Successful Laparoscopic Management of Zinner Syndrome in a Pediatric Patient

Zinner syndrome, a rare congenital anomaly affecting males, is characterized by atresia of the ejaculatory duct, seminal vesicle cysts, and ipsilateral renal agenesis. This case report details a 2-year-old boy successfully treated with laparoscopic excision of a dilated vas deferens and seminal vesicle cyst. The rarity of Zinner syndrome in pediatric patients underscores the importance of understanding its diagnosis and minimally invasive surgical management.

Plasma GDNF levels in spinal dysraphism and its relation with neurological impairment in children: A point of care study

AIMS

GDNF plays a crucial role in the stimulation of recovery, neuroplasticity and synaptic reorganization after spinal cord injury providing neuroprotection and neuroregeneration. Plasma GDNF levels are upregulated in cases of spina bifida owing to the intrauterine damage of the exposed spinal cord. Our aim was to compare the plasma GDNF levels in patients of spina bifida with non-spina bifida cases and assess the correlation with neurological impairment at one year of follow up.

METHODS

Single centre prospective analysis of cases of spina bifida from 2020 to 2022 at presentation and after one year of follow up post-surgery. Cases with hernia and hydrocele without any other disorders were recruited into the control group. Plasma GDNF levels were assessed with immunoassay kits and compared with neurological involvement.

RESULTS

85 cases were included in the study. GDNF levels were elevated in cases compared to controls (mean 6.62 vs 1.76) with significant p value (<0.01). Same was observed for open and closed defects (mean 7.63 vs 4.86: p < 0.01). At follow up of 52 cases post-surgery cases with neurogenic bladder with abnormal urodynamic studies, sphincter involvement and motor impairment had significantly elevated baseline levels of GDNF compared with those who did not have this neurological impairment (p < 0.01).

DISCUSSION

The neurotrophic factor up-regulation can reflect an endogenous attempt at neuroprotection against the biochemical and molecular cascades triggered by the spinal cord damage. This upregulation can be represented as important biochemical markers of severe spinal cord damage and can be associated with severity of spine injury in MMC patients. Our results are in keeping with these findings, that, there were increased levels of plasma GDNF levels in cases of spinal dysraphism compared to control population. Also, the type of lesion reflecting the severity whether a closed or an open dysraphism, showed significant difference in levels between them suggesting, yet again, more damage in open defect as expected. The levels were higher with involvement of bladder, sphincter and lower limb power.

CONCLUSION

There is significant elevation of plasma GDNF levels in cases of spina bifida and this elevation is proportional to the degree of spinal damage and hence the neurological impairment. GDNF levels are a good predictor for assessing the severity of the lesion and thus the outcome in these cases. Additional prospective and long-term studies with a larger cohort are needed for a better understanding of neurotrophin pattern modulation in MMC.

Role of Magnetic Compression Anastomosis in Long-Gap Esophageal Atresia: A Systematic Review

Background: Magnetic compression anastomosis (MCA) is an alternative technique for patients with long-gap esophageal atresia (EA). It allows for preservation of the native esophagus. We aimed to systematically summarize the current literature on MCA in EA. Methods: Studies where neonates with EA were treated with MCA devices were included, while studies on esophageal stenosis were excluded. All clinical studies, including comparative studies, case series, and case reports, were eligible for inclusion. Methodological quality assessment was performed using a validated tool. Results: Twelve studies with a total of 42 patients were included in this review. There was a wide variation among these studies with regard to the time of initiation of MCA (1 day to 7 months), procedure time (13-320 minutes), and magnet characteristics (strength, size, and shape of the magnets used). The time to achieve anastomosis ranged from 1 to 12 days. Stricture at the anastomotic site was reported in almost all the patients, which required multiple endoscopic dilatations (median no. of dilatations/patient = 9.8). Stent placement for refractory stricture was required in 9 (21%) patients, and surgery for stricture was required in 6 (14%) patients. Long-term outcomes included esophageal dysmotility (n = 3) and recurrent pulmonary infections (n = 3) were reported in only four studies. Conclusion: As per the findings of this review, neonates with long-gap EA undergoing MCA would invariably require multiple sittings of endoscopic dilatations (median no. of dilatations/patient = 9.8). Also, there is a wide variation among the included studies in terms of the procedure of MCA. Future studies with a standardized procedure for achieving MCA are needed to determine additional outcomes in this fragile patient population.

Pediatric Appendicitis Score or Ultrasonography? In Search of a Better Diagnostic Tool in Indian Children with Lower Abdominal Pain

OBJECTIVES

To prospectively assess the performance of pediatric appendicitis score (PAS) in diagnosing acute appendicitis in the children with lower abdominal pain and correlated with ultrasound findings; and to assess the impact of the PAS on clinical outcome and its efficacy in differentiating between complicated and uncomplicated appendicitis.

METHODS

A prospective study was done which included cases of lower abdominal pain. Appendectomy was done for PAS ≥ 6, and diagnosis was confirmed on histopathology. A receiver operator characteristic (ROC) curve was created to assess the PAS performance. The sensitivity, specificity, and accuracy of ultrasonography in diagnosing appendicitis were assessed, and analysis of agreement between ultrasonography and PAS score was done by kappa statistics.

RESULTS

Of 260 cases with lower abdominal pain, 205 were suspected of having appendicitis. One hundred fifty-nine had PAS ≥ 6. There were 2/159 (1.26%) cases of negative appendectomies and 2/46 (4.34%) cases of missed appendicitis. The mean PAS was significantly higher in patients with appendicitis than in those without appendicitis. The area under the ROC curve was 0.9925. Sensitivity, specificity, and positive and negative predictive value of PAS were 98.74%, 95.65%, 95.7% and 95.65%, respectively. Complicated appendicitis had significantly more PAS, fever, and cough tenderness than uncomplicated appendicitis. The sensitivity and specificity of ultrasonography were 86.79% and 17.39%, respectively. Agreement between ultrasonography-proven appendicitis and PAS-dependent appendicitis was weak.

CONCLUSION

PAS has high efficacy in diagnosing acute appendicitis. Clinical outcome was more favorable with the use of PAS. Ultrasonography should be used judiciously and in combination with clinical judgment.

Bibliometric Analysis and Visualization of the Extrahepatic Portal Venous Obstruction Publication Landscape

Introduction

A scientometric analysis was conducted to characterize the global research publications in extrahepatic portal venous obstruction (EHPVO), and state-of-the-art visualization graphics were generated to provide insight into specific bibliometric variables.

Materials and Methods

The Web of Science database was accessed for research productivity and bibliometric variables of countries, institutions, authors, journals, and content analysis of top-20 cited documents were performed. Collaborative networks and co-occurrence of keywords map were generated using VOSviewer software.

Results

Two hundred and sixteen records were retrieved with an annual growth rate of 2.53%. India is the leading country in productivity (n = 4339), followed by the USA and China. Post Graduate Institute of Medical Education and Research, Chandigarh, was the top productive institute. Sarin SK was the most prolific author, having the highest citations received and h-index. The hotspot topics were "portal hypertension," "cirrhosis," "children," "biliopathy/cholangiopathy," "liver fibrosis," and "liver transplantation" as per keyword co-occurrence networking. J Gastroenterol Hepatol had the most publications of EHPVO research as well the h-index. Regarding collaborative network mapping, the USA and Primignani M were the significant nodes among country and author, respectively.

Conclusion

EHPVO research publication volume is low but is gradually progressing with dominant contributions from Indian institutes and authors. Most highly cited articles are of low level of evidence, and multi-institutional collaborative research can be the way forward.

