Recto-vestibular fistula with colonic duplication: report of three cases and review of literature

Background

Anorectal malformations associated with colonic duplications are a rare condition. Double terminations of tubular colonic duplication in the perineum are even rarer. Colonic duplication may have different presentations according to its location and size and incidence of less than 15% of all gastrointestinal duplications. We hereby report three such cases of recto-vestibular fistula along with underlying tubular colorectal duplication over a period of 10 years (2010–2020) managed successfully by different surgical approaches. These cases also illustrate the diagnostic challenge and variable presentation of colonic duplications in female patients with recto-vestibular fistula.

Case presentation

Case 1 is a patient with flank heteropagus with absent anal opening and recto-vestibular fistula, while cases 2 and 3 presented as suspected H-type recto-vestibular fistula with normal anal opening. All the cases were however managed with a specific surgical approach on case basis. Duplicated colon was excised in case 1, but in case 2 and case 3, duplicated colon was converted into single channel using proximal and distal staplers. Further definitive repair of female recto-vestibular fistula was done.

Conclusions

Colorectal duplication is a rare congenital malformation, and their association with anorectal malformations is even rarer. This association can have varied presentation, and surgical approach should be according to the congenital anatomical variations on case-to-case basis. Colonic duplications should always be ruled out in a female newborn child with history of passage of stools both from the vestibule and anus.

Variability in the serum and tissue concentrations of pre-incisional ceftriaxone for surgery in paediatric population and outcome of surgical-site infections; An open labelled, prospective, non-randomized, analytical study

Studies have determined the serum concentration of ceftriaxone in the adult population, but there are only a few studies that measured the tissue concentrations. However, no studies have concurrently evaluated the serum and tissue concentrations of ceftrixaone in elective pediatric surgery patients. Therefore, our study was planned to evaluate the serum and tissue concentrations of single dose intravenous prophylactic ceftriaxone intra-operatively during an ongoing pediatric surgery and the outcome of surgical-site infections (SSIs). We did a correlation analysis to determine the relationship of various concentrations and surgery related risk factors with the outcome of SSIs. It was an open label prospective study in 50 patients who underwent elective pediatric surgery under prophylactic cover of ceftriaxone. Serum and tissue concentration were estimated by High Pressure Liquid Chromatography (HPLC). Subjects were observed for post operative complications including SSI. Serum and tissue concentrations of ceftriaxone were significant at test value of 4 ​mg/L. Tissue concentrations of ceftriaxone at incision (p ​= ​0.02) and closure (p ​= ​0.04) were significantly correlated with SSI but there was no significant association. The measured serum ceftriaxone concentrations were more than 20 times the susceptible minimum inhibitory concentration (MIC) at any given point of the surgery. On the other hand, this target level was achieved at the tissue levels in the majority of the patient. The factors associated with SSI were duration of surgery, wound category of contaminated clean type, the use of urinary catheter and implants in the surgery. An intra-operative re-dose, extension of dose or addition of another antibiotic may be considered for such patients.

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Currently, no standard guidelines are available for the pre-operative prophylactic antibiotic use in pediatric surgery.

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This study addresses the issue about antibiotic dose and frequency in context of elective pediatric surgery patients.

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The tissue concentration of ceftriaxone at incision and at closure of surgery are important predictors for SSI.

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For optimizing the antibiotic use and re-dosing in SSI prophylaxis, tissue concentration of the antibiotic should be preferred over the plasma concentrations.

A randomized comparative evaluation of C-MAC video-laryngoscope with Miller laryngoscope for neonatal endotracheal intubation

Background and Aims

An efficient neonatal airway management is peculiarly challenging even in the most experienced hands. Considering the recent interest in assessing the performance of various video-laryngoscopes (VL) in pediatric cohort, the prospective randomized study was contemplated to stage a comparative evaluation of C-MAC with Miller laryngoscope for neonatal endotracheal intubation.

Material and Methods

150 neonates were randomized to undergo intubation with either the C-MAC VL (n = 75) or the Miller laryngoscope (n = 75) performed by an experienced anesthesiologist in a tertiary care perioperative setting. The percentage of glottic opening (POGO), time to best glottic view (TTBGV), time to intubation (TTI), number of attempts, optimal external laryngeal manipulation (OELM) employed, and the complications were assessed and compared between the two groups.

Results

C-MAC group demonstrated a significantly higher POGO, compared to the Miller group (88 ± 26.7%;76.8 ± 32.1%, respectively, P = 0.022). TTBGV was significantly lower in the C-MAC (7.7 ± 0.1s) group as opposed to the Miller group (11.3 ± 1.1s). The C-MAC group displayed higher TTI values compared to the Miller group (25.4 ± 1.6s; 19.7 ± 1.2s, respectively, P < 0.01). The first-attempt intubation success rate and the number of attempts were comparable in both the groups. OELM was required in 24% of the patients in the Miller group as opposed to 10.7% in the C-MAC group (P = 0.031). Higher patient percentage in the C-MAC group required the need of stylet for assisting a successful intubation, although the difference between the two groups was not statistically significant.

