Evaluation of Mannheim's Peritonitis Index in Prediction of Mortality in Patients with Non-traumatic Hollow Viscus Perforation Peritonitis

BACKGROUND

Hollow viscus perforation peritonitis is one of the commonest surgical emergencies with high mortality and morbidity. The objective of this study was to evaluate the effectiveness of Mannheim's peritonitis index in prediction of mortality in these patients.

METHODS

This is a retrospective, observational cohort study in these patients managed in a single-center from January 1, 2013 to December 30, 2019. Total index scores were plotted in the receiver operating characteristic curves to find out the cut-off point. Sensitivity, specificity, relative risk, positive and negative predictive values were calculated. The individual risk factors were analyzed for mortality as well.

RESULTS

Case records of 395 cases of non-traumatic hollow viscus perforation peritonitis were available, there were 33 mortalities (8.2%), mean score was 22.96 (+7.6) points (range 10-43 points). The sensitivity and specificity with score cut-off of 25 came to be 75.8% and 56.35%; positive and negative predictive value being 13.7% and 96.2%. Risk of patients for mortality with scores >25 was 3.62 times those with scores <25 for mortality. Mortality rate was 2.4% with scores <21, 8.9% with 21-29 and 20.9% with >29 respectively (p-value <0.05). Univariate analysis showed age >50 years, presence of organ dysfunction, diffuse peritonitis, non-colonic origin and character of exudates were significant factors; multivariate analysis showed only organ failure as significant.

CONCLUSIONS

Mannheim peritonitis index is very useful in stratification of severity of the disease and prediction of mortality in patients with peritonitis, and should be included in management of all these patients.

A clinicopathologic study of intussusception in Nepalese adults

Introduction: Intussusception is rate in adults and is usually secondary to a definable pathology. This study was designed to review adult intussusception, including presentation, diagnosis, and pathology. Methods: A retrospective study of 18 cases of intussusception in individuals older than 18 years of age visiting the department of surgery of Civil Service Hospital from 2010 to 2018 was done. Results: There were 18 cases of adult intussusception. The mean age was 49.2 years (range 19-84 years). Abdominal pain and vomiting were the commonest symptoms. The median duration of presentation was 5 days (range 20 hours to 10 months). Three patients (16.6%) presented with generalized peritonitis. There were eight ileocolic, seven ileoileal, and three colocolic intussusceptions. Two patients (11.1%) settled spontaneously. Twelve out of the 18 patients (66.6%) had leading lesions. Benign pathologies were seen in seven cases (38.8%) and malignant in five patients (27.7%). All malignancies were in the large bowl Conclusions: Adult intussusception is a rare entity, nearly one-third of their causes are malignant. Surgery is the best recommended treatment, with or without a primary reduction of the intussusception; the latter can result in more limited bowel resection.

Solid pseudopapillary tumor in an ectopic pancreas: an unusual presentation

Pancreatic solid pseudopapillary tumor is a rare neoplasm. Very rarely, it may arise from an ectopic site. Solid pseudopapillary tumor occurring in the root of mesentery has not been described in the literature. This report summarizes a case of an adult male having the tumor arising from the mesenteric root. He underwent complete resection of the tumor followed by six cycles of adjuvant chemotherapy and remains asymptomatic till date.

Laparoscopic rectopexy for rectal prolapse

Introduction: Rectal prolapse surgery has been considered advanced laparoscopic surgery; hence it has mostly been performed by open surgery. However, with advancement, laparoscopic rectopexy can be feasible in patients with rectal prolapse.Materials and Methods: This study was done in patients presenting to Surgery Department of Civil Service Hospital who underwent laparoscopic rectopexy from January 2013 to November 2015Results: There were 8 patients (4 females and 4 males). The mean operative time was 160+49 minutes. The mean postoperative stay was 3+1.21 days. There was no conversion. One child underwent suture rectopexy, whereas adults underwent posterior mesh rectopexy. No patients needed blood transfusion. Postoperatively one patient has constipation, and she needed occasional laxatives.  Conclusion: Laparoscopic rectopexy is a minimally invasive advanced procedure with all the advantages of laparoscopy. With further experience operative time could be reduced.