Looking Beyond Toxicities: Other Health-related Morbidities Noted in Childhood Solid Tumor Survivors

Aim

In addition to the well-known toxicities of treatment, survivors of pediatric solid tumors can also develop other health-related conditions. They may either be an indirect consequence of therapy or could be unrelated to their prior history of malignancy. We aim to evaluate the nontoxicity related health conditions in survivors of pediatric solid tumors.

Materials and Methods

The study included a cohort of hepatoblastoma (HB), Wilm's tumor (WT), and malignant germ cell tumors (MGCT) survivors registered at pediatric surgical-oncology clinic from 1994 to 2016. Follow-up was done according to standard protocols and children were evaluated at each visit for any health-related conditions.

Results

Of the survivors, 318 survivors, comprising of 48, 81, and 189 survivors of HB, MGCT, and WT, respectively, were included in the analysis. We found 20.8% of patients with HB, 11.1% of patients with MGCT, and 16.4% of patients with WT to report nontoxicity-related health issues. A high prevalence of surgical conditions (3.4%), secondary malignancies (1.2%), gynecological conditions in girls (16.9%), tuberculosis (1.2%), gallstone disease (0.9%), pelvi-ureteral junction obstruction (0.9%), and neurological issues (0.9%) was noted. Two presumed survivors had died, one due to a late recurrence and the other due to a secondary malignancy.

Conclusions

A high prevalence of medically or surgically manageable conditions makes it imperative to keep these children under follow-up to address any health-related conditions they may subsequently develop.

Defining the Indications of PATIO Technique for Urethrocutaneous Fistula Repair

Introduction

Despite the advancements in technique and technology, urethrocutaneous fistula (UCF) formation continues to be the most common complication after hypospadias repair.

Objective

The objective of the current synthesis is to define the indications of PATIO technique for UCF repair.

Materials and Methods

The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Scopus, Ovid, Embase, Web of Science, and Google Scholar were interrogated for studies presenting primary data upon UCF repair by the PATIO technique. Data analysis was performed on MedCalc and R software.

Results

Eighteen studies were identified relevant to the current context: inversion of UCF tract has been described in 13 and ligation in 5. There were 2 duplications (abstract and manuscript). The overall success for PATIO is 88.2% (314/356). The success rate was variable between classic PATIO (inversion at 87.2%), ligation-inversion at 86.9%, and ligation alone at 88.9%. The success rate was not improvised upon by supplementing inversion of UCF tract with ligation (p = 0.957) or addition of a waterproofing layer (p = 0.622). PATIO has been used for single or multiple UCFs post hypospadias repair, genital piercing, and genitoplasty in cis- or transgender population for UCF up to 5 mm in size. The success rates were best for UCF <2 mm and worst for those approaching 5 mm. The results were, however, unaffected by the location of UCF along the penile shaft. Besides, the use of urethral catheter is optional and may be eliminated with shorter hospitalization.

Conclusions

PATIO repair may be considered for repair of UCFs (a) with diverse etiologies, (b) located anywhere along the penile shaft included coronal UCF, (c) preferably <4 mm in size, (d) single or multiple in number; multiple PATIOs may be done in the same setting, (e) in patients unwilling for prolonged hospitalization, (f) in patients unwilling for a urethral catheter, and (g) in hypospadias cripples wherein mobilization of distant tissues such as tunica vaginalis flap or a buccal mucosal graft may be required for supplementing the UCF repair.

Anthropometric Outcomes in Survivors of Pediatric Solid Tumors

Nutritional status is an important aspect of childhood cancer, with a bearing on the disease and subsequent survivorship. We sought to evaluate the long-term anthropometric outcomes in a cohort of pediatric solid tumor survivors treated between 1994 and 2016. Anthropometry was noted at the time of presentation, after completion of therapy, and at the last follow-up. The z-scores for weight-for-age, height-for-age, and BMI-for-age were calculated using WHO growth charts for ages <5 years and the Indian Academy of Pediatrics growth charts for age >/= 5 years. BMI was calculated for adult survivors. We included 317 survivors, comprising 48, 81, and 188 survivors of Hepatoblastoma (HB), Malignant Germ cell Tumor (MGCT), and Wilms Tumor (WT) respectively. The median age at diagnosis was 24.5 (IQR 59-13.2) months, with a follow-up ranging from 5 to 19.54 years. The z-scores of the collective cohort and individual cohorts of HB, MGCT, and WT showed an improving trend from diagnosis to the last follow-up. The difference in the prevalence of malnutrition was found to be statistically significant when any two-time points were compared. Of the 28 adult survivors, 43% were noted to be underweight. Thus, anthropometric measures improve during follow-up, however, up to 15% of children persist in being malnourished.

'Waterproofing layers' for urethrocutaneous fistula repair after hypospadias surgery: evidence synthesis with systematic review and meta-analysis

OBJECTIVE

To summarize the available evidence and to quantitatively evaluate the global results of different waterproofing layers in substantiating the UCF repair.

MATERIAL AND METHODS

After defining the study protocol, the review was conducted according to the PRISMA guidelines by a team comprising experts in hypospadiology, systematic reviews and meta-analysis, epidemiology, biostatistics and data science. Studies published from 2000 onwards, reporting on the results of UCF closure after hypospadias repair were searched for on PUBMED, Embase and Google Scholar. Study quality was assessed using Joanna Briggs Checklist (JBI) critical appraisal tool. The results with different techniques were compared with the two samples independent proportions test with the help of Microsoft Excel, MedCalc software and an online calculator.

RESULTS

Seventy-three studies were shortlisted for the synthesis; the final analysis included 2886 patients (71 studies) with UCF repair failure in 539. A summary of various dimensions involved with the UCF repair has been generated including time gap after last surgery, stent-vs-no stent, supra-pubic catheterization, suture material, suturing technique, associated anomalies, complications, etc. The success rates associated with different techniques were calculated and compared: simple catheterization (100%), simple primary closure (73.2%), dartos (78.8%), double dartos flaps (81%), scrotal flaps (94.6%), tunica vaginalis (94.3%), PATIO repair (93.5%), biomaterials or dermal substitutes (92%), biocompatible adhesives (56.5%) and skin-based flaps (54.5%). Several techniques were identified as solitary publications and discussed.

CONCLUSIONS

Tunica vaginalis and scrotal flaps offer the best results after UCF closure in the synthesis. However, it is not possible to label any technique as ideal or perfect. Almost all popular waterproofing layers have depicted absolute (100%) success sometimes. There are a vast number of other factors (patient's local anatomy, surgeon's expertise and technical perspectives) which influence the final outcome.

Response to Neoadjuvant Chemotherapy and Outcomes in Children With Wilms Tumor With Caval Thrombus: A Single Center Experience

AIM

The aim of our study is to present our experience in the management and outcome of Wilms tumor with intracaval thrombus.

MATERIALS AND METHODS

All children with Wilms tumor with intracaval thrombus who presented to us from July 2000 to December 2017 were reviewed retrospectively. We evaluated the tumor stage, management, and outcomes in these patients.

