Urinary flow rates in anterior hypospadias: Before and after repair and its clinical implication

Context

Hypospadias is a common urological anomaly which could be surgically corrected with good cosmetic results.

Aims

We aimed to detect changes in urinary flow parameters both before and after tubularised incised plate urethroplasty (TIPU) using uroflowmetry.

Settings and Design

Data collected were clinically implemented hypothesising the probability of urethrocutaneous fistula following stricture with Qmax variation.

Materials and Methods

This study is a prospective analysis done from December 2017 to October 2019. A total of 104 cases of anterior hypospadias were included in the study. A single surgical unit did TIPU. Pre-operative and post-operative uroflowmetry was done, and Qmax was recorded at 3 months, 6 months and 1 year after surgery. Mean Qmax was calculated for all intervals. A significant decrease in Qmax of a child (<2 standard deviation) was ascertained. Urethral calibration was done in those cases with a significant decrease of Qmax and analysed statistically.

Results

The mean age was 6.97 ± 2.41 years. Out of 104 children, 73 (70.2%) and 31 (29.8%) had distal and mid-shaft hypospadias, respectively. The pre-operative mean Qmax of the population was 6.20 ± 0.42 ml/s. Arithmetic mean Qmax at 3 months, 6 months and 1 year was 8.53 ± 0.42, 11.18 ± 0.47 and 13.71 ± 0.44 ml/s, respectively. On comparing the pre-operative with post-operative mean Qmax, a significant increase was found postoperatively (P < 0.0001). Twenty-four patients had significantly decreased Qmax value after 6 months. In these patients, follow-up urethral dilation was done with significant improvement.

Conclusion

The changes in maximum flow rate (Qmax) are suitable for use in routine follow-up. A significant decrease in Qmax over time indicates the onset of urethral stricture. These cases are to be intervened before venturing to redo urethroplasty.

Sandwich therapy in the management of propranolol resistant infantile hemangioma of the lip

RATIONALE

Propranolol has evolved as a first line management of infantile haemangiomas. Nevertheless, the resistance to propranolol has warranted alternative treatment modalities. We hypothesize that combination of medical and surgical therapy (sandwich therapy) to be beneficial in the management.

METHODS

Patients were divided into three groups (total=31), Group A (bleomycin sclerotherapy), Group B (surgical group), Group C (sandwich therapy). A p value &lt;0.05 was taken as significant.

RESULTS

In Group A 54.5% of patients had excellent response, 27.3% partial response and 18.2% had no response. Comparing cosmetic outcome, 25% of patients in Group B and 16.7% of patients in Group C had excellent upshot. On the contrary 18.2% of patients in bleomycin had unsatisfactory and 18.2% had poor cosmetic outcome. Sandwich therapy was cosmetically more acceptable than Bleomycin sclerotherapy (p- value = 0.049). In terms of recurrence, sandwich therapy differed significantly from surgical therapy with fewer recurrences (p-value= 0.049).

CONCLUSION

Sandwich therapy is superior to bleomycin sclerotherapy in terms of cosmetic outcome and has fewer recurrences compared to surgical group and requires single stage resection. However, further studies with the help of Doppler ultrasound are required in this regard.

Modified Laparoscopic Excision of Choledochal Cyst: Technique and Early Results

BACKGROUND

Choledochal cyst is a common congenital anomaly requiring surgical treatment. Nowadays, laparoscopic excision is the preferred approach. We studied a modification in the classical laparoscopic approach to facilitate the dissection of a cyst.

MATERIALS AND METHODS

A prospective comparative study was done on 42 Type I choledochal cyst children. One group was operated by classical laparoscopic technique, while the other group was operated by modification of classical technique by deliberately opening the cyst wall and dividing the cyst into two hemi-cups, followed by dissection and excision. The intraoperative and postoperative parameters were assessed in both the groups.

RESULTS

The age, gender ratio, clinical presentation, and cyst diameter were comparable in both the groups. There was a significantly higher success rate (95.7% vs. 73.7%, P = 0.042) and lesser time for cyst excision (96.43 ± 12.15 vs. 120.91 ± 17.38 min P < 0.001) in the modified technique when compared to the classical technique. Further in three patients, it was possible to convert the classical procedure to a modified technique and complete the cyst excision. The postoperative outcomes were similar in both the groups.

CONCLUSION

The modified laparoscopic excision shortens the operative time with higher success rate and comparable short-term morbidity vis-a-vis classical laparoscopic technique.

