Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a model-based cost-effectiveness analysis of a pragmatic, cluster-randomised trial in seven low-income and middle-income countries

BACKGROUND

Surgical site infection (SSI) is a major burden on patients and health systems. This study assessed the cost-effectiveness of routine change of sterile gloves and instruments before abdominal wall closure to prevent SSI.

METHODS

A decision-analytic model was built to estimate average costs and outcomes of changing gloves and instruments before abdominal wall closure compared with current practice. Clinical data were obtained from the ChEETAh trial, a multicentre, cluster-randomised trial in seven low-income and middle-income countries (LMICs), and costs were obtained from a study (KIWI) that assessed costs associated with SSIs in LMICs. Outcomes were measured as the percentage of surgeries resulting in SSIs. Costs were measured from a health-care provider perspective and were reported in 2021 US$. The economic analysis used a partially split single-country costing approach, with pooled outcomes data from all seven countries in the ChEETAh trial, and data for resource use and unit costs from India (KIWI); secondary analyses used resource use and costs from Mexico and Ghana (KIWI).

FINDINGS

In the base case, the average cost of the intervention was $259∙92 compared with $261∙10 for current practice (cost difference -$1∙18, 95% CI -4∙08 to 1∙33). In the intervention group, an estimated 17∙6% of patients had an SSI compared with 19∙7% of patients in the current practice group (absolute risk reduction 2∙10%, 95% CI 2∙07-2∙84). At all cost-effectiveness thresholds assumed ($0 to $14 000), the intervention had a higher likelihood of being cost-effective compared with current practice, indicating that the intervention was cost-effective. Similar results were obtained when the analysis using data from India was repeated using resource use and unit cost data from Mexico and Ghana.

INTERPRETATION

Routine sterile glove and instrument change before abdominal wall closure is effective and the costs are similar to those for current practice. Routine change of gloves and instruments before abdominal wall closure should be rolled out in LMICs.

FUNDING

National Institute for Health and Care Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, and Mölnlycke Healthcare.

Postoperative outcome of neonatal emergency surgeries in a tertiary care institute-A prospective observational study

AIMS

Neonatal surgical mortality continues to be high in developing countries. A better understanding of perioperative events and optimization of causative factors can help in achieving a favorable outcome. The present study was designed to evaluate the perioperative course of surgical neonates and find out potential factors contributing to postoperative mortality.

METHODS

This prospective observational study enrolled neonates, undergoing emergency surgical procedures in a tertiary care institute. Primary outcome was 6 weeks postsurgical mortality. The babies were observed till discharge and subsequently followed up telephonically for 6 weeks after surgery. Multivariable logistic regression analysis of various parameters was performed.

RESULTS

Out of the 324 neonates who met inclusion criteria, 278 could be enrolled. The median age was 4 days. Sixty-two (27.7%) neonates were born before 37 weeks period of gestation (POG), and 94 (41.8%) neonates weighed below 2.5 kg. The most common diagnoses was trachea-esophageal fistula (29.9%) and anorectal malformation (14.3%). The median duration of hospital stay for survivors was 14 days. The in-hospital mortality was 34.8%. Mortality at 6 weeks following surgery was 36.2%. Five independent risk factors identified were POG < 34 weeks, preoperative oxygen therapy, postoperative inotropic support postoperative mechanical ventilation, and postoperative leukopenia. In neonates where invasive ventilation was followed by non-invasive positive pressure ventilation in the postoperative period, risk of postoperative surgical mortality was significantly reduced.

CONCLUSION

Present study identified preterm birth, preoperative oxygen therapy, postoperative positive pressure ventilation, requirement of inotropes, and postoperative leukopenia as independent predictors of 6-week mortality. The possibility of early switch to noninvasive positive pressure ventilation was associated with a reduction in neonatal mortality.

Intralobar sequestration associated with gastric enterogenous cyst: gastric lung!!

Intralobar sequestration (ILS) is a rare anomaly that may manifest as recurrent pneumonia or rarely as haemoptysis. The co-existence of ILS with enterogenous cyst is extremely rare with only a single case reported. We describe a 6-month-old male infant, with haemoptysis. Evaluation revealed a consolidated segment of the left lung with a pseudoaneurysm of the pulmonary artery and spina bifida. Thoracoscopic excision of the lesion revealed ILS. Recurrent haemoptysis led to re-evaluation and thoracotomy for excision of the cyst which contained gastric mucosal content. We report a rare case of concomitant ILS with an enterogenous cyst and review the relevant literature.

Association between intraoperative anatomical variation and histopathological parameters in cases of ureteropelvic junction obstruction in children: A cross-sectional study

Introduction

The intraoperative anatomical findings (IOAF) of all ureteropelvic junction obstruction (UPJO) cases are not identical. Moreover, there is also controversy in the literature regarding histopathological (HP) findings in cases of UPJO. In the present study, we evaluated different IOAF and assessed their association with specific HP parameters.

Materials and Methods

This was a cross-sectional study set-up, which was carried out in a tertiary care centre. Children with UPJO who underwent surgery between 2017 and 2020 were enrolled. The following IOAF were noted: Type of pelvis (extrarenal or intrarenal), insertion of the ureter (high or normal), presence of lower pole crossing vessel (CV), negotiation of UPJ segment with double J stent (3 Fr) and length of internal narrowing (LIN) at UPJ. The resected segment of UPJ was assessed at three levels (pelvis, UPJ and ureter) for various HP parameters including fibrosis, oedema, inflammation and smooth muscle hypertrophy (SMH).

Results

Thirty-nine children were included in the study with a mean age of 31 months. The summary statistics of IOAF were intrarenal pelvis in 5 cases, high insertion of the ureter (HIU) in 9, CV in 6, negotiable UPJ in 23, and 16 cases showed LIN >1 cm. All cases showed SMH at the pelvis region and SMH with fibrosis at the UPJ region. At the pelvis region, there was an association between (1) HIU with oedema and chronic inflammation (CIF), (2) CV with CIF and (3) LIN with CIF and SMH. At the UPJ region, there was an association between (1) CV and negotiable UPJ with less fibrosis and (2) LIN with SMH. At the ureteric end, CV showed an association with less fibrosis and more CIF.

Conclusion

All UPJO cases have some common HP findings. Although, some particular IOAF, i.e., presence of CV, negotiable UPJ, HIU and LIN showed association with specific HP parameters.

Tracheoesophageal Fistula with Bilateral Facial Cleft: A Rare Occurrence

Commissural or lateral facial cleft (macrosomia), classified at Tessier number 7 craniofacial clefts, is a rare congenital anomaly usually associated with deformities of other structures developed from the first and second branchial arches. It affects the esthetics and functional aspect of the oral cavity. Bilateral transverse cleft occurring alone is uncommon and it's with tracheoesophageal fistula (TEF) has not been reported to the best of our knowledge. We report a case of esophageal atresia (EA) and TEF with macrosomia. EA was repaired, and the patient was discharged on full feeds. He is awaiting cleft repair.

Strategies to minimise and monitor biases and imbalances by arm in surgical cluster randomised trials: evidence from ChEETAh, a trial in seven low- and middle-income countries

BACKGROUND

Cluster randomised controlled trials (cRCT) present challenges regarding risks of bias and chance imbalances by arm. This paper reports strategies to minimise and monitor biases and imbalances in the ChEETAh cRCT.

