Laparoscopic choledochal cyst excision and biliary reconstruction in patients with previous surgery/ intervention: Feasibility and outcome.

INTRODUCTION: The aim of the study was to evaluate the feasibility and outcome of laparoscopic surgery in complicated choledochal cyst (CDC) with previous interventions (laparotomy or biliary drainage). PATIENTS AND METHODS: Patients with CDC who underwent surgery from July 2014 to July 2019 were evaluated. CDC without previous interventions (Group A) was compared with CDC that had previous interventions (Group B) to assess the feasibility and outcome of laparoscopic surgery. RESULTS: In 5 years' period, 38 patients were operated for CDC. The mean age was similar in both groups (3.78 ± 2.27 in Group A and 4.08 ± 2.73 in Group B). Out of six CDC with previous intervention (Group B), five patients were previously managed at other institutions as follows: (1) Laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) stenting. (2) Laparotomy for biliary peritonitis and ERCP. (3) Percutaneous drainage of the large cyst. (4) Laparoscopic cholecystectomy. (5) ERCP stenting. (6) Percutaneous drainage for biliary ascites. All patients underwent laparoscopic CDC excision and hepatico-duodenostomy. The mean duration of surgery was 160.3 ± 17.22 in Group A and 169.2 ± 17.5 in Group B ( P = 0.258). None required intraoperative blood transfusion. None had a bile leak. Drain was removed at 4.47 ± 0.98 in Group A, while at 4.17 ± 0.75 days in Group B ( P = 0.481). There was statistically no significant difference in feed starting time or length of stay. In follow-up of 6 months-3 years, all patients are asymptomatic. CONCLUSIONS: Laparoscopy in complicated CDC with previous intervention is technically tedious but is feasible. The procedure is safe and delivers a good outcome.

Ruptured choledochal cyst: One-stage or two-stage, open or laparoscopic surgery?

Choledochal cyst (CDC) can present with complications such as cholangitis, perforation, pancreatitis and malignancy. Compared to the open technique for CDC, advantages of laparoscopic surgery are well known. Biliary peritonitis secondary to perforation/rupture of CDC is rare and is described in <2% of cases. In ruptured CDC, there are different approaches of management like peritioneal lavage, and biliary drainage by T-tube or Cholecystosomy/choledochostomy or endoscopic retrograde cholangiopancreatography stenting and definitive repair after 4-6 weeks as two-staged procedure. Laparoscopy is a procedure of technical challenge and complexity in ruptured CDC. We discuss here our experience of single-stage laparoscopic excision and biliary reconstruction in ruptured CDC. Child was stabilised by percutaneous drain and one-stage laparoscopic reconstruction was done on day 4, reducing the burden/morbidity of carrying biliary drain, length of stay and cost factor. To the best of our knowledge one-stage laparoscopy in ruptured CDC has not been reported earlier.

Refractory congenital chylous ascites: First report of fibrin glue and mesh application by laparoscopy.

Chylous ascites (CA) is a form of ascites having leakage of lipid-rich lymph into the peritoneal cavity, due to damage or obstruction in the lymphatic system. Aetiology of CA could be congenital or acquired. Primary lymphatic hypoplasia is seen commonly in children and presents with lymphoedema, chylothorax or CA. CA is initially treated conservatively with the aim to provide gut rest and decrease intestinal secretions. Surgical treatment is recommended if 1-2 months of conservative approach fails. The success of the operation depends on identifying the site of leakage of the lymphatic duct. Surgical options are ligation of leaking lymphatics, peritoneo-venous shunt, laparotomy and fibrin glue. Laparoscopy has been used for diagnosis but not for glue and mesh application in congenital CA where the lymphatic leak is unidentified. We present here the first experience of laparoscopic fibrin glue and mesh application in congenital CA with successful outcomes.

Development and Functions of the Infant Gut Microflora: Western vs. Indian Infants.

The human gut is colonized by trillions of bacteria as well as other microorganisms, collectively referred to as the "gut microflora." This microflora plays an important role in metabolism as well as immunity, and alterations in its normal composition and pattern of colonization can disturb the development and functioning of the immune system, predisposing the individual to several diseases. Neonates acquire their gut microflora from the mother as well as the surroundings, and as the infant grows, the gut microflora undergoes several changes, ultimately acquiring an adult-like composition. Characterization of the gut microflora of healthy infants is important to protect infants from infectious diseases. Furthermore, formulation of prebiotics and probiotics for boosting infant immunity in a specific population also requires prior knowledge of the normal gut microflora in a healthy infant in that population. To this end, several studies have been performed on Western infants; however, the gut microflora of Indian infants is as yet insufficiently studied. Moreover, there has been no comparative analysis of the development and characteristics of the infant gut microflora between the two populations. In this review, we discuss the development and maturation of the infant gut microflora and its effect on immunity, as well as the factors affecting the patterns of colonization. In addition, we compare the patterns of colonization of gut microflora between Western and Indian infants based on the available literature in an attempt to identify the extent of similarity or difference between the two populations.

