Primary obstructive megaureter in children; 10 years' experience from a tertiary care center.

Introduction: Primary obstructive megaureter (POM) is a congenital dilatation of the ureter due to an adynamic segment of vesicoureteric junction obstruction. Surgical intervention is needed if nuclear scan shows obstructive curve. We analyzed our data and outcome of conservative and surgical treatment in such cases at our tertiary care hospital. Materials and Methods: We evaluated all cases of POMs during the study period. Investigations included ultrasonography (USG), voiding cystourethrogram, diethylene pentacetic acid (DTPA) scan, and dimercaptosuccinyle acid scan. In antenatal cases, any pelvic dilatation ≥12 mm after 6 weeks were subjected to reonography. Patients with anterior-posterior pelvic diameter (APPD) ≥12 mm had to undergo DTPA scan to look for DRF and drainage. Follow-up USG was done in all cases of mild-to-moderate hydroureteronephrosis, with APPD <12 at 3 months interval. Results: A total of 270 megaureters were registered and treated during the study period (2008-2019). The total number of patients included was 50 (64 ureters). The mean age of presentation in these 30 children was 21.78 ± 18.1 months (range 1-72 months) and the mean weeks of gestation in antenatal cases at presentation as megaureter was 24 ± 7 weeks (range 13-37 weeks). The mean weight of babies was 2.72 ± 0.7 g. The duration of follow-up ranged from 16 to 1W12 months. The mean APPD on the affected side was 19.99 ± 10.3 mm (range 11-43 mm). The mean ureteric diameter was 1.67 ± 0.33 mm (range 0.78-2.66 cm). The mean split function of patients with POM was 34.88% ± 11.5% on the affected side. Twenty patients (40%) had spontaneous resolution over a mean time period of 24.1 ± 11.1 months. Thirty patients underwent surgical procedures. In three children, HTN was observed over a mean follow-up period of 3 years. Conclusion: The babies with POM need a close follow-up. Surgery is indicated in prolonged t½/Tmax on renal scan, function <40% at the initial scan, or >5% split function deterioration in the subsequent renal scan.

Comparison of laparoscopic and open surgery in hepatic hydatid disease in children: Feasibility, efficacy and safety.

Background: : Surgery continues to be the mainstay of treatment of hydatid cysts of the liver. Laparoscopy provides a lesser invasive tool for achieving results same as with the established open surgical techniques. The purpose of the study was to evaluate the feasibility and safety of laparoscopic management of hepatic hydatid disease in children. Patients and Methods: It was a prospective randomised study conducted over a period of 7 years. Children with Gharbi Type I, II, III cysts, ≤3 cysts and superficial accessible cysts were treated laparoscopically and their outcomes were compared with matched controls treated by open approach. Results: Sixty patients were included in the study with thirty patients in each matched group. Thirty paediatric patients (male 12:female 18) with 35 liver hydatid cysts underwent laparoscopic surgery. The mean cyst size was 8.8 ± 2.39 cm. Two patients needed conversion to open. No significant spillage of cyst contents was observed in any of the patients. Duration of hospital stay, time to removal of drains, duration of parenteral analgesia, severity of pain in postoperative period, time to ambulation and time to return to full orals were significantly lower in laparoscopic group compared to open group. Complication rates in both the groups were similar. Conclusion: With proper patient selection, laparoscopic management of hydatid cysts of the liver in children is feasible and safe option with low morbidity, low rates of conversion and minimal complications.

Post ventriculoperitoneal shunt abdominal pseudocyst: Challenges posed in management.