Conclusion

Despite an improved view of the glottis, the TTI was higher for C-MAC compared to direct laryngoscopy with a comparable first-attempt success rate in the two techniques.

Gastric pull-up by the retrosternal route for esophageal replacement: Feasibility in a limited-resource scenario

OBJECTIVES

The authors herein report the results of esophageal replacement by gastric pull-up technique through the retrosternal route as an option for esophageal replacement in a resource-constrained setup.

METHOD

Prospectively collected data upon twenty-two consecutive patients (male:female = 17:5) with mean age 24.9 months (7 months-12 years) and mean weight 7.9 kg (4.2-32 kg) who underwent retrosternal gastric pull-up for esophageal atresia (n = 18; 16 atresia with distal fistula & 2 pure atresia) and corrosive injuries to the esophagus (n = 4) over the past 8 years are presented. The management protocol and surgical technique have been described. Observations parameters included indication for esophageal replacement, age at surgery, sex of the child and other demographic details, clinical and operative findings, post-operative outcomes and follow-up details.

RESULTS

Retrosternal gastric pull-up could be performed in all cases with no mortality or graft loss. Of 22, 20 cases were extubated on-table and 2 cases were extubated within 48 hours of surgery. Mean operative duration was 265 min (range: 175 min to 310 min) and blood loss was 115.3 ml (range: 80-400 ml). Dense vascular adhesions in the region of the esophageal hiatus were encountered in patients with abdominal esophagostomy (n = 4) which were probably related to the local dissection at the time of previous surgery. Minor anastomotic leak was observed in 8 of 22 patients which settled spontaneously over 21 days mean period (range: 18 to 31 days). Antegrade dilatation was required in 3 of 8 cases with minor leak. None of them required revision of anastomosis. Mean follow-up duration is 63 months (range: 11 months - 94 months). Weight gain after surgery was close to or beyond the 25th centile. Symptoms of dumping syndrome or GER were not observed in our cohort.

CONCLUSION

Our data have demonstrated the safety and feasibility of esophageal replacement by gastric transposition through the retrosternal route in a resource-limited setup. No significant difference has been observed from the results and complications reported in literature for the same procedure.

TYPE OF STUDY

Prospective observational study / treatment study.

LEVEL OF EVIDENCE

Level III.

Single-Centre Open-Label Comparative Trial of Video-Assisted Fibreoptic-Bronchoscope-Guided Oral Versus Nasal Intubation in Anaesthetised Spontaneously Breathing Paediatric Patients

Objective

Flexible fibreoptic intubation is challenging in paediatric patients. Very few studies have compared fibreoptic intubation via oral and nasal routes in children. We hypothesised that the total time to a successful fibreoptic-guided tracheal intubation would be faster through the nasal route when compared to the oral route.

Methods

Sixty children aged 6–12 years were randomised to receive fibreoptic tracheal intubation through oral (group FOI) or nasal route (group FNI). We measured the time to glottic view and total time to successful tracheal intubation. The number of attempts needed, first attempt and overall success rate, external manoeuvres needed to obtain an adequate laryngeal view, subjective assessment of ease of intubation and complications, if any, were also recorded.

Results

The time to glottic view (76.26±.7 s vs. 46.33±16.9 s; p=0.001) and total intubation time (4.55±1.07 min vs. 3.05±0.60 min; p<0.0001) were significantly higher in the FOI group as compared to the FNI group. An overall success rate was 100% in the FNI group and 96.6% in the FOI group. The haemodynamic parameters (mean heart rate and blood pressures) changes were comparable in the two groups at all time intervals. The subjective assessment of ease of intubation was comparable in the two groups (p=0.21). Complications were minor and self-limiting.

Conclusion

Intubation guided by a nasal flexible fibreoptic bronchoscope is easier and faster when compared to oral intubation in children aged 6–12 years with normal airway, and it should be preferred for intubation in children requiring fibreoptic intubation.

Pancreas as a Content in Congenital Diaphragmatic Hernia: A Rarity

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Sacrococcygeal Teratoma: Clinical Characteristics, Management, and Long-term Outcomes in a Prospective Study from a Tertiary Care Center

Introduction:

The study focuses on the clinical presentation, management, and outcomes (both short term and long term) in patients with sacrococcygeal teratoma managed over a decade in a tertiary care center.

Materials and Methods:

This is a prospective study on children with sacrococcygeal teratoma over 12 years data collected included antenatal diagnosis, mode of delivery, age at diagnosis, clinical presentation, physical extent of mass (including Altman classification), levels of alpha-fetoprotein, surgical approach, histopathology, clinical outcome, recurrence and long-term results including bladder-bowel dysfunction and neurological impairment. Functional results were evaluated clinically and radiologically.