Laparoscopic management of Hydatid cyst

Introduction and Objective: Hydatid cyst of the liver is a fairly common parasitic condition. We present here a series of 9 patients with hydatid cyst of the liver managed by minimally invasive surgeryMaterials and Methods: It was a prospective study in patients presenting with hydatid cyst of the liver to Surgery Department who were managed laparoscopically from January 2013 to November 2015.Result: There were 9 patients (5 males and 4 females). The mean operative time was 124+32 minutes. One patient developed mild allergy in the form of skin rashes on 3rd postoperative day, and another patient developed cholangitis which resolved on conservative management. There was no conversion.Conclusion: Laparoscopic management of hydatid cysts is possible, and looks promising provided we have advanced energy sources.

Laparoscopic splenectomy: case series of 24 patients

Introduction and Objective: Splenectomy has mostly been performed by open surgery. Laparoscopy seems to be a meaningful alternative to open technique.Materials and Methods: This study was done in patients presenting to hematology and surgery department of Civil Service Hospital who underwent laparoscopic splenectomy from January 2013 to November 2015Results: There were 24 patients (16 females, 8 males). The diagnoses were idiopathic thrombocytopenic purpura in 19, hereditary spherocytosis in 2, @hemolytic anemia in 2, b-hemolytic anemia in 1. The mean operative time was 130+49 minutes. The mean postoperative stay was 5+2.11 days. Laparoscopic splenectomy could be completed in 21 patients. Rest 3 needed conversion to open (causes being excessive bleeding form splenic vein, splenic tear, and excessively low platelet counts). Three patients needed additional pfanneinsteil/lumbar incision to retrieve the spleen.Conclusion: Laparoscopic splenectomy could be successfully contemplated in patients with hematological diseases, more so if spleen is of normal or mildly enlarged; and could be an advantageous alternative to open splenectomy.

Laparoscopic cloasure of Duodenal ulcer perforation

Introduction and Objective: Duodenal ulcer perforation creates a peritonitis which is sometimes hard to manage, especially with minimally invasive approach. This study is about laparoscopic approach to peritonitis due to duodenal ulcer perforation.Materials and Methods: It was a prospective study in patients presenting with duodenal perforation peritonitis to emergency of Civil Service Hospital from January 2013 to November 2015.Result: There were 6 patients (4 males and 2 females). The mean duration of presentation was 16+2.32 hrs. The mean operative time was 55+17.34 minutes. One patient developed right lower zone pneumonia which resolved on conservative management. There was no conversion.Conclusion: Laparoscopic management of duodenal perforation is a feasible procedure in select young patients who present early and without any without comorbities

Chilaiditi's sign secondary to Richter's hernia or Chilaiditi's syndrome?

Chilaiditi's sign and syndrome seem similar but are actually different entities, difficult to distinguish from each other. A 60-year-old female presented with a clinical scenario of intestinal obstruction, which was thought to be Chilaiditi's syndrome because of the unusual impression of gas under the diaphragm, but was confirmed as Chilaiditi's sign after laparotomy. The interposition of dilated small bowel loops below the diaphragm due to distal obstruction somewhere else can also produce a Chilaiditi's sign.

Simultaneous laparoscopic management of Morgagni hernia and cholelithiasis: two case reports

Background

Morgagni hernia is a rare type of diaphragmatic hernia. Though in the past, it has been dealt with an open approach, nowadays laparoscopic management is a favored approach. However, there are few controversies in this scenario.

Case presentation

We present here two females of Aryan ethnicity, one 55 and another 45 years old, who presented with pain at upper abdomen and retrosternal chest pain; on investigations were found to have cholelithiasis along with Morgagni hernia which were managed via the laparoscopic approach in the same sitting.

Conclusion

Repair of Morgagni hernia also via the minimally invasive technique can be offered to the patients like that for cholelithiasis.