METHODS

ChEETAh was an international cRCT (hospitals as clusters) evaluating whether changing sterile gloves and instruments prior to abdominal wound closure reduces surgical site infection at 30 days postoperative. ChEETAh planned to recruit 12,800 consecutive patients from 64 hospitals in seven low-middle income countries. Eight strategies to minimise and monitor bias were pre-specified: (1) minimum of 4 hospitals per country; (2) pre-randomisation identification of units of exposure (operating theatres, lists, teams or sessions) within clusters; (3) minimisation of randomisation by country and hospital type; (4) site training delivered after randomisation; (5) dedicated 'warm-up week' to train teams; (6) trial specific sticker and patient register to monitor consecutive patient identification; (7) monitoring characteristics of patients and units of exposure; and (8) low-burden outcome-assessment.

RESULTS

This analysis includes 10,686 patients from 70 clusters. The results aligned to the eight strategies were (1) 6 out of 7 countries included ≥ 4 hospitals; (2) 87.1% (61/70) of hospitals maintained their planned operating theatres (82% [27/33] and 92% [34/37] in the intervention and control arms); (3) minimisation maintained balance of key factors in both arms; (4) post-randomisation training was conducted for all hospitals; (5) the 'warm-up week' was conducted at all sites, and feedback used to refine processes; (6) the sticker and trial register were maintained, with an overall inclusion of 98.1% (10,686/10,894) of eligible patients; (7) monitoring allowed swift identification of problems in patient inclusion and key patient characteristics were reported: malignancy (20.3% intervention vs 12.6% control), midline incisions (68.4% vs 58.9%) and elective surgery (52.4% vs 42.6%); and (8) 0.4% (41/9187) of patients refused consent for outcome assessment.

CONCLUSION

cRCTs in surgery have several potential sources of bias that include varying units of exposure and the need for consecutive inclusion of all eligible patients across complex settings. We report a system that monitored and minimised the risks of bias and imbalances by arm, with important lessons for future cRCTs within hospitals.

Profile of 193 pediatric cancer patients managed with radiation therapy: Challenges and lessons learned

Background

Series on radiotherapy (RT) practice in pediatric malignancies are limited in India as only a few centers practice pediatric RT, particularly under anesthesia. We aimed to study the clinical profile of pediatric cancer patients treated with RT and to analyze various challenges in pediatric RT under anesthesia.

Materials and Methods

The data were prospectively maintained in Microsoft Excel spreadsheets. Pediatric cancer patients aged 0-14 years, registered in the RT department between February 1, 2019 and July 30, 2021were analyzed.

Results

A total of 193 pediatric cancer patients (noncentral nervous system) received RT during the said period. Median age at presentation was 5.2 years (range: 9 months to 14 years) with a male-to-female ratio of 1.8:1. The majority of the patients were in the age group of 0-4 years (52.8%) followed by 5-9 years (29.5%) and ≥10 years (17.6%). Most common indications for RT included bone and soft-tissue tumors, retinoblastoma, Wilms tumor, neuroblastoma, and hematological malignancies. One hundred and seventy-nine (92.7%) patients received RT with curative intent, while 14 (7.3%) patients received palliative RT. Thirty (15.5%) patients needed anesthesia for RT. Ten (5.18%) patients required RT interruption due to toxicities with a median gap of 3 days.

Conclusions

RT is challenging yet an important aspect of multidisciplinary care in paediatric cancers. Estimating the burden of pediatric patients in the RT department may help in assessing unmet needs, resource development, and prioritization, which may improve the cure rates.

Epidemiology, Clinical Profile, Intensive Care Needs and Outcome in Children with SARS-CoV-2 Infection Admitted to a Tertiary Hospital During the First and Second Waves of the COVID-19 Pandemic in India

OBJECTIVES

To compare the epidemiological, clinical profile, intensive care needs and outcome of children hospitalized with SARS-CoV-2 infection during the first and second waves of the pandemic.

METHODS

This was a retrospective study of all children between 1 mo and 14 y, admitted to a dedicated COVID-19 hospital (DCH) during the first (1st June to 31st December 2020) and second waves (1st March to 30th June 2021).

RESULTS

Of 217 children, 104 (48%) and 113 (52%) were admitted during the first and second waves respectively. One hundred fifty-two (70%) had incidentally detected SARS-CoV-2 infection, while 65 (30%) had symptomatic COVID-19. Comorbidities were noted in 137 (63%) children. Fifty-nine (27%) and 66 (30%) children required high-dependency unit (HDU) and ICU care respectively. Severity of infection and ICU needs were similar during both waves. High-flow oxygen (n = 5, 2%), noninvasive ventilation [CPAP (n = 34, 16%) and BiPAP (n = 8, 5%)] and invasive ventilation (n = 45, 21%) were respiratory support therapies needed. NIV use was more during the second wave (26% vs. 13%; p = 0.02). The median (IQR) length (days) of DCH stay among survivors was longer during the first wave [8 (6-10) vs. 5.5 (3-8); p = 0.0001].

CONCLUSIONS

Disease severity, associated comorbidities, PICU and organ support need and mortality were similar in the first and second waves of the pandemic. Children admitted during the second wave were younger, had higher proportion of NIV use and shorter length of COVID-19 hospital stay.

Short Bowel Syndrome in neonates and early infancy

Short bowel syndrome (SBS) is the commonest cause of intestinal failure in neonates. SBS results from widespread damage to the small intestine, leading to loss of functional capacity of this organ. This is generally secondary to conditions like necrotizing enterocolitis, gastroschisis, intestinal atresia, and midgut volvulus. The small bowel usually adapts to this damage in due course of time. The clinician's role usually entails the management of parenteral nutrition and the fluid and electrolyte balance to tide over this phase. The management should be initiated as soon as the diagnosis is suspected, especially post-surgical resection of the bowel. This should comprise enteral nutrition, with proactive monitoring and supplementation of electrolytes and micronutrients. Intestinal lengthening procedures like the Serial transverse enteroplasty (STEP), and Longitudinal intestinal lengthening and tailoring (LILT) may be considered in infants, where medical therapy fails to correct the pathology. The intricate nature of the condition warrants a multi-disciplinary approach, involving clinicians, intensivists, and surgeons, which ensures the best neonatal outcomes, in terms of the survival rates in these babies.

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.

Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a pragmatic, cluster-randomised trial in seven low-income and middle-income countries

BACKGROUND

Surgical site infection (SSI) remains the most common complication of surgery around the world. WHO does not make recommendations for changing gloves and instruments before wound closure owing to a lack of evidence. This study aimed to test whether a routine change of gloves and instruments before wound closure reduced abdominal SSI.

METHODS

ChEETAh was a multicentre, cluster randomised trial in seven low-income and middle-income countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, South Africa). Any hospitals (clusters) doing abdominal surgery in participating countries were eligible. Clusters were randomly assigned to current practice (42) versus intervention (39; routine change of gloves and instruments before wound closure for the whole scrub team). Consecutive adults and children undergoing emergency or elective abdominal surgery (excluding caesarean section) for a clean-contaminated, contaminated, or dirty operation within each cluster were identified and included. It was not possible to mask the site investigators, nor the outcome assessors, but patients were masked to the treatment allocation. The primary outcome was SSI within 30 days after surgery (participant-level), assessed by US Centers for Disease Control and Prevention criteria and on the basis of the intention-to-treat principle. The trial has 90% power to detect a minimum reduction in the primary outcome from 16% to 12%, requiring 12 800 participants from at least 64 clusters. The trial was registered with ClinicalTrials.gov, NCT03700749.

