina (1), and traumatic stricture of the vagina (1). The bowel segments used were sigmoid (50), ileum (2), anorectovestibular fistula ( 2), and loop rectovaginoplasty (1). RESULTS: Thirty-nine patients who had the proximal vagina or uterus anastomosed to the bowel segment reported regular menstrual flows. Three patients are sexually active with satisfactory coital function. None of our patients developed pyometra. Five patients had neovaginal mucosal prolapse. Two patients had severe stenosis requiring excision of the neovagina. Seven patients had mild stenosis requiring dilatations in 6 patients and V-Y meatoplasty for 1 patient. One patient had a descending colon anastomotic leak requiring a diversion ileostomy. CONCLUSIONS: Genital reconstruction with bowel vaginoplasty is a highly skilled operation that provides a durable and lubricated replacement of the vagina with good outcomes. Utero-coloneovaginoplasty is a safe procedure preserving the menstrual flow in patients with a functional uterine fundus.

Cervicovaginal atresia with hematometra: restoring menstrual and sexual function by utero-coloneovaginoplasty.

BACKGROUND: Cervicovaginal atresia is a rare Mullerian anomaly. The management of cervicovaginal atresia has evolved from historical recommendations of hysterectomy to various reconstructive procedures more recently. The latter carries a risk of significant morbidity and unknown fertility. We present our experience in the management of this complex anomaly. METHODS: Twenty patients with cervicovaginal atresia were operated in our hospital from January 2004 through December 2013. The details of their anatomical variations and functional outcomes were analyzed. RESULTS: Eighteen out of twenty patients had cervical agenesis. Two patients had cervical hypoplasia. All patients underwent utero-coloneovaginoplasty. Post operatively, all patients have regular menstrual cycles. One patient is married, sexually active and has satisfactory coital function. One patient had a bowel anastomotic leak that required a diversion ileostomy. Two patients developed mild stenosis. One patient has mild neovaginal mucosal prolapse. No patient has developed pyometra. CONCLUSION: Patients with cervicovaginal atresia need to be counselled about the various reconstructive options available and the potential risks. Social and economic factor play a significant role in determining the plan of management. For patients from conservative societies, utero-coloneovaginoplasty provides a safe conduit for the passage of menstrual flow and coitus, at the cost of permanent infertility.

An uncommon twist: isolated fallopian tube torsion in an adolescent.

We report a 13-year-old girl with bilateral paratubal cysts and left isolated fallopian tube torsion (IFTT). Paratubal cysts are uncommon in children, and IFTT is a rare complication. Awareness of this entity and prompt surgical intervention could potentially salvage the fallopian tube preserving fertility.

A helping clamp for thoracoscopic plication of eventration of the diaphragm.

BACKGROUND AND AIM: It is difficult to suture an extremely thin and billowed up congenital eventration of the diaphragm thoracoscopically, without insufflation. MATERIALS AND METHODS: The authors describe their technique using an intestinal clamp to control the redundant tissue and a feeding tube as a flexible knot pusher, to perform the thoracoscopic plication without risking hypercapnia. RESULTS: A satisfactory result was obtained in all the four children. CONCLUSION: This is a useful adjunctive for thoracoscopic plication of diaphragmatic eventration.