Prostate cancer screening in a healthy population cohort in eastern Nepal: an explanatory trial study

BACKGROUND

Prostate cancer features a substantial incidence and mortality burden, similarly to breast cancer, and it ranks among the top ten specific causes of death in males.

OBJECTIVE

To explore the situation of prostate cancer in a healthy population cohort in Eastern Nepal.

MATERIALS AND METHODS

This study was conducted in the Department of General Surgery at B. P. Koirala Institute of Health Sciences, Dharan, Nepal from July 2010 to June 2011. Males above 50 years visiting the Surgical Outpatient Department in BPKIHS were enrolled in the study and screening camps were organized in four Teaching District Hospitals of BPKIHS, all in Eastern Nepal. Digital rectal examination (DRE) was conducted by trained professionals after collecting blood for assessment of serum prostatic specific antigen (PSA). Trucut biopsies were performed for all individuals with abnormal PSA/DRE findings.

RESULTS

A total of 1,521 males more than 50 years of age were assessed and screened after meeting the inclusion criteria. The vast majority of individuals, 1,452 (96.2%), had PSA ≤4.0 ng/ml. Abnormal PSA (>4 ng/ml) was found in 58 (3.8%). Abnormal DRE was found in 26 (1.72%). DRE and PSA were both abnormal in 26 (1.72%) individuals. On the basis of raised PSA or abnormal DRE 58 (3.84%) individuals were subjected to digitally guided trucut biopsy. Biopsy report revealed benign prostatic hyperplasia in 47 (3.11%) and adenocarcinoma prostate in 11 (0.73%). The specificity of DRE was 66.0%with a sensitivity of 90.9% and a positive predictive value of 38.5%. The sensitivity of PSA more than 4ng/ml in detecting carcinoma prostate was 100% and the positive predictive value for serum PSA was 19.0%

CONCLUSIONS

The overall cancer detection rate in this study was 0.73% and those detected were locally advanced. Larger community-based studies are highly warranted specially among high-risk groups.

Abdominal cocoon in an adolescent male

Abdominal cocoon is an uncommon peritoneal condition characterized by partial or complete encasement of small bowel by a thick rind of fibrous tissue and adhesions. Only few cases of this disease have been reported in world literature. The etiology of this condition is unknown, and most often it is found in adolescent girls from tropical or subtropical countries, and usually diagnosed incidentally on exploration. Surgery (membrane dissection and extensive adhesiolysis) is the treatment of choice. Here, we report a case of abdominal cocoon in a 20-year-old male patient, with a brief review of the literature.

Laparoscopic inguinal hernia repair: a prospective evaluation at Eastern Nepal

Introduction

Inguinal hernias have been treated traditionally with open methods of herniorrhaphy or hernioplasty. But the trends have changed in the last decade with the introduction of minimal access surgery.

Methods

This study was a prospective descriptive study in patients presenting to Surgery Department of B. P. Koirala Institute of Health Sciences, Dharan, Nepal with reducible inguinal hernias from January 2011 to June 2012. All patients >18 years of age presenting with inguinal hernias were given the choice of laparoscopic repair or open repair. Those who opted for laparoscopic repair were included in the study.

Results

There were 50 patients, age ranged from 18 to 71 years with 34 being median age at presentation. In 41 patients, totally extraperitoneal repair was attempted. Of these, 2 (4%) repairs were converted to transabdominal repair and 2 to open mesh repair (4%). In 9 patients, transabdominal repair was done. The median total hospital stay was 4 days (range 3-32 days), the mean postoperative stay was 3.38±3.14 days (range 2-23 days), average time taken for full ambulation postoperatively was 2.05±1.39 days (range 1-10 days), and median time taken to return for normal activity was 5 days (range 2-50 days). One patient developed recurrence (2%). None of the patients who had laparoscopic repair completed complained of neuralgias in the follow-up.

Conclusion

Laparoscopic repair of inguinal hernias could be contemplated safely both via totally extra peritoneal as well as transperitoneal route even in our setup of a developing country with modifications.