RESULTS

Thirty-four patients were included in the study. The median age of presentation was 48 months (11 to 84 mo). Preoperative chemotherapy was given in 32 (94%), with a median duration of 8 weeks. Intracaval thrombus completely resolved in 9 (26%) children after neoadjuvant chemotherapy. Surgical intervention for residual inferior vena cava (IVC) thrombus was performed in 32 patients. The median follow-up was 30 months (5 to 150 mo). At the last follow-up, 24 patients (70%) were alive and disease free. The 5-year overall survival (OS) and event-free survival were 67% (95% confidence interval, 50% to 84%) and 59% (95% confidence interval, 42% to 76%). The OS in children with nonmetastatic disease (94%) was significantly higher than those with metastases (29%; P <0.01). The OS in children with complete resolution of IVC thrombus (100%) was significantly higher than those with persistent thrombus (48%; P =0.025). Analysis of survival outcomes in children with nonmetastatic disease (stage III) revealed no significant difference on comparison with cohort with stage III disease with absence of IVC thrombus. The P -value was 0.224 and 0.53 for 5-year OS and event-free survival, respectively.

CONCLUSION

The management of Wilms tumor can be complicated by the presence of caval thrombus. Patients with metastasis have a significantly poor outcome. Patients in whom, there is complete resolution of intracaval thrombus on neoadjuvant chemotherapy have a significantly higher OS.

Role of Procalcitonin as a Biomarker in Early Identification of Adverse Events Following Esophageal Atresia Surgery

Introduction

Surgical complication following esophageal atresia repair is one of the several factors known to influence the final outcomes. Early identification of such complications may help in timely institution of therapeutic measures and translate into improved prognosis.

Objective

The objective of this study was to evaluate the role of procalcitonin in early prediction of the adverse events after surgery in patients of esophageal atresia and the temporal relationship with clinical manifestations and other inflammatory biomarkers such as C-reactive protein (CRP).

Materials and Methods

This was a prospective study on consecutive patients of esophageal atresia (n = 23). Serum procalcitonin and CRP levels were assessed at baseline (prior to surgery) and on postoperative days (POD) 1, 3, 5, 7, and 14. The trends in the biomarker values and temporal relationships of deviation in trend with the clinical and conventional laboratory parameters and patient outcomes were analyzed.

Results

Baseline serum procalcitonin was elevated (n = 23; 1.7 ng/ml: min: 0.07 ng/ml-max: 24.36 ng/ml) in 18/23 (78.3%) patients. Procalcitonin nearly doubled on POD-1 (n = 22; 3.28 ng/ml: min: 0.64 ng/ml-max: 16.51 ng/ml) followed by a gradual decline. CRP was also elevated on POD-1 (three times the baseline) and depicted a delayed peak at POD-3. POD-1 procalcitonin and CRP levels correlated with survival. POD-1 procalcitonin cutoff at 3.28 ng/ml predicted mortality with a sensitivity and specificity of 100% and 57.9% (P = 0.05). Serum procalcitonin and CRP were higher for patients who sustained complications, so was the time required for hemodynamic stabilization. Procalcitonin (baseline and POD-5) and CRP (POD-3 and POD-5) values correlated with the clinical course after surgery. Baseline procalcitonin cutoff at 2.91 ng/ml predicted the possibility of a major complication with a sensitivity of 71.4% and a specificity of 93.3%. POD-5 procalcitonin cutoff at 1.38 ng/ml predicted the possibility of a major complication with a sensitivity of 83.3% and a specificity of 93.3%. Patients who sustained major complications depicted a change in serum procalcitonin trend 24-48 h ahead of clinical manifestation of an adverse event.

Conclusions

Procalcitonin is a good indicator to identify the adverse events in neonates after surgery for esophageal atresia. The procalcitonin levels in patients who sustained a major complication depicted a reversal in trend 24-48 h of clinical manifestation. POD-1 procalcitonin correlated with survival while the baseline and POD-5 serum procalcitonin predicted the clinical course.

Multi-time point imaging in 99m Tc-pertechnetate scintigraphy of ectopic gastric mucosa in duplication cysts: value-added services

OBJECTIVES

The aim of our study was to describe the scintigraphic patterns of 99m Tc-pertechnetate uptake in patients who were referred to the department of nuclear medicine for evaluating and diagnosing ectopic gastric mucosa in foregut and midgut duplication cysts.

MATERIALS AND METHODS

This hospital-based, retrospective cum prospective research spans a period of 8 years from April 2014 to January 2022. Previous hospital medical records were analyzed and subsequently, a database was prepared which included the age, sex, clinical indication of a 99m Tc-pertechnetate scan, and the planar and SPECT-computed tomography (CT) imaging findings. Postoperative histopathological reports were available for 21 patients. Dynamic and planar static imaging was performed. We included SPECT-CT in suspected duplication cysts to increase the sensitivity and specificity which is a tradeoff for a small amount of additional radiation exposure. A total of 69 patients were subjected to a 99m Tc-pertechnetate scan for suspected foregut or midgut duplication cysts. All were subjected to dynamic planar and delayed static images up to 24 h or until focal uptake of radiotracer was noted which corroborated the anatomical findings, whichever was earlier. SPECT-CT was performed along with the planar study in 31 patients which confirmed the findings. Previously performed CT scans were used for anatomical correlation in the remaining ones.

RESULTS

Duplication cysts were localized in a total of 28 patients (19 foregut duplication cysts and 12 small bowel duplications - 3 patients had dual duplication cysts, both foregut, and midgut). Forty-one patients had no scintigraphic evidence of ectopic gastric mucosa. Of these 69 patients, histopathological diagnosis was available for 21 patients (22 lesions). The report was concordant with the scan findings in 15 patients (16 lesions) and 6 patients showed discordance in histopathological diagnosis and scan findings.

CONCLUSION

In conclusion, multi-time point imaging is the key to diagnosing ectopic gastric mucosa of various sizes and in various locations. An abnormal radiotracer uptake in dynamic sequences, even before the appearance of the stomach in the region of the small bowel is indicative of intestinal duplication, and delayed radiotracer visualization in the region of the thorax is characteristic of intrathoracic foregut duplication cyst.

A Bibliometric Study of the Pediatric Inguinal Hernia Publication Landscape from the Web of Science Database

Background

The number of times a research work gets cited by another article is one of the article-level metrics for assessing the quality of a research publication. Citation analysis by bibliometric review has been performed in several disciplines. The current study was aimed to systematically review the literature available on pediatric inguinal hernia since 1960 in terms of the 25 most cited articles in this field and analyze the bibliometric variables author and organizational collaborative patterns.

Methods

Thomson Reuters Web of Science citation indexing database and research platform were used to retrieve the most cited articles in pediatric inguinal hernia (PIH) using appropriate search strings. The characteristics (name of authors, the total number of authors, the title of publication, journal of publication, year of publication, etc.) of the 25 top-cited articles were recorded. Specific bibliographical parameters were derived and analyzed. Visualization maps were generated using VOSviewer software.

Results

The analysis revealed that the Journal of Pediatric Surgery was leading the choice of journal for publication. While most of the publications originated from the United States of America, Schier was the most influential author. Five of the eight top-productive authors are also the most connected.

Conclusion

Articles on laparoscopic repair in PIH have been heavily cited. Following the United States of America, Turkey stands out as the topmost productive country in PIH. The publications on PIH show that "collaboration" is the bridging force between productivity and influence on the academic community.

Publication landscape of Posterior urethral valve- A scientometric study

To assess the global research landscape in the field of Posterior urethral valve (PUV), a scientometric study was conducted to determine the quantity and quality of the research output and get insight into the key research areas and pattern of collaboration in the research community.

