Lessons learned from early experience of per oral endoscopic myotomy in children.

BACKGROUND/AIMS: Achalasia cardia (AC) is rare in children, and the standard treatment is open or Laparoscopic Heller's myotomy with or without fundoplication if pneumatic dilatation has failed. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with good results in adults. We report POEM in four children and the outcome with special emphasis on the technique and management of intra-operative complications. METHOD: Four children aged 7-15 years presenting with progressive dysphagia, cough, night-time aspirations, and weight loss of six months to one year were investigated with upper GI contrast study, flexible endoscopy and biopsy, oesophageal manometry, and a diagnosis of Type 1 & 2 AC was made. An experienced adult endoscopist in collaboration with the paediatric surgical team performed POEM. RESULTS: POEM was performed successfully using ERBE HYBRID knife setup and waterjet injection for the submucosal tunnelling. Operative time was 25-40 min (mean 31 min). The hospital stay was 3-8 days with last 3 patients discharged on day three. No major intraoperative or post-operative complications were seen. The Eckardt score changed from above 4 to 0 at one-month follow-up. All four are well at one year post-operatively and beyond. Two patients had subcutaneous emphysema post-operatively. One developed pneumoperitoneum intra-operatively. CONCLUSION: POEM was successfully performed with only minor adverse events in experienced hands. Anticipation and preparation for potential intraoperative complications and assigned responsibilities to each team helped the safe completion in the shortest time. Rectifying pneumoperitoneum concurrently without interruption of the operation exemplified teamwork. LEVEL OF EVIDENCE: III.

Vitello-intestinal duct fistula--a rare presentation of a patent vitello-intestinal duct: a case report.

Patent Vitello-intestinal Duct (VID) results as of failed obliteration of the fetal omphalocele coelom (herniated loops of intestine in the umbilical cord) during the development of the midgut. We report a case of an infant who presented at 11 months of the age with history of persistent umbilical discharge since birth. The VID was confirmed with a fistulogram using gastrograffin contrast studies and a wedge resection with primary anastomosis. The infant was discharged 5 days post-op without any post-operative complications. This case report highlight a rare cause of umbilical discharge and the surgical intervention required.

Missed diagnosis: blunt abdominal injury-case report.

Acute pancreatitis is an uncommon finding in children and therefore one must have a high index of suspicion when evaluating children with blunt abdominal trauma. It can cause severe morbidity and mortality and requires one to be vigilant to make the diagnosis and to ensure appropriate management. We report on a case of acute pancreatitis that had diagnostic and management dilemmas at Colonial War Memorial Hospital (CWMH) in Fiji.

Recurrent abdominal pain post appendectomy--a rare case.

Right iliac fossa pain in young adults who have previously had an appendicectomy represents a diagnostic challenge. In such cases it is important to review the histology of the appendix and the previous operation notes. The appendix stump, if left long following an appendectomy, can result in chronic appendicitis of the stump, or it can rarely develop into a mucocele. This case report describes a patient with an appendix stump mucocele who presented with chronic pain under the right iliac fossa incision and was successfully treated by laparoscopic resection.

A case report: simple and effective external fixator for finger fractures.

A case report on a very simple and very effective technique of achieving finger fracture fixation. This cost effective and yet simple tool and technique of immobilization is cheap and can be readily used in the South Pacific. This procedure provides us with an alternative to amputation of the digit. It is also a very reliable and cost effective procedure which could be easily taught to junior surgical registrars.