Adverse Drug Reactions Following Propranolol in Infantile Hemangioma

OBJECTIVES

To assess the adverse effects of propranolol therapy in infantile hemangioma.

METHODS

An ambispective study was conducted from August 2011 to December 2019. In retrospective arm all children managed for infantile hemangioma with propranolol were included and case records were assessed for adverse reactions. In prospective arm the adverse reactions were identified on the basis of predefined criteria.

RESULTS

A total of 514 patients (358 retrospective records) were included. A majority, 378 (73.5%) patients had an excellent response, 75 (14.5%) had partial response and 61 (11.8 %) had no response. A total of 82 (15.9%) patients experienced at least one adverse effect. Diarrhea with weight loss (27, 32.9%) and irritability with decreased sleep (21, 25.6%) were the most common adverse effects. The adverse effects in 22 (4.2%) cases lead to the discontinuation of propranolol. Younger age, low body weight and early onset were risk factors for development of severe adverse reactions.

CONCLUSIONS

Young children with low body weight were at higher risk for adverse effects of propranolol.

Adverse Drug Reactions Following Propranolol in Infantile Hemangioma

OBJECTIVES

To assess the adverse effects of propranolol therapy in infantile hemangioma.

METHODS

An ambispective study was conducted from August 2011 to December 2019. In retrospective arm all children managed for infantile hemangioma with propranolol were included and case records were assessed for adverse reactions. In prospective arm the adverse reactions were identified on the basis of predefined criteria.

RESULTS

A total of 514 patients (358 retrospective records) were included. A majority, 378 (73.5%) patients had an excellent response, 75 (14.5%) had partial response and 61 (11.8 %) had no response. A total of 82 (15.9%) patients experienced at least one adverse effect. Diarrhea with weight loss (27, 32.9%) and irritability with decreased sleep (21, 25.6%) were the most common adverse effects. The adverse effects in 22 (4.2%) cases lead to the discontinuation of propranolol. Younger age, low body weight and early onset were risk factors for development of severe adverse reactions.

CONCLUSIONS

Young children with low body weight were at higher risk for adverse effects of propranolol.

Endoscopic Third Ventriculostomy in Infants Less than One Year of Age: A Short Series of 14 Cases

BACKGROUND

Endoscopic third ventriculostomy (ETV) is currently considered as an alternative to cerebrospinal fluid (CSF) shunt systems in the treatment of obstructive hydrocephalus. This procedure allows the CSF to drain in the basal cisterns and reabsorbed by arachnoid granulations, and avoiding implantation of exogenous material.

AIMS AND OBJECTIVES

The purpose of this study was to assess the success rate of ETV in infants less than 1 year of age with congenital noncommunicating hydrocephalus.

MATERIAL AND METHODS

This study was a 2-year prospective study from August 2017 to July 2019. ETVs were performed in 14 patients younger than 1 year with diagnosis of noncommunicating hydrocephalous. A failure was defined as the need for shunt implantation after ETV. Phase-contrast MRI of the brain was done after 6 months to see patency of ETV fenestration and CSF flow through ventriculostomy.

RESULTS

ETV was tried in 18 patients and successfully performed in 14 patients. Out of the 14 patients, shunt implantation after ETV was performed in 3 patients (failed ETV). In the successful cases, etiology was idiopathic aqueductal stenosis in 8, shunt complications in 2, and 1 case was a follow-up case of occipital encephalocele; the mean age was 7.7 months (range 3-12). In the 3 failed cases, etiology was aqueductal stenosis, mean age was 7.6 months (range 3-11). In all ETVs, failed patients MPVP shunting was done. Follow-up of nonshunted patients was done from 6 to 24 months (mean 15 months). There was no mortality or permanent morbidity noted following ETV.

CONCLUSION

ETV is a good surgical procedure for less than 1-year-old children.

Management of Mesenteric Cysts in Pediatric Population: Five-year Experience in Tertiary Care Center

Introduction To study the clinical features, diagnosis and treatment of mesenteric cysts in pediatric age group (< 15 years).

Materials and Methods This was a retrospective analysis which inculded 35 children diagnosed and treated for mesenteric cysts in the pediatric surgery department from January 2014 to January 2019. Patient’s data were retrieved from case sheets and analyzed. Patients with atleast one year follow-up were included in the study.

