Evaluation and Management of Achalasia Cardia in Children: A Retrospective Observational Study.

Background: Achalasia cardia is a neuromuscular disorder of unknown etiology characterized by aperistalsis of the body of the esophagus and failure of relaxation of the lower esophageal sphincter. The diagnosis of achalasia cardia is delayed due to the rarity and the ability to mimic other common conditions in children. Hence, a study was conducted to evaluate the clinical presentation and the management of achalasia cardia in children. Materials and Methods: A retrospective observational study was conducted in the department of pediatric surgery at a tertiary center. The children with achalasia cardia who presented between January 2014 and December 2021 were included. Results: A total of 12 patients were treated for achalasia cardia during the study period. All children presented with recurrent episodes of vomiting, whereas dysphagia was seen in six (50%) children. Eighty-three percent of the children presented with a history of weight loss, whereas failure to thrive was seen in nine (75%) children. Five (42%) children were managed as gastroesophageal reflux disease (GERD) for more than a year before presenting to us. Three (25%) children underwent open cardiomyotomy with Thal fundoplication and the rest nine (75%) underwent laparoscopic cardiomyotomy. All are thriving well. Conclusion: Achalasia is an important differential diagnosis in children with suspected GERD. The most common symptom of achalasia cardia is vomiting followed by dysphagia. Weight loss and failure to thrive are important presenting features in children with achalasia which are uncommon in adults. Cardiomyotomy without fundoplication is safe and effective to treat achalasia cardia in children without having any extra complications.

Factors contributing to mortality in neonates with congenital diaphragmatic hernia and eventration.

Introduction: Despite all the advances, the mortality rate of congenital diaphragmatic hernia (CDH) ranges from 30% to 60% for isolated CDH and as high as 89% when they are associated with additional structural or chromosomal anomalies. Hence, a study was conducted to evaluate the factors contributing to the mortality of neonates treated for CDH or the eventration of diaphragm. Materials and Methods: A retrospective study was conducted in the department of paediatric surgery at a tertiary centre. The neonates admitted with a diagnosis of CDH or eventration requiring surgery, between March 2013 and March 2021, were included in the study. Results: A total of 123 neonates were included in the study. The variables, earlier median age at presentation (1 [1-23] vs. 3 [1-28]; P < 0.001; Mann-Whitney U-test), preterm birth (10/79 vs. 0/44; P = 0.01; Fischer's exact test), inborn (68/79 vs. 27/44; P = 0.002; Chi-square test), weight ≤2 kg (18/79 vs. 1/44; P = 0.003; Chi-square test), central cyanosis at presentation (21/79 vs. 1/44; P < 0.001; Chi-square test), antenatal detection (47/79 vs. 14/44; P = 0.003; Chi-square test) and earlier mean age at surgery (3.66 ± 1.47 vs. 7.66 ± 6.88; P < 0.001; Independent sample t-test) were associated with increased mortality. On multinominal logistic regression analysis, the factors preterm (odd's Ratio [OR] =4.735; P = 0.03), weight ≤2 kg (OR = 5.081; P = 0.02), central cyanosis at presentation (OR = 6.969; P = 0.008) and antenatal detection (OR = 7.471; P = 0.006) were found to be independently associated with increased mortality in CDH/eventration. Conclusion: The factors: prematurity, weight <2 kg, cyanosis at presentation and antenatal diagnosis were independently associated with increased mortality in neonates with CDH/eventration requiring surgery.

Sequelae of Corrosive Injury in Children: An Observational Study.

Aim: This study aims to determine the sequelae of corrosive ingestion in children. Methods: A retrospective study was conducted in the Department of Pediatric Surgery at a Tertiary Center. The children presenting between January 2015 and December 2020 with a history of ingestion of caustic agents were included in the study. Results: A total of 26 children were included in the study. The children with suicidal attempts were significantly older than those who ingested the corrosive agents accidentally (14.2 ± 1.9 years vs. 6 ± 3.3 years; P < 0.01; Student's t-test). Sixteen (62%) children had esophageal strictures, 8 (31%) had pyloric strictures, and a child (4%) had both esophageal and gastric strictures. Eight (31%) children required an initial feeding jejunostomy and 6 (23%) required a feeding gastrostomy as they had significant weight loss on presentation. Eleven (65%) esophageal strictures responded to the dilatation regimen and are symptom-free on follow-up. Three (18%) children with esophageal stricture underwent esophageal replacement. Eight (31%) children had a pyloric stricture and all of them were treated with a modified Billroth I gastro-duodenostomy. The children who presented after 2 months were found to have a significantly increased need for esophageal replacement (3/9 vs. 0/17; P = 0.03; Fischer's exact test). Conclusion: The corrosive ingestion in children is associated with higher morbidity. The sequelae include esophageal and antro-pyloric strictures. A feeding gastrostomy or jejunostomy was required in more than half of the patients. The children presenting after 2 months of ingestion were associated with an increased need for esophageal replacement.

