Effect of preoperative estrogen on complications after proximal hypospadias repair: A randomized controlled trial.

Introduction: Proximal hypospadias repair has many postoperative complications such as urethrocutaneous fistulae, wound dehiscence, and urethral stricture. The beneficial effect of estrogen to promote wound healing has been known. We designed a study to determine whether preoperative stimulation of tissue with estrogen can reduce the postoperative complications associated with wound healing in patients undergoing hypospadias repair. Methods: Patients with proximal hypospadias requiring two-stage repairs (chordee correction followed by urethral tubularization) were randomized to estrogen and control groups before the second stage of surgery. In the former, topical estrogen cream (0.5 mg of estriol) was applied to the ventral penis for a month, whereas normal saline gel was applied to the latter; the urethroplasty was carried out thereafter. Patients were followed up for complications. Results: There were 29 patients in the estrogen group and 31 in the placebo group after the exclusion criteria were met. There was no significant difference in the overall postoperative complications between the estrogen group (44.8%) and the placebo group (51.6%). The occurrence of urethrocutaneous fistula (37.9% vs. 51.6%) and dehiscence (41.4% vs. 45.2%) was not significantly different between the estrogen and placebo groups. Neourethral stricture occurred in four patients in the estrogen group, while none of the patients in the placebo group developed stricture. Conclusions: The preoperative application of topical estrogen cream to the ventral penis failed to demonstrate any significant effect on wound healing and complications.

Prevalence of Pancreato-Biliary Maljunction in Children with Choledochal Cyst - A Prospective Observational Study.

Background: Pancreatico-biliary maljunction (PBM) is often found to be associated with choledochal cysts (CCs). According to a European multicenter study, the prevalence of PBM in cases of CC is found to be 72.2%, however, there is no Indian study depicting the prevalence of PBM in Indian children with CCs, which is one of the main postulated factors in the etiopathogenesis of CC. In this study, we have attempted to observe prospectively the prevalence of PBM in children with CC and correlate this to its morphological and biochemical parameters. The association between the presence of PBM and histopathological findings such as epithelial changes of the mucosa of the CC, inflammation, metaplasia or dysplasia, and histopathology of the liver has also been evaluated. Materials and Methods: We carried out a single center, prospective observational study with a single arm study group. We prospectively selected all patients of CC admitted for surgery from November 2018 to October 2020. Data on biochemical, radiological, and histopathological parameters were collected and analyzed. Results: We included a total of 20 patients in our study. The mean age of the participants was 6.22 ± 4.32 years. Among them, 11 (55.0%) were male and 9 (45%) were female. Abdominal pain was the most common presenting complaint among our patients (75.0%) and had a significant association with the presence of a PBM (P = 0.001). In symptomatic children, the mean duration of symptoms was 4.50 ± 2.26 months for jaundice, 4.50 ± 1.98 months for abdominal distension, and 5.07 ± 2.02 months for abdominal pain. Among the 3 children with cholangitis, the mean number of episodes was 3.33 ± 2.08, with a median of four episodes. Fourteen (70.0%) of the children had type I a CC, 1 (5.0%) participant each for types I b, I c, II and IV a and 2 (10.0%) of them had type IV b cyst. The mean size of the cyst (cm) was 7.41 ± 3.03 with a median of 6.85 cm. Among the children, 9 (45%) showed the presence of PBM on magnetic resonance cholangiopancreatography (MRCP), with 7 (77.8%) showing Komi's C-P type and 2 (22.2%) showing Komi's PC type. The mean common channel length (mm) on MRCP was 8.11 ± 2.47 with a median length of 8.00 mm. The biochemical analysis of a bile fluid amylase and lipase is the functional indicator of the presence of a PBM. Histopathological examination showed the presence of ulceration in the walls of the CC in 10 (50.0%) of the specimens. There was a significant association of the presence of PBM and ulceration in the mucosa of the CC (P ≤ 0.001), with the median levels being the highest in the PBM present group. Conclusion: Abdominal pain is the most common complaint in a child with CC, and when present, it is significantly associated with the presence of a PBM. MRCP is the gold standard tool to detect CCs and find out the morphology of PBM. The prevalence of PBM in children with CC of 45% with a mean common channel length of 8.11 mm. The biochemical analysis of a bile amylase and lipase is the functional indicator of the presence of a PBM and there is a significant association of their higher levels and presence of PBM. The presence of chronic inflammation and microscopic ulcers is significant histologic parameters depicting the presence of a PBM.

Biliary Cystadenoma in a Child: A Rare Entity.