METHODS

Primary data was acquired from the Scopus® database. Various parameters like the total research productivity, citations, citations per publication, citations per year, citations per publication per year, the scientific output of countries, institutions, authors, and journals were calculated. Key research areas were inferred by examining the top-cited articles (citations >150). Collaborative maps were generated by calculating co-authorship links amongst countries and authors using VOSviewer software.

RESULTS

One thousand seven hundred fourteen results were found published from 1913 to 2019, receiving a total of 27,253 citations, authored by 5138 authors from 125 countries. The top three countries were the United States of America (USA), India, and the United Kingdom (UK). The leading institutes were the Children's Hospital Boston, USA (n = 48), All India Institute of Medical Sciences (AIIMS, Delhi), India (n = 38), and Great Ormond Street Hospital, UK (n- = 27). The journals which published the most articles on PUV were the Journal of Urology (n = 278), Journal of Pediatric Urology (n = 121), followed by Urology (n = 86). Leading authors were Glassberg, K. L and Bajpai M (n = 17, each), Canning DA & Kajbafzadeh, AM (n = 16, each), followed by Peters CA with 14 manuscripts. The top-cited documents (n = 10) received 2104 citations and were published between 1986 and 2010. The key areas of interest found were "long-term outcomes" (n = 4) and "fetal surgery" (n = 2). The most productive countries were also the most collaborative countries (the USA and UK).

CONCLUSION

In the research landscape of PUV, the USA, Children's Hospital Boston, and Glassberg, K. L, along with Bajpai, M were the top contributors in terms of the country, organization, and authors, respectively. The "Journal of Urology" and "Pediatric Nephrology" stands out in terms of bibliometric parameters considered. The hotspot topics based on the number of citations received were "long-term outcomes" and "fetal surgery" in PUV. The most productive countries were also the most collaborative countries (the USA and UK).

Lower Gastrointestinal Bleed Playing Hide and Seek

A 13-year-old adolescent male presented with an episode of rectal bleed. He has had five such episodes in the past year where he witnessed black tarry stools mixed with fresh blood, painless, not associated with fever or hematemesis. Clinical examination revealed pallor and a soft, non-tender abdomen. Vitals were stable. Blood investigations revealed haemoglobin of 102g/L, WBC count of 10 X 109/L and platelet count of 165 × 109/L. The clotting screen was normal. Upper GI endoscopy and colonoscopy revealed no abnormality. The patient underwent Tc-99m pertechnetate scintigraphy to look for Meckel's Diverticulum in view of painless lower GI bleed.

An Exploratory Study on Pediatric Inguinal Hernia Videos on the YouTube Platform

AIM

A study was conducted to explore the characteristics of the videos on pediatric inguinal hernia repair on YouTube and compare the most popular videos (MPV) with the least popular ones in terms of educative value vis-a-vis their popularity.

MATERIALS AND METHODS

The term "Pediatric inguinal hernia repair" was searched for on YouTube on August 15, 2021, with the filter set to "view rate." Pertinent data were collected from the 50 MPV and the 50 least popular videos (LPV) and then compared. The h-index and affiliation of the surgeon were obtained from the Scopus database, and their affiliation was further categorized as academic or nonacademic.

RESULTS

One hundred and seventy-five videos were found with median views of MPV: LPV being 9270 (interquartile range [IQR] - 12099):127 (IQR - 194), respectively (P < 0.0001). Most of the videos in the MPV and LPV groups were uploaded from the United States of America (USA) (MPV - 17 and LPV - 13) and India (MPV - 15 and LPV - 15). The MPV were on YouTube for a median duration of 3.1 (IQR - 5.5) years as compared to 1.2 (IQR - 2.3) years for the LPV (P < 0.0001). Ninety-two surgeons were identified. The median h-index of the surgeons of MPV was 3 (IQR - 12) in comparison to 1 (IQR - 10) of LPV (P = 0.13). The ratio of academic versus nonacademic affiliation among MPV and LPV was almost equal in both the groups.

CONCLUSIONS

On either end of the spectrum of popularity, the majority of the pediatric inguinal hernia videos on YouTube were surgical videos uploaded from the USA and India. The educative value of these videos was found to be low and widely dispersed. Surgeons from both academic and nonacademic affiliations had contributed similarly.

Whether prophylactic intraoperative chest drain insertion in esophageal atresia-tracheoesophageal fistula is an evidence-based practice or just a prejudice: A systematic review and meta-analysis

BACKGROUND

Various controversial practices in the management of Esophageal atresia-tracheoesophageal fistula (EA-TEF) can be noticed among pediatric surgeons. Routine intraoperative chest drain (IOCD) insertion is often debated and lacks any concrete evidence. This meta-analysis aims to compare the postoperative outcomes among newborns with and without IOCD insertion.

METHODS

The authors searched EMBASE, PubMed, Scopus, and Web of Science on 30^th April 2021. The requirement for chest drain in the postoperative period (POCD), anastomotic leak (and/or pneumothorax), mortality rate, and revisit(s) to the operation room (RVOR) were compared among two groups of newborns, i.e. groups A and B with and without IOCD insertion respectively. The statistical analysis was performed using a fixed-effects model. The pooled risk ratio (RR) and heterogeneity (I²) were calculated. The methodological quality of the studies was assessed utilizing the Downs and Black scale.

RESULTS

A total of 498 newborns were included in the present analysis. As compared to group B, newborns within group A showed no significant difference in the requirement for POCD (RR 2.47; 95% CI 0.88-6.98, p = 0.09), the occurrence of anastomotic leak and/or pneumothorax (RR 1.35; 95% CI 0.89-2.06, p = 0.16), and mortality rate (RR 2.24; 95% CI 0.81-6.26, p = 0.12). However, RVOR was significantly higher in group A (RR 1.75; 95% CI 1.07-2.87, p = 0.03). All included studies had a moderate risk of bias.

CONCLUSIONS

The present meta-analysis revealed no additional benefit of prophylactic IOCD insertion. However, due to moderate risk of bias, further studies need to be conducted for an optimal comparison between the two groups.

Paediatric thoracic wall lipoblastoma in a 7-year old: a rare tumour of childhood

Lipoblastoma is a rare benign mesenchymal tumour derived from embryonic white fat tissue. Lipoblastoma generally occurs in children less than 3 years of age, and fewer than 200 cases have been reported in the English literature. There are hardly a dozen reports describing intrathoracic and thoracic involvement. We report a case of a 7-year-old boy who presented with a slowly growing right thoracic wall mass for a duration of 1 year. Radiological investigations (ultrasonography and contrast-enhanced CT of the chest showed the presence of a fat-containing, low density extrapulmonary soft tissue mass) could not confirm the diagnosis, and repeat biopsies also were not conclusive. The mass was excised and histopathology confirmed it as lipoblastoma. A review of literature pertaining to the clinical presentation, radiological features and histopathology of this rare condition has been discussed.

Evaluation of Interstitial Cells of Cajal-Like Cells at the Pelviureteric Junction in Children with Pelviureteric Junction Obstruction: A Prospective Study and Review of Literature

INTRODUCTION

The etiopathogenesis of pelviureteric junction obstruction (PUJO) has been debated. Recently, the role of interstitial cells of Cajal-like cells (ICC-LC)has been studied and reported to be the cause of this functional obstruction. We studied the histopathology and ICC-LC density at PUJ and compared it with that of PUJ of the control group and distal ureteric margin of the study group.

METHODS

A prospective study was conducted which included PUJO patients in the study group and the renal tumor patients in the control group. Histopathological examination (muscle hypertrophy and fibrosis) and immunohistochemistry (ICC-LC density) were done. The muscle hypertrophy, fibrosis, and ICC-LC density at the PUJ in both the groups were compared. A similar comparison was performed between the findings at the PUJ and the distal margin in the study group.