External Jugular Venous Cutdown versus Percutaneous Technique for Chemoport Insertion in Children: A Comparative Study.

Aims: We aimed to compare the external jugular vein (EJV) cutdown technique with the percutaneous technique for difficulties in insertion, maintenance, and other complications of chemoport placement in children. Materials and Methods: A retrospective study was carried out in children who underwent chemoport insertion between January 2007 and December 2019 either by EJV cutdown or percutaneous technique in the department of pediatric surgery at a tertiary center. All children aged <18 years undergoing chemoport insertion by EJV cutdown or percutaneous technique were included in the study. Data collected included the indication, procedure time, early and late complications, and the time to removal of chemoport. Results: There was no significant difference between the EJV group and the percutaneous group in terms of the time taken for chemoport placement (40.9 ± 7.6 min vs. 37.6 ± 18.9 min; P = 0.14), failure to cannulate (one vs. six; P = 0.05), and the mean chemoport indwelling days (816.8 ± 729.2 days vs. 854.5 ± 705.1 days; P = 0.73). The chemoport placement by EJV cutdown method was found to have significantly fewer overall complications (4 vs. 14; P = 0.01) and a lesser rate of premature chemoport removal (4 vs. 12; P = 0.04) compared to the percutaneous group. Conclusions: Chemoport placement by the EJV cutdown was found to have fewer port-related complications and a lesser rate of premature chemoport removal compared to the percutaneous technique. The time taken for port placement and the mean chemoport-indwelling days were similar in both techniques.

The Management of Perineal Trauma in Children.

Aims: This study aimed to evaluate the outcome of perineal trauma in children and to a define protocol for their management. Methods: It is a retrospective study of children who presented with perineal injury between August 2012 and December 2020. The patients were classified into three groups: Group-1 included children with perineal and genitourinary injuries; Group-2 included patients with perineal and anorectal injuries; and Group-3 included patients with perineal, genitourinary, and anorectal injuries. All patients underwent primary repair. Those with full-thickness anorectal injury underwent an additional covering colostomy, while urethral disruption was initially managed by a diverting suprapubic cystostomy (SPC). Results: A total of 41 patients were studied. Impalement injury (n = 11; 27%) and sexual abuse (n = 11; 27%) were the most common mechanisms of injury. Twenty (49%) patients had anorectal injuries with 10 (24%) each of partial-thickness and full-thickness injury. There were 24 (59%) genital injuries and five (12%) urethral injuries. One patient each developed anal and vaginal stenosis, both were managed with dilatation. One patient developed a rectovaginal fistula repaired surgically at a later date. Conclusion: Perineal injuries with resultant anorectal or genital damage require a careful primary survey. Following stabilization, an examination under anesthesia as a set protocol will help determine the treatment strategy. A colostomy is essential in the acute management of severe anorectal injuries to reduce local complications and preserve continence. Urethral injuries may warrant an initial diverting SPC in selected cases.

Factors Associated with a Failed Nonoperative Reduction of Intussusception in Children.

AIMS: The aim of this study was to evaluate the factors associated with the failure of nonoperative reduction of intussusception in children. METHODS: A retrospective study was conducted in a tertiary care pediatric surgery hospital. The children admitted to the department of pediatric surgery between November 2013 and February 2020 with the diagnosis of Intussusception were included. RESULTS: A total of 106 (67%) children underwent pneumatic reduction. Eighty-nine (84%) children had a successful reduction. A higher rate of failed reduction was found in children who presented at or after 48 h of the onset of symptoms (P = 0.03) and abdominal distension at presentation (P < 0.002). On multiple logistic regression analysis, the children presenting at or after 48 h of the onset of symptoms (odds ratio [OR] = 11.3; P = 0.039) and abdominal distension at presentation (OR = 4.46; P = 0.021) were found to be associated with increased risk of failure of nonoperative reduction. The variables age <1 year, weight <10 kg, pain abdomen, vomiting, bilious vomiting, fever, bleeding per rectum, and palpable mass were not associated with the failed nonoperative reduction. The variables, presentation at or after 48 h of the onset of symptoms (OR = 2.812; P = 0.045) and abdominal distension at presentation (OR = 8.758; P = 0.000) were found to be associated with an increased need for surgery. CONCLUSION: The risk factors for failed nonoperative reduction of intussusception include a presentation at or after 48 h of the onset of symptoms and the presence of abdominal distension at presentation. The delayed presentation was associated with the increased need for surgery and increased chances of intestinal nonviability.

Limb Salvage in an Extensive, Complicated Vascular Lesion of the Arm in an Infant.

When a vascular lesion involving a limb poses a hazard to the life, treatment options are excision or amputation of the limb. Although excision can be hazardous, limb salvage with vascular control is the best treatment option. We report limb salvage in an infant with an extensive infected congenital hemangioma complicated with consumptive coagulopathy.