Rare Location of Primary Non-Hodgkin's Lymphoma in the Rectum

Lymphomas of the gastrointestinal tract are usually secondary. Primary rectal lymphoma is veryrare by virtue of its location. We present here a 60 years old lady diagnosed as primary rectal diffuselarge B-cell Non-Hodgkin's lymphoma managed operatively. The optimum management of thisentity is still much debated._______________________________________________________________________________________Keywords: Non-Hodgkin’s lymphoma; primary; rectum.

Rare location of primary non-Hodgkin's lymphoma in the rectum

Lymphomas of the gastrointestinal tract are usually secondary. Primary rectal lymphoma is very rare by virtue of its location. We present here a 60 years old lady diagnosed as primary rectal diffuse large B-cell Non-Hodgkin's lymphoma managed operatively. The optimum management of this entity is still much debated.

An alarming but self-limited case of isolated large spontaneous liver hematoma in pregnancy

Spontaneous subcapsular liver hematoma is rare but potentially life-threatening complication of pregnancy usually associated with severe preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). We present here a case of such a large spontaneous liver hematoma presenting in pregnancy, but without other known associated abnormalities, which has not been described before and it resolved on itself without any intervention.

Rise in liver enzymes after laproscopic cholecystectomy: a transient phenomenon

The purpose of this study was to investigate the effect of laparoscopic surgery on liver function in humans and the possible mechanisms behind such effect. Blood samples from 30 patients who underwent laparoscopic cholecystectomy (LC) and 20 patients who underwent open cholecystectomy (OC) were tested for liver function by measuring the level of serum alanine aminotrasferase (ALT) and aspartate aminotrasferase (AST) before and after surgery. The level of serum ALT and AST increased significantly during the first 24 hours after surgery in laparoscopic cholecystectomy. However, no significant change of the serum liver enzymes was detected in open cholecystectomy patients. As a result, there was statistically significant difference in change of both ALT and AST levels between LC and OC patients. The effect was transient and reverted back to normal by the 7th day post operation. Transient elevation of hepatic transaminases occurred after laparoscopic surgery. The major causative factor seemed to be the CO2 pneumoperitoneum. In most of the laparoscopic surgery patients, the transient elevation of serum liver enzymes showed no apparent clinical implications.

Redo-laparotomies: reasons, morbidity and outcome

A large number of patients undergo various operative procedures every day and laparotomy forms a large proportion. At times, laparotomies have to be redone due to complications like biliary peritonitis, faecal fistula, burst abdomen or anastomotic leak. Our objectives were to determine the causes of Redo-laparotomy evaluate morbidity associated with it and analyze its outcome. A prospective study of patients in BP Koirala Institute of Health Sciences (BPKIHS) from 1. 1. 2009 to 31. 12. 2009 was done. Institutional ethical clearance was taken. The Statistical analyses were done using SPSS version 11.5. Redo-laparotomy was performed in 40(1.99%) cases. The mean age was 31.99 +/- 21.49 years with a M: F ratio of 4:3. The indications of Redo-laparotomy were: burst abdomen (n = 9; 22.5%), followed by intra-abdominal collection and abscess (n = 7; 17.5%), fecal (n = 6; 15%), and biliary peritonitis (n = 5; 12.5%). The mean duration between first laparotomy and Redo was 9.42 +/- 7.56 days and the mean duration of hospitalization was 26.98 +/- 12.50 days. Lower gastrointestinal surgeries usually lead to a Redo. The mortality in our study was 30% and 21/40 patients had to be managed in the intensive care unit. Clinical acumen formed the basis (87.5%) to decide for Redo-laparotomy in the majority. Redo-laparotomies that are performed following complicated abdominal surgeries have high morbidity and mortality rates. Multiple factors may lead to a Redo-laparotomy which is beyond the hands of a clinician yet a vigilant and vigorous management could help reduce the rate of Redo-laparotomies.