FINDINGS

Between June 24, 2020 and March 31, 2022, 81 clusters were randomly assigned, which included a total of 13 301 consecutive patients (7157 to current practice and 6144 to intervention group). Overall, 11 825 (88·9%) of 13 301 patients were adults, 6125 (46·0%) of 13 301 underwent elective surgery, and 8086 (60·8%) of 13 301 underwent surgery that was clean-contaminated or 5215 (39·2%) of 13 301 underwent surgery that was contaminated-dirty. Glove and instrument change took place in 58 (0·8%) of 7157 patients in the current practice group and 6044 (98·3%) of 6144 patients in the intervention group. The SSI rate was 1280 (18·9%) of 6768 in the current practice group versus 931 (16·0%) of 5789 in the intervention group (adjusted risk ratio: 0·87, 95% CI 0·79-0·95; p=0·0032). There was no evidence to suggest heterogeneity of effect across any of the prespecified subgroup analyses. We did not anticipate or collect any specific data on serious adverse events.

INTERPRETATION

This trial showed a robust benefit to routinely changing gloves and instruments before abdominal wound closure. We suggest that it should be widely implemented into surgical practice around the world.

FUNDING

National Institute for Health Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, Mölnlycke Healthcare.

External and internal parasitic conjoined twinning: Diverse presentation and different surgical challenges

BACKGROUND

Parasitic conjoined twin is a rare but well-known entity with unclear embryopathogenesis. Abnormal conjoined twinning can result in an externally attached parasitic twin (PT), an enclosed foetus in foetu, or a mature teratoma. The treatment requires complete excision and reconstruction of local anatomy which is not always straightforward.

MATERIALS AND METHODS

PT cases presenting over 12 years were analysed. Patients with complete data, histopathological diagnosis and follow-up were included in the study. During follow-up, specific complications and related investigations were considered.

RESULTS

A total of five patients at four different sites were identified: two retroperitoneal foetus in foetu and three externally attached PTs which were located in the lumbar region, sacrococcygeal area and on the lower anterior abdominal wall. All patients underwent complete surgical excision. In foetus in foetu cases, the blood supply was directly from the aorta with a short stump while the three externally located ones required meticulous and careful dissection with the reconstruction of local anatomy.

CONCLUSION

Parasitic conjoined twinning can present at different sites and surgical challenges vary accordingly. For surface lesions, reconstruction may be as complicated as excision. Prognosis can be affected by the excellence of anatomical restoration. Long-term follow-up is essential to address problems specific to the site of lesion and method of surgical reconstruction.

Postoperative hyponatremia in neonates with esophageal atresia and tracheoesophageal fistula receiving restricted hypotonic fluids

Background

During the postoperative course following neonatal surgery, several stimuli like respiratory distress, pain, and stress cause the release of the antidiuretic hormone which can induce hyponatremia. This hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH) in neonates can lead to neurologic impairment and in severe cases can cause significant morbidity and mortality. Lung involvement in neonates undergoing TEF makes this subset of patients vulnerable to this entity because most of them are sick and require ventilation in the postoperative period. The incidence of postoperative hyponatremia following neonatal surgery has not been studied vastly. To the best of our knowledge, this is the first prospective study that has analyzed the incidence of postoperative hyponatremia in this vulnerable population.

Methods

Prospective observational study to assess the incidence of postoperative hyponatremia in neonates with esophageal atresia and tracheoesophageal fistula (EA and TEF) receiving restricted hypotonic fluids. As per the unit policy N/4 5% D is given in the postoperative period. Most neonatal units follow a protocol in which fluid is hiked daily to reach 150 ml/kg/day in 5–7 days. However, in our neonatal surgical unit a protocol to restrict the maintenance fluid at 100 ml/kg/day irrespective of day of life is followed.

Results

Out of a total of 90 neonates (270 sodium measurements), we identified 16 with hyponatremia (11%). Most of the neonates had mild hyponatremia(130–135 meq/l). The incidence of moderate and severe hyponatremia was low.

Conclusion

Postoperative restriction of fluids especially in neonates who are at a high risk for developing SIADH can lead to decreased incidence of severe hyponatremia.

Clinical utility of time to positivity of blood cultures in cases of fungaemia: A prospective study

PURPOSE

Fungaemia due to yeast is a major cause of morbidity and mortality in critically ill patients. Although, automated blood cultures have improved the time to diagnosis, very few studies have systematically evaluated the utility of blood culture time to positivity (TTP) of fungaemia in the clinical scenario. In this study, we evaluated the TTP for different yeast species to determine its clinical utility.

MATERIAL AND METHODS

A prospective study including 244 consecutive patients admitted to the adult (n ​= ​76) and paediatric (n ​= ​168) intensive care units (ICUs) was conducted between December 2017 through March 2019. The clinical and demographic characteristics, BACTEC blood culture results and TTP for yeast positive blood cultures were recorded for analysis.

RESULTS

A total of 244 patients with 357 episodes of candidaemia were enrolled during the study period. The TTP (mean ​± ​SD) for all yeast species was 26.8 ​± ​23.6 ​h while it was significantly longer in paediatric than adult patients (30.5 ± 24.7 vs. 25.2 ​± ​22.9 ​h; p ​= ​<0.0001). Wickerhamomyces anomalus and Cyberlindnera jadinii (previously C. utilis) were exclusively isolated from paediatric population where W. anomalus demonstrated significantly longer TTP than C. jadinii. Among adult cases, C. albicans exhibited significantly longer TTP than C. tropicalis. In paediatric cases, >80% of C. tropicalis and C. utilis flagged positive in blood culture before 24 ​h while majority (65.9%) of W. anomalus isolates flagged positive later than 24 ​h. Similarly in adult samples, 63% of C. tropicalis isolates beeped positive before 24 ​h.

CONCLUSION

TTP for yeast may provide insight regarding the responsible yeast species before final identification among critical patients with candidaemia. Larger studies are warranted for evaluating clinical utility of TTP considering other complex factors like yeast burden, generation time, virulence and host factors, which may affect TTP.

Correlation of Urinary Biomarkers (Interleukin-6, Transforming growth factor-β, E-Cadherin, and MCP-1) with Conventional Parameters of Disease Progression in Patients of Posterior Urethral Valves: A Comparative Analysis

AIMS

Posterior urethral valves (PUV) are the leading cause of end-stage renal disease in boys. The study aimed to look at the ongoing renal damage and profibrotic activity by measuring the levels of Interleukin-6 (IL-6), Transforming growth factor-β (TGF-β), E-cadherin, and Monocyte Chemoattractant Protein-1 (MCP-1) and observing trends in subsequent follow-ups and at the same time correlating them with the established parameters of disease progression.

MATERIALS AND METHODS

This prospective study included 36 consecutive patients of PUV, managed over a period of 18 months. IL-6, TGF-β, E-cadherin, and MCP-1 were measured in urine samples at the time of admission, pre-fulguration and 3 months' and 9 months' post fulguration. The observed values were correlated with the conventional parameters used in clinical practice.

RESULTS

All the biomarkers showed statistically significant trends when these values were compared on admission, postoptimization and 3 months' and 9 months' postfulguration. None of the biomarkers showed a significant correlation with renal function tests. E-Cadherin and TGF-β showed a positive and a negative correlation with ultrasonography (USG) kidney, ureter, and bladder (KUB) respectively. E-Cadherin showed a positive correlation, whereas IL-6 and TGFβ showed negative correlation respectively with micturating cystourethrogram (MCUG). IL-6 showed statistically a significant negative correlation with dimercapto succinic acid (DMSA). MCP-1 did not show any significant correlation with USG KUB, MCUG and DMSA.

CONCLUSION

This study concludes that E-Cadherin, IL-6, TGF-β can be promising urinary biomarkers for early detection of the ongoing renal damage in patients of PUV following valve fulguration. MCP-1 may have more complex interactions, with inflammatory markers; which warrants further research.