Results Thirty-five patients were included in the study. Twenty-one (60%) were males and fourteen (40%) were females. Mean age of presentation and surgery was 24 months. Twenty-six (74.2%) patients were managed by bowel resection, while 9 (25.7%) were managed by simple cystectomy. The average size of the cyst was 15 cm (ranging from 5 to 25 cm). Content of cysts was mostly chylous (82.9% cases). No recurrence was found throughout the follow-up period (1–2 years).

Conclusion Mesenteric cyst should be considered as a differential diagnosis in pediatric patients with acute or subacute intestinal obstruction and with or without a palpable lump in the abdomen. Mesenteric cysts can be managed surgically with favorable outcomes.

Role of Urinary Transforming Growth Factor Beta-B1 and Monocyte Chemotactic Protein-1 as Prognostic Biomarkers in Posterior Urethral Valve

Background:

Posterior Urethral Valves (PUV) are the most common cause of congenital LUT obstruction in males. Biomarkers of glomerular or tubular injury may be of particular value in predicting the need for surgical intervention or in tracing progression of chronic kidney disease. Measurement of biomarker in urine is relatively easy.

Aim:

To evaluate the changes in values of urinary Transforming Growth Factor Beta 1(TGF-B1) and Monocyte Chemotactic Protein (MCP-1) before and after valve ablation and its prognostic value in Posterior urethral valve.

Material and Method:

This prospective study was conducted from September 2016 to August 2018. The study group included 20 consecutive male babies with the diagnosis of PUV treated and followed up versus equal numbers of age matched control without any renal or urinary tract disease. Pre-operative urine samples were collected in Operative room. Cystoscopy and valve ablation was done. Follow up was done clinically by urinary stream and radiologically with VCUG. Follow-up was planned at 1 month, 3 months and 6 months following cystoscopic valve ablation. All collected urine samples were centrifuged at 10,000 rpm for 20 minutes. Supernatant was collected and two divided aliquots were stored at -200c to be thawed on the day of assay. Optical density of each well was recorded at 450 nm and 540 nm A p-value of <0.05 was considered to be statistically significant.

Result and Discussion:

Out of 20 cases of PUV, 14 (70%) cases were 1st born males of their family. The median age at the time of valve ablation in PUV cases was 2.5 (1.20-3.87) years.. Most common symptoms are fever and UTI. The preoperative median serum creatinine level was 1.65 mg/dl(1.22-2.42) pre-ablation, and fall significantly after ablation. Median eGFR level (calculated) was 25.635 (16.38-35.40) and after 6 months was 71.490 (45.44-96.93). Preoperative median MCP1 in PUV cases was 147.2 (82.8-512.5) and significant difference was also found in 1st, 3rd and 6th months after surgery (p<0.001, p=0.004 and p=0.002).Preoperative median TGF-B1 level was 197.8 pg/ml (79.9-386.4). There was no statistically significant change in TGF-B1 level at preoperative to 1 month and preop to 3 months after surgery but at 6 months after surgery the median TGF-B1 level significantly decreased as compared with preoperative TGF-B1 level.

Conclusion:

TGF β1 and MCP1 can be considered as prognostic urinary biomarkers in patients of PUV and can be used to specify and counsel patient's attendant regarding possibility of ESRD and need for further intervention.

Electron impact ionization cross sections of hydrogen fluoride molecule

Partial and total ionization cross sections of hydrogen fluoride molecule are determined from the ionization threshold to high energy (5 KeV) by using a modified Jain-Khare semiempirical approach. Partial single and double differential cross sections with their sums (total) through direct and dissociative ionization have been also evaluated at fixed primary electron energies 100 eV, 200 eV, and 500 eV. There is no other data for partial ionization cross sections and differential ionization cross sections for comparison. In this paper, the total ionization cross sections data have compared with available experimental data and/or with other theoretical data which are available from intermediate to high energy. It is found that the present result gives a better account for the ionization cross sections up to higher energies.

