Randomized controlled trial to evaluate the rate of successful neonatal endotracheal intubation performed with a stylet versus without a stylet

INTRODUCTION

Neonates in intensive care units often require endotracheal intubation and mechanical ventilation. During this intubation procedure, a stylet is frequently used along with an endotracheal tube. Despite the widespread use of a stylet, it is still not known whether its use increases the intubation success rate. This study examined the association between stylet use and the intubation success rate in surgical neonates.

METHODOLOGY

This single-center study was conducted between December 2021 and December 2022 in the Neonatal surgical intensive care unit of a tertiary care center in Northern India. Infants were randomized to have the endotracheal intubation procedure performed using either an endotracheal tube alone or with a stylet. The primary outcome of the study was to assess the successful first-attempt neonatal endotracheal intubation rate with and without using a stylet. Apart from the rate of successful intubation, the duration of the intubation and complications during the intubation procedures as measured by bradycardia, desaturation episodes, and local trauma were also recorded. Both groups were thus compared on above mentioned outcomes.

RESULTS

The total number of neonates enrolled were 200, and the overall success rate (81% in the stylet group vs. 73% in the non-stylet group) was not statistically significant. Intubation time was however less, when stylet was used (16.2 ± 4.3 vs. 17.5 ± 5.0 s, p = .046). When the endotracheal tube size was 3 or less, the success rate was substantially higher in the stylet group (80%) than the non-stylet group (63%), p = .03. No statistical difference was recorded for bleeding and local trauma, though the esophageal intubation rate was higher when intubation was attempted without the stylet.

CONCLUSION

Endotracheal intubation using a stylet did not significantly improve the success rate of the procedure, however, intubation time significantly varied between groups and in different conditions. The rigidity and curvature provided by the stylet may facilitate the process of intubation when smaller caliber endotracheal tubes are used.

Extragonadal Germ Cell Tumor with Hepatic Infiltration in a Child: Aberrant Somatostatin Receptors and the Diagnostic Conundrum

Extragonadal germ cell tumors (GCTs) are challenging to diagnose. We present a case of suprarenal GCT, with hepatic infiltration where differential diagnosis included neuroblastoma and hepatoblastoma. The positive positron emission tomography scan further obfuscated the situation. The diagnosis was clinched by fine-needle aspiration cytology and cell block immunohistochemistry.

Penile Epithelioid Hemangioendothelioma in a Child

An 8-year-old boy initially thought to have a penile arteriovenous malformation was later diagnosed with a rare vascular sarcoma, epithelioid hemangioendothelioma (EHE). Despite challenges in diagnosis, he underwent supraselective angioembolization and partial penectomy for oncological clearance. EHE, a low-grade malignancy, requires prompt identification and treatment due to potential systemic involvement.

Tubularized incised plate urethroplasty and grafted tubularized incised plate urethroplasty: systematic review, meta-analysis and trial sequential analysis

Background

Hypospadias is one of the most common genital birth defects. There are around 300 various techniques available for the repair of hypospadias. This study aims to compare the reported outcomes of Tubularized incised plate urethroplasty (TIP) and Grafted TIP (GTIP) repair in children undergoing primary hypospadias repair.

Methods

This meta-analysisadhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and we framed our research question using the population, intervention, control and outcomes format. We conducted comprehensive electronic searches across various databases, employing a Boolean search strategy with predefined search terms. Only randomized controlled trials (RCTs) were included for quantitative analysis.

Results

Totally, 10 RCTs met our inclusion criteria for quantitative analysis. The results indicated that urethrocutaneous fistula, glans dehiscence, and stricture rates were comparable between the two groups. The incidence of meatal stenosis was found to be significantly lower in the GTIP group with a relative risk (RR) of 0.32 (95% confidence interval (CI) 0.15 to 0.67).

Conclusion

The coucomes UCF, glans dehiscence, and stricture rates were comparable between the two groups. Notably, the incidence of meatal stenosis was found to be significantly lower in the grafted TIP group. In terms of operative time, our quantitative synthesis demonstrated that the TIP group had a shorter operative time than the GTIP group with significant heterogeneity.

Differential invasiveness & expression of antimicrobial peptides in Shigella serotypes

Background & objectives

The study of Shigella pathogenesis at present is severely hampered by the lack of a relevant animal model that replicates human bacillary dysentery. Different Shigella serogroups cause varying severity of clinical illness. Ex vivo colonization of Shigella flexneri, S. dysenteriae and S. sonnei were characterized in human paediatric colonic pinch biopsies in the in vitro organ culture (IVOC) model to study the invasiveness of Shigella by gentamicin protection assay (GPA). Furthermore, the expression of antimicrobial peptides (AMPs) in response to different serotypes of Shigella was also studied in IVOC model.

Methods

IVOC explants were inoculated with 109 colony forming units of different serotypes of Shigella and recovery of bacteria studied. Histopathological analysis was carried out to study inflammatory immune responses. GPA was done to elucidate the invasiveness of different serotypes of Shigella. Secretions of AMPs were measured by enzyme-linked immunosorbent assay (ELISA). Western blotting was performed to check the expression of AMPs and nuclear factor kappa B in IVOC explants.

Results

After 24 h post-infection, the colon biopsies showed intense inflammatory reaction. In both IVOC and GPA, S. dysenteriae 1 was the most invasive as compared to S. flexneri and S. sonnei. S. sonnei was the least invasive. ELISA demonstrated that S. sonnei dampened the HBD (human β-defensin)-2 responses whereas there was augmentation by S. dysenteriae and there was a modest but non-significant increase by S. flexneri. A modest increase in HBD-3 by S. sonnei and S. flexneri was observed but was not found to be significant. However, western blotting data showed upregulation of all AMPs by all serotypes. Western blotting is more sensitive than ELISA.

