Risk factors and outcome of antenatally diagnosed congenital diaphragmatic hernia following in-utero transfer in a busy public-sector tertiary care center in North India.

We analyzed the risk factors and outcomes of antenatally diagnosed congenital diaphragmatic hernia (CDH) from a tertiary-care children's hospital following in-utero transfer. A total of 41 antenatally detected cases of CDH were included; 30 were live-born and 11 were still-born. The primary outcome was postnatal survival. The secondary outcome was the probable factor affecting survival. No medical termination of the pregnancy was done. The mean gestational age at diagnosis was 23 weeks. The diagnostic accuracy of antenatal ultrasonography was 40/41 (97.5%). Lung-to-head ratio (LHR) was <1 in 20 cases (survived 2), LHR was >1 in 10 cases (survived 8), and LHR was not recorded in 11 cases (survived 4). Overall survival was 14/41 (34.1%). Survival in fetuses with polyhydramnios was 0% (n=3; survived 0), associated anomalies were 33.3% (n=3; survived 1), and liver herniation was 22.2% (n=9; survived 2). Postnatally, significant risk factors included a low Apgar score, the need for ventilation, and neonatal intensive care unit (NICU) management. Survival in live-born cases was 14/30 (46.6%) and in operated cases was 14/19 (73.6%). We concluded that antenatal ultrasound had a high accuracy rate for detecting CDH. Antenatal risk factors affecting outcomes were low LHR, maternal polyhydramnios, liver herniation, and associated malformations. Postnatal risk factors included a low Apgar score, NICU admission, and a need for ventilation. The overall survival rate, as well as the survival rates for live-borns and those undergoing surgery, were 34.1%, 46.6%, and 73.6%, respectively. This data will guide clinicians in counseling the families of antenatally diagnosed CDH.

Two-year postnatal outcome of 263 cases of fetal ventriculomegaly.

Objectives: To find out the outcome of fetal ventriculomegaly (VM) in terms of survival at birth and after two years and to evaluate the antenatal factors which influence the postnatal outcome.Method: We performed a 10-year prospective, observational study (2008-2018) including all prenatally detected fetal VM. Two years follow up of all live born was done to observe their survival, physical morbidity, and developmental delay.Results: Fetal VM was seen in 263/648 (40.6%) cases with central nervous system malformation. VM was severe in 85.9% and was associated with other anomalies in 56.3% of the cases. Total 40.3% cases with VM were live born. The outcome at birth and was poorest with severe VM (40.7%) and when VM was associated with multiple defects (30%). Only 23.6% survived beyond two years of age. There was developmental delay in 24.2% cases. Logistic regression showed that, the presence of associated defect and severe VM were significant poor prognostic factors for survival at birth (p = .001) and after two years of age (p = .002).Conclusions: In a low resource setup the problems associated with fetal VM were compounded by late referral. The knowledge of the outcome in existing setup provides data for realistic counselling to the couple.

The position of the anal dimple in newborns and infants with anorectal malformations and its correlation with the normal anal position.

