Factors contributing to poor results of treatment of esophageal atresia in developing countries

The results of treatment of 341 consecutive cases of esophageal atresia/tracheoesophageal fistula over an 11-year period have been analyzed to determine the factors resulting in a poorer prognosis of these cases in a developing country; 121 neonates in the first 6-year period are compared with 220 in the last 5 years. In the latter group only 8% were in Waterston's group A; 46% reached the hospital within 24 h of birth, 13% were normothermic on presentation, 70% had a chest infection, and 28% had major associated malformations. This was similar to the preceding 6-year period. In the last 5 years the overall mortality was 58%, compared to 67% in the preceding 6 years. Despite improvement in survival in the last 5 years, the overall survival is far inferior to that reported from the developed countries. The factors resulting in poorer results have been analyzed and remedial actions suggested.

Management of metastatic Wilms tumor: an eleven year experience

During the last 11 years, 101 patients of Wilms tumor were seen. Of these, 13 patients had metastatic disease at onset while 24 patients presented with relapse at a latter date. Seven patients have been cured, all had favourable histology. The risk factors associated with relapse were found to be unfavourable histology, lymph node involvement, age more than 6 years, diffuse spill, capsular and vascular invasion, and aneuploidy. Of the 18 patients who had relapsed, 14 were found to be aneuploid. Judicious use of various therapeutic options like radiotherapy to metastatic sites, second look surgery, resection of pulmonary metastasis and use of cis-platinum, VP-16 and Ifosfamide as "alternative chemotherapy protocols" were used to achieve cure in these advance cases.

Effect of treatment with phenobarbital and stiripentol on carbamazepine-induced teratogenicity and reactive metabolite formation

A model using SWV mice was developed to investigate the mechanistic basis of carbamazepine (CBZ)-related fetotoxicity. Drug administration was initiated prior to conception and continued until day 18 of gestation. The incidence of malformation was 33% following CBZ exposure (1,500 mg/kg/day), compared with a 5% incidence in pair-fed control animals (P < 0.05). Coadministration of nonteratogenic doses of phenobarbital (PB; a cytochrome P-450 inducer) (45 mg/kg/day) and CBZ (1,000 mg/kg/day) increased the frequency of malformation from 10% to 26% (P < 0.05), compared with mice dosed with CBZ alone (1,000 mg/kg/day). Coadministration of stiripentol (STP; a cytochrome P-450 inhibitor) (300 mg/kg/day) decreased the incidence of malformations produced by CBZ (1,500 mg/kg/day) from 33% to 16.7% (P < 0.05). The effect of PB administration on the binding of 14C in maternal and fetal tissue was assessed in dams that received CBZ (1,000 mg/kg/day) with or without PB (45 mg/kg/day) or STP (300 mg/kg/day) chronically and a single i.p. dose of 14C-CBZ on day 12 of gestation. In all instances, binding was greatest in maternal liver, then in the placenta, fetal head and body, and maternal thigh muscle. In all tissues, PB caused a two-to threefold increase in binding, compared with binding in mice exposed to CBZ alone. STP administration decreased protein adduct formation only in maternal liver. The binding of 14C was also assessed in hepatic microsomes prepared from female mice exposed to CBZ and PB or STP as in the in vivo study of 14C binding. The extent of irreversible binding was 67% greater in microsomes prepared from mice pretreated with PB and CBZ than with CBZ alone, while STP resulted in only 21% inhibition of 14C adduct formation (P < 0.05). The results are consistent with the formation of a chemically reactive teratogenic metabolite of CBZ in mice by cytochrome(s) P-450.

Technetium-99m-HMPAO SPECT cerebral blood flow study in children with craniosynostosis

Premature closure of cranial sutures (primary craniosynostosis) in children leads to characteristic skull deformities and prevents the constricted brain from growing normally. Although the cause remains unknown, several etiological factors have been cited. Recently, hypovascularity has been reported as a possible cause of craniosynostosis.

METHODS

In a prospective study regional cerebral blood flow studies were carried out with 99mTc-HMPAO SPECT in seven children with craniosynostoses. Five preoperative and six postoperative studies were conducted and the results correlated with radiological and surgical findings.

RESULTS

Preoperative studies revealed regional hypovascularity in the underlying cerebral hemisphere, corresponding to the fused sutures. Postoperative studies revealed disappearance of these perfusion defects in most cases, indicating normalization of perfusion following surgical decompression.

CONCLUSION

This study establishes the presence of cerebral hypovascularity in craniosynostoses and suggests that early surgery and release of craniostenosis is essential to achieve optimum perfusion and brain development.