Interpretation & conclusions

In the present study, differences in invasiveness and AMP production induced by different serotypes of Shigella were found. Human intestinal IVOC represents a model system to investigate early interaction between pathogenic bacteria and the human gut.

A Randomized Control Trial to Evaluate the Effect of Local Instillation of Mitomycin-C at the Porta after Kasai Portoenterostomy in Patients of Biliary Atresia

Background

Kasai portoenterostomy (KPE) is the initial treatment for biliary atresia (BA). Even after initial jaundice clearance, a significant number of children presented with the reappearance of symptoms due to ongoing fibrosis involving porta and intrahepatic ducts. Mitomycin-C (MMC) is an antifibrotic agent, and the study hypothesized that local application of MMC at porta can decrease fibrosis, which can improve jaundice clearance and lead to better native liver survival (NLS).

Materials and Methods

This prospective randomized control trial included children with BA, who were allocated to groups A or B. The patients in both groups underwent standard KPE; in addition, a 5 French infant feeding tube (IFT) was placed near the porta through the Roux limb in Group B children. During the postoperative period, MMC was locally instilled over the porta in Group B children through IFT. Postoperative jaundice clearance and NLS were assessed and compared.

Results

A total of 27 children were enrolled in the study, 16 in Group A and 11 in Group B. Both groups were comparable preoperatively. Although the NLS was not statistically significant in Group B, the survival was quite higher, that was 91%, 81%, and 73% at 6 months, 1 year, and 2 years, respectively, compared to 63%, 50%, and 38% in Group A.

Conclusion

Children in Group B clinically showed an early jaundice clearance and a better trend of serial bilirubin levels as well as longer NLS than Group A, but it was not statistically significant. The procedure was technically easy, and no complication was encountered related to surgical technique or MMC instillation.

Colonic Atresia Associated with Biliary Atresia

Colonic atresia (CA) is an uncommon type of intestinal atresia commonly associated with other anomalies, while biliary atresia (BA) is also rare but usually an isolated anomaly. The pathogenesis for either of the anomalies is unclear. The co-occurrence of both pathologies has not been mentioned in the literature. We here discuss the management of CA with BA and the review of pertinent literature.

Factors affecting stress levels in parents of surgical neonates: A prospective observational study

BACKGROUND

There is a paucity of research focusing on the stress levels in parents of newborns undergoing surgery. Resource challenged systems have to deal with overcrowding, a shortage of workforce along with demographic and socioeconomic issues like delayed presentations and out of pocket expenses. The primary objective of this study was to understand the factors associated with stress in the parents of these congenitally malformed neonates.

METHODOLOGY

This was a prospective cohort study, which was conducted in a neonatal surgical ICU of a tertiary care teaching hospital. Factors affecting stress levels in parents of surgical neonates were studied in 100 participants. A multi-dimensional questionnaire - The PSS: NICU score was utilized in the study. The parents were interviewed on Day 3-5 after surgery.

RESULT

59% of the respondents were fathers. The majority of the parents were in the age bracket of 24 to 35 years. The mean scores for the subscales sights and sounds, looks and behavior and alteration in the parental role were 3.24±0.8, 3.52±0.63, 3.55±0.8 and 2.8 ± 0.9 respectively. The highest level of stress was found in the domains of alteration of parental role and infant appearance and behavior. Comparisons showed significantly higher maternal scores in all the domains. Overall stress scores were highest for abdominal wall defects.

CONCLUSION

Parents of neonates undergoing surgery suffer from significant stress levels and appropriate counseling targeted towards specific stressors is required to allay this important parental issue.

Congenital Malignant Rhabdoid Tumor of Neck

Malignant rhabdoid tumors (MRT) are uncommon, highly aggressive tumors arising usually from the central nervous system and kidneys. Nonrenal and noncentral nervous systems MRT are rare in neonates. To the best of our knowledge, only five cases of congenital MRT of neck have been described till date. We present a rare case of congenital MRT of the neck in a neonate along with review of literature.

Transcutaneous Electrical Nerve Stimulation in Management of Neurogenic bladder Secondary to Spina Bifida

AIMS

To assess the role of transcutaneous electrical nerve stimulation (TENS), alone or in combination with anticholinergic drugs in the management of neurogenic bladder (NB) in spina bifida (SB).

MATERIALS AND METHODS

All the consecutive patients, visiting outpatient clinic between July 2017 and December 2018, who were toilet trained and at least 1 year post-SB surgery with clinical and/or urodynamic evidence of NB, were included in the study. Out of 65 patients, 40 fulfilled the inclusion criteria and were randomised into: group A (ten patients, placebo TENS with anticholinergic agents), Group B (14 patients, TENS therapy with placebo medications) and Group C (16 patients, TENS therapy with anticholinergic medications). All the patients maintained a voiding diary and underwent assessment before and after the intervention. The study was approved by the Institutional Ethics Committee.