Results:

During the study, 41 patients (male to female ratio of 1:3.1) with a median age of 36 days (1 day–11.6 years) with sacrococcygeal teratoma were managed at our center. The mean follow-up duration was 54 months (range 19–110 months). Nearly, two-thirds of the tumors were either Altman Type 1 or 2. Yolk sac tumor was present in 8 (19.5%) patients, while the rest has either mature or immature teratoma. Tumors were removed through a posterior sagittal or a chevron incision. In seven patients, abdominosacral approach was necessary. Eight patients with malignant disease received chemotherapy (neoadjuvant in 5). Overall survival was 95% at a mean follow-up of 54 months. Among the late complications, three patients had a local recurrence of tumor, and urinary dribbling was present in three patients.

Conclusions:

Teratomas are the most common germ cell tumors of the sacrococcygeal region. Most of the tumors are benign, and the incidence of malignancy increases with age. The evaluation of malignancy is, therefore, necessary in these children. Excellent survival of 95% was achieved in this series. Morbidity due to associated malformation, disease recurrence, and treatment may persist in these patients; hence, proper follow-up is needed.

Total Intestinal Atresia: Revisiting the Pathogenesis of Congenital Atresias

Despite various theories to explain the pathogenesis of atresias, the exact mechanism is still controversial. Currently, atresias are believed to result from vascular accidents and less likely due to the failure of recanalization. We report a case which challenges this belief. A 1-day-old neonate was explored for suspected jejunal atresia. Apart from Type III jejunal atresia, 15 cm from DJ junction, there was surprisingly no distal lumen in the intestine from jejunum till rectum. Multiple enterotomies revealed the whole of the remaining jejunum, ileum, and large colon to be a solid cord-like structure. No distal luminal contents or histopathological evidence of ischemic damage was seen, thus suggesting the probable etiology to be a failure of recanalization of the gut cord rather than a late vascular accident. Such rare cases provide insights into possible embryogenetic mechanisms which can then aid in formulating preventive measures.

Approach to pediatric renal tumors: an imaging review

Renal tumors comprise 7% of all childhood cancers. A wide variety of renal tumors can affect the pediatric kidneys, which can be broadly classified as primary benign tumors, primary malignant tumors, and metastatic lesions. This article aims to enumerate usual benign and malignant renal tumors that can occur in childhood and emphasizes the characteristic imaging appearances which aid in their differential diagnosis. Additionally, the leading role of the Radiologist in primary diagnosis of renal infiltration by hematological malignancies and contiguous invasion by neuroblastoma is also introduced and unraveled. Imaging protocol comprises initial Ultrasound evaluation with subsequent computed tomography (CT) and/or Magnetic resonance imaging (MRI), all of which are invaluable in confirming the diagnosis, documenting the organ of origin, describing extent of local and distant spread. The complimentary role of nuclear medicine studies in delineating differential renal function, post-operative complications, and metastasis is also highlighted.

Gastric Duplication Cyst Associated with Esophageal Atresia and Anorectal Malformations: A Rare Association

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) and anorectal malformations (ARM) in a newborn usually present with frothing of saliva and massive abdominal distension rendering it difficult to diagnose associated intrabdominal pathologies. We report a large gastric duplication (GD) cyst in a 2-day-old neonate with EA and TEF. GD cyst was detected in the early post-operative period as the abdominal distension persisted after repair of EA and TEF. The baby underwent excision of GD cyst with good outcome thereafter.

Primary presentation of Jeune's syndrome as gastric motility disorder in an infant: A case report

We report a case of a 4-week-old female neonate with Jeune's asphyxiating thoracic dystrophy (JATD) and coexistent situs anomaly, primarily presenting as gastric motility disorder. The child presented with abdominal distension and nonbilious vomiting since birth with failure to thrive. However, skeletal survey revealed JATD. Upper gastrointestinal contrast study showed situs inversus with delayed gastric emptying. Pyloric biopsy and intraoperative antro-duodenal manometry confirmed association of gastric motility disorder. Awareness of the unusual possibility of primary presentation of Jeune syndrome as gastric motility disorder will improve the management approach in such infants.

Hemodynamic, Airway Pressure, and Capnometric Changes and Perioperative Outcome in Pediatric Laparoscopic Inguinal Herniorrhaphy: A Comparison with Open Inguinal Herniorrhaphy

Background:

Laparoscopic procedures which are now established in pediatric population as well exposes the child to supplemental cardiorespiratory changes due to increase in intraabdominal pressure (IAP) and hypercarbia.

Aims:

This study aims to analyze the effects of pneumoperitoneum and postural modifications on cardiorespiratory system (primary outcome) during pediatric laparoscopic herniorrhaphy (LH) and its comparison with open herniorrhaphy (OH) and assessment of overall perioperative outcome (secondary outcome).

Settings and Design:

A prospective, observational study conducted in a tertiary care hospital.

Materials and Methods:

Fifty children undergoing either LH (n = 25) or OH (n = 25) were included in the study. Anesthetic procedure was standardized. Parameters monitored were heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressures (MAP), electrocardiogram lead-II, end-tidal CO₂ (ETCO₂), airway pressures P_Peak, P_Plateau, P_Mean, pulse oximetry, IAP, minute ventilation/respiratory rate alterations.