Therapeutic Enteral Formulas in Children.

PURPOSE: A variety of enteral formulas for various diseases have become available in India in the last few years. Awareness among pediatricians about the availability and indications for these therapeutic formulas is low. METHODS: A literature search was conducted in PUBMED and relevant data collected from all English language publications available. Data on the commercial preparations was sourced from the individual companies, the Diet 4 life initiative as well as FSSAI (Food safety and standards authority of India). CONCLUSIONS: Therapeutic enteral formulas, which are indicated in various disease states belong to four categories - lactose modified, hydrolyzed, MCT based and metabolic disease specific formulas. Lactose modified formulas which are used in temporary or permanent lactose intolerance and Galactosemia are either casein or soy protein based. Hydrolyzed formulas could be partially hydrolyzed, extensively hydrolyzed or amino acid based. Only extensively hydrolyzed formula should be recommended in milk protein allergy. Amino acid (elemental) formulas are mainly indicated in patients with diffuse intestinal mucosal disease. MCT formulas are used in chronic liver disease with cholestasis, and have 30 to 80% MCT. Formulas for inborn errors of metabolism are free of specific carbohydrate, amino acid or fatty acid. Proprietary formulas presently available in India with their specifications have been listed.

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.

Management of Childhood Functional Constipation: Consensus Practice Guidelines of Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition and Pediatric Gastroenterology Chapter of Indian Academy of Pediatrics.

JUSTIFICATION: Management practices of functional constipation are far from satisfactory in developing countries like India; available guidelines do not comprehensively address the problems pertinent to our country. PROCESS: A questionnaire-based survey was conducted among selected practising pediatricians and pediatric gastroenterologists in India, and the respondents agreed on the need for an Indian guideline on the topic. A group of experts were invited to present the published literature under 12 different headings, and a consensus was developed to formulate the practice guidelines, keeping in view the needs in Indian children. OBJECTIVE: To formulate practice guidelines for the management of childhood functional constipation that are relevant to Indian children. RECOMMENDATIONS: Functional constipation should be diagnosed only in the absence of red flags on history and examination. Those with impaction and/or retentive incontinence should be disimpacted with polyethylene glycol (hospital or home-based). Osmotic laxatives (polyethylene glycol more than 1 year of age and lactulose/lactitol less than 1 year of age) are the first line of maintenance therapy. Stimulant laxatives should be reserved only for rescue therapy. Combination therapies of two osmotics, two stimulants or two classes of laxatives are not recommended. Laxatives as maintenance therapy should be given for a prolonged period and should be tapered off gradually, only after a successful outcome. Essential components of therapy for a successful outcome include counselling, dietary changes, toilet-training and regular follow-up.

Coagulation abnormalities in children with Celiac disease.

We prospectively analyzed the coagulation abnormalities in 111 children with Celiac disease at diagnosis and its association with histology grade on duodenal biopsy; 27% had deranged prothrombin time. There was an increasing proportion of coagulopathy with progression of Marsh Grade on duodenal histology.

Peroperative enteroscopy and polypectomy in Peutz-Jegher syndrome.

We report a 32-year-old who lady when presented with anemia and was detected to have Peutz-Jegher syndrome. She had malignancies of the colon and ovary over a 2-year follow up and was successfully managed. On screening the family two more members were confirmed to have Peutz-Jeghers syndrome and have been put on surveillance.

Triple A syndrome.

Triple A syndrome (Allgrove syndrome) is an autosomal recessive disorder consisting of achalasia, alacrima and Addison insufficiency. We report an 11-year-old girl with predominant symptom of achalasia who was diagnosed as Triple A syndrome almost 3 years after initial presentation.

Non responsive celiac disease due to coexisting hereditary fructose intolerance.

Celiac disease is associated with several genetic disorders, but its association with hereditary fructose intolerance is rare. Hereditary fructose intolerance is a rare autosomal recessive disease of fructose metabolism presenting as vomiting after intake of fructose. An association between these two distinct genetic gastrointestinal disorders is important as treatment failure of celiac disease calls for careful evaluation for hereditary fructose intolerance. We report a patient with an association of these two disorders.