Antifungal prescription practices and consumption in a tertiary care hospital of a developing country

BACKGROUND

Antifungal stewardship is a less explored component of antimicrobial stewardship programmes, especially in developing countries.

OBJECTIVE

We aimed to determine antifungal prescription practices in a tertiary centre of a developing country to identify the challenges for antifungal stewardship programmes.

METHODS

Four single-day point prevalent surveys were performed in inpatient units and data were collected from medical records. Antifungal use was recorded in terms of consumption, therapeutic strategies and appropriateness.

RESULTS

We found a 2.42%-point prevalence of antifungal prescriptions. Antifungal use was higher in children than adults (4.1% vs. 2.03%), medical than surgical units (3.7% vs. 1.24%) and ICUs than general wards (5.8% vs. 1.9%). The highest antifungal use was observed in the haematology-oncology units (29.3%) followed by emergency (16.2%) and gastroenterology units (11.6%). Among 215 prescriptions, amphotericin B was the most commonly prescribed (50.2%) followed by fluconazole (31.6%). The targeted antifungal therapy was practised more commonly (31.5%) than empiric (29.1%), pre-emptive (22.6%) and prophylactic (16.8%) therapy. Amphotericin B was commonly used for pre-emptive (p = .001) and targeted (p = .049) therapy, while fluconazole (p = .001) and voriconazole (p = .011) for prophylaxis. The prescriptions were inappropriate in 25.1% due to the wrong choice of antifungal (44.4%), indication (27.7%) and dosage (24%). The overall mean antifungal consumption was 2.71 DDD/1000 PD and 8.96 DOT/1000 PD.

CONCLUSIONS

We report here the low prevalence of antifungal use at a tertiary care centre in a developing country. Though training for antifungal use would be important for antifungal stewardship, the challenge would remain with the affordability of antifungals.

Anorectal Malformations: The Earlier the Diagnosis, the Better the Outcome

OBJECTIVE

To estimate the impact of delayed presentation of anorectal malformation (ARM) in neonates and to compare the presenting characteristics and outcomes of early versus delayed presentation.

METHODS

This is a prospective observational study of all neonates (age < 28 d) with ARM over 2 y. Delayed presentation was defined as presentation beyond 48 h of birth. Various presenting features and their early postoperative outcomes were compared.

RESULTS

Nearly half (26, 48%) of the 54 neonates with ARM had delayed presentation. Early and late presenters did not differ in terms of gender, gestational age, birth weight, place of delivery, and type of ARM (p > 0.05 for all). Delayed group had lower weight at presentation (p = 0.008), higher incidence of severe abdominal distension (p = 0.05), and sepsis (p = 0.171) and required longer time for resuscitation (p = 0.007) and more inotropes (p = 0.015), preoperatively. Early postoperative outcomes including time for stoma to function, initiate feeds and time to reach full feeds were significantly delayed in late presenters. They also had more wound infections, longer hospital stay and higher mortality.

CONCLUSIONS

Delayed diagnosis of ARM is associated with significantly higher morbidity and mortality. Adequate awareness and training of health workers for early identification of ARM by careful perineal examination of all newborns at birth is the need of the hour.

A Rare Association of Obstructed Hemivagina with Ipsilateral Renal Agenesis with Congenital Pouch Colon

BACKGROUND

Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA), or Herlyn-Werner-Wunderlich syndrome, is a rare Mullerian duct anomaly. Several associations of OHVIRA with other anomalies are being reported.

CASE

A 13-year-old girl reported with acute onset abdominal pain. Patient was operated on in the past for type IV congenital pouch colon (all stages complete). She was diagnosed with hematometrocolpos and underwent tube vaginostomy. Further workup was suggestive of OHVIRA, which was subsequently managed with surgical repair.

CONCLUSION

Delineation of reproductive anomalies in female patients with anorectal malformations is of paramount importance. OHVIRA syndrome should be considered at a high index of suspicion in female patients with a solitary functioning kidney. Nonspecific symptoms in an adolescent female can lead to erroneous judgment, leading to unnecessary investigations, which, if not well managed in time, can be detrimental to fertility.

Oral Atenolol versus Propranolol in the Treatment of Infantile Hemangioma: A Systematic Review and Meta-Analysis

Background

Infantile hemangioma (IH) is the most common benign vascular tumor of infancy. Propranolol is considered first-line therapy for IH. However, it is associated with side effects. Therefore, there was a need for alternative therapy. Atenolol, a selective b1-blocker may be free from such side effects. Hence, the present study aims to develop a more accurate estimate of the safety and efficacy of atenolol compared to propranolol in the treatment of IH.

Methodology

A search of various literature databases (PubMed, Embase, Ovid, Scopus, Cochrane Central, CINAHL, Web of Science, and Google Scholar) was done to identify studies which compared propranolol versus atenolol in the treatment of IH. The combined odds ratio along with corresponding 95% confidence intervals (CIs) were evaluated using a fixed-effects model.

Results

A total of 300 articles were screened of which five studies including 116 patients in atenolol arm and 138 patients in the propranolol arm were analyzed. Atenolol was comparable to propranolol in terms of efficacy as no significant difference was seen between both the treatment arms in terms of hemangioma activity score (mean difference 0.25 [95% CI;‒0.21, 0.71]) and complete response (odds ratio [OR] =0.43; 95% CI; 0.17, 1.11; P = 0.08,). Atenolol therapy was better than propranolol in terms of safety, i.e., serious/potentially serious side effect, (OR = 0.11; 95% CI; 0.02, 0.51; P = 0.005) and wheezing/bronchial hyperreactivity (OR = 0.11; 95% CI; 0.02, 0.51; P = 0.005).

Conclusion

The present meta-analysis provides evidence that atenolol has got a comparable efficacy and better safety profile with propranolol.

Reverse Gastric Tube Esophagoplasty with and without Lower Esophageal Stump Wrap - Comparison of Outcome

Aim and Objectives

The aim of the study is to compare the outcome in children born with long-gap esophageal atresia following reverse gastric tube esophagoplasty (RGTE) with or without the lower esophageal stump as a "fundoplication" wrap.

Materials and Methods

All children who underwent RGTE between 2008 and 2018 were retrospectively analyzed. Patients in whom the lower esophagus (LE) had been excised as is done routinely in RGTE (Group 1) were compared with those where the LE was wrapped partially or completely around the intraabdominal neo-esophagus (Group 2). Both vagal nerves were preserved to the extent possible. Complications and final outcome, including weight and height centiles were assessed. Follow-up upper gastrointestinal contrast study and reflux scans were studied.

Results

Nineteen patients (mean age: 15.78 ± 5.02 months [range 10-30 months] at RGTE) were studied; nine in Group 1 and ten in Group 2. Both groups had similar early postoperative complications as well as the requirement of dilatation for anastomotic stricture. Dysphagia for solids was noticed in two patients with complete lower esophageal wrap (n = 4), one requiring removal. More patients in Group 2 had absent reflux (n = 7) compared to Group 1 (n = 3) (P = 0.118). At a mean follow-up period of 45.75 ± 18.77 months (14-84 months), Group 2 children reached better height and weight percentiles compared to Group 1.

Conclusion

We have described a novel method of using the LE as a "fundoplication" wrap following RGTE. Vagi should be preserved. Those with complete esophageal wrap may develop dysphagia to solids and this is, therefore, not recommended. Lower esophageal wrap patients appeared to have a better outcome in terms of growth and less reflux.