Statistical Analysis Used:

Student's t-test and Chi-square test were applied to compare different variables between the two groups. Intragroup analysis was done using the analysis of variance test.

Results:

The HR was comparable in both groups. The rise in SBP, DBP, and MAP was 9% (102.88 ± 6.91–121.32 ± 6.63), 19% (60.88 ± 4.94–77.00 ± 9.75), and 14.8% (73.92 ± 4.65–90.40 ± 8.42), respectively, in group LH. The rise in peak, plateau, and mean airway pressures was 19.4% (14.20 ± 2.00–18.00 ± 2.54), 20.1% (13.32 ± 1.89–16.89 ± 2.60), and 16.1% (6.20 ± 1.00–7.47 ± 0.96), respectively, in group LH. ETCO₂ showed a maximum rise of 19.4% (34.52 ± 3.61–41.21 ± 3.99) in group LH. In laparoscopic group, recurrence was seen in 3 patients.

Conclusions:

We found significant hemodynamic, airway pressure, and capnometric changes during pediatric LH with comparable perioperative outcome among the two groups.

Surgical Surprise in a Case of Pure esophageal atresia: How High Can the Lower Pouch Be?

The gap between the upper and lower pouches in case of pure esophageal atresia (EA) is usually long and requires multistaged repair. However, in rare cases, the gap may be short and can be repaired primarily commonly through thoracotomy approach. We report an unusual case of a 2-day-old baby girl who presented with short gap EA where the lower esophageal pouch was found adjacent to the blind upper pouch in the neck and primary repair could be performed through the cervical route itself.

Anorectal malformations: Role of MRI in preoperative evaluation

PURPOSE

To evaluate the spectrum of magnetic resonance imaging (MRI) findings in pediatric patients with anorectal malformation (ARM) and compare the accuracy of MRI and distal cologram (DC) findings using surgery as reference standard.

MATERIALS AND METHODS

Thirty pediatric patients of age less than 14 years (19 boys and 11 girls) with ARM underwent preoperative MRI. MRI images were evaluated for the level of rectal pouch in relation to the pelvic floor, fistula, and development of sphincter muscle complex (SMC). Associated spinal and other anomalies in lumbar region and pelvis were also evaluated. DC was done in 26 patients who underwent colostomy. Ultrasound of abdomen and pelvis was also done for associated anomalies.

RESULTS

Overall accuracy of MRI and DC to detect the exact level of rectal pouch including cloacal malformation was 93.33% and 76.9% respectively. MRI and DC could correctly identify presence or absence of fistula in 76.6% and 76.9% cases respectively. MRI and DC correctly identified the anatomy of fistula in 76% and 65% cases respectively. On MRI, correlation of development of levator ani and puborectalis with the level of rectal pouch as found on surgery was significant (P = 0.008; 0.024 respectively). Subjective assessment of sphincter muscle development on MRI correlated well with the surgical assessment [P = 0.019 and 0.016 for puborectalis and external anal sphincter (EAS) respectively]. Lumbosacral spine anomalies were present in 33.3% of patients and were most common in high type of ARM. Vesicoureteric reflux and renal agenesis were the most common renal and urinary tract anomalies and were present in 40% of cases.

CONCLUSION

MRI allows reliable preoperative evaluation of ARM and should be considered as a complementary imaging modality for preoperative imaging in ARM.

Evaluation of two-staged Fowler-Stephens laparoscopic orchidopexy (FSLO) for intra-abdominal testes (IAT)

INTRODUCTION

The best operative intervention for intrabdominal testis (IAT) has not been standardized as yet. The question of whether to bring down an IAT with a single-staged vessel-intact laparoscopic orchidopexy (VILO) or a two-staged laparoscopic Fowler-Stephens orchidopexy (FSLO) is still undergoing debate, with both the procedures being popular. The present study has been designed to evaluate the factors predicting the success or failure of two-staged FSLO for (IAT).

METHODS

43 boys with 49 non-palpable testes underwent diagnostic laparoscopy out of which 35 underwent two-staged FSLO. Size of the testis was measured with a graduated probe in both stages. Independent variables such as age, height, testis-to-internal ring distance (T-IR), neo internal ring-to-midscrotal distance (NIR-MS), and mobility-to-contralateral ring (MCIR) were analysed. Postoperatively 34 IATs were followed up clinically as well as ultrasonologically after 6 months, to see for the size, position, and vascularity. Based on this, the patients were divided into two groups, Group A (successful) and Group B (Failed).

RESULTS

24 IATs had a successful outcome (Group A) and 11 were failure (Group B). The overall success rate of the study was 68.6%. The difference in mean age of patients in both groups was insignificant (p = 0.89) (Fig. 1), and similarly, the difference in mean height was insignificant (p = 0.61). The difference in mean T-IR in both the groups was insignificant (1.85 versus 2.77 cm; p = 0.09) and mean NIR-MS was 5.41 cm in Group A and 5.10 cm in Group B, and the difference again was insignificant (p = 0.23).