RESULTS

The study and control groups included 37 PUJO patients and 13 Wilms tumor patients. The ICC-LC density at PUJ in the study group was significantly lower than that in the control group (P < 0.001) and that at the distal resected margin of the study group (P < 0.001). Significantly increased muscle hypertrophy (P < 0.001) and fibrosis (P = 0.002) were seen at PUJ in the study group compared to the control group. No significant association was noted between the ICC-LC density and muscle hypertrophy at PUJ and the distal resected margin in the study group.

CONCLUSION

A significant decrease in the density of ICC-LC and increased fibrosis and muscle hypertrophy at PUJ in children with PUJO play a role in the etiopathogenesis of the disease.

Electronic Medical Record System-Based Teleconsultations in Pediatric Surgery: An Initiative from a Tertiary Care Public-Funded Hospital in North India to Alleviate the COVID-19 Imposed Hospital Visit Restrictions

Background

There has been a dramatic effect of the coronavirus disease 2019 pandemic on the daily health-care services. The era of physical consultations is slowly being replaced with teleconsultation, and this current pandemic has tipped the scales further. This study highlights the preliminary experience in providing teleconsultation to pediatric surgical patients at a tertiary care hospital in north India.

Materials and Methods

A retrospective analysis of the electronic medical record system records of the patients undergoing teleconsultation at the authors' department between the June 26, 2020 and the September 26, 2020 was performed. The data were categorized on the basis of the type of consultation (urgent, semi-urgent, or routine) and the type of intervention. A comparison with the data from the corresponding months of 2019 was also performed.

Results

A total of 261 teleconsultations were conducted during the study period, with a success rate of 69% (181/261). Of these, 96% (171/178) were follow-up patients and 56% (99/178) presented with genitourinary complaints. After triaging, only 10% (18/178) of the patients required urgent medical/surgical attention.

Conclusion

In the current as well as postpandemic phase, teleconsultation can act as a potent triaging tool and can help in better utilization of resources alongside helping in the maintenance of social distancing by decreasing the number of physical visits to the hospital.

Serum Matrix Metalloproteinase 7 as a Diagnostic and Prognostic Biomarker for Extrahepatic Biliary Atresia

Background

Differentiation of neonatal cholestasis into neonatal hepatitis (NH) and extrahepatic biliary atresia (EHBA) is essential to formulate the treatment plan; promptness is indispensable for optimal outcomes. The clinical and nonoperative algorithms lack precision; the gold standard investigations (liver biopsy or per-operative cholangiogram) are invasive. There is a need for a noninvasive test which is both, sensitive and specific and has a high likelihood ratio.

Aim

To study the (diagnostic) role of matrix metalloproteinase 7 (MMP-7) as a serum biomarker to differentiate between EHBA and NH and evaluate the prognostic significance in EHBA based on its correlation with liver histopathology and serological predictors of liver fibrosis - Aspartate-to-Platelet Ratio Index (APRI) and Fibrosis-4 (FIB-4).

Materials and Methods

This was a prospective study conducted upon patients of neonatal cholestasis presenting with acholic stools (n = 46) with equal number of controls (n = 45) with no liver pathology. Observational parametric included disease-specific workup and serum MMP-7 levels (all participants); liver biopsyl and APRI-FIB-4 (EHBA).

Results

(Diagnostic) Serum MMP-7 levels were significantly elevated in EHBA (n = 25; 28 ng/mL) as compared to those in NH (n = 21; 1.88 ng/mL) and normal infants (n = 45; 1.2 ng/mL) (P < 0.001 for both). Serum cutoff at 4.99 ng/mL differentiated EHBA-NH with a high sensitivity (96%), specificity (90.5%), and a negative predictive value (95%), with the number needed to misdiagnose being 23. (Prognostic) Inflammatory activity and fibrosis-stage on liver histopathology (METAVIR-and-Ishak scores) correlated with MMP-7 levels. APRI and FIB-4 scores also depicted a strong correlation with each other, age of the patient, and liver fibrosis.

Conclusions

MMP-7 has a diagnostic value in differentiating EHBA from NH and may also be used as a prognostic biomarker in the follow-up of these patients. MMP-7 levels in controls may be used as a baseline for future studies.

Pediatric Neuroblastoma - Impact of Nutritional Status on Complications and Outcomes

AIM

The aim is to study the impact of nutritional status on outcomes and treatment-related complications in patients of neuroblastoma.

MATERIALS AND METHODS

Anthropometry (height, weight, weight for height [in <5 years], mid-arm circumference [MAC] [in <5 years], and body mass index [BMI]), hemoglobin level, and serum albumin level were recorded.

RESULTS

Twenty-four neuroblastoma patients, 16 males and 8 females, with a mean age of 42.7 months were treated and followed up over a period of 0.03-170 months. Of 24 patients, 16 survived (complete response - 9, partial response - 2, no response - 2, progressive disease - 3). Height <2 standard deviation [SD] was seen in 12.5% (3/24). Mortality and complications were found in 66.7% (2/3) and 100% (3/3), respectively. Weight <2SD was seen in 37.5% (9/24). Mortality and complications were found in 33.3% (3/9) and 67% (6/9), respectively. Weight for height <2 SD was seen in 35% (7/20). Mortality and complications were found in 42.9% (3/7) and 71.4% (5/7), respectively. MAC <2 SD was seen in 15.8% (3/19). Mortality and complications were found in 66.7% (2/3) and 66.7% (2/3). BMI <2SD was seen in 29.2% (7/24). Mortality and complications were found in 42.8% (3/7) and 28.6% (2/7). Anemia was seen in 62.5% (15/24), of which nine survived. Complications were seen in 58.3% (14/24) (P = 0.001). Hypoproteinemia was seen in 20.8% (5/24). Mortality and complications were 40% (2/5) and 80% (4/5).

CONCLUSION

Neuroblastoma has poor outcome in Indian children, and there does not appear to be a major role played by nutrition in determining the response to treatment and survival.

Delayed Presentation of Jejunal Atresia with Multiple Enteric Fistula: A Case Report and Review of Literature

A 6-month-old boy presented with features of intestinal obstruction. Laparotomy revealed Type IIIa jejunal atresia. The proximal and distal bowel loops were in continuity through multiple fistulae between the adjoining bowel loops. To the best of our knowledge, it is the first report of congenital Type IIIa intestinal atresia surviving beyond the neonatal age without surgery.

Choledochal Cyst of the Cystic Duct - A Supplement to Todani's Classification

Choledochal cyst of the cystic duct is a rare anomaly; broadly classified, the pathology may either present as a solitary anomaly or with concomitant involvement of other parts of the biliary tree. In the absence of standard guidelines for surgical planning, the definitive management is based on the experience shared in the literature in the form of case reports and case series. The available options should be discussed with the patient while explaining the possible short- and long-term complications. The authors herewith present two cases of choledochal cyst of the cystic duct along with a review of literature relevant to their etiopathogenesis and its implications for the definitive management.

Can sealing promote healing?: A systematic review and meta-analysis highlighting the adjunctive role of tissue sealant application during urethroplasty for hypospadias

BACKGROUND

A significant proportion of children require multiple surgeries for successful repair of hypospadias. This is not only a source of a financial burden to the family but also causes long-term social and psychosexual issues. Tissue sealant application can provide additional coverage to the suture line and subsequently prevents operative failure. However, a consensus statement regarding its usage during urethroplasty is lacking. This systematic review and meta-analysis aims to compare the outcomes of hypospadias surgery, in terms of its complications, in children with and without tissue sealant application.