BACKGROUND/PURPOSE: The anal position index (API) defines the normal anal position as the ratio of fourchette-anal distance to fourchette-coccyx distance for females and the scrotum-anal distance to scrotum-coccyx distance for males. In this study, measurement of the API in newborns and infants with anorectal malformations (ARM), using the center of the midline anal dimple (AD) to represent the center of the proposed neoanus, was performed to assess whether or not the AD was located in a significantly abnormal position as correlated with the normal anal position. METHODS: The cases comprised 65 consecutive newborn and infants with ARM, divided into 2 age-based groups (Group A: 1st day to 1month; Group B: 1-12months), without sacral or significant perineal abnormalities. Controls included an equal number of age and gender matched patients admitted for other conditions. The characteristics of the AD ('well developed' or 'moderately developed') as well as those of the midline perineal raphé in males and the perineal groove in females were also recorded. RESULTS: Combining both age groups, the mean API±SD was 0.41±0.012 in male cases and 0.53±0.07 in male controls (p value 0.003). The corresponding values for female cases and controls were 0.31±0.09 and 0.36±0.07 respectively (p = 0.040). In male newborns, the API in cases was significantly lower than the API in controls (p<0.001). Combining both males and female newborns, the differences between the API in cases and controls was also statistically significant (p<0.001). In older boys as well as in girls from both age groups, apart from cases of persistent cloaca, the API was lower in cases than in controls, especially in boys, although the difference was not statistically significant. On comparing the API in individual male ARM with that in male controls, cases of rectobulbar urethral fistula (RBUF) and rectovesical fistula had a statistically significant lower API (p<0.001). In the 4 cases of persistent cloaca, the mean API (0.40±0.1) was higher than the mean API in female controls and the AD was well developed with a well-delineated, narrow perineal groove. The majority (53/65; 81.53%) of patients had a 'well developed' AD. Twelve patients (18.47%) had a 'moderately developed' AD including 10 females and 2 males. There were 15 patients with a depressed AD (anal fossette); of these 12 (80%) were females. All boys had a well delineated perineal raphé in contrast to 10 girls (29.4% of total female ARM) who had a poorly delineated midline perineal groove. CONCLUSIONS: During definitive surgery for ARM, if the AD is taken as the site of the proposed neoanus, the neoanal position is likely to be anterior to the normal anal position in both males and females and especially so in males. Overall, girls with ARM appear to be more likely to have a relatively poorly developed and/ or depressed AD and a poorly delineated perineal groove. TYPE OF STUDY: Clinical Research. LEVEL OF EVIDENCE: Level III.

Protocol-based management of 154 cases of pediatric liver abscess.

AIM: Although liver abscess (LA) is prevalent worldwide, especially in developing countries, there is a paucity of data regarding the protocol for management of LA in children. The aim of this study was to analyze the outcome of a protocol-based management of pediatric LA from a single institution. MATERIALS AND METHODS: This prospective observational study was conducted in a tertiary-care children's hospital and included all patients with LA managed over a 5-year period. Detailed clinical, laboratory, microbiological and imaging parameters were recorded, and the patients were treated according to a standardized management protocol. Small abscesses (<5 cm) and those with solid appearance on initial ultra-sonogram (US) were managed with antimicrobial therapy alone. Liquefied abscesses on imaging were additionally subjected to US guided percutaneous needle aspirations (PNA). Large abscesses pointing to the surface were treated by percutaneous drainage (PCD). Ruptured LA, abscess inaccessible to image-guided drainage and those not responding to other modes of treatment were subjected to open surgical drainage (OSD). Pleural collections were treated by aspirations or intercostal tube drainage. Outcome was analyzed in terms of duration of recovery and complications including mortality. RESULTS: Over the 5-year period, 154 pediatric LA patients underwent protocol-based management. The mean age of the patients was 6.76 years with the male:female being 1.26:1. Medical management alone, PNA, PCD and OSD were successful in 38 (24.6%), 76 (49.3%), 11 (7.14%) and 29 (18.8%) cases, respectively. Pleural collections developed in 43 (27.9%) patients out of which aspiration/drainage was needed in 24 (55.81%) cases. The mean duration of hospital stay was 20.67 ± 9.52 days. Ongoing sepsis and multi-organ failure lead to mortality in 6 (3.8%) cases; rest of the patients were doing well on follow-up. CONCLUSION: Ultra-sonography was useful for the initial diagnosis, monitoring the progress and management of LA in children. The outcome of a protocol-based management of LA in children was favorable.

Role of nasogastric tube in children undergoing elective distal bowel surgery.