Biliary cystadenoma, a rare potentially malignant hepatic cystic lesion, is characterized by multiloculations and septations. It is common in middle-aged females (about 5% of nonparasitic liver cysts); only 12 cases are described in children. We report a rare case of hepatic biliary cystadenoma in a 3-year-old girl, with a gradually increasing lump in the right upper abdomen. Complete excision with a healthy liver margin was done.

Phimosis - Are we on right track?

Background: Phimosis, a common paediatric condition, is defined as the inability to retract the preputial skin behind the glans. Current practice shows there is some confusion among the paediatricians towards this common condition and in differentiating it from the more common physiological preputial adhesion; leading to frequent referrals to a paediatric surgeon or a general surgeon, which can be addressed by the parents and the child physicians themselves. Aim: To find out the awareness towards the management of phimosis among the paediatricians. Materials and Methods: A questionnaire on this topic was generated using 'Google Forms' and was circulated among junior and senior residents, faculty in various medical colleges and consultants in private practice all over India and their response was collected and analysed. Results: We received a total of 221 responses from all over India from paediatric medicine trainees and consultants. Among them, majority (48%) were senior residents. According to the survey participants, the most (46%) find inability to retract the prepuce as the major presenting complaint. A straight away reference to a paediatric surgeon was preferred by majority of paediatricians (62.9%), though most of them were aware of them were aware of physiological adhesions and conservative management (94.2%). There was a belief among 43% about counselling each and every patient presenting with phimosis for circumcision. Among the respondents, 60.2% advised ultrasound of kidneys, ureter, and bladder to their patients and believed that backpressure changes alter the management of the child. A urine routine examination was advised by 70.1% of participants, with 46.6% believing that the presence of urinary tract infection changes the management of phimosis. Waiting up to 1 year of age before going for surgery was advocated by 71.5%. A major proportion of respondents (76%) believed all cases of phimosis should be referred to a surgeon, only 58.8% would voluntarily follow them up. There is still a belief among 69.7% of participants that all cases of phimosis should be referred to a paediatric surgeon and only few of them, 5.4% feel referring only indicated cases. Conclusion: Physiological phimosis is a common condition which can be addressed by the paediatricians themselves. Awareness is to be increased among them, especially during the training period regarding the proper management of this common condition, avoiding unnecessary circumcisions.

Pedunculated cavernous lymphangioma of the newborn oral cavity.

Oral swellings and ulcers in neonates are a spectrum of diseases often creating a sense of anxiety among parents. Early detection, high index of suspicion, proper investigations, and prompt diagnosis can aid in accurate management of the same. Lymphangiomas are benign hamartomas which are basically malformed lymphatics do not drain into other lymphatics or veins and hence there is lymphatic accumulation and enlargement following cystically dilated spaces. We hereby present a rare case of a neonate born with a cystic mucosal swelling at the upper gingival sulcus since birth.

Ultrasound-guided transverse abdominis plane block, ilioinguinal/iliohypogastric nerve block, and quadratus lumborum block for elective open inguinal hernia repair in children: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Ultrasound-guided ilioinguinal/iliohypogastric (II/IH) nerve blocks and transverse abdominis plane (TAP) blocks are widely used for postoperative analgesia in children undergoing inguinal hernia repair (IHR). Quadratus lumborum block (QLB) provides analgesia for both upper and lower abdominal surgery. Very few randomized controlled trials in children have assessed the efficacy of QLB in IHR. Thus, this study was designed to find the comparative effectiveness of QLB versus TAP and II/IH blocks in children undergoing open IHR. MATERIALS AND METHODS: Sixty children scheduled for open IHR were randomly allocated in groups of 20 to receive either ultrasound-guided TAP block with 0.4 mL/kg of 0.25% ropivacaine, II/IH nerve block with 0.2 mL/kg of 0.25% ropivacaine, or QLB with 0.4 mL/kg of 0.25% ropivacaine. Anesthesia was standardized for all patients, and an experienced anesthesiologist performed the blocks after anesthesia induction. PRIMARY OUTCOME: Time to first analgesia. SECONDARY OUTCOMES: Postoperative pain scores, intraoperative and postoperative opioid consumption, cumulative paracetamol usage, block performance time, and block-related complications. RESULTS: The median time to first analgesia was 360 (120), 480 (240), and 720 (240) min in the TAP block, II/IH block, and QLB groups, respectively; and was significantly longer in the QLB versus TAP (p<0.001) and II/IH (p<0.001) groups. The time to first analgesia was not significantly different between the TAP and II/IH groups (p=0.596). The mean postoperative tramadol consumption was 11 (12.7), 4 (7.16), and 3 (8) mg in the TAP, II/IH, and QLB groups, respectively (p=0.023); and it was lowest in the QLB group. No significant differences were found between the groups for other secondary outcomes. CONCLUSIONS: QLB provides a prolonged period of analgesia and leads to decreased opioid consumption compared with TAP blocks and II/IH nerve blocks in children undergoing open IHR. TRIAL REGISTRATION NUMBER: CTRI/2019/09/021377.