Unusual manifestations of Peutz-Jegher's syndrome in children

PeutzJegher's syndrome (PJS) is a rare, autosomal dominant disease, characterized by gastrointestinal (GI) polyps and perioral hyperpigmentation along with the increased risk of certain malignancies. In children, the most common presentation is recurrent intussusception due to polyps. These polyps can involve any part of the GI tract and can present with a variety of clinical presentations. Usually, these polyps can be removed endoscopically but often require surgical excision also. In this report, we discuss two children of PJS with uncommon presentations, one presented with retrograde intussusception and another with gastric outlet obstruction. The first child underwent laparoscopy and another required open surgery with intraoperative enteroscopy.

Duodenal and Pyloric Web in Children: Clinical Presentation and Management

BACKGROUND

Duodenal and pyloric web (DW/PW) can present at any age, symptoms depend upon the location of the web along with the presence and size of the opening in the web. The surgical management is not straightforward always. Here, in this study, we aim to assess clinical characteristics, management, and outcome of children with DW/PW.

MATERIALS AND METHODOLOGY

This was a retrospective study from 2005 to 2019, and data were collected from record registers. All children of DW/PW presented between this duration were included in this study.

RESULTS

A total of 45 patients (age range = 1 day to 11 years) included in the study, 40 had DW while 5 had PW. Seven patients were diagnosed antenatally and 20 patients had associated congenital anomalies. Most patients presented with vomiting either bilious or nonbilious. Plain X-ray was sufficient for the diagnosis in 60% of patients, the rest diagnosed on contrast study. The web excision and pyloroplasty were done for PW. The web excision and Heineke-Mikulicz type enteroplasty was the preferred surgery for DW but some patients were required Kimura's duodeno-duodenostomy. For postoperative nutrition, enteral feeding was established through the placement of a feeding tube beyond anastomosis. Ten patients died due to septicemia and associated anomalies. Four patients had a minor leak which was managed by conservative means. Four patients required redo surgery, adhesive obstruction was the most common indication. During follow-up, all 35 patients were doing well with no major complaints.

CONCLUSION

DW/PW has different presentations as compared to other intestinal atresia and can present at any age. A contrast study confirms the diagnosis when plain X-ray is inconclusive. Associated anomalies and septicemia are the poor prognostic indicators. Postoperative enteral feeding helps in maintaining adequate nutrition and improves the outcome even in children with a minor anastomotic leak.

Abdominal wall yolk sac tumor in a child

Midline vascular abdominal wall lesions are likely to be mistaken for vascular malformations in young children. We report a case of large yolk sac tumor located in the anterior abdominal wall just below xiphisternum in a 20-month-old girl diagnosed by raised serum alpha fetoprotein levels and fine-needle aspiration cytology. Preoperative chemotherapy helped in reducing its size allowing wide resection and primary wound closure. This case is reported for the unusual location and role of chemotherapy in management.

Pediatric PseudoTumoral Hepatic Tuberculosis. A Great Mimicker!!

Pediatric liver masses are rare and difficult to treat. Common liver masses in children include hepatoblastoma, hemangiomas, liver abscesses, and hydatid disease. Isolated liver tuberculosis (TB) is rare in children and can have variable clinical presentations. We report a child with isolated liver TB masquerading as a liver tumor.

A fix for a scalp varix! A rare case of cirsoid aneurysm in a child

Cirsoid aneurysm (CA) is a rare arteriovenous fistula of the scalp. There exists scant literature on the incidence and approach to CA in children. We describe a case of CA in a 7-year-old boy which was diagnosed by angiography and managed with angiographic embolization followed by surgical excision.

Primary Repair of Pediatric Posttraumatic Complete Bladder Neck Horizontal Transection: Our Experience

Complete transverse transection just below the bladder neck is extremely rare. We present two such cases with associated pelvic fracture following trauma. Both underwent early primary vesicourethral anastomosis with no postoperative complications and are continent in the follow-up.

Benign Renal Tumors in Pediatric Age Group: Retrospective Analysis

Background:

Benign renal tumors are extremely rare and were studied here. This series also includes a renal teratoma in a horseshoe kidney, probably only the second in the pediatric literature.

Materials and Methods:

Retrospective review of children with benign renal tumors operated between 2006 and 2018 at one center.

Results:

Twelve patients (M:F ratio 10:2), age range 3 weeks (31-week gestation) to 13 years presented with large palpable renal swelling (n = 12) and hematuria (n = 3). Computed tomography (CT) scan showed features typical of the tumor. Final histopathology (age group [mean]) showed: multilocular cystic nephroma (MLCN) - n = 5 (41.7%), (11–16 months [13.6]); congenital mesoblastic nephroma (CMN) - n = 4 (33.3%) (classic 1, cellular 3) (0.75–5 months [2.125]); mature cystic teratoma - n = 1 (8.3%): (48 months, in a horseshoe kidney), and angiomyolipoma (AML) - n = 2 (16.7%) (144 months [sporadic] and 156 months [tuberous sclerosis]) One patient with cystic teratoma with no calcification on CT scan received pre-operative chemotherapy as fine-needle aspiration cytology (FNAC) reported malignant small blue cell tumor. Nephroureterectomy with Gerota's fascia could be done easily in all without intraoperative complications. Delay in presentation in MLCN and CMN led to increased symptoms and CT scan changes. All patients did well in 1.5–12 years (median 3 years) follow-up including cellular mesoblastic nephroma.

Conclusions:

Benign renal tumors often occur in specific age groups but may overlap that of Wilms tumor. Proper interpretation of clinical presentation, CT scan, and FNAC findings help in avoiding preoperative chemotherapy. Upfront nephroureterectomy is curative. Histopathological findings decide further treatment. Children with AML and tuberous sclerosis need lifelong follow-up.

Effect of diffusion of anaesthetic gases on fibre-optic view change of laryngeal mask airway and post-operative laryngo-pharyngeal morbidity in children - A randomised controlled trial

Background and Aims:

The diffusion of nitrous oxide (N₂O) into the air-filled cuff of the classic laryngeal mask airway (LMA) may lead to an increase in cuff pressure (CP) and displacement of LMA affecting its performance. This study was conducted to evaluate the change in optimal position of LMA by fibre-optic bronchoscope, the changes in cuff pressure and oropharyngeal leak pressure (OLP), and post-operative laryngo-pharyngeal morbidity during N₂O–oxygen (O₂) anaesthesia in children.

Methods:

After ethics committee approval and written informed consent, 84 children, aged 2 to 8 years undergoing lower abdominal surgery using LMA were included. Anaesthesia was induced with sevoflurane and maintained with either 33% O₂ in air (Group 1) or with 33% O₂ in 67% N₂O (Group 2) along with sevoflurane. The position of LMA using fibre-optic bronchoscope, CP and OLP were recorded at 30, 60 and 90 minutes and at the end of surgery. The incidence of post-operative sore throat, hoarseness of voice and dysphagia was assessed for 24 hours.

Results:

A mild (Grade 1) change in fibre-optic position of LMA was observed in 6 out of 42 children maintained with N₂O–O₂ anaesthesia. The cuff pressure was higher than baseline in group 2 at all three time points with the maximum at 90 minutes (93.23 ± 14.86 cm H₂O vs. 39.78 ± 7.75 cm H₂O; P < 0.05). The OLP was comparable between the groups during the initial 60 minutes and then increased in group 2. The incidence of post-operative sore throat was significantly higher in group 2 (P = 0.008).

Conclusion:

The diffusion of anaesthetic gases into the air-filled cuff does not change the fibre-optic position of the LMA significantly but increases the cuff pressure and incidence of post-operative laryngo-pharyngeal complications in children.