RESULTS

The presenting symptoms were urinary incontinence (100%), increased frequency (45%), straining during micturition (22.5%), urgency (22.5%), and hesitancy (30%). The demographic parameters were comparable in all the groups. After group specific intervention, the wet episodes/day significantly improved in Group C (P = 0.001). Similarly, the mean wet days/week also improved significantly in Group C (6.5-4.37 days/week, P = 0.01). Out of 40 patients, 29 had abnormal findings on ultrasonography before the start of the therapy. Following intervention, only two patients in Group C showed normalization of findings. On Urodynamic studies, detrusor pressure (Pdet max) decreased in all the groups; however, the patients in Group C, showed the maximum reduction (56.6 ± 11-30 ± 6.7 cm H₂O). Similarly compliance (9.4 to 14.5 cm H₂O, P = 0.02) and bladder capacity (68%-88% of EBC, P = 0.001) also improved significantly in Group C as compared to other 2 groups Overall, nine patients (Group A, B, and C = 1, 3, and five patients, respectively) showed detrusor instability, while post therapy, only one patient (Group B) had unstable bladder. Maximum decrease in postvoid residue (mean) was also observed in Group C (77-41 ml, P = 0.01).

CONCLUSIONS

The application of TENS in NB secondary to SB is effective and its application led to improvement in symptoms, decrease in the wet episodes/day, maximum detrusor pressure, instability, bladder compliance, and capacity. TENS therapy in combination with anticholinergic agents had a better outcome as compared to monotherapy with either of the two modalities.

Comparative Assessment of Autogenous Cancellous Bone Graft and Bovine-Derived Demineralized Bone Matrix for Secondary Alveolar Bone Grafting in Patients With Unilateral Cleft Lip and Palate

OBJECTIVE

Comparison between bovine-derived demineralized bone matrix (DMBM) and iliac crest graft over long term for secondary alveolar bone grafting (SABG) in patients with unilateral cleft lip and palate (UCLP) in terms of radiological and clinical outcomes.

DESIGN

Prospective, randomized, parallel groups, double-blind, controlled trial.

SETTING

Unit of Oral and Maxillofacial Surgery, Oral Health Science Centre, Postgraduate Institute of Medical Education & Research, Chandigarh.

PARTICIPANTS

Twenty patients with UCLP.

INTERVENTIONS

Patients were allocated into group I (Iliac crest bone graft) and group II (DMBM) for SABG. Outcomes were assessed at 2 weeks, 6 months, and then after mean follow-up period of 63 months.

OUTCOMES MEASURES

Volumetric analysis of the grafted bone in the alveolar cleft site was done through cone beam computed tomography using Cavalieri principle and modified assessment tool. Clinical assessment was performed in terms of pain, swelling, duration of hospital stay, cost of surgery, alar base symmetry, and donor site morbidity associated with iliac crest harvesting.

RESULTS

Volumetric analysis through Cavalieri principle revealed comparable bone uptake at follow-up of 6 months between group I (70%) and group II (69%). Modified assessment tool showed no significant difference between horizontal and vertical bone scores over short- and long-term follow-up. In group II, there was higher cost of surgery, but no donor site morbidity unlike group I.

CONCLUSIONS

Demineralized bone matrix proved analogous to iliac crest bone graft as per volumetric analysis over shorter period. However, although statistically insignificant, net bone volume achieved was lower than the iliac crest graft at longer follow-up.

Pen Cap Aspirations: Maneuvering for Successful Extraction

Aim of this study was to analyze the therapeutic approach with enhanced success of bronchoscopy. We retrospectively analyzed the results of bronchoscopic extraction of pen cap aspirations in our unit from 2000 to 2014. Out of 239 bronchoscopies performed for foreign bodies in airways, there were 8 cases of pen cap aspirations. All 8 were males and age ranged from 5 to 11 years. Seven cases had definitive history, while one patient had a history of chronic respiratory ailment. The foreign bodies were lodged in right and left bronchi in four cases each and seven had their open-end toward the proximal airways. Bronchoscopic extraction was successful in seven patients. The maneuver of rotating the optical forceps by 90 degrees so as to align the pen cap with the vocal cords resulted in success in all the cases. One patient underwent thoracotomy and bronchotomy for removal. Pen cap aspirations occur in school-going children. Aligning the optical forceps with vocal cords during extraction avoids the need for tracheostomy or thoracotomy.

Consensus on the Management of Posterior Urethral Valves from Antenatal Period to Puberty

The need for successful management of posterior urethral valves always captivates the minds of pediatric surgeons. Its success, however, depends on several factors ranging from prenatal preservation of upper tracts to postoperative pharmacological compliance. Regardless of measures available, some cases do not respond and progress to end stage. The management depends on several issues ranging from age and severity at presentation to long-term follow-up and prevention of secondary renal damage and managing valve bladder syndrome. This article is based on a consensus to the set of questionnaires, prepared by research section of Indian Association of Paediatric Surgeons and discussed by experienced pediatric surgeons based in different institutions in the country. Standard operating procedures for conducting a voiding cystourethrogram and cystoscopy were formulated. Age-wise contrast dosage was calculated for ready reference. Current evidence from literature was also reviewed and included to complete the topic.

Endoscopic Management of Vesicoureteral Reflux and Long-term Follow-up

OBJECTIVE

To report our experience with endoscopic management of vesicoureteral reflux (VUR) by injection of a tissue bulking substance - Dextranomer/ hyaluronic acid co-polymer at vesicoureteric junction.

DESIGN

Retrospective analyses of case records.

SETTING

Pediatric Surgery department in a tertiary care government Institute.

PARTICIPANTS

500 children (767 renal units) consecutively referred to the out-patient department with vesicoureteral reflux noted on micturating cysto-urethrogram (MCU) over a period of 13 years (2004-2016).