Inferior vena cava injury repair, a successful outcome

Inferior ver a cava (IVC) injuries are very very infrequent; yet it still happens to be the most frequently injured retroperitoneal vascular structure. Fifty percent of the patients can't even make it to the hospital. Even when half of them manage to attend the hospital the mortality rates for the great vessel injury are still very high perhaps due to the low index of suspicion, delayed or inadequate volume resuscitation, difficulty in diagnosis and also due to some technical problems associated in its repair. We present a young male with an abdominal stab injury who had a near transected inferior vena cava at operation. Aggressive perioperative management and the correct judgement by our team at the right time possibly made the patient survive. The rarity of this condition and a review of the literature with some discussion are presented.

Benign cystic mesothelioma of the peritoneum in a child-case report and review of the literature

A 4-year old female child presented with clinical features of ascites that, on computed tomography, showed a huge thin-walled cystic lesion in the peritoneum. Laparotomy confirmed a unilocular cyst in the peritoneum adhered to the parietal wall and bowel but not originating from any internal organs. Histopathologic examination of the cyst wall was consistent with the diagnosis of benign mesothelioma. Benign cystic mesothelioma of the peritoneum has rarely been reported in children.

Childhood Intussusception: A Prospective Institutional Study at BPKIHS

Introduction: Intussusception is the commonest cause of bowel obstruction in infancy and childhood. The present study deals with the presentation, management and outcome of children presenting with intussusception at the Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal. Materials and Methods: Forty-seven children presenting at Department of Surgery, B. P. Koirala Institute of Health Sciences over a 5-year period were prospectively studied. Results: There were 27 (58.6%) males and 20 (41.4%) females, with male-to-female ratio of 1.4:1. The ages ranged from 2 months to 13 years, with a median age of 30 months. The mean duration of presentation was 10.7 ± 30.66 days (range 1-180 days). The triad of abdominal pain, bloody mucoid stools and palpable abdominal mass was seen in 10 (21%) of the cases. Surgical exploration was done in 42 (89.3%) patients. The commonest lead point was non-specific hyperplastic lymph nodes, occurring in 22 (54.3%), followed by idiopathic variety (16.6%), Meckel's diverticulum (9.5%), ileocaecal junction (7.1%), submucous lipoma (4.7%), Non- Hodgkin's lymphoma (4.7%), appendix (2.3%) and a mucosal polyp (2.3%). Overall mortality rate was 6.3%. Conclusion: The presenting age group and the time of presentation are higher than other studies. The mortality rate of 6.3% is comparable to other studies in the developing world. Earlier presentation could have avoided surgery, with a higher possibility of cases being managed conservatively. Key words: Delayed diagnosis; intussusception; lead point DOI: 10.3126/jnps.v31i1.3682J Nep Paedtr Soc 2010;31(1):6-10

Multiple skeletal metastases as unusual manifestations of hepatocellular carcinoma in a noncirrhotic liver

Hepatocellular carcinoma is the most frequent primary malignant tumor of the liver. Bony metastases of hepatocellular carcinoma are usually rare, in which most common sites involved are vertebra and pelvis. Still rarer are metastases to the chest wall and skull. We report a case of a 45-year old man with unusual metastases of hepatocellular carcinoma to skull, sternum and ribs. These combinations of metastases have rarely been reported in literature.

Caecal volvulus: a twisted tale

Caecal volvulus is an uncommon cause of acute intestinal obstruction caused by axial twisting of the caecum along with the terminal ileum and ascending colon. Early diagnosis is essential in order to reduce the high mortality rate, though the condition is rarely diagnosed correctly at the time of presentation. We report a series of four cases describing their presentation, management and subsequent outcome.

Postoperative intussusception following transverse colostomy: a case report with its pathogenesis

Postoperative idiopathic intussusception is considered to be a distinct entity, and has been reported following different operations. We present a 45-year-old female with postoperative ileoileal intussusception following a transverse loop colostomy for sigmoid volvulus, in which there was a kinked loop of bowel forming the lead point. The pathogenesis and literature review of this disorder is discussed.

Transhepatic perforation of the gallbladder: rare complication of a common disease

Acute cholecystitis leading to gallbladder perforation is relatively common. However, transhepatic perforation of the gallbladder leading to biliary peritonitis is very rare. We present a rare case of biliary peritonitis caused by transhepatic perforation of the gallbladder.

