Choledochal Cyst of Cystic Duct in Children a Rare Entity.

Choledochal cyst of the cystic duct is an uncommon entity which may occur as isolated disease or may be associated with choledochal cyst of the other part of the biliary tree. In most of the reported series it was diagnosed at time of operation but now days to better investigation modality it can be diagnosed preoperatively if the index of suspicion is high. We are presenting a series of such case in pediatric age group (which includes an infant) where the diagnosis was made during operation with a light on means and ways for suspecting this entity before operation and how to differentiate other lesion with this entity with relevant review of literature.

Placement of the peritoneal end of a ventriculoperitoneal shunt in the suprahepatic space: does it improve prognosis?

INTRODUCTION: Hydrocephalus is a common pediatric problem. Ventriculoperitoneal shunts (VPS) are the most frequent operative procedures used to treat hydrocephalic children. The peritoneal end is usually placed in the general peritoneal cavity. We present an alternative site of peritoneal end placement in the suprahepatic space in an attempt to reduce the abdominal complications. MATERIAL AND METHODS: All patients with a diagnosis of congenital hydrocephalus were included in the study. In group 1, the lower end of the VPS was placed in the suprahepatic space. Patients were evaluated for abdominal complications like pseudocyst formation, intestinal obstruction and blockage of the lower end of the VPS. The data were compared with those patients in whom the peritoneal end was placed in the general peritoneal cavity (group 2). RESULTS: The total number of patients in groups 1 and 2 was 133 and 175, respectively. Complications in group 1 were dislodgement of the shunt in the general peritoneal cavity in 28 (21.05%), suprahepatic pseudocyst formation in 2 (1.5%) and blocked lower end in 2 patients (1.5%). In group 2, complications noted were pseudocyst formation in 5 (2.8%), blocked lower end in 25 (14.2%), intestinal obstruction in 9 (5.1%), inguinoscrotal migration in 10 (5.7%) and perforation of viscera in 6 patients (3.4%). The overall follow-up period ranged from 1 to 7 years. CONCLUSIONS: Placement of the lower end of the shunt in the suprahepatic space can be advantageous to placing it in the general peritoneal cavity. The procedure is simple and results can be rewarding.

Amyand's hernia in infant: a rare entity.

The chance of vermiform appendix lying with in a hernial sac is 1% or less and is known as Amyand's hernia and it is very rare in infant and neonate. Till date, only twenty cases had been reported in English literature. We are reporting a rare case of Amyand's hernia where appendix was present in right inguinal sac of non-obstructed inguinal hernia in a seven month old male infant during operation. The appendectomy was done along with right inguinal herniotomy. In most of the reported cases, appendix was inflamed or perforated, expect in one case where appendix was not inflamed but patient presented with inguinal hernia. This case is reported because of the rarity of Amyand's hernia in infant, the appendix was not inflamed, hernia was not obstructed, and whether in such types of cases appendix should be preserved or not.

Eviscerated urinary bladder via ruptured umbilical hernia: a rare occurrence.

Umbilical hernia is a common problem encountered in children. Rupture and evisceration are very rare phenomena, and the usual content that is eviscerated is the bowel. We present an infant who had a ruptured umbilical hernia with eviscerated urinary bladder dome. As this is the first case of its kind, it is being reported with a brief review of literature.

Acute gastric volvulus in neonates - a diagnostic dilemma.

INTRODUCTION: Gastric volvulus is a rare, potentially life-threatening condition, which is difficult to diagnose. This study presents a series of acute gastric volvulus in neonates with the aim of describing this rare disease and its varied clinical manifestations. MATERIAL AND METHODS: The data of all neonates presenting with acute gastric volvulus between January 2001 and January 2007 was retrospectively reviewed. Diagnosis was made on suspicion and was documented by a barium study. All patients were operated by open anterior gastropexy with or without a feeding gastrostomy. RESULTS: Four patients were male and 1 was female. All were treated with gastropexy with or without feeding gastrostomy. Four patients recovered well after surgery. There was one postoperative death. CONCLUSION: Gastric volvulus is extremely rare in neonates but it should be considered in the differential diagnosis after sudden onset or recurrent vomiting in the pediatric age group. Early diagnosis and treatment gives excellent results.

Necrotising fasciitis in children and neonates: current concepts.

While the incidence is very low, necrotising fasciitis in neonates and children is a potentially life-threatening infection that requires rapid diagnosis and treatment. This review describes its aetiology, symptoms, clinical feature and treatment.

An unusual presentation of hydatid cyst in anterior abdominal wall.

Hydatid disease is a parasitic infestation caused by the larval form of the cestode worm Echinococcus. The most commonly encountered form of the disease is visceral hydatid cyst caused by Echinococcus granulosus or dog tapeworm. Muscular involvement has been reported in only 3-4% cases. We are reporting this case because of its rarity, difficulty to diagnose clinically, dramatic response to medical treatment and to alert the reader of this rare infestation so that open biopsy will be avoided.

Is ligation of azygos vein necessary in primary repair of tracheoesophageal fistula with esophageal atresia?