CONCLUSION

The success rate of FSLO was 68.6%. None of the above-described independent variables have any effect on the outcome of two-staged FSLO. While VILO remains the treatment of choice for IAT located at or near the ring, but IAT higher than this, two-staged FSLO gives a better chance for achieving intra-scrotal orchidopexy.

Congenital Duodenal Obstruction, Situs Inversus Totalis, and Gastric Perforation in a Neonate

We report a rare case of incomplete congenital duodenal obstruction (Type 1 duodenal atresia) in association with situs inversus totalis presenting with gastric perforation in a neonate. The infantogram was suggestive of perforation with air under diaphragm along with dextrocardia. On exploration, a pin point perforation at fundus near lesser curvature along with situs inversus was noted. Primary closure of gastric perforation was done. Patient was then discharged on full breast feeds but was readmitted with intolerance to feeds and recurrent bilious vomiting. Further, upper GI contrast study revealed partial duodenal obstruction. On re-exploration, duodenal web with central aperture was seen and duodeno-duodenostomy was done.

Mesenteric Cyst in Association with Type-II Jejunoileal Atresia

A rare case of type-II jejunoileal atresia with mesenteric cyst in a neonate is being reported here with a brief review of literature.

Transanal impalement of double J steel bar with colonic and jejunal injury: A unique pediatric case report

Pediatric transanal impalement injuries are relatively uncommon and most are attributed to accidental fall on offending objects, sexual assault or blunt trauma. There may be difficulty in recognizing or properly treating such injuries because their severity may not be reflected externally. Evaluation of suspected rectal impalement injury involves careful history and physical examination and proper investigation. There are very few reports on pediatric perianal impalement with associated visceral injuries. We report a case of assault transanal impalement injury associated with mesenteric tear and jejunal perforation leading to devitalization of proximal jejunum in a 2 year male child and relevant literatures were reviewed. To the best of our knowledge, such dual proximal and distal gastrointestinal injury in such a small child has not been reported in any of the English literature so far.

Herlyn-Weber-Wunderlich syndrome with ectopic ureter in prepubertal female

We report a rare case of uterovaginal duplication in a prepubertal female. The patient also had a permeable ureter (ureter with urine passing through it) subtending a poorly functioning kidney with ectopic insertion in the obstructed hemivagina.

Assessment of lexical semantic judgment abilities in alcohol-dependent subjects: an fMRI study

Neuropsychological studies have shown that alcohol dependence is associated with neurocognitive deficits in tasks requiring memory, perceptual motor skills, abstraction and problem solving, whereas language skills are relatively spared in alcoholics despite structural abnormalities in the language-related brain regions. To investigate the preserved mechanisms of language processing in alcohol-dependents, functional brain imaging was undertaken in healthy controls (n=18) and alcohol-dependents (n=16) while completing a lexical semantic judgment task in a 3 T MR scanner. Behavioural data indicated that alcohol-dependents took more time than controls for performing the task but there was no significant difference in their response accuracy. fMRI data analysis revealed that while performing the task, the alcoholics showed enhanced activations in left supramarginal gyrus, precuneus bilaterally, left angular gyrus, and left middle temporal gyrus as compared to control subjects. The extensive activations observed in alcoholics as compared to controls suggest that alcoholics recruit additional brain areas to meet the behavioural demands for equivalent task performance. The results are consistent with previous fMRI studies suggesting compensatory mechanisms for the execution of task for showing an equivalent performance or decreased neural efficiency of relevant brain networks. However, on direct comparison of the two groups, the results did not survive correction for multiple comparisons; therefore, the present findings need further exploration.

Metanephric stromal tumor: An unusual pediatric renal neoplasm

A renal tumor in a 14-month- old child, who was initially diagnosed as mesoblastic nephroma, but on review post surgery was diagnosed as hyper-differentiated metanephric stromal tumor, with its excellent prognostic outcome. An attempt is made to document imaging features that may enable one to suspect this rare condition. The literature is reviewed with emphasis on its distinction from its look-alikes in the pediatric age group.

Predictive factors for successful vessel-intact laparoscopic orchiopexy for intra-abdominal testes

OBJECTIVE

To identify the predictive factors for successful vessel-intact laparoscopic orchiopexy (VILO) for nonpalpable intra-abdominal testes (NPIT).

MATERIALS AND METHODS

25 boys with 28 NPITs within 2 cm of the internal ring underwent VILO. They were divided into two groups based upon outcome, for statistical comparison. Group A (successful VILO): patients with testes pexed in scrotum during surgery, and maintained viability and scrotal position of testes at 3-month & 6-month postoperative follow up. Group B: failed VILO.