INTERVENTION

Preoperative VUR grading and renal scars on radionuclide scans were documented. Dextranomer hyaluronic acid copolymer was injected through a cystoscope at the vesicoureteral junction as a day care procedure under short anesthesia. Patients were followed (average duration 27.3 mo) with clinical assessment, periodic urine cultures and renal scans.

MAIN OUTCOME MEASURE

Cessation of VUR and symptomatic relief / clinical success postoperatively at 3 months.

RESULTS

Complete symptomatic relief was obtained in 482 (96.4%) patients. In 681 units where MCU was available, 614 (90%) units showed resolution of VUR.

CONCLUSIONS

Endoscopic injection of tissue bulking substances at vesicoureteric junction to stop VUR seems to be an effective intervention.

Omphalocele and epigastric heteropagus: implications and treatment

In heteropagus twins, the parasitic twin is incompletely formed which is attached to the autosite. We report a case of epigastric heteropagus twins with omphalocele. The parasite had two lower limbs, a rudimentary upper limb, genitalia with developed phallus and scrotum but absent testis. An omphalocele was present just below the attachment of the parasitic twin. A single kidney with ureter and a bladder filled with urine seen during exploration. The parasite bowel was attached to a sleeve of liver tissue from the autosite within the omphalocele sac and this connection was also the main source of its blood supply. Less than 20 cases of omphalocele with EH have been reported previously. The thin sac with underlying adherent bowel led us to go ahead with surgery in the neonatal period for both, excision of epigastric heteropagus and omphalocele repair. The rectus sheath around the omphalocele sac helped in the final wound closure.

Erb's palsy complicating a case of annular pancreas

We report an unusual presentation of annular pancreas with pneumoperitoneum in a newborn with an associated left sided Erb's palsy. The neurological deficit caused considerable confusion in the diagnosis and unexpected complications after surgery. We highlight the importance of clinical examination and the complications that an Erb's palsy can cause. This unusual triad of Erb's palsy, eventration of diaphragm and annular pancreas has hitherto not been described in literature.

Blunt Trauma Pancreas in Children: Is Non-Operative Management Appropriate for All Grades?

PURPOSE

Blunt trauma of pancreas in children is uncommon and its management varies from observational to early operative intervention. We analysed the feasibility and outcome of non-operative management in all grades of paediatric pancreatic injuries.

METHODS

A total of 15 patients of pancreatic trauma seen in a Paediatric Surgery Unit were retrospectively analyzed.

RESULTS

Age of the patients ranged from 3-11 years (mean, 7.7 years). The mode of injury was local trauma in 9 children. Only 3 patients had associated injuries and all were haemodynamically stable. Serum amylase levels were raised in 12 patients at admission which ranged from 400-1,000 IU. Computed tomography scan made a correct diagnosis in 14 patients. Grades of the injury varied from grade I-V (1, 3, 6, 4, 1 patients respectively). Fourteen patients were managed conservatively. One patient underwent laparotomy for suspected superior mesenteric hematoma. The average duration of enteral feeds was 3.7 days and of hospital stay was 9.4 days. Six patients formed pancreatic pseudocysts; two were managed conservatively while the other four underwent cystogastrostomy. The patients were followed up for a period of 1-12 years. All remained asymptomatic and none had exocrine or endocrine deficiencies.

CONCLUSION

Non-operative treatment for isolated blunt trauma of pancreas in children may be safely followed for all the grades of injury; if associated injuries requiring surgical intervention are ruled out with a good quality imaging and the patients are hemodynamically stable. It did not increase the hospital stay and morbidity and avoided operative intervention on acutely injured pancreas.

Is urodynamic evaluation a must in all operated cases of open neural tube defects

BACKGROUND

Spina bifida is a common cause of pediatric neurogenic bladder. It causes renal failure in almost 100% of patients if the associated detrusor sphincter dyssynergia (DSD) is inadequately managed. Detrusor instability and high detrusor pressures (Figure) have been implicated as the major factors predictive of renal damage in these patients. Urodynamic studies provide early identification of "at risk" kidneys so that appropriate intervention can be made. However, the role in post-operative patients of spina bifida who have no clinical manifestations remains unclear.

OBJECTIVE

To study the bladder dynamics in asymptomatic post-operative patients of spina bifida and to determine whether routine urodynamic study is justifiable.

MATERIAL AND METHODS

Urodynamics was performed on 15 operated patients of spina bifida who did not have any neurological deficit and were asymptomatic.

RESULTS

The mean age of the patients was 4.97 years. None of the patients had any urological complaints with their ultrasonography being normal. None had scars on nuclear scan. Of the 15 patients, 12 (80%) had abnormal findings on urodynamic assessment. Three patients (20%) had detrusor pressures greater than 40 cm of H₂O. One patient had significant residual urine and detrusor instability.

DISCUSSION

The use of urodynamic studies in asymptomatic patients of spina bifida remains controversial, with one school of thought advocating early invasive urodynamic testing. In contrast, some favor noninvasive sonological monitoring, reserving invasive tests only for patients with renal tract dilatation. In our subset of patients none had renal tract dilatation but three patients (20%) had "at risk" bladders. These patients would benefit from early intervention aimed at renal preservation. The study is limited by a small sample size because of the relative rarity of the patient profile included. A further multicenter study with a case-control design could conclusively indicate the role of urodynamic testing in these patients.

CONCLUSION

Patients of spina bifida, even when asymptomatic, have a high incidence of unsafe bladders. Early identification and appropriate measures can protect kidneys from long-term damage, hence urodynamic profiling is mandatory for identification of potentially high-risk bladders.