Systematic review and meta-analysis of safety and efficacy of early enteral nutrition as an isolated component of Enhanced Recovery After Surgery [ERAS] in children after bowel anastomosis surgery.

BACKGROUND: Postoperative feeding practices are not uniform in children undergoing bowel anastomosis surgery. Primary aim of this review was to evaluate the safety and efficacy of early enteral nutrition (EEN) as an isolated component of enhanced recovery in children undergoing bowel anastomosis surgery. METHODS: Medical search engines (PubMed, CENTRAL, Google scholar) were accessed from inception to January 2021. Randomized Controlled Trials (RCT)s, non-randomized controlled trials, observational studies and retrospective studies comparing EEN, initiated within 48 h vs late enteral nutrition (LEN), initiated after 48 h in children ≤ 18 years undergoing bowel anastomosis surgery were included. Primary outcome measure was the incidence of postoperative complications (anastomotic leak, abdominal distension, surgical site infection, wound dehiscence, vomiting and septic complications). Secondary outcome measures were the time to passage of first feces and the length of hospital stay. RESULTS: Twelve hundred and eighty-six children from 10 studies were included in this review. No difference was seen between the EEN and LEN groups in the incidence of anastomotic leak (1.69% vs 4.13%; p = 0.06), abdominal distention (13.87% vs 12.31%; p = 0.57), wound dehiscence (3.07% vs 2.69%; p = 0.69) or vomiting (8.11% vs 8.67%; p = 0.98). The incidence of surgical site infections (7.51% vs 11.72%; p = 0.04), septic complications (14.02% vs 26.22%; p = 0.02) as well as pooled overall complications (8.11% vs 11.27%; RR 0.71; 95% CI = 0.56 to 0.89; p = 0.003; I2 = 33%) were significantly lower in the EEN group. The time to passage of first feces (MD - 17.23 h; 95% CI -23.13 to -11.34; p < 0.00001; I2 = 49%) and the length of hospital stay (MD -2.95 days; 95% CI -3.73 to -2.17; p < 0.00001; I2 = 93%) were significantly less in the EEN group. CONCLUSION: EEN is safe and effective in children following bowel anastomosis surgery and is associated with a lower overall incidence of complications as compared to LEN. EEN also promotes early bowel recovery and hospital discharge. However, further well designed RCTs are required to validate these findings. LEVEL OF EVIDENCE: V.

Intussusception in children aged under two years in India: Retrospective surveillance at nineteen tertiary care hospitals.

OBJECTIVE: Intussusception has been linked with rotavirus vaccine (RVV) as a rare adverse reaction. In view of limited background data on intussusception in India and in preparation for RVV introduction, a surveillance network was established to document the epidemiology of intussusception cases in Indian children. METHODS: Intussusception in children 2-23 months were documented at 19 nationally representative sentinel hospitals through a retrospective surveillance for 69 months (July 2010 to March 2016). For each case clinical, hospital course, treatment and outcome data were collected. RESULTS: Among the 1588 intussusception cases, 54.5% were from South India and 66.3% were boys. The median age was 8 months (IQR 6, 12) with 34.6% aged 2-6 months. Seasonal variation with higher cases were documented during March-June period. The most common symptoms and signs were vomiting (63.4%), bloody stool (49.1%), abdominal pain (46.9%) and excessive crying (42.8%). The classical triad (vomiting, abdominal pain, and blood in stools) was observed in 25.6% cases. 96.4% cases were diagnosed by ultrasound with ileocolic location as the commonest (85.3%). Management was done by reduction (50.8%) and surgery (41.1%) and only 1% of the patients' died. 91.1% cases met Brighton criteria level 1 and 3.3% Level 2. Between 2010 and 2015, the case load and case ratio increased across all regions. CONCLUSION: Intussusception cases have occurred in children across all parts of the country, with low case fatality in the settings studied. The progressive rise cases could indicate an increasing awareness and availability of diagnostic facilities.

Congenital absence of appendix: A Surgeon's dilemma during surgery for acute appendicitis.

Congenital absence of the vermiform appendix is very rare in human beings with a reported incidence of 1 in 100,000 cases. Here, we report an incidence of a surgeon's dilemma to detect such a rare finding during surgery for a diagnosed case of acute appendicitis.