Chemoport-A Savior in Children Who Require Chronic Venous Access: An Observational Study.

PURPOSE: Long-term venous access is cumbersome in children because of their thin caliber veins, less cooperative nature, and easy compromise of venous integrity. Hence, a study was conducted to evaluate the indication, efficacy, and safety of chemoport in children who require chronic venous access. MATERIALS AND METHODS: Children who underwent chemoport insertion between January 2008 and December 2017 were retrospectively evaluated. RESULTS: A total of 159 children (169 chemoports) were included in the study. The most common indication for chemoport insertion was acute lymphoblastic leukemia (51.5%). The mean chemoport days were 832±666 days. Among the 169 chemoports, 55.0% were removed after treatment completion. The chemoport was not removed in 35.5% of the patients, as 28.4% of the patients were still under treatment and 7.1% died during the treatment. Sixteen patients (0.1 per 1,000 chemoport days) had a premature chemoport removal. The indications were port-related bloodstream infection (12 patients), port pocket infection (1 patient), exposed chemoport (1 patient), and blocked chemoport catheter (2 patients). Twenty-two patients (0.15 per 1,000 chemoport days) had complications of port-related bloodstream infection (0.09 per 1,000 chemoport days), making it the most common. Other complications include block, fracture, arrhythmias, avulsion, bleeding, decubitus-over-port, and port pocket infection. CONCLUSION: Owing to the safe, reliable, and low complication rate of chemoports, more children can be saved from deadly illnesses. Chemoport is the best option for children who require chronic venous access.

Squamous papilloma of the renal pelvis mimicking transitional cell carcinoma.

Squamous papilloma of the renal pelvis is an extremely rare entity. To the best of our knowledge, no case has been reported till date. A 45-year-old female presented to us with flank pain for two months. She had undergone left-sided percutaneous nephrolithotomy three years ago. Preoperative evaluation suggested the presence of a transitional cell tumor arising from the left renal pelvis. Diethylene-triamine-pentaacetic acid renogram showed a non-functional left kidney. She underwent left nephroureterectomy. Histopathology showed squamous papilloma of the renal pelvis. Subsequent follow-ups have been uneventful.

Cecal duplication: A mimicker of intussusception: A case report and review.

INTRODUCTION: Cecal duplication is a rare congenital anomaly and to the best of our knowledge, only 43 cases have been reported in the literature till date. Most of them present within the first year of life. They can mimic intussusception, and the delay in diagnosis can lead to high morbidity. CASE REPORT: A five-year boy presented with pain abdomen for a week. He was found to have ileocolic intussusception. The intussusception could only be partially reduced by the hydrostatic method. On laparotomy, a submucosal solid mass was found in the cecum with multiple enlarged lymph nodes. Mass was resected with clear margins and lymph nodes sampled. Histopathology was conclusive of cecal duplication. Post-operative course was uneventful, and the child is thriving well, last reviewed at three-year follow-up. CONCLUSION: Incomplete reduction of intussusception, intussusception with atypical presentation or intussusception in atypical age group should alert to the possibility of cecal duplication.

Bartholin's gland abscess in a prepubertal female: A case report.

Bartholin's gland abscess is one of the common inflictions of vulva seen in females of reproductive age group with a recurrence rate of up to 38%. Although it's encountered by many Paediatric Surgeons, it's very rarely reported in prepubertal age. Till date, only six cases have been reported to the best of our knowledge. A seven-year-old female child presented with a recurrent labial abscess. She was found to have Bartholin's gland abscess and was treated with partial excision of cyst wall along with the overlying mucosa and drainage. There has been no recurrence for the past six months at follow-up. Bartholin's gland abscess, although rare in children, should be considered as one of the differential diagnosis of a labial swelling. Adequate drainage is essential to prevent recurrence.

Lesson learnt from a migrated drain: A case report.

INTRODUCTION: Though surgical drainage is used as a safety measure, it's not without complications. Migration of various drains has been described, but very little literature refers to the migration of peritoneal drain. PRESENTATION OF CASE: A 55-year male underwent anterior Gastro-Jejunostomy for inoperable metastatic carcinoma of the Gastric Pylorus. We found the peritoneal drain missing on the third post-operative day. On further evaluation, we found it to have migrated into the peritoneal cavity. We opened the operative wound for a partial length and retrieved the drain. DISCUSSION: We did research to find why drain migrates and searched literature on migration of peritoneal drains. The possible etiologies for drain migration are (1) Drain hasn't been fixed properly (2) Cutting through of suture material (3) Relatively low abdominal pressure (4) Pressure over the drain by patient's body weight when he lies on the same side as drain. CONCLUSION: Every use of drain should be weighed for its needs and risks. Proper precautions during drain placement avoid unnecessary complications, morbidity and prolonged hospital stay.