Anorectal Malformations in Males: Pros and Cons of Neonatal versus Staged Reconstruction for High and Intermediate Varieties

BACKGROUND

High and intermediate types of anorectal malformations (ARMs) in male neonates may be managed either by primary neonatal reconstruction without colostomy cover or by traditional policy of staged reconstruction after neonatal colostomy. Posterior sagittal anorectoplasty (PSARP) is the current widely practiced reconstructive technique with varied results.

AIM

To assess our functional results of PSARP without colostomy in male neonates with high and intermediate ARMs compared to 3-stage (neonatal colostomy - PSARP - colostomy closure) methodology in a high volume tertiary care institution of a developing country.

PATIENTS AND METHODS

The number of colostomies performed for male high/intermediate anomalies and the number of babies who completed 3-stage reconstruction during a 10-year period is analyzed. The outcome of primary neonatal PSARPs during the same period was analyzed. Eighty primary PSARPs were compared to 81 staged reconstructions for outcome analysis, using Kelly score.

RESULTS

A total of 453 colostomies were performed, but only 253 of them completed all stages of reconstruction (52%). Good continence was achieved in 45% of cases of primary PSARP versus 26% in 3-staged surgery.

CONCLUSIONS

Primary PSARP in neonatal period without colostomy is a good option for high and intermediate ARMs in males if the treating surgeon is reasonably skilled in neonatal surgery and PSARP procedures.

Role of glycopyrrolate in healing of anastomotic dehiscence after primary repair of esophageal atresia in a low resource setting-A randomized controlled study

AIMS

To investigate the role of glycopyrrolate in decreasing oral secretions in patients of esophageal atresia (EA) with anastomotic leak and evaluate its effect on healing of anastomotic dehiscence.

METHODS

The study comprised consecutive neonates of esophageal atresia, who had undergone primary surgery and developed anastomotic leak. The patients were randomized into two groups with the observer blinded to the group. The patients in the treatment group were administered glycopyrrolate in the dose of 8 μg/kg 8 hourly, whereas placebo group patients were injected normal saline only. Neonates, in both the groups, were managed conservatively based on the clinical and radiological parameters. The end points of the study were either resolution or progression of the leak. The study was approved by the institute ethics committee.

RESULTS

There were 21 patients each in two groups with comparable preoperative characteristics. All the cases had anastomotic leaks clinically detectable in the chest tube. Saliva alone constituted the leak material in 18 cases in the treatment group and 10 in the placebo group. Cumulative total of mean chest tube output per patient for all patients in the treatment group was 124.15ml as compared to 370.27ml in the placebo group (p=0.001). Anastomotic leak stopped in 16 cases (76%) in the treatment group, as compared to 6 cases (29%) in the placebo group (p=0.004). The postoperative ventilation was required in 8 cases (8/21, 38%) in the treatment group and 17 cases (17/21, 81%) in the placebo group (p=0.010). In the treatment group, the diversion procedures were carried out in 2 out of 21 cases (10%), whereas in the placebo group, 52% of the patients (11/21) required such an intervention (p=0.003). At the time of discharge, the oral feeds could be started in 15 cases (15/21, 71%) in the treatment group, as compared to 3 (3/21, 14%) in the placebo group (p=0.0004).

CONCLUSIONS

Administration of glycopyrrolate in patients of anastomotic leak after primary repair of esophageal atresia resulted in reduced oral secretions, which helped in healing of the anastomotic dehiscence in a significant number of patients.

Hyperchloremic Metabolic Acidosis Following Total Gut Irrigation with Normal Saline in Pediatric Patients: A Rare Occurrence

Use of 0.9% sodium chloride for total gut irrigation (TGI) through nasogastric route is an effective method of bowel preparation in children undergoing colorectal surgeries. TGI with normal saline (NS) can result in nausea, vomiting, abdominal distension, and mild electrolyte imbalance; however, hyperchloremic metabolic acidosis has not been documented. We report two cases of hyperchloremic metabolic acidosis in children posted for colorectal surgery following TGI with NS who were successfully managed.

Cloacal dysgenesis sequence with bilateral renal agenesis and normal pulmonary development in twin pregnancy

Cloacal dysgenesis sequence (CDS) is a rare congenital anomaly. It is characterised by a smooth perineum with absence of anal and genitourinary orifices, with reported incidence of 1:50,000-250,000 births. Association with bilateral renal agenesis is still rarer and resultant severe oligohydramnios is associated with pulmonary hypoplasia. Only a few cases of CDS with bilateral renal agenesis have been reported in the English language literature, with associated pulmonary hypoplasia as a default phenomenon. We report a case of CDS and bilateral renal agenesis without associated pulmonary hypoplasia in a twin pregnancy, which, to the best of our knowledge, is the second reported case of this amalgamation.

Emergent repair of bronchial transection: both right and left main bronchial lung ventilation at surgery makes it easy for all

Maintaining adequate gas exchange is crucial during surgical repair of tracheobronchial injuries in children and reflects the skills of the anaesthetist and the surgeon. We present a 7-year-old girl who underwent urgent repair of the bronchial transection and novel use of ventilation of the transected lung helped accomplish the repair successfully.

Long Upper Pouch in Esophageal Atresia: A Rare Variant

The earliest clinical sign of esophageal atresia (EA) is excessive salivation and the diagnosis is made by failure to pass an infant feeding tube (IFT) into the stomach. The diagnostic errors may occur due to presence of an unusually long upper pouch, when the IFT seems to pass into the stomach. We describe one such case and review the relevant literature.