Extrapulmonary Pleuropulmonary Blastoma in a 3-Year-Old Child: A Case Report and Review of Literature

Pleuropulmonary blastomas (PPBs) are very rare, highly aggressive, dysembryonic neoplasms of thoracopulmonary mesenchyme. These have been reported in the pediatric population and account for only 0.5%-1% of all primary malignant lung cancers. They normally arise from lung tissue, however rarely the parietal pleura may be the tissue of origin (extra pulmonary PPB) which are extremely rare. Common age of presentation is three to 4 years. The prognosis is poor with distant metastasis to central nervous system and bone with survival rate of approximately 42.9% at 5 years. They are managed by aggressive multimodal therapies including surgery and chemotherapy. We report a case of a 3-year-old male child with Type 2 PPB of the left hemithorax, managed by surgical excision of the mass and adjuvant chemotherapy.

Cystic hygroma and esophageal atresia with tracheoesophageal fistula: Is there a genetic association?

Background: Tracheoesophageal fistula (TEF) is associated with many other congenital anomalies like cardiac, renal, and vertebral, but the association with cystic hygroma is very rare. Case Presentation: We report a neonate, antenatally diagnosed with cystic hygroma of the neck and incidentally diagnosed to have TEF. The baby was operated on after adequate stabilization and the cystic hygroma was managed with injection sclerotherapy. The genetic analysis for the FOX genes complex has been done in this case and the results showed no association between the two. Conclusion: There is a need for future studies to find out if the association between cystic hygroma and TEF is by chance or if any embryological or genetic cause can be attributed to it.

Chest MRI as an emerging modality in the evaluation of empyema in children with specific indications: Pilot study

OBJECTIVES

To assess the diagnostic role of chest magnetic resonance imaging (MRI) for evaluating empyema in children with specific indications.

METHODS

Nineteen children (5-16 years) with a diagnosis of empyema were enrolled in this prospective study from January 2018 to February 2020. MRI and multidetector computed tomography (MDCT) of the chest was performed within 48 h of each other. Two pediatric radiologists independently evaluated the MRI and CT images for the presence of fluid and air in the pleural cavity, septations within the fluid, pleural thickening, pleural enhancement, drainage tube tip localization, consolidation, and lymphadenopathy. Kappa test of agreement was used to determine the agreement between the MRI and MDCT findings. Chance-corrected kappa statistics were used for calculating the interobserver variation.

RESULTS

The kappa test showed almost perfect agreement (κ = 1) between MRI and MDCT for detecting fluid, pleural thickening, pleural enhancement, drainage tube tip localization, consolidation, and lymphadenopathy. Septations within the fluid were detected in 16 (84.2%) patients on MRI, and in 14 (73.7%) patients on MDCT. Almost perfect agreement (κ = 0.81-1.00) was seen for all the findings on CT and MRI between the two radiologists, except for pleural thickening for which a strong agreement (κ = 0.642) was observed.

CONCLUSION

MRI is comparable to MDCT for the detection of various findings in children with empyema. MRI may be considered in lieu of CT, as a problem-solving tool and as a radiation-reducing endeavor in children with empyema, specifically, only where CT is required for preoperative planning and evaluation of complications.

Growth and Development Assessment of Children (1-5 Years) Operated for Tracheoesophageal Fistula/Esophageal Atresia: A Case Control study

Introduction

Among children, esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is one of the major and common congenital anomalies. It is a life-threatening emergency and at birth may be associated with three C's coughing, choking, and cyanosis. It requires surgical interventions in the early neonatal period. The postsurgical period is associated with poor growth which can be developmental outcomes particularly in the first 5 years of life and attributed to postsurgical complications. The aim of the study is to assess and compare the growth and development of the children (1-5 years) operated for TEF/EA attending Pediatric Surgery OPD/admitted inwards at APC, PGIMER, Chandigarh versus healthy controls.

Materials and Methods

A case-control study was conducted on age-matched 40 children aged between 1 and 5 years operated for TEF/EA and healthy controls. The sampling technique for cases was total enumeration and for controls was purposive sampling. Tools used were socio-demographic sheets of children, clinical profile of children, Trivandrum Development Screening chart, and Vineland Social Maturity Scale for Indian adaptation.

Results

Majority 33 (82.5%) of children had distal TEF and more than two-third 28 (70%) have undergone primary repair. More than one-third 14 (35%) had a respiratory infection, 12 (30%) anastomosis leakage and 6 (15%) had Gastroesophageal reflux (GER) as one of the early and late postoperative complications. More than one-fourth 11 (27.5%) of TEF/EA operated children had less weight, 11 (30%) had less height and 16 (40%) had less weight for height for their reference age. A significant difference was found for height for age, weight for height, and social maturity among children who had TEF repair as compared to their healthy counterparts.

Conclusion

Growth monitoring reflected (more than one-fourth of children were underweight and stunted while more than one-third were wasted) and showed development delay in TEF/EA operated children as compared to healthy controls.

Robotic Excision of Choledochal Cyst with Hepaticoduodenostomy (HD): Report of HD Technique, Initial Experience, and Early Outcome

INTRODUCTION

 Minimal access surgical approach to choledochal cyst (CC) is becoming a standard of care in pediatric age group. Robotic-assisted excision of CC is increasingly being practiced at centers which have access to the system. We present our experience and technique of hepaticoduodenostomy (HD). Over all initial experience, short-term outcomes and complications are also presented and discussed.

MATERIALS AND METHODS

 Patients with CC and undergoing robotic excision were retrospectively studied. Patients with active cholangitis, liver dysfunction, and perforated CC were excluded for robotic procedures. All included patients were preoperatively evaluated as per the defined protocol. They underwent excision of CC with HD. The duodenal anastomosis was done after limited mobilization and emphasis was laid on anastomosing the distal D2 part to the common hepatic duct. This prevents bile reflux into stomach. The follow-up evaluation was done for these patients. Hepatobiliary iminodiacetic acid (HIDA) scan for duodenogastric reflux (DGR) was done only if patients reported symptoms related to it.

RESULTS

 A total of 19 patients (10 females) were studied. The mean age was 84 months. Type 1b was present in 12 patients and the rest were type IVb. Complete cyst excision with HD was done in all patients except conversion to open in one patient. The mean surgical time was 170 ± 40 minutes with console time of 140 ± 20 minutes. Median follow-up duration is 2.5 years (range: 3.5-0.5 years). HIDA scan was done in five patients who had reported epigastric pain. Of these five, one patient had a positive DGR. He is on conservative management.

CONCLUSION

 Robot-assisted CC excision with HD is feasible as proven by the outcome of 19 patients presented in this series. HD is to be done away from pylorus in distal part of down curving D2. This particular step prevents DGR and is the most important point of technique in doing HD. The presented series is the first report of robotic excision of CC with HD. The robot is a facilitator for complex and difficult operations as CC excision and HD.

Clinical Presentation, Treatment, and Challenges in the Management of Child Sexual Assault at a Tertiary Care Referral Center in India

BACKGROUND

Child Sexual Assault (CSA) is not an uncommon but an under-reported crime. Along with social and psychological critical issues, there are multiple challenges faced by the surgical team for the treatment of complex perineal injuries associated with CSA. This study was conducted to find clinical presentation and management of CSA along with its problems and challenges encountered by the pediatric surgical team.

MATERIALS AND METHODS

This was a retrospective study from 2010 to 2019, conducted in the department of pediatric surgery at a tertiary referral center. All-female patients with a definitive history of sexual assault were included in the study.

RESULTS

Seven patients fulfilled the inclusion criteria and the mean age was 5.3 years. After a primary survey, all patients were taken up for examination under anesthesia (EUA). Three patients were managed by the primary repair of the wound and did well during follow-up. Four patients had grade 4 perineal injury and required stage reconstruction. As a first stage, repair of rectal tear, vaginal tear, and the perineal body reconstruction was done along with diversion colostomy. One patient required redo repair of the perineal body and one had developed a rectovaginal fistula. Three patients completed all stages and they are fully continent.