Isolated pancreatic tuberculosis mimicking as carcinoma: a case report and review of the literature

INTRODUCTION

Pancreatic tuberculosis is a rare disease even in endemic countries for tuberculosis. Here, we report a case of pancreatic tuberculosis from tuberculosis endemic zone presenting as obstructive jaundice mimicking pancreatic cancer.

CASE PRESENTATION

A 41-year-old male presented with features of malignant obstructive jaundice. Ultrasonography and computed tomography scan showed mass in the pancreatic head and uncinate process. He underwent a pancreatoduodencetomy. Histological examination showed typical features of tuberculosis. Antitubercular drugs were started and he remains well six months after surgery.

CONCLUSION

Tuberculosis should be considered as a differential diagnosis to an obscure pancreatic mass in younger or middle aged patient residing in tuberculosis endemic zone.

A report of a rare congenital malformation in a Nepalese child with congenital pouch colon: a case report

Congenital pouch colon is one of rare congenital anomalies. We report a 3-day-old male child with congenital pouch colon who underwent a window colostomy but died because of overwhelming sepsis. Due to its rarity, many surgeons in our part of the world may not be aware of it, hence increasing the potential to its mismanagement. However, with simple keen observations, we can safely come to its diagnosis. The aim of this report is to bring attention to congenital pouch colon associated with anorectal malformation in our country, with a brief emphasis on an approach to its diagnosis and initial management.

Anorectal tuberculosis coexisting with adenocarcinoma: an unusual association

Introduction

Tuberculosis affecting the anorectum is an uncommon extra-pulmonary form of the disease, and its association with malignancy is highly unusual.

Case report

A 35 year lady presented with lower gastrointestinal bleed, altered bowel habit and significant weight loss. On examination, she had nodular stricture in the lower rectum, with friable mucosa, bleeding easily on touch. With the diagnosis of carcinoma lower rectum, she underwent abdomino-perineal resection of the growth. The histopathological examination revealed carcinoma rectum with coexisting tuberculosis.

Conclusion

The aetiological association between the tuberculosis and anorectal cancer is a matter of debate. However, the treating surgeon should be aware of this association, to avoid confusion and delay in the management.

Omphalocele with Dextrocardia - A Rare Association

Omphalocele is frequently associated with many other congenital malformations. In cardiacanomalies, association of omphalocele with dextrocardia has been rarely noticed before. We presenthere a child with dextrocardia and omphalocele alongwith a brief review of the literature on this rareassociation.Key Words: congenital malformations, dextrocardia, omphalocele

Omphalocele with dextrotardia-A rare association

Omphalocele is frequently associated with many other congenital malformations. In cardiac anomalies, association of omphalocele with dextrocardia has been rarely noticed before. We present here a child with dextrocardia and omphalocele alongwith a brief review of the literature on this rare association.

One-stage correction of recto-vestibular fistula by trans-fistula anorectoplasty (TFARP)

BACKGROUND

The present article details a new technique for the repair of recto-vestibular fistula.

MATERIALS AND METHODS

Twenty-five patients with recto-vestibular fistula, between 13 days and 4 years of age underwent surgical correction by trans-fistula ano-recto-plasty (TFARP). The technique, described in detail, involves mobilization of the fistula and the rectum through the fistula and creation of a new anus in the anatomically normal site by preserving both the perineal skin bridge (skin between the neo-anus and the posterior fourchette) and the levator muscle.

RESULTS

The mean operating time was 85 min, and the mean hospital stay was 5 days. Moderate anal stenosis developed in 1 patient and was treated successfully by anal dilatations using Hegar dilators. A diverting colostomy was not required in any patient, and none of the patients developed rectal prolapse. Eleven patients who are now 3 years of age or older have voluntary bowel movements with good fecal continence scores. The 14 neonates and infants, who are still too young to be evaluated for continence, have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination. The average number of bowel movements per day was three to five, without the need for any laxative or enema.