METHOD

The authors systematically searched the databases PubMed, EMBASE, Web of Science and Scopus through September 2020. The occurrence of overall complications, and specific complications (including urethrocutaneous fistula, wound-related complications, flap-related complications, complications involving the neo-urethral tube and meatal stenosis) were the primary and secondary outcomes, respectively. Statistical analysis was performed using a random-effects model, and pooled risk ratio (RR) and heterogeneity (I²) were calculated. The methodological quality of the studies was assessed utilizing the Downs and Black scale.

RESULT

Four comparative studies were included in the meta-analysis. The different types of tissue sealants such as fibrin glue, cyanoacrylate glue, BioGlue and cryocalcium glue were used in these studies. As compared to without sealant application, hypospadias repair performed with sealant application showed no significant difference in the incidence of overall postoperative complications (RR 0.63; 95% CI 0.34-1.14, p = 0.13). However, a significant reduction in some specific complications including urethrocutaneous fistula (RR 0.37; 95% CI 0.19-0.72, p = 0.003), wound-related complications (RR 0.57; 95% CI 0.38-0.86, p = 0.008) and complications involving the neo-urethra (RR 0.15; 95% CI 0.04-0.54, p = 0.004) was observed with sealant usage. The average Downs and Black scale scores ranged from 16 to 18, with all studies having a moderate risk of bias. Kappa statistics showed a value of 0.962 (p < 0.001), highlighting an almost perfect agreement among the two observers.

CONCLUSION

The present meta-analysis revealed no additional benefit of the repair of hypospadias performed with tissue sealants as compared to without sealants in terms of reducing the overall postoperative complications. However, a significant reduction in the occurrence of some specific complications, including UCF, wound-related complications and complications involving the neourethra was observed with sealant application. The level of evidence of the published comparative studies is limited. Therefore, further studies need to be conducted for optimal comparison between the sealant and no sealant (or placebo), and different types of sealants.

Quality Assessment of YouTube Videos on Laparoscopic Pyloromyotomy Using a Validated Tool: An Appeal to Trainees to Follow the Peer-Reviewed Videos for Learning Purposes

Background: Surgical trainees often resort to operative videos on the internet during preparation for surgery; YouTube is the most commonly explored video source by them. However, the quality of these videos is often questioned. This study was performed to assess the quality of available YouTube videos on laparoscopic pyloromyotomy (LP). Materials and Methods: The term "laparoscopic pyloromyotomy" was searched on YouTube on June 2, 2021, and 20 most-viewed videos on LP were included. A reference video on LP from WebSurg was also selected. The laparoscopic surgery video educational guidelines (LAP-VEGaS) tool was utilized for quality assessment of these videos. Descriptive variables, including the surgeon's details; year of video upload; duration of the video; view, like, and dislike counts; number of ports used; and instruments used for pyloromyotomy, were recorded and their relationship with video quality was studied. Results: The majority of videos were from the United States and India, and a surgeon could be identified in 90% of them. The median (range) video duration and view, like, and dislike counts were 2.89 (0.68-8.80) minutes, 2308 (1102-23,682), 5 (0-59), and 0 (0-11), respectively. The LAP-VEGaS score of the reference video was 17. In contrast, the scores of YouTube videos ranged from 1 to 14. The quality of these videos was poor in 5/9 domains. None of the descriptive variables showed a significant association with high video quality. Conclusion: Compared with the reference video, the overall quality of YouTube videos on LP was poor. Therefore, until a screening tool is available for selection of high-quality YouTube videos, trainees must resort to peer-reviewed video platforms.

Secret Key Generation Schemes for Physical Layer Security

Physical layer security (PLS) has evolved to be a pivotal technique in ensuring secure wireless communication. This paper presents a comprehensive analysis of the recent developments in physical layer secret key generation (PLSKG). The principle, procedure, techniques and performance metricesare investigated for PLSKG between a pair of users (PSKG) and for a group of users (GSKG). In this paper, a detailed comparison of the various parameters and techniques employed in different stages of key generation such as, channel probing, quantisation, encoding, information reconciliation (IR) and privacy amplification (PA) are provided. Apart from this, a comparison of bit disagreement rate, bit generation rate and approximate entropy is also presented. The work identifies PSKG and GSKG schemes which are practically realizable and also provides a discussion on the test bed employed for realising various PLSKG schemes. Moreover, a discussion on the research challenges in the area of PLSKG is also provided for future research.

Assessment of Sexual Dimorphism in Mandibular Ramus: An Orthopanoramic Study

Background Mandible is the largest and strongest bone of the face, is very durable, and hence remains well preserved than many other bones. In cases of mass disasters where an intact skull is not found, the mandible may play a vital role in sex determination as it is the most dimorphic bone of the skull. Morphometric analysis of mandibular ramus provides highly accurate data to discriminate sex. This can be accomplished by the use of panoramic radiography which is widely available and is used routinely to assess the mandibular structures. Objective To evaluate and compare the various parameters of the mandibular ramus and to determine the usefulness of the mandibular ramus as an aid in sex determination. Method Orthopantomograms of 140 samples (70 males and 70 females) were collected from the archives and traced manually on matte acetate tracing paper. Various parameters of mandibular ramus were measured on the right and left sides. The obtained measurements were subjected to discriminant function analysis. Result Mandibular measurements on the right side were greater than on the left side. However, only the ramus breath (minimum and maximum) and projective height of ramus were statistically significant (p < 0.05). All the measurements were higher for males than females. F-statistic values indicated that the highest sexual dimorphism was seen with the projective height of ramus and least with minimum ramus breath. Conclusion Mandibular ramus measurements can be a useful tool for gender determination and can be an essential tool in forensic science especially when there is damaged or partially preserved mandibles and may be helpful for medico-legal purpose in Nepal.

Mucosal Schwann Cell Hamartoma of the Gall Bladder

Mucosal Schwann cell hamartoma (M-SCH) of the intestinal mucosa is a rare entity and incidental finding in histological examination. Histological characteristics are Schwannonian cell proliferation in lamina propria with S100-positivity. M-SCH-like lesion in the gall bladder is even rarer and is a recently reported entity. We report this extremely rare lesion in a cholecystectomy specimen of a 4-year-old boy, which makes it the youngest patient to be having M-SCH-like lesion in the gall bladder.

Rare Paratesticular Masses in Children

Pediatric paratesticular mass is common in pediatric surgical practice, and they could be because of an underlying encysted hydrocele, a teratoma, or an epididymal cyst. Furthermore, a malignant lesion such as rhabdomyosarcoma should be ruled out. Rare entities, such as fibrous hamartoma of infancy and cellular angiofibroma, are rarely encountered. We report two such cases of paratesticular masses with these rare pathologies.

Cystic biliary atresia with congenital absence of portal vein

A 126-day female child presented with jaundice since day 7 of life. She was icteric and had hepatosplenomegaly. Radiological investigations revealed three extrahepatic and multiple intrahepatic biliary cysts, absent gall bladder and portal vein. These findings were confirmed on laparotomy. To the best of our knowledge, this is the first report of cystic biliary atresia associated with congenital absence of portal vein.