BACKGROUND: Nasogastric tubes are being routinely used in children and adults undergoing elective abdominal surgery without much scientific evidence supporting their true usefulness. The aim of our study was to assess the role of nasogastric tube in children undergoing elective distal bowel surgery. MATERIALS AND METHODS: All pediatric patients undergoing elective distal bowel surgery were enrolled and randomized into two groups: those with nasogastric tube (NG group) or without nasogastric tube (NNG group). Outcome parameters such as resumption of bowel function, enteral feed tolerance, postoperative complications, hospital stay and patient with their parent satisfaction were compared between the groups. RESULTS: A total of 60 patients were included with equal distribution in the NG and NNG groups. Patient variables were comparable in both the groups. Patients in NNG group progressed to full oral feeds significantly earlier (57 ± 18 vs. 106.07 ± 18.35 h, p < 0.001) and had shorter duration of hospital stay (91.93 ± 26.03 vs. 114.67 ± 18.83 h, p < 0.001) as compared to the NG group. Significant number of patients with nasogastric tube reported sore throat (9 vs. 1 p = 0.03) and nausea (5 vs. 0 p = 0.010). There was no significant difference in return of bowel function (39.43 h ± 15.92 vs. 43.60 h ± 17.77, p = 0.171), hiccups, sleep disturbance, complications and nasogastric tube reinsertion rate between the two groups. CONCLUSION: Routine use of nasogastric tube after elective distal bowel surgery in children is not necessary.

Intrapericardial diaphragmatic hernia: a rare type of congenital diaphragmatic hernia.

An extremely rare case of congenital intrapericardial diaphragmatic hernia is presented. Since 1981, only 14 cases have been reported in the literature. A 5-year-old girl presented with dyspnea on exertion and easy fatigability. Computed tomography was suggestive of an anterior diaphragmatic hernia. Laparoscopy followed by successful open repair of hernia was performed.

Spectrum of ectopic ureters in children.

We reviewed the clinicopathological features, diagnosis, and surgical treatment of ectopic ureters (EU) in children in order to evaluate the anatomy, renal function, outcome, and the existence of any racial or regional difference in this abnormality. The records of 27 consecutive patients with 33 EU managed over a period of 7 years were analyzed. There were 25 female and two male patients. Their age ranged from 1 to 13 years, with an average of 4.5 years. The presenting features included history of continuous dribbling of urine with otherwise normal voiding in toilet-trained female patients, incontinence of urine, urinary tract infection, abdominal pain, and renal failure. The diagnostic work-up included ultrasonography (US) in all 27 patients, intravenous pyelography (IVP) in 23, micturating cystourethrogram (MCU) in 19, nuclear imaging (NI) in 16, and computed tomogram (CT) in five patients. All patients underwent examination under anesthesia (EUA) and cystourethrovaginoscopy immediately before the operation. Single-system ectopic ureter (SSEU) was present in 19 patients with 25 ureters (six bilateral), and duplex with ectopic ureter was present in eight cases. The left side was involved in 14 cases, the right side in seven, and the anomaly was bilateral in six cases. Abnormalities noted in the imaging studies were USG 23/27, IVP 23/23, MCU 11/19, NI 13/16, and CT 5/5 cases. EUA and cystourethrovaginocsopy helped in localization of the ectopic site and evaluation of the bladder. The surgical treatment included nephroureterectomy (NUT) for non-functioning kidney in 7 patients, heminephroureterectomy (HNUT) for non functioning upper pole of duplex kidney with EU in 6 patients, ureteric reimplantation (UTR) in 13 patients (19 ureters, 6 bilateral), and ureteropyelostomy (UTP) in one patient. In the follow-up period ranging from 1 to 5 years, 20 patients achieved continence; however, six cases with bilateral SSEU and one case of unilateral SSEU, who also had a patulous bladder neck, continued to dribble urine. SSEU was more common than duplex with ectopic ureter. A large number of functioning renal units associated with SSEU deserved preservation. The success of surgical treatment in terms of achievement of continence was high and depended on the integrity of the bladder neck.