CONCLUSIONS

Trans-fistula ano-recto-plasty is a simple surgical procedure that does not divide the levator muscle or the perineal body. Preservation of these structures contributes significantly toward improvement of the aesthetic appearance of the perineum and of fecal continence.

Congenital unilateral lower lip palsy and eventration of diaphragm

Congenital unilateral lower lip palsy is a rare but well-known limited variation of congenital unilateral facial palsy. We report a three-month-old boy with diaphragmatic eventration and isolated lower lip palsy, a combination that to our knowledge, has not been described before. Probable causes of this combination of multiple congenital malformations, in this case, could be due to nonrandom and heterogeneous mutations. The diaphragmatic eventration was treated successfully.

Single-stage transanal endorectal pull-through for Hirschsprung's disease: perspective from a developing country

BACKGROUND/PURPOSE

The aim of this study was to evaluate the feasibility, results, and cost-effectiveness of totally transanal endorectal pull-through (TEPT) in the management of rectosigmoid and midsigmoid Hirschsprung's disease (HD) in a low-income country.

METHODS

Between March 2004 and December 2005, 19 children underwent totally TEPT procedure. The patients' ages ranged from 6 days to 13 years. The primary diagnosis in all 19 patients was HD confined to the rectosigmoid region in 15 and midsigmoid in 4. None had a preoperative colostomy. Follow-up period ranged from 4 to 20 months (mean, 8 months).

RESULTS

Ages ranged from 0.25 to 65 months, with a mean of 16.24 months. Weights ranged from 3.4 to 13 kg, with a mean of 6.5 kg. Mean time from diagnosis to pull-through procedure was 26 days (range, 6-39 days). The mean length of rectosigmoid resection was 30 cm (range, 20-50 cm). The mean operative time was 95 minutes (range, 75-140 minutes). Mean intraoperative blood loss was 25 mL (range, 15-40 mL). There was one death unrelated to the procedure. One patient had enterocolitis 3 months postoperatively. Average frequency of defecation was 3 (range, 1-6) stools per day. TEPT was associated with a shorter operating time, less blood loss, early return to feeds, and an overall reduced cost.

CONCLUSION

The safety and cost-effective benefits of transanal endorectal pull-through in the treatment of HD are of special interest for a developing country. Our data also suggest that functional outcome following TEPT is highly satisfactory and comparable with other established procedures.

Triple tube therapy: a novel enteral feeding technique for short bowel syndrome in low-income countries

BACKGROUND/PURPOSE

Short bowel syndrome (SBS) is a global malabsorption syndrome that results from extensive intestinal resection. We report our experience of 10 neonates with short bowel managed by a novel triple tube enteral feeding technique. The aim of this research was to provide justification for enteral nutritional strategies to enhance intestinal adaptation, especially in developing countries where parenteral nutrition is either unavailable or expensive.

METHODS

From March 2004 to January 2006, 10 neonates underwent extensive bowel resection, enterostomy, and mucous fistula for necrotizing enterocolitis or midgut volvulus and were managed postoperatively with triple tube enteral feeding technique. Gestational age, birth weight, primary abdominal pathology, timing of surgery, surgical procedure performed, complications, duration and feasibility of refeeding, and weight gain were recorded.

RESULTS

The group was composed of 8 male and 2 female neonates with a mean gestational age of 34.2 +/- 4.6 weeks and mean birth weight of 2580 +/- 993 g. Necrotizing enterocolitis accounted for 7 (70%) and midgut volvulus accounted for 3 (30%) cases of SBS. Mean gestational age at surgery was 35.5 +/- 2.2 weeks. Mean residual small bowel length and colon length after resection were 35.5 +/- 3.5 and 30.5 +/- 1.5 cm, respectively. Weight gain during refeeding ranged from 3 to 6 g/kg per day with duration of refeeding lasting 20 to 156 days. Reanastomoses was done 92 +/- 4.2 days after the primary surgery. There were 3 surgery-related complications, but no mortality. Mean period of follow-up was 12 +/- 2.4 months. Five of the 10 children are now 19 months old and have a body weight of -1.5 +/- 0.64 SD scores and height of -1.75 +/- 0.99 SD scores.