BACKGROUND: In patients with hydrocephalus, the abdominal cavity has been used for absorption of cerebrospinal fluid (CSF) since 1905. Ventriculoperitoneal (VP) shunt operation is followed by abdominal complications in about 5-47% cases. Abdominal CSF pseudo cyst is an uncommon, but well described complication. AIM: This survey was conducted to study the clinical profile and management of this entity. We present our experience with cases of CSF pseudo cyst in children. MATERIALS AND METHODS: Retrospective analysis of 4 cases diagnosed to have abdominal pseudo cyst following VP shunt between 2008 and 2013. All the four cases were suspected clinically and diagnosis was confirmed by abdominal ultrasonography. RESULTS: In three patients, the cyst was multilocular and of varying size. Fourth one had a unilocular cyst at the lower end of VP shunt. All the four patients had features of varying degree raised intracranial pressure and a two patients had abdominal signs also. All the patients needed open exploration. Cyst fluid was drained and partial to complete excision of the cyst was done along with the repositioning of the shunt in abdominal cavity in three patients and exteriorization of shunt in one patient. Patients were followed for any further complication over a period of 1-year. CONCLUSION: Abdominal pseudo cyst is a rare complication after VP Shunt and could result in shunt malfunction or abdominal symptoms and signs. Whenever suspected it should be confirmed by imaging, followed by open exploration and repositioning of the shunt.

Use of gastrografin in the management of worm-induced small bowel obstruction in children.

OBJECTIVE: Ascaris-induced small bowel obstruction (SBO) is a common sequel of Ascaris lumbricoides (AL) infestation. Most cases respond to conservative treatment practiced in different centers worldwide. We conceived a prospective randomized trial to compare the conservative treatment with gastrografin administered in addition to the conservative treatment. STUDY DESIGN: This prospective randomized study was conducted between January 2011 and June 2014 at Department of Paediatric and Neonatal Surgery, a tertiary-care hospital. Patients were divided into two groups, one group received conservative treatment and the other received gastrografin in addition to conservative treatment. Forty patients having uncomplicated AL-induced SBO were included in each group. Gastrografin was administered through nasogastric tube and serial clinical and radiological monitoring was performed. The duration of hospital stay, time between admission and first oral feed, passage of worms/flatus were compared in the two groups. Student's t test was used for comparing these variables. RESULTS: Average time for passage of flatus or worms and resolution of abdominal signs and was shorter in gastrografin group as compared to the conservative group. This difference was found to be statistically significant. The average duration of hospital stay in gastrografin group was 25.20 ± 8.01 h whereas it was 61.12 ± 14.64 h in the conservative group (P < 0.001). The difference in the operation rate was statistically insignificant (2 in gastrografin group and 3 in the conservative group).No serious adverse reaction was noted after gastrografin administration. CONCLUSION: Use of gastrografin resulted in faster relief of signs and symptoms of AL-induced SBO, early passage of worms/flatus and return to oral feeds. However, the role of gastrografin role in reducing the likelihood of laparotomy remains inconclusive. Adverse effects of gastrografin can be prevented if it is used in well-hydrated patients.

Tunica vaginalis flap following 'Tubularised Incised Plate' urethroplasty to prevent urethrocutaneous fistulaa.

INTRODUCTION: Surgery for hypospadias has been continuously evolving, implying thereby that no single technique is perfect and suitable for all types of hypospadias. Snodgrass technique is presently the most common surgical procedure performed for hypospadias. MATERIALS AND METHODS: We analysed the results of tunica vaginalis flap (TVF) as an additional cover to the tubularised incised plate (TIP) repair. RESULTS: A total of 35 patients of hypospadias were repaired using TIP urethroplasty and TVF as a second layer. Mean age at the time of presentation was 6.63 ± 3.4 years. Post-operative complications namely wound infection, flap necrosis, scrotal haematoma, scrotal abscess, urethral fistula, meatal stenosis were recorded and analysed during follow-up period. Need for re-do surgery was considered as failure of the operative procedure. Out of 35 patients, 8 (22.85%) patients had proximal penile hypospadias and 27 (77.14%) patients had distal penile hypospadias. Mean post-operative follow-up was 24.53 months. During the follow-up complications noticed included wound infection (n = 2), urethrocutaneous fistula (n = 1) and meatal stenosis (n = 1). Wound infection was managed with appropriate antibiotics as per hospital policy/culture and sensitivity reports. Meatal stenosis responded to bougie dilatation/calibration during follow-up. CONCLUSION: To conclude, TVF as an additional cover is associated with an acceptable complication rate and good cosmetic results if performed with meticulous tissue handling.