RESULTS

Intrascrotal fixation at VILO was achievable for 17/28 NPITs. Postoperative follow up and final outcome data were available for 25/28 NPITs, of which 14 were successful (A) while 11 had failed VILO (B). The mean age of patients in group A differed significantly from that of patients in group B (4.16 years versus 6.64 years; p = 0.035). The mean testis-to-internal ring distance was 0.50 cm for group A and 1.05 cm for group B, but this was not statistically significant (p = 0.141). There was statistically a highly significant difference (p = 0.002) with respect to the mean internal ring-to-midscrotum distances in groups A and B: 5.56 cm and 7.05 cm, respectively. A scatter-plot of age or height against internal ring-to-midscrotum distance showed a fairly linear relationship.

CONCLUSIONS

Age or height of the patient at surgery is an independent factor predicting the success of VILO for intra-abdominal testis. The internal ring-to-midscrotum distance increases with age/height, resulting in increased testis-to-midscrotum distance and higher failure rate of VILO in older children.

SACRAL syndrome

Haemangiomas are the most common tumours of infancy and early childhood. They are usually present in the neonate in the first 2 weeks of life. Haemangioma usually involves the head and neck area but less commonly involves the lumbosacral and perineal areas. Involvement of lumbosacral, perineal and other areas with associated anomalies are very rare. We present a neonatal case with extensive superficial haemangioma from the perineum to the neck along with multiple congenital anomalies.

Voxel-based morphometric analysis in hypothyroidism using diffeomorphic anatomic registration via an exponentiated lie algebra algorithm approach

The present study aimed to investigate whether brain morphological differences exist between adult hypothyroid subjects and age-matched controls using voxel-based morphometry (VBM) with diffeomorphic anatomic registration via an exponentiated lie algebra algorithm (DARTEL) approach. High-resolution structural magnetic resonance images were taken in ten healthy controls and ten hypothyroid subjects. The analysis was conducted using statistical parametric mapping. The VBM study revealed a reduction in grey matter volume in the left postcentral gyrus and cerebellum of hypothyroid subjects compared to controls. A significant reduction in white matter volume was also found in the cerebellum, right inferior and middle frontal gyrus, right precentral gyrus, right inferior occipital gyrus and right temporal gyrus of hypothyroid patients compared to healthy controls. Moreover, no meaningful cluster for greater grey or white matter volume was obtained in hypothyroid subjects compared to controls. Our study is the first VBM study of hypothyroidism in an adult population and suggests that, compared to controls, this disorder is associated with differences in brain morphology in areas corresponding to known functional deficits in attention, language, motor speed, visuospatial processing and memory in hypothyroidism.

Management of female anterior perineal injuries with urethrovaginal disruption by anterior sagittal transanorectal approach

OBJECTIVE

Urethrovaginal disruption injury poses a considerable challenge in surgical correction, mainly due to difficult access to the receded urethrovaginal unit deep in the scarred anterior perineum. We assessed the feasibility, safety and efficacy of the anterior sagittal transanorectal approach (ASTRA) in the repair of anterior perineal injury with urethrovaginal disruption in female children.

MATERIALS AND METHODS

Three girls with urethrovaginal disruption following perineal injury were operated by ASTRA between March 2008 and December 2010. All of them had severe scarring of the anterior perineum at the time of definitive repair by this approach. One underwent ASTRA repair without a covering colostomy.

RESULTS

Total urethrovaginal mobilization and anchorage of urethral and vaginal orifices at the vestibule were successfully achieved in all patients. One patient has developed vaginal stenosis at 1.5 years follow up. Despite the absence of a colostomy cover in one case, there were no wound complications in the early postoperative period.

CONCLUSION

The ASTRA is safe and efficacious in the repair of traumatic urethrovaginal disruption in children.

Retrocaval ureter: a rare cause of hydronephrosis in children

Retrocaval ureter is a relatively rare developmental anomaly of the inferior vena cava. It commonly manifests in the third to fourth decade of life; however, pediatric reports of this condition are very rare. Individuals with this anomaly are symptomatic because of ureteric obstruction. All symptomatic patients need surgery where the ureter is divided and anastomosed anterior to inferior vena cava. We report our experience of a child who presented with flank pain and, on evaluation, were found to have right hydronephrosis. During surgery, retrocaval anomaly was noticed and appropriately dealt with.

Fasciolopsiasis presenting as intestinal perforation: a case report

Infestation by the zoonotic trematode Fasciolopsis buski (fasciolopsiasis) is seen in several parts of South-East Asia. Abdominal pain, diarrhoea, mucosal ulceration, intestinal obstruction, anasarca, and even fatality are described following heavy infestation. We present here the case of a 10-year-old boy from the Barabanki district of Uttar Pradesh, India with heavy infestation by Fasciolopsis buski causing intestinal perforation. Fasciolopsiasis is by no means rare but its presentation as a case of intestinal perforation is extraordinary.

Congenital pouch colon: Massive redilatation of the tubularized colonic pouch after pull-through surgery

BACKGROUND/PURPOSE

Children with a type I/II congenital pouch colon (CPC) malformation associated with imperforate anus usually are treated by subtotal excision of the colonic pouch, tubularization of the remaining portion, and pull-through of the tubularized colon during definitive surgery. The authors report 3 patients treated in this fashion who presented 2 to 10(1/2) years later with massive redilatation of the previously tubularized colon and enterocolitis

METHODS

There were no anal strictures or malpositioning of the pulled through bowel. Contrast enema showed massive redilatation of the colonic pouch. Near-total excision of the redilated pouch with anastomosis of normal proximal ileum/colon with the retained distal portion of the pouch was performed by the abdominal approach.