CONCLUSION

This technique represents a safe and effective enteral nutrition strategy that eliminates the need for total parenteral nutrition for SBS in developing countries.

Doppler study of splanchnic hemodynamics in Hirschsprung's disease

BACKGROUND

Doppler studies of splanchnic vessels have demonstrated alteration in blood flow in bowel obstruction and strangulation. The aim of this study was to evaluate hemodynamic changes in celiac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) using pulsed Doppler sonography (PDS) in Hirschsprung's disease.

MATERIAL AND METHODS

Fasting splanchnic flowmetry of CA, SMA, and IMA arteries was performed using PDS preoperatively in 13 patients with Hirschsprung's disease and 13 healthy age- and sex-matched controls. Diagnostic workup for Hirschsprung's disease included a barium enema and a rectal biopsy. A primary transanal pull through was performed if the transition zone was at rectosigmoid or midsigmoid. Doppler studies were repeated on the 1st and 7th postoperative day under similar conditions. Mean flow velocity (V(mean)) and the pulsatility index (PI) of the three major vessels was measured.

RESULTS

Patients with Hirschsprung's disease showed increased blood flow velocities in CA, SMA, and IMA (p < 0.001), an increased resistance to blood flow in IMA (p < 0.001) and a decreased resistance to blood flow in CA and SMA (p < 0.005 and p < 0.001, respectively). The blood flow velocity for IMA normalized after resection of the aganglionic segment (r = 0.41, p < 0.005, 95% CI: 45.4-52.7).

CONCLUSIONS

Hirschsprung's diseaseis associated with alterations in splanchnic vessel hemodynamics which are reversible after corrective surgery. Doppler studies may play an important role in the assessment of bowel function after surgery.

Nonfamilial juvenile polyposis coli manifesting as massive lower gastrointestinal hemorrhage: report of two cases

Juvenile polyposis syndrome is an uncommon hamartomatous disorder with gastrointestinal (GI) manifestations of varying degree and malignant potential. We report the cases of an 8-year-old girl and a 5-year-old girl who suffered massive lower GI hemorrhage. Neither patient had a family history of polyposis. After the patients were stabilized, radiological evaluation, laparotomy, and intraoperative colonoscopy revealed multiple polyps in the colon. Both patients underwent total colectomy, mucosal proctectomy, and ileoanal anastomosis. The diagnosis of nonfamilial juvenile polyposis was based on the histological findings and the absence of a family history. To our knowledge, this presentation of juvenile polyposis has been reported only twice before. We discuss the clinical features and diagnosis of juvenile polyposis and the treatment options. Although juvenile polyposis is a rare condition in children, it should be considered in the differential diagnosis of life-threatening GI hemorrhage.

Falciform ligament abscess with portal pyemia in a newborn

An 18-day-old female neonate presented with abdominal distention and bilious vomiting for 5 days. Abdominal examination showed hepatomegaly and a mass in the right hypochondrium. Ultrasound showed an extrahepatic cyst with internal echoes and dilated intrahepatic radicals. A contrast computer tomography showed a large cyst arising from the falciform ligament, extending into the liver parenchyma and a dilated portal venous system. Diagnosis of falciform ligament abscess with portal pyemia was made. Excision of the falciform ligament was done. After a follow up of 1 year, the child remains asymptomatic. To our knowledge, a falciform ligament abscess causing intrahepatic portal pyemia in a newborn has not been previously been described.

Antral mucosal valve: a rare cause of gastric outlet obstruction in newborn

A 15-day male neonate presented with postprandial nonbilious vomiting. Barium meal suggested pyloric obstruction. Ultrasound of the stomach after saline loading revealed an echogenic antral valve. Subsequent laparotomy confirmed the ultrasound findings. Excision of the valve resulted in excellent recovery. To our knowledge, gastric outlet obstruction because of an antral mucosal valve in a neonate has not previously been described.