Duplications of the alimentary tract: clues to the missing links

This is a review of the past 10 years' experience with duplications of the alimentary tract at the All India Institute of Medical Sciences, New Delhi, during which 14 infants and children with a total of 15 duplications were treated. Esophageal duplications represented the majority of cases (55%). Certain unexplained associations in this malformation led the authors to perform (1) detailed histological studies of the duplication cysts to seek explanation for the high incidence of gastric mucosa in their walls and its presence in duplications even in the distal parts of the gut, and (2) myelography and postmyelography computerized axial tomography scans to substantiate the spinal pathology. Three of four myelograms in patients with esophageal duplications showed an intraspinal pathology, and all three had vertebral defects. Histological evaluation of the cyst wall showed that gastric mucosa was the most common ectopic tissue in the walls of the cysts, and the tissues were in various primitive stages of differentiation. On the basis of these data, the authors hypothesize that (1) the embryonic endoderm of the entire alimentary tract has the potential to develop into gastric mucosa at the time of inception of duplications, which explains the high incidence of gastric mucosa and its presence in duplications even in the distal parts of the gut, (2) persistence of the embryonic relationship of the esophagus with the vertebral column is responsible for the high incidence of vertebral defects in esophageal duplications. The results of myelography in this series also support the theory of split notochord syndrome.

Spina bifida and intraspinal lipomas

Experience with nine consecutive cases of intraspinal lipomas revealed some unreported observations. The results of surgery are discussed with regard to pathology, timing of surgery and a modified surgical technique. Earlier compared to later operative intervention produces less bleeding, shorter operation time, easier removal of softer lipoma and easier reconstruction of conus and cord after removal of mass. Adequate dura cover can always be obtained by stripping off the dura from the fibro fatty stalk of lumbosacral lipoma. Watertight closure of dura prevents cerebrospinal fluid (CSF) leak and is ensured by the use of continuous monofilament suture material such as prolene.

Role of ultrasound guided percutaneous antegrade pyelography (USPCAP) in the diagnosis of obstructive uropathy

Ultrasound guided percutaneous antegrade pyelography (USPCAP) was performed in 6 cases between 1 month and 8 years age, presenting with obstructive uropathy. The procedure in this age group was characterized by (i) ease of performance without sedation in the neonates and with sedation in older children, and (ii) use of smaller needles and catheters. The procedure enabled delineation of the intimate anatomy of complicated urological abnormalities such as obstructed duplex system, primary megaureters, posterior urethral valves, prune belly syndrome, obstructive hydronephrosis and vesicoureteric reflux. Percutaneous renal puncture may be established rapidly using ultrasonic guidance in severely ill pediatric patients with obstructive uropathy. B-mode ultrasonography has proved to be rapid, accurate and free of radiation hazards, making it applicable to children with little or no sedation. Guided by ultrasound, percutaneous antegrade pyelography should be considered in the few, selected children with obstructive uropathy when the diagnosis is critical for management and difficult with the usual imaging procedures.

Histochemical pattern in alimentary tract duplications of children

Detailed histological and histochemical studies using PAS, AB-PAS, and high-iron diamine-AB were done on 12 alimentary tract duplication cysts in children. Nine of these were thoracic and three were abdominal in location. A total of 11 cysts (nine thoracic and two abdominal cysts) were lined by gastric mucosa seen in varying stages of maturation. One triloculated cyst had, in addition, small intestinal mucosa and bronchial wall mucosa. One intra-mucosal rectal cyst was lined exclusively with primitive rectal mucosa. The cysts showed a variable pattern of mucin histochemistry. In three cysts, the gastric mucosa showed neutral mucins. In another three cysts, in addition to neutral mucins, focal positivity for sulphomucins was observed in the apical region of the surface epithelial cells. In the remaining five cysts, the gastric mucosa showed neutral mucins along with a variable mixture of sulpho- and sialomucins. A correlation was seen between mucin histochemistry and the age of the patient. Neutral mucins or focal positivity for sulphomucins was seen in patients aged 7 months or more, whereas a mixture of sulpho-, sialo-, and neutral mucins was identified in patients who were 1 month old, or less.

Spina bifida occulta: radiographic and operative correlation

The clinical and myelographic evaluation in 24 children with spina bifida occulta has been correlated with the operative findings. Myelograms were done using Myodil in 11 patients and Metrizamide in 13 patients. The diagnostic quality of myelograms done with Metrizamide was comparatively better. Myodil myelography failed to demonstrate diastematomyelia in one case and a dural sac in 3 cases of lipomeningomyelocele, whereas, Metrizamide failed to demonstrate a sac in one case of lipomeningomyelocele only. Worsening of the neurological status was observed in only 3 cases in whom myelography was done with Myodil. The radiographic and operative correlation has been discussed.

Surgical management of traumatic hemobilia in children by direct ligation of the bleeding vessel

The surgical management of traumatic hemobilia by direct ligation of the bleeding vessel is described in two children. The operative procedures were performed with ease and without postoperative problems. Other available operative procedures are also discussed. Direct ligation of the bleeding vessel is recommended as the operative procedure of choice.