Long Upper Pouch in Esophageal Atresia: A Rare Variant

The earliest clinical sign of esophageal atresia (EA) is excessive salivation and the diagnosis is made by failure to pass an infant feeding tube (IFT) into the stomach. The diagnostic errors may occur due to presence of an unusually long upper pouch, when the IFT seems to pass into the stomach. We describe one such case and review the relevant literature.

Esophageal perforations due to foreign body impaction in children

AIMS

The treatment of perforating esophageal foreign body impaction (FBI) is complex and unclear. We present the outcome of surgical treatment of esophageal perforations due to FBI in children along with a management algorithm.

METHODS

During a period of 7 years, 7 cases of esophageal perforations due to foreign body (FB) ingestion were referred to our unit. We analyzed the FB types, lodging duration and location, complications, and the surgical approaches.

RESULTS

There were 4 male and 3 female patients. Mean age was 28 months (5 months-6 years). Six patients had metal FBs of variable shapes and 1 had glass marble. Three patients had witnessed history of FB ingestion. Duration of ingestion was variable and unknown in half of the patients. The site of impaction was cervical (1) and thoracic (5) esophagus. One patient had a marble as FB in the superior mediastinum. One patient manifested with features of perforation after removal of the impacted FB and 5 patients presented with perforations. Two patients presented with subcutaneous emphysema. One patient had trachea-esophageal fistula (TEF) after disc battery ingestion. Rigid esophagoscopy failed in 4 out of 6 patients. Five patients underwent thoracotomy, and repair with a pleural patch reinforcement. One patient had lateral esophagotomy in the cervical esophagus for removal of the impacted FB. Mediastinal FB was removed without opening the esophagus. All the patients were discharged uneventfully.

CONCLUSIONS

Esophageal perforation following FBI is rare and requires prompt treatment. Surgical treatment tailored to the needs of individual patients is associated with a successful outcome and decreased morbidity.

Factors affecting quality of life in early childhood in patients with congenital hydrocephalus

BACKGROUND

Predicting the outcome of congenital hydrocephalus in early infancy and childhood is difficult. Various consequences of hydrocephalus like ophthalmic, audiometric, musculoskeletal, and the developmental abnormalities play a complex role. We analyzed the quality of life of these patients in early life.

METHODS

A prospective multispecialty assessment of the patients with congenital hydrocephalus, who had undergone ventriculoperitoneal shunt in the Pediatric Surgery unit of a tertiary care hospital, was carried out and analyzed.

RESULTS

There were 24 boys and 6 girls. Eighty-three percent were operated before the age of 3 months. Mean age at follow up was 6 years (3-9 years). Shunt complications were seen in 53% (16) of the patients, out of which 68.75% had shunt blocks. In 70% (21) of the patients, the ventricle to hemisphere ratio (VHR) was between 51 and 70%, 20% (6) had a VHR of more than 70% and only 3 patients had a VHR between 40-50%. Audiological and ophthalmic problems were seen in 20 and 66% of the children, respectively. Musculoskeletal abnormalities were present in 36% of the patients. Developmental profile showed 44% being normal, 30% retarded, and 26% were borderline cases. The schooling had started in 56.6%, out of which only one child went to a special school.

CONCLUSIONS

A multitude of problems associated with congenital hydrocephalus should be diligently diagnosed, aggressively followed and intervened with in the early years of life. Preschool management well before the peer interaction should optimize the social integration and improve the quality of life in these patients.

A randomized study of surgical site infiltration with bupivacaine or ketamine for pain relief in children following cleft palate repair

BACKGROUND

Wound infiltration with ketamine reduces postoperative pain after tonsillectomy by NMDA receptor blockade and local anesthetic effect.

OBJECTIVES

To evaluate the postoperative analgesia after surgical site infiltration with bupivacaine or ketamine in children undergoing cleft palate surgery.

MATERIALS AND METHODS

After institutional ethics committee approval and parental consent, 50 ASA-1 children of age 1-6 years undergoing palatoplasty were included in this prospective randomized double-blind study. A standardized technique of general anesthesia was used. The surgical site was infiltrated with either 2 mg·kg(-1) of bupivacaine (Group B) or 0.5 mg·kg(-1) of ketamine (Group K). Pain (Children Hospital Eastern Ontario Pain Score), sedation, dysphagia, nausea, vomiting, and sleep pattern were assessed postoperatively up to 24 h.

RESULTS

CHEOPS scores were similar in both the groups up to 12 h but were lower with ketamine compared with bupivacaine at 24 h postoperatively (P = 0.01). Fewer children required rescue analgesics in Group K (28%) than in Group B (64%; P < 0.01). The time to first rescue analgesic and the amount of analgesics used in 24 h were similar in the two groups. Fewer children suffered from dysphagia in Group K (52%) than in Group B (88%; P < 0.01). More children in Group B had disturbed sleep than in Group K at 6 (88% vs 56%; P = 0.012) and 12 h (60% vs 24%; P = 0.01) postoperatively. None of the children had deep sedation, desaturation or respiratory depression.

CONCLUSION

Surgical site infiltration with either bupivacaine or ketamine provides adequate analgesia and is devoid of major side effects. Ketamine is superior to bupivacaine in terms of requirement of rescue analgesic, peaceful sleep pattern and early resumption of feeding.

