Ashwin Pimpalwar

Outcomes after peritoneal dialysis catheter placement

BACKGROUND The purpose of this study was to review surgical outcomes after elective placement of peritoneal dialysis (PD) catheters in children with end-stage renal disease. METHODS Children with PD catheters placed between February 2002 and July 2014 were retrospectively reviewed. Outcomes were catheter life, late (>30days post-op) complications (catheter malfunction, catheter malposition, infection), and re-operation rates. Comparison groups included laparoscopic versus open placement, age<2, and weight<10kg. Univariate and multivariate analysis were performed. RESULTS One hundred sixteen patients had 173 catheters placed (122 open, 51 laparoscopic) with an average patient age of 9.7±6.3years. Mean catheter life was similar in the laparoscopic and open groups (581±539days versus 574±487days, p=0.938). The late complication rate was higher for open procedures (57% versus 37%, p=0.013). Children age<2 or weight<10kg had higher re-operation rates (64% versus 42%, p=0.014 and 73% versus 40%, p=0.001, respectively). Adjusted for age and weight, open technique remained a risk factor for late complications (OR 2.44, 95% CI 1.20-4.95) but not re-operation. DISCUSSION Laparoscopic placement appears to reduce the rate of late complications in children who require PD dialysis catheters. Children <2years age or <10kg remain at risk for complications regardless of technique.

Minimally invasive surgery in neonates and infants

Minimally invasive surgery (MIS) has significantly improved the field of surgery, with benefits including shorter operating time, improved recovery time, minimizing stress and pain due to smaller incisions, and even improving mortality. MIS procedures, including their indications, impact, limitations, and possible future evolution in neonates and infants, are discussed in this article.

Multimodality Image-Guided Sclerotherapy of Low-Flow Orbital Vascular Malformations: Report of Single-Center Experience

PURPOSE To evaluate the role of multimodality imaging tools for intraprocedural guidance and outcome evaluation during sclerotherapy of low-flow orbital vascular malformations. MATERIALS AND METHODS A retrospective review was performed of 17 consecutive patients with low-flow orbital malformations (14 lymphatic, two venous, and one venolymphatic) who underwent multimodality image-guided sclerotherapy between November 2012 and May 2015. Sclerotherapy technique, image guidance tools, and complications were recorded. Sclerotherapy outcome was evaluated using clinical response, magnetic resonance (MR) image-based lesion volumetry, and proptosis quantification. RESULTS There were 22 sclerotherapy sessions performed. Intraprocedural ultrasound (US), fluoroscopy, cone-beam computed tomography (CT) and MR image fusion were used for image guidance with 100% technical success. Resolution of presenting symptoms was observed in all patients at 1-month follow-up. Four major sclerotherapy complications were successfully managed. Statistically significant reduction in lesion volume (P = .001) and proptosis (P = .0117) by MR image analysis was achieved in all patients in whom 3-month follow-up MR imaging was available (n = 13/17). There was no lesion recurrence at a median follow-up of 18 months (range, 8-38 mo). CONCLUSIONS Multimodality imaging tools, including US, fluoroscopy, cone-beam CT, and MR fusion, during sclerotherapy of low-flow orbital malformations provide intraprocedural guidance and quantitative image-based evaluation of treatment outcome.

Esophageal bronchus in an infant—a rare cause of recurrent pneumonia

A 4-month-old female infant presented to our institute with recurrent pneumonia and was diagnosed with a right lower lobe esophageal bronchus. This congenital anomaly is extremely rare with very few cases reported in the literature. We describe the diagnostic workup and management that led to a successful outcome.

Routine gastrostomy tube placement in children: Does preoperative screening upper gastrointestinal contrast study alter the operative plan?