CONCLUSION

The spectrum of injuries varies widely in CSA and more chances of high-grade perineal injuries in children due to distinctive local anatomy. EUA is crucial to assess the extent of the injury and to decide the course of management. Meticulous anatomical repair and diversion stoma is the key for successful complex repair and excellent long-term outcomes in terms of continence for the severe grade of perineal injuries.

Fungaemia due to rare yeasts in paediatric intensive care units: A prospective study

BACKGROUND

Considering the emergence of fungaemia due to rare yeasts at our centre, we performed a systematic epidemiologic study on fungaemia due to rare yeasts.

OBJECTIVES

We undertook the present prospective observational study to explore the epidemiological features and clinical characteristics of fungaemia due to rare yeasts in paediatric ICUs at our centre.

METHODS

The successive yeasts isolated from blood at our PICUs during December 2017 through March 2019 were identified by molecular methods. Fungaemia due to yeasts other than C. albicans, C. tropicalis, C. glabrata, C. krusei and C. parapsilosis was categorised as rare yeast fungaemia. Antifungal susceptibility testing of the yeast isolates was performed as per clinical and laboratory standards institute (CLSI) guidelines. We also compared different clinical parameters of fungaemia due to common versus rare yeasts, and rare yeasts in neonates versus non-neonates.

RESULTS

During the study period, 212 yeast isolates were obtained from 159 patients at PICUs of our hospital, and 127 isolates from 98 patients (61.6%) were categorised as rare yeasts. Neonates acquired fungaemia significantly earlier after ICU admission than non-neonates (median: 4 vs 6 days; p = .005). of rare yeast fungaemia, Wickerhamomyces anomalus (43.8%) and Candida utilis (40.8%) were common isolates; surgical intervention and gastrointestinal disease were significantly associated; overall, azole, echinocandin and amphotericin B resistance was at 9.1%, 1.02% and 1.02%, respectively; overall mortality was 65.3%.

CONCLUSIONS

The emergence of rare yeasts especially W. anomalus and C. utilis causing fungaemia in our children demands urgent attention to control the spread.

Survival in patients with high-risk neuroblastoma treated without autologous stem cell transplant or dinutuximab beta

The majority of patients with high-risk neuroblastoma (HR-NB) in low- and middle-income countries (LMIC) do not have access to autologous stem cell transplant (ASCT) and dinutuximab. Consolidation with nonmyeloablative chemotherapy is not well-defined, and the outcomes are variable. We report a single-center outcome of patients with HR-NB, treated with nonmyeloablative consolidation. A tabulated compilation of similar reports is included. A retrospective chart review of patients with HR-NB was performed from January 2009 till June 2016. Patients were treated on the backbone of HR-NBL1/SIOPEN protocol. Treatment included induction with rapid-COJEC, surgery, followed by consolidation. Consolidation involved 4 cycles of topotecan, vincristine, and doxorubicin (TVD) instead of ASCT. Infusion of vincristine and doxorubicin were modified for ease and to enable administration in the clinic. Subsequent treatment included radiotherapy to the primary tumor and differentiation therapy with isotretinoin. Over 7½ years, 28 patients with HR-NB were treated. Two (7%) patients had therapy-related mortality. A relapse or disease progression occurred in 11 (39%) patients at a median duration of 17 months (IQR: 5, 18). Treatment abandonment was observed in 4 (14%) patients. The median follow-up of disease-free patients was 49 months (IQR: 45, 79). Patients with relapse were not treated further. A 4-year EFS of 29.3% was observed when 4-cycles of TVD were administered instead of ASCT in patients with HR-NB. The study and the review will aid decision-making for care of patients in LMIC while considering the options of treatment for HR-NB if access to ACST and dinutuximab is lacking.

Role of urodynamics in male patients of high-anorectal malformations: a prospective study

PURPOSE

Association of spinal or vertebral anomalies and the iatrogenic denervation during surgical correction of anorectal malformation patients especially in boys can lead to neurogenic bladder inthese subset of patients. The paucity of literature with regard to urodynamic studies focusing exclusively in male children with high-anorectal malformations (HARM) lead us to analyze the urodynamic changes. The objective was to study urodynamic profile in male patients who have undergone surgery for anorectal malformation.

METHODS

Male high-anorectal malformation patients who had completed all the stages of repair were prospective studied. Following the basic work up, all patients based on the urodynamics were categorized into 2 groups as safe or unsafe bladders. Unsafe bladder was defined as detrusor pressure > 40 cm (high detrusor pressure) or pressure variability of 15 cm of water (detrusor overactivity) or significant post-void residue. MRI was limited to patients with only abnormal urodynamics to rule out spinal causes of neurogenic bladder and due to financial constraints, it could not be offered to all patients.

RESULTS

41 HARM meet the exclusion criteria. All patients were asymptomatic with none having history of urinary tract infections. Ultrasound showed bladder wall thickening in 31.7% patients. UDS revealed reduction in bladder capacity and compliance was noted in 31.7% and 30% patients, respectively. Elevated detrusor pressures (> 40 cm of water) were noted in 10% (4/41), detrusor overactivity with concomitant elevated detrusor pressures in 19.5% (8/41) and normal UDS in 70% (29/41). 13 patients (31.7%) had abnormal cystometric parameters with 12(30%) having unsafe bladders. MRI confirmed sacral agenesis in 1 patient with unsafe bladder.

CONCLUSION

Urodynamics can demonstrate occult neurovesical dysfunction in patients with HARM. This would help in early renal protective therapy and prevent the burden of long-term sequelae of neurovesical dysfunction in HARM patients.

Bladder Mass Masquerading as Eosinophilic Cystitis in a Child: When to Think Beyond Malignancy?

Eosinophilic cystitis is a rare inflammatory disease in the pediatric population with varied presentations. Diagnosis requires a high index of suspicion and cystoscopy with biopsy of the bladder mass. There are no standard treatment guidelines, however, these patients usually respond with medical management, but recurrence is a possibility. We present a case of eosinophilic cystitis in a 6-year-old boy who presented with lower urinary tract symptoms, gross hematuria, and bladder mass.

Roux En Y drainage of a large hepatic hydatid cyst as treatment for recalcitrant bile leak: a case report

Background

Hydatid disease is relatively uncommon in children and thus rarely reported in literature. Pediatric patients with large hydatid cysts can have grave complications due to mass effect. Postoperative bile leak is the most common morbidity and continues to be a challenge for the treating surgeon.

Case presentation

A 7-year-old boy diagnosed with a giant hydatid cyst of the liver, almost replacing the right lobe, and underwent a laparotomy and excision of cyst with tube drainage. He developed postoperative major bile leak which did not subside even after a redo laparotomy and closure of the suspected bile leak areas. The child underwent a third laparotomy after a hepatobiliary scintigraphy (HIDA scan) which confirmed a persisting major leak. A Roux En Y cystojejunostomy was done this time which drained the bile adequately postoperatively with no evidence of bile in the subhepatic drain. Oral feeds were resumed on the fifth postoperative day. He was discharged in a satisfactory condition and is doing well in the follow-up. Repeat HIDA scan showed no evidence of spillage, with adequate bilio-enteric drainage.

Conclusion

Persistent major bile leak requiring ERCP with sphincterotomy can be managed successfully in children by internal drainage as Roux En Y cystojejunostomy.