Congenital midureteric stricture: challenges in diagnosis and management.

Background. Congenital midureteric stricture (MUS) is a rare malformation. We report our experience with five cases seen over a period of 4 years from 2010 to 2014. Materials and Methods. The study was based on the retrospective analysis of five patients diagnosed as having MUS. Diagnosis was suspected after fetal ultrasonography (USG) in one patient and magnetic resonance urography (MRU) in four patients. Retrograde pyelography (RGP) was performed on three patients. The final diagnosis was confirmed during surgical exploration in all the patients. Results. MRU was found to be a good investigation method. It showed the site of obstruction in the ureter in all instances. Intravenous urography detected proximal ureteric dilatation present in two of the patients. RGP delineates the level of stricture and the course of ureter, as shown in our cases. All patients had significant obstruction on the affected side. Four patients underwent ureteroureterostomy, all of whom had satisfactory results. In one patient, ureteric reimplantation was carried out due to distal small ureteric caliber. Conclusion. This rare entity is often misdiagnosed initially as pelviureteric junction obstruction. MRU is an excellent option for the anatomical location and functional assessment of the involved system. At the time of surgical correction of a ureteral obstruction, RGP is a useful adjunct for delineating the stricture level and morphology.

Inguinal Hydatid cyst in a child: A rare case report.

INTRODUCTION: Hydatid disease is a common health problem in developing countries and liver and lungs are the most commonly involved organs. Hydatid cyst in inguinal canal is very rare and no case in children has been reported in literature. PRESENTATION OF CASE: We describe a four year male child with right inguinal swelling with occasional pain and gradually increase in size. The diagnosis of lipoma of the cord was made. Up on inguinal exploration, coincidently Hydatid cyst was detected. Postoperatively histopathological examination (HPE) of the cyst confirmed the diagnosis of Hydatid disease and patient was put on albendazole therapy for three months. DISCUSSION: Hydatid disease is very rare in the inguinal canal and no case in children has been reported. In adults fewer than five cases has been reported and is usually coincidently detected during surgical exploration, as was in our case. Ultrasonography, CT, MRI and other serological tests may help in pre-operative diagnosis. CONCLUSION: In endemic areas, patients with progressive enlarging groin swelling, possibility of Hydatid cyst should be kept in mind and should be operated as early as possible.

Solitary crossed ectopia with vesicoureteric junction obstruction: A rare case report.

Solitary crossed renal ectopia (SCRE) is a very rare anomaly of urinary tract. Most cases are diagnosed incidentally. We report a case of SCRE associated with vesicoureteric junction obstruction in a 7-year-old child which has not been reported in the literature till date.

Outcome of split thickness skin grafting and multiple z-plasties in postburn contractures of groin and perineum: a 15-year experience.

Background. Groin and perineal burn contracture is a rare postburn sequel. Such postburn contractures causes distressing symptoms to the patients and in the management of these contractures, both functional and cosmetic appearance should be the primary concern. Aims. To study the outcome of surgical treatment (STSG and multiple Z-plasties) in postburn contractures of groin and perineum. Material and Methods. We conducted a study of 49 patients, with postburn groin and perineal contractures. Release of contracture with split thickness skin grafting (STSG) was done in 44 (89.79%) patients and release of contracture and closure by multiple Z-plasties was done in 5 (10.21%) patients. Results. Satisfactory functional and cosmetic outcome was seen in 44 (89.79%) patients. Minor secondary contractures of the graft were seen in 3 (6.81%) patients who were managed by physiotherapy and partial recurrence of the contracture in 4 (8.16%) patients required secondary surgery. Conclusion. We conclude that postburn contractures of the groin and perineum can be successfully treated with release of contracture followed by STSG with satisfactory functional and cosmetic results. Long term measures like regular physiotherapy, use of pressure garments, and messaging with emollient creams should not be neglected and should be instituted postoperatively to prevent secondary contractures of the graft and recurrence of the contracture.