RESULTS

Anastomotic leaks occurred in 2 patients but were treated successfully. Postoperatively, the patients had relief from their abdominal symptoms and improvement in fecal continence.

CONCLUSIONS

The colonic pouch in CPC has a marked tendency to undergo redilatation, even after tubularization. The surgical procedure described here for the treatment of these patients appears to be satisfactory.

Congenital diaphragmatic hernia: delayed presentation with asymptomatic spleenic herniation

Patients with congenital diaphragmatic hernia (CDH) usually present in the immediate neonatal period with respiratory distress. Presentation beyond the neonatal period has, however, been reported. We report a case of a 3-year-old child who presented with a six months history of respiratory symptoms and had been subjected to a variety of therapies like antibiotics, antitubercular medication and two attempts at putting an intercostal tube, as radiographs were suggestive of pleural effusion. This study highlights the importance of a high index of suspicion, relevance of thorough clinical examination and non-invasive diagnostic modalities along with an uncommon occurrence of asymptomatic spleenic herniation at such a later age. Spleenic herniation is rare outside neonatal period.

Spontaneous bladder rupture secondary to posterior urethral valves in a neonate

Bladder rupture is a rare cause of ascites in neonates. A review of literature revealed about 32 cases including both iatrogenic and spontaneous rupture. This case report describes a successfully treated case of spontaneous rupture of bladder with ascites in a neonate with posterior urethral valves.

Modulation of omega-3/omega-6 polyunsaturated ratios with dietary fish oils in men with prostate cancer

OBJECTIVES

The results of epidemiologic and animal studies support the role of a low-fat diet supplemented with omega-3 fatty acids contained in fish oil in preventing the development and progression of prostate cancer. As a first step in studying the role of a low-fat, fish oil-supplemented (LF/FOS) diet in a clinical setting, we conducted a prospective study in men with untreated prostate cancer to evaluate whether a 3-month dietary intervention affects the ratio of omega-3 to omega-6 fatty acids in plasma and gluteal fat. In addition, we evaluated the feasibility of studying cyclooxygenase-2 (COX-2) expression in serial prostate needle biopsy specimens before and after the diet.

METHODS

Nine men with untreated prostate cancer consumed an LF/FOS diet for 3 months. Plasma, gluteal adipose tissue, and prostate needle biopsy specimens were obtained from each patient before and after the intervention. The fatty acid compositions of the plasma and gluteal adipose tissue were determined by gas-liquid chromatography, and the COX-2 expression in the prostatic tissue specimens was determined by semiquantitative reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

Short-term intervention with an LF/FOS diet caused a significant increase in the omega-3/omega-6 fatty acid ratio in plasma (P = 0.002) and gluteal adipose tissue (P = 0.002) in men with prostate cancer. The COX-2 expression in prostatic tissue was quantitated by RT-PCR in 7 of 9 patients, and COX-2 expression decreased in 4 of these 7 patients.

CONCLUSIONS

A short-term dietary intervention in men with prostate cancer leads to a significant increase in the omega-3/omega-6 fatty acid ratios in plasma and adipose tissue. The potential for this diet to prevent the development and progression of prostate cancer by way of altered COX-2 expression and prostaglandin production in prostatic tissue requires further study.

Complete diphallia associated with features of covered exstrophy

This report describes a 1-day-old boy with complete true diphallia associated with features of covered or pseudo-exstrophy and an anorectal malformation. The urinary bladder and rectum were single. A divided sigmoid colostomy was constructed at birth for the anorectal anomaly. Complete diphallia and its likely embryogenesis are discussed.

Spontaneous rupture of choledochal cyst

Choledochal cyst in an uncommon congenital anomaly with classic presentation triad of abdominal pain, jaundice and right upper abdominal mass. Presentation due to biliary peritonitis following cyst rupture is extremely rare. One such case which was successfully treated is being reported.

Retroperitoneal ganglioneuroma: report of a case diagnosed by fine-needle aspiration cytology, with review of the literature

A case of ganglioneuroma presenting as a retroperitoneal mass in a 5-yr-old girl was diagnosed by preoperative fine-needle aspiration cytology. The cytologic smears predominantly showed clusters of Schwann cells, with scattered mature ganglion cells. The cytologic diagnosis of ganglioneuroma was subsequently confirmed on histopathologic examination. To date, very few reports on the cytologic features of this tumor exist. The importance of considering a confident diagnosis by cytology, and of the uncommon age group that may be affected, is stressed. Diagn. Cytopathol. 1999;21:194-196.