Spin reorientation in antiferromagnetic Dy2FeCoO6 double perovskite

We explored the electronic and magnetic properties of the lanthanide double perovskite Dy₂FeCoO₆ by combining magnetization, Raman and Mössbauer spectroscopy and neutron diffraction along with density functional theory (DFT) calculations. Our magnetization measurements revealed two magnetic phase transitions in Dy₂FeCoO₆. First, a paramagnetic to antiferromagnetic transition at T _N = 248 K and subsequently, a spin reorientation transition at T _SR = 86 K. In addition, a field-induced magnetic phase transition with a critical field of H _c ≈ 20 kOe is seen at 2 K. Neutron diffraction data suggested cation-disordered orthorhombic structure for Dy₂FeCoO₆ in Pnma space group which is supported by Raman scattering results. The magnetic structures ascertained through representational analysis indicate that at T _N, a paramagnetic state is transformed to Γ₅(Cx, Fy, Az) antiferromagnetic structure while, at T _SR, Fe/Co moments undergo a spin reorientation to Γ₃(Gx, Ay, Fz). The refined magnetic moment of (Fe/Co) is 1.47(4) μ _B at 7 K. The antiferromagnetic structure found experimentally is supported through the DFT calculations which predict an insulating electronic state in Dy₂FeCoO₆.

Analysis of Top ten-Cited Articles Published in the Journal of Indian Association of Pediatric Surgeons Over a 10-Year Period

Aim:

The objective was to identify, analyze, and categorize the characteristics (the type of article, country of origin, institution, authorship, topic, and the number of citations) of the articles published in the Journal of Indian Association of Pediatric Surgeons (JIAPS) from 2008 to 2017, with particular focus on the top ten-cited articles.

Materials and Methods:

The above characteristics of the individual articles were tabulated in the Microsoft Excel^® sheet. The number of citations of an article was obtained from three databases (CrosssRef, MEDLINE, and Google Scholar). A final tally was obtained after removing common entries in the databases.

Results:

The total number of articles published was 613. There were 255 case reports, 209 original articles and review articles, and 149 brief communications. The top five countries of origin of the articles were India, United Kingdom (UK), Turkey, Iran, and Saudi Arabia, with 526, 14, 9, 7, and 6 articles, respectively. The institution, authorship, and topics of the top ten-cited articles were noted.

Conclusion:

Case reports are the most common type of articles published in JIAPS. Most of the articles originated from India, followed by the UK and middle-east countries. This analysis may provide insights to the editorial board and the members of IAPS about the trend of research and publications among the pediatric surgeons of India.

Intraobserver and interobserver variations in cortical transit time measurement in children with pelviureteric junction obstruction

Cortical transit time (CTT) has recently been shown to be a useful parameter in the management of children with pelviureteric junction obstruction (PUJO). The aim of this study was to assess intraobserver and interobserver variations in the qualitative and quantitative assessment of CTT in children with PUJO. A retrospective study was performed, and ^99mTc-MAG3 renogram images of all children with PUJO performed from January 2016 to December 2017 were retrieved. The images were assessed by three observers at two different time points. CTT was qualified as delayed if CTT was more than 3 min else; it was noted as normal. The intraobserver and interobserver variations in the results of the CTT of the normal kidney and affected kidney both before and after surgery were studied. The kappa statistic was used to compare the interobserver variation of qualitative interpretation of CTT. The Bland–Altman plot was used to evaluate the intraobserver and interobserver variations of the quantitative interpretation of CTT. A total of 57 ^99mTc-MAG3 renal scintigraphies were evaluated. Overall, 114 renal units were evaluated with 51 normal renal units and 63 renal units with PUJO. Of these, 63 renal units with PUJO, 31 renal units had been operated upon, whereas the remaining 32 renal units had no intervention at the time of the study. The kappa statistic in the normal, affected operated, and affected unoperated kidneys was interpreted as almost perfect, substantial to almost perfect, and moderate to substantial level of agreement, respectively. The Bland–Altman plot revealed a large mean difference and wide 95% limits of agreement in affected kidneys (both operated and unoperated). The study concludes that the qualitative CTT interpretation in the affected renal unit which is most commonly used in recent studies is a reliable and reproducible parameter in children with PUJO. The quantitative measurement had wide inter- and intraobserver variation for clinical use.

Esophageal Button Battery in the Pediatric Population: Experience from a Tertiary Care Center

OBJECTIVES

To highlight different patterns of clinical presentation, share authors' experience in the management of children following button battery ingestion and their outcomes.

METHODS

This is a single center descriptive cohort study with a total duration of 5 y (January 2014 through December 2018). Battery removal was performed by urgent rigid esophagoscopy following department protocols. Outcomes and complications were observed in the post-operative period in all children. Contrast esophagogram was performed at 4-6 wk post battery removal for assessing esophageal emptying and detecting sequelae (stricture).

RESULTS

Fifty-two children (M:F = 31:21) with a mean age (+SD) at presentation of 47 (+27) mo were managed at authors' center during the study period. Most common source of button battery was electronic appliance remote (50%) and common symptoms at presentation were vomiting after feeds, dysphagia, chest pain etc. During endoscopic retrieval, majority (60%) of the batteries were lodged in the upper esophagus and predominant impaction was noticed at anterior wall (81%) of esophagus. Upon injury assessment, grade 3 followed by grade 2 were detected in 59% and 41% cases respectively. Five children developed complications. Two deaths due to catastrophic hemorrhage (aorto-esophageal fistula) and refractory sepsis (tracheoesophageal fistula) occurred in present cohort. While contrast esophagogram was normal in all survivors, self-limiting symptoms like mild chest pain during swallowing and cough were observed during the follow-up. Median (IQR) duration of hospital stay and follow-up were 2 d (1-2.75) and 14.5 mo (8.5-17.5) respectively.

CONCLUSIONS

Accidental button battery ingestion can be life-threatening. Diagnosis is often delayed due to non-specific clinical presentation and unwitnessed ingestions. Esophagoscopic retrieval is the treatment modality of choice. Despite having significant esophageal injury at the time of removal, no long-term sequelae (clinical or radiological) were observed in present study.

Tumor-Infiltrating Lymphocytes in Wilms Tumor

Purpose: T-lymphocytes-infiltrating tumors (TILs) are white blood cells (CD3+) found within the tumor and are thought to indicate a T-cell-mediated specific immune response. The purpose was to evaluate the presence and the subtypes of TILs in Wilms tumor (WT) specimens. Materials and Methods: A prospective study was conducted, and consecutive cases of WT registered and treated at our center were included in the study. The resected tumor was processed by taking multiple sections from the tumor and the peritumoral area. The sections were then processed for evaluating TILs and their subtypes (CD4 + and CD8+). TILs were assessed as a percentage of the total mononuclear cell infiltration in both these areas in all specimens. Results: Twenty-four consecutive specimens of WT were studied. The mean TILs (CD3+) counts was significantly higher (P = 0.001) in the peritumoral area (22.64 ± 1.42; range 20.2%–25%) as compared to the tumor (21.08 ± 2.42; range 14.6%–23.1%). The mean T-Helper (CD4+) counts was also significantly higher (P < 0.001) in the peritumoral area (13.04 ± 1.79; range 10.5%–16.5%) than in the tumor (7.30 ± 1.81; range 4.2%–10.1%). The mean cytolytic T-lymphocytes (CTLs-CD8+) counts in peritumoral area were 6.64 ± 1.09 (range 4.2%–9.2%), while in the tumor, it was 11.96 ± 3.09 (range 3.6%–16.4%). Two patients died on follow-up due to recurrence. These patients showed a markedly lower CD8+ cell count and higher CD4+/CD8+ ratio in the tumor. Conclusion: T-cells infiltration takes place in WT, and most of the patients demonstrate a higher concentration of CTL (CD8+) in the tumor as compared to the peritumoral area.