INTRODUCTION: Congenital tracheoesophageal fistula with esophageal atresia (TEF with EA) is not an uncommon disease of newborns. Classical approach for primary repair of TEF with EA is right thoracotomy with extrapleural approach, ligation of the azygos vein, identification and ligation of tracheoesophageal fistula, identification of upper esophageal pouch and end-to-end anastomosis. This study was conducted to evaluate if the ligation of the azygos vein is a must during primary repair of TEF with EA. METHOD: We studied 50 randomly selected cases in the last two years (Jan 2003 - Jan 2005). In 25 babies (group A), primary repair was done with preservation of the azygous vein while 25 babies (group B) were operated with a classical approach with ligation and division of the azygos vein. The postoperative result was comparative in both cases. RESULT: Postoperative pneumonitis was higher in the babies operated with the classical approach (56 % in group B and 12 % in group A) and was found to be statistically significant. In postoperative complication, anastomotic leak was slightly higher in group B but was not statistically significant. Mortality rate was similar in both groups. Babies in group A were hemodynamically more stable in comparison to group B. CONCLUSION: Preservation of the azygos vein maintains the normal venous drainage of mediastinum and hence decreases the postoperative chest congestion and pneumonitis in the postoperative period in cases of congenital esophageal atresia with tracheoesophageal fistula, so it should be preserved whenever possible.

Paediatric pancreatic problems: a five-year experience.

BACKGROUND: To analyse a tertiary care experience with various pancreatic problems in the paediatric age group and clarify the frequency of various pancreatic diseases in the same patient population as well as the role of surgical or conservative management in their treatment. PATIENTS AND METHODS: All patients with clinical suspicion of disease pertaining to the pancreas, substantiated by laboratory investigations or imaging modalities over a period of five years are included in our study. RESULTS: Of the total 228 patients with various pancreatic problems, who presented to us, mostly with acute pancreatitis and pancreatic trauma, 64 needed surgical interventions. The total mortality rate encountered was a meagre 3.5%. CONCLUSION: Paediatric pancreatic disorders are not so infrequent; and a high index of suspicion aided by the newer modalities of investigation greatly helps in the appropriate and timely management.

Typhoid sigmoid colon perforation in an 18-month-old boy.

BACKGROUND: Typhoid fever is a severe infective disease endemic in the areas where sanitation is poor. Its serious complication is bowel perforation with terminal ileum as the commonest perforation site. We report a case of an extremely unusual site of perforation in sigmoid colon due to typhoid fever. METHODS: An 18-month-old boy presented with no passage of flatus and feces along with guarding and rigidity. Exploratory laparotomy revealed sigmoid colon perforation and Widal test was strongly positive for typhoid fever. Sigmoid loop colostomy was performed on the patient. RESULTS: Postoperative period was uneventful. Colostomy started functioning on the 4th post-operative day. There was superficial wound dehiscence. The patient was given oral food intake on the 7th post-operative day. He was discharged from the hospital in satisfactory conditions on the 10th day after operation. CONCLUSIONS: While tackling a case of enteric perforation suspected with typhoid fever, one should keep in mind the extremely rare site of sigmoid colon perforation.

Rectal atresia with rectolabial fistula.

Rectal atresia is a rare condition in which the anus and sphincter muscles are normally developed, with usually no fistulous communication with the urinary tract. We describe an unusual case of membranous rectal atresia with recto-labial fistula. It was treated by blind perforation of rectal membrane with lay opening of fistlous tract.

Comparative evaluation of 5-HIAA (5-hydroxy indoleacetic acid) and HVA (homovanillic acid) in infantile hydrocephalus.

BACKGROUND: Infantile hydrocephalus is a common congenital problem. Functional and behavioral disturbances associated with hydrocephalus may be due to altered neurotransmitters in the brain. The role of neurotransmitters has been established in various psychiatric and neurological conditions. Therefore, we decided to study the role of 5-hydroxy indoleacetic acid (5-HIAA) and homovanillic acid (HVA) in cerebrospinal fluid (CSF) of hydrocephalic patients as diagnostic and prognostic marker. MATERIALS AND METHODS: Ventricular CSF samples were taken from hydrocephalic patients peroperatively and at days 7 & 30. Control CSF samples were taken from nonhydrocephalic patients operated for other conditions. Samples were analyzed for 5-HIAA and HVA, and results were obtained accordingly. RESULTS: Values of 5-HIAA and HVA showed a highly significant decrease after shunt insertion. No significant difference in values of 5-HIAA and HVA were observed in relation to age and duration of disease. The CSF ventriculo-lumbar gradient for both 5-HIAA and HVA done in six patients was statistically significant only in the noncommunicating group. CONCLUSION: Both the neurotransmitter metabolites 5-HIAA and HVA are found to be significantly high in the hydrocephalus, but 5-HIAA is a more sensitive parameter. These markers levels decrease after shunt insertion. Thus, estimation of these metabolites could be valuable markers for its diagnosis and follow-up.