Comparative Study of Snodgrass and Mathieu's Procedure for Primary Hypospadias Repair.

Objective. Present study was undertaken to compare the results of two single stage hypospadias repairs, namely, Tubularized Incised Plate (TIP) repair and Mathieu's repair. Methods. The study included 100 patients of distal penile hypospadias, from January, 2008 to January, 2013. After a detailed history, local examination was performed with reference to the site of meatus, shape of glans, and presence of chordee. TIP repair was performed in 52 patients and Mathieu's repair in 48 patients. On follow-up, the patients were examined for the position of meatus, shape of meatus, urinary stream, urethrocutaneous fistula, and stricture formation. Results. The mean age of presentation was 6.2 ± 3.2 years (range 1.5-15years). The mean operative time was 63.7 ± 14.3 (45-90) minutes and 95.0 ± 19.1 (70-125) minutes in TIP and Mathieu's repair, respectively.Complications after surgery were urethero cutaneous fistula in 3(5.76%) and 7 (14.5%), meatal stenosis in 3(5.33%) and 4(8.33%), wound infection in 19.2% and 8.3% cases in TIP repair and Mathieu repair, respectively. The shape of meatus was slit-like and vertically oriented in 48(92.3%) patients who had undergone TIP repair. Conclusion. The Snodgrass repair is significantly faster, with more natural cosmetic appearance of the meatus than the Mathieu's repair.

Late-presenting congenital diaphragmatic hernia.

BACKGROUND: This study was undertaken to highlight the clinical profile, misdiagnosis, surgical treatment,and prognosis of late-presenting congenital diaphragmatic hernia (CDH) cases in a tertiary level hospital. PATIENTS AND METHODS: This retrospective study included all the babies and children >1 month of age with CDH who were admitted in our Hospital (Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India) during the period between January 2008 and December 2013. Babies with age <1 month were excluded from the study. Data regarding clinical profile, operative records, and follow-up was reviewed and analysed statistically. RESULTS: A total of 20 patients were included in this study. The clinical picture ranged from respiratory distress (13 patients) to non-specific gastrointestinal complaints (5 patients). In two patients, CDH was misdiagnosed as pneumothorax and had got chest tube inserted in other hospitals before referral to this tertiary care centre. In 14 patients chest, X-ray revealed the diagnosis of CDH and in remaining five patients (including the two patients with misdiagnosis) further investigations were undertaken to establish the diagnosis. Age ranged from 45 days to 17 years with an average age of 58.9 months. There were 12 male and 8 female patients. In all the 20 patients, surgical procedures were undertaken with the retrieval of herniated contents from the thoracic cavity and repair of the diaphragmatic defect. There was no mortality in our series. All the 20 patients were followed-up for a period ranging from 6 months to 5 years (median 3.1 years). CONCLUSIONS: Late-presenting CDH can have diverse clinical presentation. Late diagnosis and misdiagnosis can result in significant morbidity and potential mortality if these cases are not managed properly at an appropriate stage. Outcome is favourable if these patients are expeditiously identified and surgically repaired.

Suppurative parotitis and submandibular sialadenitis.

Suppurative involvement of salivary gland in neonates is a rare disorder. Parotid gland being the most commonly involved. We described a case of suppurative parotitis leading to abscess formation and subsequent involvement of the submandibular gland. Incision and drainage of the abscess was performed, most of the purulent material was drained. Symptoms and signs resolved within 2 days. Pus culture grew Staphylococcus aureus.

Bloodless, sutureless circumcision.