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.

Correlation of functional echocardiography and clinical parameters in term neonates with shock

BACKGROUND

To evaluate the correlation between functional echocardiography and clinical parameters in term neonates with shock.

METHOD

Cross sectional study of 30 full term newborns who were clinically detected to have shock compared to 30 full term hemodynamically stable neonates. For statistical analysis, cases were further sub classified into cardiogenic and septic shock.

RESULT

Functional echocardiography revealed inferior vena cava collapsibility index (cIVC), fractional shortening (FS), ejection fraction (EF), cardiac output and superior vena cava (SVC) flow were significantly lower whereas myocardial performance index (MPI) was significantly higher in babies with cardiogenic and septic shock as compared to the controls. Left ventricular end diastolic area (LVEDA) was significantly higher in cardiogenic shock whereas it was significantly lower in septic shock as compared to the controls. Also, cIVC was significantly lower and LVEDA was significantly higher in cardiogenic as compared to the septic shock. In cardiogenic shock SVC flow correlated significantly with capillary filling time and systolic blood pressure. The correlation between functional echocardiographic parameters of cardiogenic and septic shock showed that EF, FS and MPI were positively and significantly correlated (r 0.742, p 0.022 for EF, r 0.766, p 0.016 for FS and r 0.478, p 0.05 for MPI) whereas SVC flow and cIVC were negatively and significantly correlated between cardiogenic and septic shock (r - 0.655, p 0.045 for SVC flow and - 0.578, p 0.05 for cIVC).

CONCLUSION

In the complex environment of neonatal intensive care unit detection of shock continues to be a major challenge. Functional echocardiography provides an adjunct information to the clinical assessment of shock and helps in monitoring the response to treatment.

Does caudal analgesia increase the rates of urethrocutaneous fistula formation after hypospadias repair? Systematic review and meta-analysis

INTRODUCTION

Caudal block analgesia is administered to lower the requirements of systemic and inhaled anesthetic drugs during hypospadias surgery. However, recent reports, all clustered in a short time-span have generated controversial and mutually opposing results while evaluating caudal block as an independent risk factor for urethroplasty-related complications after hypospadias repair. There is no consensus statement on the role of caudal block analgesia in formation of urethrocutaneous fistula (UCF) after hypospadias surgery. We performed a systematic review and meta-analysis of the studies evaluating the relative rates of UCF formation after hypospadias surgery in patients who were administered caudal block analgesia versus in those who were not.

METHODS

Electronic searches were performed using PubMed, PubMed Central, Google Scholar, Ovid, and the Cochrane library. Statistical analysis was performed using a fixed-effect model, odds ratios, risk ratios (RR), and heterogeneity (I2) were calculated. Funnel plot was used to assess for publication bias.

RESULTS

Seven studies with 1706 patients were included. Caudal block analgesia is associated with a significantly higher risk of UCF formation (RR: 1.81; 95% confidence interval [CI]: 1.30-2.53), (P = 0.0004) and other urethroplasty-related complications (RR 2.01; 95% CI: 1.48-2.74), (P < 0.00001) after hypospadias surgery. Funnel plots indicate some publication bias.

CONCLUSIONS

In patients undergoing hypospadias repair, administration of caudal analgesia is associated with a higher risk of UCF formation and other urethroplasty-related complications.

Surgical Surprise during Posterior Sagittal Anorectoplasy: A Rectal Duplication

An 8-month-old boy with anorectal malformation (ARM) was incidentally found to have double rectal pouches during posterior sagittal anorectoplasty. The distal blind-ending pouch was excised, and the larger proximal pouch was tapered and anorectoplasty performed. The excised pouch was confirmed as rectal duplication cyst. One must be aware of such uncommon associations with ARM.

Cervical congenital infantile fibrosarcoma: a case report

Background

Congenital infantile fibrosarcoma is a rare mesenchymal tumor seen in children as well as adults. The congenital variety is rare and out of the reported cases only one case sited in the neck has been reported so far. Another such case is presented here who was successfully managed.

Case presentation

A 3-month-old Hindu baby boy presented with a congenital neck swelling. The apparent clinical diagnosis was lympho-venous malformation. With a remote possibility of malignancy, an excisional biopsy was done. Histopathology revealed congenital infantile fibrosarcoma.

Conclusion

A successful excision of cervical congenital infantile fibrosarcoma has not been reported. This diagnosis should be kept as a possibility in all congenital cervical swellings. These are commonly misdiagnosed as lympho-venous malformations and histopathology is confirmatory.

Congenital colonic stenosis with absent caecum and appendix: a rare association

Congenital colonic stenosis is a rare condition with less than 20 cases reported in the literature since 1966. We report an interesting case of a 7-month-old baby girl who presented with features suggestive of acute intestinal obstruction. On exploration, it was a case of ascending colon stenosis with absence of caecum and appendix. A double barrel ileocolostomy was performed. The histopathology confirmed the diagnosis of colonic stenosis and ruled out the presence of Hirschsprung's disease in the distal colon. The child underwent second stage surgery (stoma closure) after 9 months. In complex cases of congenital colonic stenosis, an early decompressive surgery followed by a delayed second stage closure is recommended in patients with poor general condition.

Single-nucleotide and copy-number variance related to severity of hypospadias

BACKGROUND

The genetic association of hypospadias-risk studies has been conducted in Caucasians, Chinese-Han populations and few in Indian populations. However, no comprehensive approach has been followed to assess genetic involvement in the severity of the disorder.

METHODS

The study evaluated to establish the correlation between genotyped single nucleotide and copy number variants (SNPs/CNVs) and severity of hypospadias by an association in a total 30 SNPs in genes related to sex hormone-biosynthesis and metabolism; embryonic-development and phospholipase-D-signalling pathways on 138 surgery-confirmed hypospadias-cases from North India (84 penile and 28 cases of penoscrotal-hypospadias as compared with 31 cases of glanular + coronal), and analyzed and identified CNVs in four familial cases (18 members) and three paired-sporadic cases (6 members) using array-based comparative-genomic-hybridization and validated in 32 hypospadias samples by TaqMan assay.

RESULTS

Based on odds ratio at 95% CI, Z Statistic and Significance Levels, STS gene-rs17268974 was associated with Penile-Hypospadias and 9-SNPs [seven-SNPs (rs5934740; rs5934842; rs5934913; rs6639811; rs3923341; rs17268974; rs5934937)] of STS gene; rs7562326-SRD5A2 and rs1877031-STARD3 were associated with penoscrotal-hypospadias. On aggregate analysis with p < 0.001, we identified homozygous-loss of Ch7:q34 (PRSS3P2, PRSS2). On validation in previously CNV-characterized and new (32 hypospadias cases), we identified PRSS3P2-loss in most of the grade 3 and 4 hypospadias. Hence, Grade 1 and 2 (coronal and granular) show no-PRSS3P2-loss and no-association with SNPs in STS; SRD5A2; STARD3-gene but Grade 3 and 4 (Penile and Penoscrotal) show PRSS3P2-loss accompanied with the association of SNPs in STS; SRD5A2; STARD3.

CONCLUSIONS

Hence, homozygous-loss of PRSS3P2 accompanied with the association of STS; SRD5A2; STARD3 may link to the severity of the disease.