Retroperitoneal ganglioneuroma: report of a case diagnosed by fine-needle aspiration cytology, with review of the literature

A case of ganglioneuroma presenting as a retroperitoneal mass in a 5-yr-old girl was diagnosed by preoperative fine-needle aspiration cytology. The cytologic smears predominantly showed clusters of Schwann cells, with scattered mature ganglion cells. The cytologic diagnosis of ganglioneuroma was subsequently confirmed on histopathologic examination. To date, very few reports on the cytologic features of this tumor exist. The importance of considering a confident diagnosis by cytology, and of the uncommon age group that may be affected, is stressed. Diagn. Cytopathol. 1999;21:194-196.

Congenital pouch colon in females

From January 1995 to March 1998, congenital pouch colon (CPC) with anorectal agenesis was diagnosed in ten girls who were classified into four groups based on the length of normal colon proximal to the colonic pouch. Of six girls with little or no normal colon, one had a cloacal anomaly while five had a colovesical or colovestibular fistula along with a completely bifid uterus and cervix and a septate vagina. Initial surgery consisted of ligation of the fistula and subtotal pouch excision with tubularization of the remaining colon in four girls, ileostomy after excision of a gangrenous pouch in one, and window colostomy in another. None of the patients had a sacral abnormality or associated major malformation. Definitive surgery using the posterior sagittal approach consisted of a pull-through of the tubularized colon in three girls (including one in whom one-stage cloacal reconstruction was performed), the ileum in one, and the proximal colon in another. The four girls with a longer length of normal colon had an associated vestibular fistula. In these, a colostomy was constructed just proximal to the pouch with definitive surgery in two patients consisting of excision of the pouch and pull-through of the proximal colon. Definitive surgery was well tolerated in all seven patients. The embryogenesis of this condition and the related genitourinary tract abnormalities are discussed.

Covered exstrophy with incomplete duplication of the bladder

A rare exstrophy variant in a 1(1/2)-year-old girl is reported. The child had a wide, scar-like lesion over the lower central abdomen with divarication of the recti and a spread symphysis pubis. The underlying bladder was divided into two unequal chambers by a complete sagittal septum with only the right chamber communicating with the single urethra and the left draining by a vesicocutaneous fistula. Both kidneys were normal. The clitoris was bifid and the anus anteriorly placed. Preliminary surgical management consisted of dissection of the bladder from its prevesical covering, excision of the sagittal septum, and cystocystostomy. Postoperatively, the child had normal urinary continence. The literature is reviewed with special reference to the various forms of duplicate exstrophy.

Preadipocytes stimulate breast cancer cell growth

Mammary fat may affect human breast cancer development. In this study a novel coculture system was used to investigate stromal-epithelial cell interactions in vitro. The extent of differentiation of a feeder layer of 3T3-L1 preadipocytes affected the clonal growth of breast cancer cells under anchorage-independent conditions. When the feeder-layer preadipocytes were proliferating, the clonal growth of estrogen receptor-positive MCF-7 and estrogen receptor-negative MDA-MB-231 and MDA-MB-436 cells was stimulated by 100%, 43%, and 60%, respectively. In contrast, after differentiation the feeder layer of mature adipocytes inhibited clonal growth of breast cancer cell lines by 60%. No clonal growth stimulation of human pancreatic (Panc-1) or prostatic (PC-3) cancer cells was noted when these cells were grown under identical conditions with a proliferating 3T3-L1 cell feeder layer. These findings suggest that proliferating preadipocytes may be associated with factors that specifically stimulate breast cancer cell growth.

Complete penoscrotal transposition and associated malformations

Complete transposition of the penis and scrotum, or prepenile scrotum, is an uncommon congenital malformation. Concomitant genitourinary abnormalities, often life-threatening in nature, are frequently seen, and major malformations involving other organ systems may also be present. We report a newborn in whom complete penoscrotal transposition was accompanied by urethral atresia and radial dysgenesis.

Inferior vesical fistula

Exstrophy variants are uncommon developmental anomalies of the bladder; the variants involving only the bladder neck are extremely rare. There are only two case reports of inferior vesical fissure to date, and inferior vesical fistula (IVF) as an exstrophy variant has not been described previously. We report a case of IVF in a 20-month-old female. The urethra was normal in calibre and position and the bladder capacity was adequate. Simple closure of the fistula was followed by a normal micturition pattern.

Pseudoexstrophy associated with congenital pouch colon

Pseudoexstrophy or covered exstrophy is a rare exstrophy variant. The authors report a case of covered exstrophy that presented as a newborn with widely separated pubic bones and rectus muscles, a low-set umbilicus, and a subcutaneous bladder. The anal opening was absent, and there was a complex malformation of the external genitalia consisting of a small, laterally displaced penis and a right-sided ectopic hemiscrotum. Micturition and urinary continence were normal. The child also had a high anorectal malformation with a coexistent type IV congenital pouch colon (CPC) malformation. Both kidneys were normal. Preliminary surgery consisted of a divided sigmoid colostomy proximal to the colonic pouch. The literature is reviewed and the embryogenesis of pseudoexstrophy and its associated malformations are discussed.