Development of a biomarker of efficacy in second-line treatment for lymphangioma of the tongue: a pilot study

Lymphangioma of the tongue is a rare lymphatic malformation, and various authors have reported the successful use of sirolimus for its treatment. However, the safety of sirolimus in children needs further evaluation so that those who do not respond are not necessarily exposed to its potential adverse effects. We hypothesised that assessment of lymphangiogenesis can be used to predict whether the patient will respond to sirolimus, so we organised a prospective study after ethics committee approval had been given. After clinical and histological diagnoses of lymphangioma of the tongue had been confirmed, 16 patients were given sirolimus 0.8mg/day in three divided doses. Clinical response was assessed and compared with lymphatic microvessel density (LMVD), which was calculated immunohistochemically using the monoclonal antibody D2-40 as the lymphatic endothelial marker. Nine patients responded well, five partially, and two failed to respond. Mean (SD) LVD among the good responders was 21.00 (3.74), whereas among non-responders it was 8.00 (4.24). There was a significant difference in mean LVD between good responders, partial responders, and non-responders (p=0.04). Sirolimus is effective in treating children with lymphangioma of the tongue, and lymphangiogenesis is a useful therapeutic predictive marker.

Homocysteine and vitamin B12: Other causes of neural tube defects in Eastern Uttar Pradesh and Western Bihar population

Background

Neural tube defects (NTDs) are congenital malformations with an incidence of 1-10/1000 live births. Homocysteine and vitamin B12 metabolism have been shown to be associated with NTDs.

Aim

To investigate the status of maternal and neonate's folic acid, homocysteine, and vitamin B12 levels and their association with the risk of development of NTDs in the population of Eastern Uttar Pradeshand Western Bihar, India.

Materials and Methods

This study is a cross-sectional, retrospective study where 96 mothers who either had a first NTD child or had a history of NTD child in the family and 126 neonates with spina bifida were recruited during the period 2012-2015. Eighty-four control mothers whose previous and current pregnancies were normal, and 87 control neonates who had no defects and were within the same age range as the NTD affected neonates, recruited from the department of pediatric surgery, were enrolled in the study. Plasma concentrations of folic acid, vitamin B12, and homocysteine were compared between cases and controls.

Results

The folic acid level in the mothers and neonates was within the normal limit. A significant increase in the level of homocysteine in mothers with affected pregnancy and in neonate cases in comparison to control mothers was obseved. Further, a significant decrease in the level of vitamin B12 in mothers with NTD neonates and in the affected neonates was noted. A negative correlation was found between homocysteine and vitamin B12 levels in case and control mothers.

Conclusion

A correlation of an increase in serum homocysteine with a decrease in vitamin B12 was seen in mothers of neonates with NTD. A similar observation as made in the neonates with NTDs. It may be suggested that maternal decrease in vitamin B12, in mothers who have normal folic acid may be associated with NTD in their children.

Role of intralesional bleomycin and intralesional triamcinolone therapy in residual haemangioma following propranolol

With the emergence of propranolol as the first choice of treatment for problematic infantile haemangioma at many centres, the number of patients with a partial or non-response to propranolol has also been growing. This study investigated the role of intralesional bleomycin and triamcinolone in patients with residual disease following propranolol therapy for infantile haemangioma. Sixty-seven patients with residual haemangioma were assigned randomly to receive either intralesional bleomycin (group A, n=36) or intralesional triamcinolone (group B, n=31). The response to treatment and adverse effects were assessed in both groups. All patients received at least four doses and a maximum of six doses of the assigned drug. In group A (mean follow-up 9.38months), 47.2% had an excellent response and 44.4% a good response. In group B (mean follow-up 7.42months), 25.8% had an excellent response and 48.4% a good response. There was no difference in overall response between the groups (P=0.074). Among patients who were initially non-responders to propranolol, bleomycin showed a better response than triamcinolone (P=0.037). This may be due to an overlap in the mechanism of action of propranolol and triamcinolone. Thus, intralesional bleomycin should be preferred in patients with no initial response to propranolol therapy, while bleomycin or triamcinolone can be used in patients with a partial response to propranolol therapy, as they have equal efficacy.

Effectiveness of Proseal laryngeal mask airway and laryngeal tube suction in elective non-laparoscopic surgeries of up to ninety minutes duration: A prospective, randomized study

Background and Aims:

Proseal laryngeal mask airway (LMA) and laryngeal tube suction (LTS) are both supraglottic devices with an esophageal suction port. In the present prospective, randomized study, the effectiveness of airway seal, hemodynamic variables, ability to pass orogastric tube, and postoperative complications with the two devices were evaluated.