Vesicoureteral reflux: Endoscopic therapy and impact on health related quality of life

Aim:

To evaluate the health related quality of life (HRQOL) after endoscopic injection treatment for vesico ureteral reflux (VUR) in children.

Materials and Methods:

Fifty four children received treatment and were prospectively evaluated for their quality of life scores, according to resolution of reflux on cystograms and status of renal scars.

Results:

Of the 81 refluxing units, 72 (89%) had resolution of reflux whereas 9 (11%) did not resolve. The total average QOL was higher for the patients in the resolved group as compared to the non resolved group. Comparison of pre and post procedure renal DMSA scans in 44 patients showed status quo in 26, regression of scars in six, progression in two and formation of new scars in 6. The total increase in HRQOL was highest in regression group (67.91), and lowest in progression group (36.45).

Conclusions:

Successful endoscopic treatment of VUR is associated with improved quality of life, as indicated by higher HRQOL scores in the resolved group.

Esophageal atresia and tracheoesophageal fistula with unilateral pulmonary agenesis - hypoplasia

Association of unilateral severe pulmonary hypoplasia or agenesis and esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is an exceedingly rare and highly lethal combination. We report a case of full term male baby who had EA with TEF and right lung hypoplasia, managed at our centre. He is alive and doing well at 10 years of age.

Esophageal Atresia and Tracheoesophageal Fistula with Unilateral Pulmonary Agenesis - Hypoplasia

Association of unilateral severe pulmonary hypoplasia or agenesis and esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is an exceedingly rare and highly lethal combination. We report a case of full term male baby who had EA with TEF and right lung hypoplasia, managed at our centre. He is alive and doing well at 10 years of age.

Quality of life of very young spina bifida patients after initial surgical treatment

OBJECTIVE

The objectives of this study were to assess the quality of life (QOL) of operated patients with spina bifida (SB) in their initial years and to elucidate the factors affecting the QOL and the timing of proposed interventions.

PATIENTS AND METHODS

We studied 18 patients operated on for SB, aging 3 years or more at the time of assessment. The quality of life score was calculated for all the patients by the parental-administered questionnaire method. The impact of all these factors on the social and school lives of these patients was studied.

RESULTS

Eleven patients were having neurogenic bladder. Thirteen patients were having stool problems which ranged from mild to severe constipation and soiling. Five patients were having lower limb deformities interfering with normal ambulation. Ten patients were able to walk on their own without any help, four patients were using either crutches or help of the caregiver for ambulation while the remaining four patients were non-ambulatory. Twelve patients were attending school. The calculated QOL scores ranged from 2 to 15. The Barthel Index (BI) ranged from 15 to 100. The QOL questionnaire score and BI were showing significant positive correlation.

CONCLUSIONS

The patients operated on for SB commonly have the neurological sequelae. The QOL score identifies the important problems in the initial years after surgery which can help in initiating and maintaining rehabilitative services in these patients. The treatment of urinary and fecal incontinence very early in life will allow these children to have a normal social and school life.

Transanal Swenson's operation for recto-sigmoid Hirschsprung's disease

BACKGROUND

Transanal Swenson's operation is a relatively new single-stage procedure for Hirschsprung's disease. The results of this procedure at our centre are presented.

PATIENTS AND METHODS

Seventeen patients of recto-sigmoid Hirschsprung's disease underwent single-stage transanal Swenson's procedure. The diagnosis was based on the evidence of a transition zone on barium enema examination. A full thickness incision was made on the rectal wall posteriorly, 0.5 cm above the dentate line. The mobilised segment was resected about 5 cm above the transition zone. Frozen sections were performed whenever the transition zone was not clearly seen intra-operatively. The operation was completed by full thickness colo-anal anastomosis.

RESULTS

There were fourteen male and three female patients. The ages of the patients ranged from two months to eight years (median 14 months). The median hospital stay was four days (range four to seven days). Two patients required additional abdominal mobilisation. The anatomical transition zone as seen intra-operatively correlated with the pathological transition zone in all the cases. Two patients had episodes of post-operative enterocolitis and the other two patients developed stricture of the anastomosis. The follow-up period ranged from six to 45 months (Mean 35.4 months). Post-operative soiling was observed in all the patients and lasted from two to six weeks (Mean 3.4 weeks). There were no injuries to the surrounding structures. No patient had voiding disturbances and post-void residual urine was normal in all the patients. Initial increased frequency of bowel movements had settled to one to three per day.

CONCLUSIONS

Transanal Swenson's pull through not only avoids laparotomy, but also the problems associated with the muscular cuff of transanal endorectal pull-through. The anatomical transition zone can be safely utilised to decide the resection limits. By a meticulous technique of dissection, injury to the surrounding structures can also be avoided.

Esophageal atresia and tracheoesophageal fistula: Effect of pleural cover on anastomotic dehiscence

Background:

A significant number of esophageal atresia and tracheoesophageal fistula patients have long gaps and a high propensity to leak. Anastomotic leak in esophageal atresia is associated with a significant morbidity and mortality.

Aim:

In a prospective randomized trial, we analyzed the risk factors leading to anastomotic dehiscence and studied the effect of pleural wrap as an additional vascular cover around the esophageal anastomosis.

Materials and Methods:

Forty patients were divided into two groups A and B randomly. In 20 patients of group A, pleural wrap was utilized for covering the anastomosis and in 20 patients of group B, no such wrap was utilized.