Congenital giant Bednar tumor in a child: surgical challenges in a young infant: a case report

Background

Bednar tumor is a pigmented variant of the uncommon dermatofibrosarcoma protuberans (DFSP). It is a disease of the middle aged and elderly and has been rarely described in the pediatric population.

Case presentation

We report a rare case of a giant Bednar tumor present since birth, in a 2-year-old male child. It was present over the lower back and managed by surgical excision.

Conclusions

Bednar tumor is a rarity in children and is managed with aggressive wide local excision with margin of at least 1 cm. A close clinical follow-up is mandatory.

Outcome of antenatally diagnosed cystic hygroma - Lessons learnt

PURPOSE

This study is carried out to characterize the prognosis and outcome of antenatally diagnosed cystic hygroma in a series of registered pregnancies.

METHODS

This is a prospective cohort study, carried out over a period of 4 years (Jan 2016-Sept 2019). All the pregnancies referred from the department of obstetrics with antenatally detected cystic hygroma or increased nuchal thickness on level II ultrasonography suggestive of lymphangiomas were registered in the Pediatric Surgery outpatient department. Amniocentesis, fetal ECHO and fetal MRI (if indicated)were done. Prognosis was explained to the family and mode of delivery was planned as per the obstetric indications. Postnatal evaluation included general physical examination along with ultra sound (USG)doppler of the lesion. The neonates were admitted in neonatal surgical ICU for the administration of intralesional bleomycin in a dose of 0.3 IU/kg under strict observation. All the babies were followed up at 3, 6 and 12 months. Results were segregated as excellent, good and still in follow up cohort as per the final outcome. The fetal neck masses detected antenatally and the age at first dose of bleomycin were compared with the number of sclerotherapy doses required to achieve good response.

RESULTS

Only nine patients out of 626 registered pregnancies (1.4%) were diagnosed with cystic hygroma. One antenatal mother opted for termination of pregnancy at 19 weeks of gestation and another patient was lost to follow up after receiving two doses of bleomycin in postnatal period. Maternal hypothyroidism was noted in two pregnancies. Antenatal USG shows increased nuchal thickness in 2 cases (first trimester) and 6 cases in level II scan. Amniocentesis shows normal fetal karyotyping in all these pregnancies. Fetal ECHO suggests normal biventricular function in 100% cases while fetal MRI done in one case completely ruled out any aerodigestive compromise. Mode of delivery is found to be planned elective LSCS in 57% of cases while normal vaginal delivery attained in 43% of cases as per the obstetric guidelines. Six cases achieved good response with >50% reduction in size out of which 4 cases received the dose at the first 10 days of life. Complete disappearance of lesion at the end of 6 months of follow up were seen in two babies.

CONCLUSIONS

Antenatal screening for early detection of fetal cystic hygroma with possible associated congenital aneuploidies helps in prognostication and planning the mode of delivery. A multimodality approach during intra and postpartum increases safety margin. Even huge neck masses without associated anomalies carry fair prognosis. Intralesional bleomycin is safe and prevents surgical morbidity.

TIMP-2 as a noninvasive urinary marker for predicting neurogenic bladder in patients under follow-up for spina bifida

INTRODUCTION

Neurogenic bladder (NB) post-meningomyelocele (MMC) repair is a major challenge and needs lifelong follow-up. Many cytokines have been implicated in the pathogenesis of NB. To avoid repeated urodynamic studies (UDS) and renal scans, we studied urinary tissue inhibitors of metalloproteinases-2 (TIMP-2) levels and correlated with urodynamic profiles to establish their efficacy.

MATERIALS AND METHODS

Prospective case-control study on children between 6 months to 12 years of age, who were at least 6 months post-MMC repair and had NB on UDS. Patients were evaluated under 4 cohorts of 20 patients each: Group A (NB on treatment), Group B (NB not on treatment), Group C (no NB), and Group D (Controls). All groups underwent radiofrequency thermocoagulation, urine culture, ultrasonography. Urine samples were stored at -800°C and analyzed using a validated Human ELISA kit for TIMP-2.

RESULTS

Eighty patients with a mean age of 3.54 ± 2.1 years were studied. A common ultrasound finding was a thickened urinary bladder (33.3%). All UDS parameters showed a statistically significant differences between groups with NB (Groups A and B) and a group without NB (Group C). Analysis of TIMP-2 levels between individual groups was statistically significant. The area under the receiver operating characteristic curve between urinary TIMP-2 and cystometric parameters indicated that urinary TIMP-2 levels are highly diagnostic of NB. TIMP-2 value of 358.5 pg/ml was found to be the least value with 93.5 sensitivity and 86.2% specificity.

CONCLUSION

This study highlights the potential of urinary marker TIMP-2 as noninvasive and cost-effective test to initially diagnose and predict the progression of disease in NBs with reasonable sensitivity and specificity.

Challenges in the management of localized Ewing sarcoma in a developing country

Survival in pediatric Ewing sarcoma (ES) lags in low- and middle-income countries (LMICs). This study analyzed factors contributing to a lower outcome in an LMIC center. A retrospective case review of children with localized ES treated from January 2011 till December 2017 was performed. Neoadjuvant chemotherapy with alternating cycles of vincristine, doxorubicin, cyclophosphamide; and ifosfamide, etoposide was administered 3-weekly for 48 weeks. Reassessment was planned for week 12, followed by local therapy (surgery/radiotherapy or both) tailed by adjuvant chemotherapy. Forty-eight patients with mean age 8 years (range: 0.7-14) were evaluated. Extremity and central axis tumors were seen in 25 (52%) and 23 (48%) patients. Three patients died of neutropenic sepsis and five abandoned therapy. Local therapy included primary surgery, radiotherapy and a combination of surgery and radiotherapy in 7 (16%), 20 (45%) and 17 (39%) patients. The 3-year event-free survival (EFS) and disease-free survival (DFS) for the cohort were 47.7 ± 11% and 57.6 ± 11.2%. Time to local therapy >16 weeks was associated with inferior DFS vs. local therapy administered within 16 weeks [46.6 ± 12.4 vs. 63.9 ± 19.4, p=.046]. Older age, axial site, large size and incomplete surgical resection did not predict relapse/progression. Patients who received wide local excision, as local therapy, had 100% DFS. Coordinated efforts to ensure timely therapy can improve outcome in pediatric ES. Abandonment and treatment-related mortality (TRM) are additional challenges that need to be tackled in LMICs.

Modified Duhamel's Two-Staged Procedure for Hirschsprung's Disease: Further Modifications for Improved Outcomes

Aims and Objectives

We studied the short- and long-term outcomes and quality of life (QOL) in patients undergoing a two-staged modified Duhamel's procedure for Hirschsprung's disease.

Materials and Methods

Patients who had undergone this modified procedure, with initial Hartmann's procedure based on contrast enema, followed by bowel preparation and low colo-anal anastomosis below the dentate line were included. The patient who underwent this procedure over 10 years with a minimum 2-year follow-up were analysed based on an interview-based questionnaire.

Results

Of the 152 patients, 69 responded. Mean age at the time of interview was 7.72 ± 3.04 years with mean follow-up of 4.9 years (2-11 years). Perineal excoriation and soiling was present in 60.9% and 36.2% of patients initially which reduced to 0 and 4.3% by the end of 2 years. In the first 6 months, postoperative period, 15.9% of patients had constipation and 78.2% had altered stool consistency. Good fecal continence score was present in 97.1% of patients in the long term. About 95.4% had good QOL scores. There was no mortality in this series.

Conclusions

Although short-term outcomes showed altered bowel function, soiling, and perineal excoriation, this improved significantly in the long term, with good QOL scores in the majority.