Material and Methods:

This was a prospective, randomized, single-blind study conducted in a hospital-based setting. Sixty patients (American Society of Anesthesiologists Grade I and II) undergoing elective general surgery were randomly allocated to Group A (Proseal LMA) or Group B (LTS), and airway seal pressure (primary outcome), peak pressure, hemodynamic parameters (blood pressure, pulse rate and pulse oximetry) during and 5 min after insertion, insertion time, ease of insertion, and postoperative complications (sore throat and hoarseness of voice for a period of 24 hours) (secondary outcomes) were noted. The quantitative data was summarized as mean and standard deviation, and analyzed using Student's t-test. All the qualitative data were summarized as proportions and analyzed using Chi-square test. The levels of significance and α-error were kept 95% and 5%, respectively, for all statistical analyses. P ≤ 0.05 was considered significant (S).

Results:

Proseal LMA had shorter insertion time (16.4 ± 5.6 vs. 20.0 ± 3.9 s), higher seal pressure (27.6 ± 4.6 vs. 24.1 ± 5.6 cm of H₂O), lesser peak pressure (16.3 ± 2.3 vs. 18.5 ± 3.9 cm of H₂O), higher success rate of orogastric tube passage (86.7 vs. 76.7%), and lesser postoperative sore throat (3.3 vs. 10%).

Conclusions:

Both Proseal LMA and LTS were acceptable alternatives for airway management in elective surgeries with controlled ventilation, but the quality of ventilation was found to be significantly better with Proseal LMA (in terms of higher seal pressure, lesser peak pressure, lesser insertion time, and lesser complications).

Intradural teratoma in a neonate with meningomyelocele

Meningomyelocele is a common congenital problem. The teratoma is a neoplasm composed of tissues foreign to the part in which they arise. An intradural teratoma within a meningomyelocele is a very rare association. We report a case of intradural teratoma with a brief review of the relevant literature.

Primary Eosinophilic Gastritis in a Child with Gastric Outlet Obstruction

A 3-year-old girl presented with multiple episodes of vomiting, fever, and hematemesis for the past 2 months. Except for hemoglobin, her rests of the laboratory tests were unremarkable. Her barium X-ray showed absence of the duodenal bulb and the C-loop. Her endoscopy showed deformed stomach with multiple ulcers and diverticuli. The gastric outlet was not visualized. Distal gastrectomy with gastro-duodenal anastomosis was performed. Histopathological findings revealed transmural dense infiltrates of eosinophils, consistent with eosinophilic gastritis.

In Vitro Evaluation of Carbachol and Endothelin on Contractility of Colonic Smooth Muscle in Hirschsprung’s Disease

BACKGROUND

The hypomotility of colon observed in Hirschsprung’s disease (HD) has been attributed to congenital aganglionosis only. So far, it is not clear whether the contractility of colonic smooth muscle in this condition is altered or not. Therefore, the present study attempted to understand the contractile status of colonic segments of HD patients by examining carbachol and endothelin (ET-1) evoked colonic smooth muscle contractions in vitro .

METHODS

Contractile responses were recorded from strips of colonic segments obtained from HD patients, using organ bath preparations. Cholinergic agonist carbachol and ET-1 along with their antagonists were used to evoke contractile responses. Thereafter, the samples were histopathologically confirmed for HD.

RESULTS

Colonic strips of HD did not show any spontaneous contractions but responded to carbachol and ET-1 to a lesser extent. In HD, response of carbachol was blocked by atropine and hexamethonium by nearly 73% and 50% respectively. ET-1 induced contractile responses were blocked by ET-A and ET-B antagonist up to 40%, signifying the possible role of ET-A and ET-B receptors in HD colon contractility.

CONCLUSION

As evidenced by lack of spontaneous contractions and impaired carbachol and ET-1-induced contractile responses, it is concluded that, in addition to aganglionosis, decreased contractility of colonic smooth muscle may contribute to hypomotility observed in patients with HD.

Single stage management of a unique variant of congenital pouch colon with triplet fistula and normal anus

Congenital pouch colon (CPC) in the female patient presents with highly variable and anomalous anatomy. We herein report the first case of CPC with uterus didelphys having normal anal opening, H-type vestibular fistula, two other fistulous communications between pouch colon and two vagina managed in a single stage with excellent postoperative outcome.

Novel technique of repair of large tracheo-esophageal fistula following battery ingestion in children: review of two cases

Surgical repair of acquired tracheo-esophageal fistula may result in tracheal stenosis or esophageal stricture. We used fistula with esophageal cuff as flap to repair the tracheal defect. Esophageal repair was performed by rotating ends through 90° in opposite direction. This technique offers excellent repair in a single stage.