BACKGROUND: W e present our experience of sutureless and bloodless elective circumcision in neonates and infants with Gomco clamp. PATIENTS AND METHODS: From March 2008 to May 2011, 200 babies with age ranging from 2 weeks to 7 months underwent Gomco circumcision. All patients were given chlorohydrate 50 mg/kg, paracetamol suppository 15 mg/kg, and local anesthesia. Procedure was done in minor operation theatre (OT) and babies were observed for 1 h in recovery room before discharging them home. RESULTS: Two of our patients (1%) required immediate suturing on table after Gomco clamp was removed, five patients (2.5%) were shifted back from the recovery room to minor OT for suture repair and eight patients (4%) required reinforcement of primary dressing to control the minor ooze. There was no other complication. Cosmesis was to the satisfaction of the surgeon as well as the parents. CONCLUSION: Gomco clamp is a bloodless, sutureless, simple, and safe method of circumcision in newborns and infants. It is cost-effective and can be performed under local anesthesia and sedation with excellent cosmetic results.

Post-partum pyogenic abscess containing Ascaris lumbricoides.

We report an unusual case of multiple pyogenic liver abscesses containing Ascariasis lumbricoides in a 35-year-old post-partum female who had delivered 1 month back. Open drainage of liver abscess along with liver worm was done. Patient did well post-operatively.

Outcome of wide local excision in dermatofibrosarcoma protuberans and use of radiotherapy for margin-positive disease.

PURPOSE: Wide local excision (WLE) is the preferred treatment of dermatofibrosarcoma protuberans (DFSP). The aim is to achieve negtive margins. We followed the impact of radiotherapy used postoperatively for both margin-negative and margin-positive DFSP tumors. MATERIALS AND METHODS: Outcome of treatment of 36 patients of DFSP treated at our hospital was assessed. Thirty patients received radiotherapy postoperatively and six patients received radiotherapy alone. The maximum dimension of the lesion was 15 cm(2). Patients were followed up for varying periods of time for any recurrence. RESULTS: 10-year actuarial local control rate was determined. Local control was realized in six patients who were treated with radiotherapy alone. 30 patients were treated by radiotherapy and surgery. Out of these 30 patients, there were 6 local failures (failure rate 10%). Actuarial control rate was 82%. The failures were among patients who had positive margins. CONCLUSION: Radiotherapy is effective, and it decreases the recurrence rate in the treatment of DFSP. It is especially helpful in margin-positive disease. This appears true for patients treated with radiotherapy alone or radiotherapy used postoperatively.

Dermatofibrosarcoma protuberans: Role of wide local excision.

OBJECTIVES: The main objective of the present study was to study the outcome of surgical treatment of dermatofibrosarcoma protuberans. MATERIALS AND METHODS: This study included 45 patients both retrospective and prospective from December 1995 to December 2010. RESULTS: Out of 45 patients, 30 were males and 15 females with the male to female ratio of 2:1. Mean age of presentation was 38.4 + 13.2 years. Commonest mode of presentation was raised firm multinodular lesion with fixity to overlying skin. Site distribution was 42.22% trunk, 57.88% extremities and head and neck. None of the patients had lymph node involvement All patients underwent wide local excision. On histological examination, 8 patients had positive margins. Overall recurrence rate was 22.22%. (please clarify what is the difference between the rate of recurrence following surgery and the overall recurrence rate) Only 2 patients developed metastasis to lungs in the course of their follow-up. Out of 45 patients, 35 remained recurrence free over a varying period of 5 months to 13 years (mean 68 months). Ten patients developed one or more local recurrences. Average time from initial treatment to recurrence was 32 months. All patients with recurrent tumors were subjected to salvage treatment, i.e., re-excision. Average recurrence-free period was 36 + 44 months within a mean follow-up of 68 months. CONCLUSION: Because of the potential of local recurrence, therapy for DFSP should be directed toward adequate local excision of the primary lesion. Minimal resection should include a surrounding margin, comprising 3-cm margin of normal skin and removal of underlying deep fascia. Compromising on margins invites higher chances of local recurrence.

Hydatid cyst of liver: Spontaneous rupture and cystocutaneous fistula formation in a child.

A case of spontaneous formation of cutaneous fistula from rupture of an infected hydatid cyst of liver in a female child is reported.