Results:

Both the groups were comparable regarding age, sex, weight, gap length, tension at anastomosis and the hospital stay. The overall leak rate was 25% (10/40) in both the groups. The leak rate was not significantly different in two groups whenever a gap length was less than 2 cm or more than 3 cm. However, for a gap length of 2–3 cm, the leak rate in group A was 18% (2/11) and in group B was 50% (4/8) (P = 0.05). Thirty percent (3/10) of patients, whose anastomosis was under tension, leaked in group A as compared to 75% (6/8) in group B patients (P = 0.001).

Conclusions:

Use of pleural wrap was associated with less anastomotic dehiscence in patients with moderate gap esophageal atresia (2–3 cm) especially when the anastomosis was under tension.

Spontaneous intestinal perforation in neonates: is surgery always indicated?

The usual accepted mode of treatment of neonates with necrotizing enterocolitis (NEC) and pneumoperitoneum is surgical. However, in a select group of patients conservative treatment is feasible. Pneumoperitoneum without peritonitis is a rare phenomenon which creates a management problem for the treating surgeon. We present two cases of pneumoperitoneum to discuss the non-surgical management of pneumoperitoneum and describe their outcomes.

Covered exstrophy with anorectal malformation and vaginal duplication

Covered exstrophy is a rare variant of the exstrophy-epispadias complex. We report a female newborn with covered exstrophy, absent anal opening and duplication of the introitus and the lower vagina. This rare, previously unreported, combination of anomalies highlights the complexity of the embryological events in the caudal area during separation of the hindgut and allantois.

Association of angiotensin converting enzyme and angiotensin type 2 receptor gene polymorphisms with renal damage in posterior urethral valves

OBJECTIVE

To examine the association with renal damage in patients with posterior urethral valves (PUV) of two renin-angiotensin system gene polymorphisms: angiotensin converting enzyme insertion/deletion (ACE I/D) and angiotensin type 2 receptor (AT2R A1332G), PATIENTS AND METHODS: In 120 patients with PUV, after stabilization, transurethral fulguration or a Blocksom vesicostomy was performed. Records were reviewed for age at diagnosis, biochemical renal function at diagnosis, results of urine cultures, voiding cystourethrograms, radiologic, sonographic and nuclear medicine scan findings, and follow-up data. ACE I/D genotypes were determined by the polymerase chain reaction using allele specific primers.

RESULTS

The frequency of the ACE DD genotype was significantly higher in patients with chronic kidney disease (P=0.02) and renal scarring (P=0.05). These genotypes were also associated with a statistically higher incidence of vesicoureteral reflux, diurnal incontinence, proteinuria and hypertension. A significantly higher frequency of the AT2R GG genotype was found in PUV patients as compared to healthy unrelated control subjects (P=0.001), and in PUV patients with scarring (P=0.02).

CONCLUSION

The ACE DD and AT2R GG genotypes are associated with chronic kidney disease and scarring in PUV patients. The GG genotype incidence is higher among PUV patients compared to the control population, and further studies in this area may help understanding of the genetic basis of PUV.

Bilateral ovarian cysts in a neonate with salt-wasting congenital adrenal hyperplasia

Congenital adrenal hyperplasia is by far the most common cause of ambiguous genitalia. The occurrence of ovarian cysts has not been previously described in the classical salt-wasting form of 21-hydroxylase-deficient congenital adrenal hyperplasia. We report a very rare case of bilateral ovarian cysts in one such neonate.

Etiological spectrum of acute intestinal obstruction

Gastrointestinal obstruction in children may be due to a variety of conditions. 150 cases of acute intestinal obstructions seen over a period of 180 months were reviewed. Intestinal atresia was the comonest cause (34, 22.4%).

The role of audiological diagnostics in children with cleft lip & palate (CLP)

OBJECTIVE

To assess the otologic and audiologic status of patients with cleft lip and palate (CLP) operated in the Department of Pediatric Surgery attached to the Advanced Pediatric Centre, Post Graduate Institute of Medical Education & Research (PGIMER), India. The main idea of carrying out this study was to know the incidence of middle ear pathologies in a group where no complaints have been noticed.

SETTING

Research study was carried in Post Graduate Institute of Medical Education & Research (PGIMER) which is one of the tertiary care institutions in India.

PARTICIPANTS

55 children (Mch: 28; Fch: 27) in the age range of 4-13 years constituted the study group. These children were operated upon by the same surgeon (JKM) during the period 1996-1998 and were attending the speech clinics at PGIMER. None of these children/parents had complained of any ear problem and were taken up for the study to find out the middle ear pathology. The ontological and audiological evaluation was done for all the children.

RESULTS

53 of 110 ears had normal hearing status. None of the ears had severe or profound hearing loss. The air conduction thresholds ranged from 20.2 to 29.63 dB across the frequencies whereas the bone conduction thresholds varied from 7.13 to 12.41 dB. Only 42% of the right (R) ears and 47% of the left (L) ears had a normal tympanic membrane.

CONCLUSION

On the basis of this finding, investigation of the benefits of early and routine follow-up for otologic and audiologic status is warranted. Patients with cleft lip and palate should have an intense and detailed otologic and audiologic follow-up to identify any ME pathology/hearing loss so that timely intervention can be taken.

Mayer-Rokitansky-Kuster-Hauser syndrome with H-type anovestibular fistula

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is characterized by Mullerian duct structures agenesis. Anorectal malformations are uncommonly associated with MRKH syndrome, and among them, rectovestibular fistula and cloacal malformations have been commonly described. H-type of anovestibular fistula associated with MRKH syndrome has not been reported previously. One such case along with its treatment is reported.