BACKGROUND Upper GI (UGI) studies are routinely ordered to screen for malrotation before routine placement of gastrostomy (G) tubes. However, the usefulness of this study is unknown. METHODS A retrospective review of children with surgically placed G-tubes over a 2 year period (2011-2013) was performed. Patients with concomitant fundoplications were excluded. RESULTS Three hundred ninety-three patients underwent G-tube placement. Of these, 299 patients (76%) had preoperative UGI, and 11 patients (3.7%) were identified with malrotation on UGI. Five (1.7%) patients underwent a Ladds procedure. The remaining 6 either had malrotation associated with gastroschisis (n=5) or were lost to follow-up (n=1). Children <1 year did not have different rates of malrotation compared to older children (4.3% vs. 3.2%, p=0.617). Likewise, children with neurologic impairment (NI) had similar rates of malrotation compared to neurologically normal (NN) children (2.6% vs. 3.8%, p=0.692). The only significant difference in malrotation rate was between those with congenital gastrointestinal anomalies (24%) and those without (1.5%) (p<0.001). CONCLUSION Preoperative screening UGI before routine G-tube placement led to an unexpected diagnosis of malrotation in only 1.7%. Given the added radiation risk associated with an UGI, our data suggest that an UGI is unnecessary prior to routine G-tube placement. A larger prospective study is warranted to validate these results.

Recurrent tracheoesophageal fistula after thoracoscopic repair: vanishing clips as a potential sign

We present a case of a neonate who underwent surgery for esophageal atresia (EA) with tracheoesophageal fistula (TEF) with an unusual finding on postoperative chest radiographs. In retrospect, this was a clue to a recurrent TEF: disappearance of the surgical clips from the site of surgical repair. Knowledge of this radiographic finding could aid in the diagnosis of a recurrent fistula in patients with previous repair of EA.

Transaxillary subcutaneouscopic sternocleidomastoid tumor division for treatment of persistent torticollis in children: our technique

The purpose of this study was to evaluate the effectiveness of the transaxillary subcutaneous endoscopic sternocleidomastoid muscle division for treatment of persistent torticollis. Traditionally persistent sternomastoid torticollis is treated with a neck incision which results in a neck scar. We report our technique of transaxillary subcutaneouscopic sternocleidomastoid (TASS) division for treatment of persistent torticollis which avoids a neck scar and provides a better view of the neck structures. A 10-year-old girl presented to the clinic for the first time with a history of right sided torticollis. Contralateral (left) side neck rotation and extension were extremely limited. She was able to flex and rotate her neck slightly to the same side. A tough fibrous cord was felt on palpation of her right sternomastoid which was limiting her neck motion. Her neck position was flexed and rotated to the right at rest. The right sternocleidomastoid muscle was divided using the transaxillary subcutaneouscopic technique. The patient tolerated the procedure very well with full range of motion (was able to flex and extend the neck fully and also able to move it side to side [rotation] to the full extent on both sides) of her neck and had good cosmetic results with almost invisible scars hidden in the axilla. Finally, we concluded that the transaxillary subcutaneouscopic sternocleidomastoid muscle division is a good surgical technique for treatment of persistent torticollis in children.

Papillary adnexal neoplasm (Aggressive digital papillary adenocarcinoma) on the ankle of a 15 year old girl: case report and review of literature from a pediatric perspective

Digital papillary adenocarcinoma is a rare malignant tumor of the sweat glands, most commonly encountered in adult males. Only few pediatric cases have been reported, with an apparent predominance of females and none on the ankle. We report a case of a 15‐year‐old girl with a slowly growing, non‐tender mass on the right ankle presenting with difficulty in walking; clinically believed to be a keloid. Excision of the mass revealed a glandular neoplasm with largely eccrine and focally apocrine differentiation. Histologic features do not reliably predict biologic behavior. Because of the existing confusion over the nomenclature, we propose that such tumors be called ‘papillary adnexal neoplasms of distal extremities’.

Subcutaneoscopic Excision of External Angular Dermoid Cysts: Our Covert Scar Approach in 11 Cases

Introduction External angular dermoid cysts, or epidermoid inclusion cysts, are a common subcutaneous tumor of the head and neck. For the majority of these lesions, excision is relatively simple and performed through an incision immediately overlying the mass. Facial lesions in pediatric patients present a unique challenge in that a direct approach carries the potential for visible scar formation. Objective This article aims to detail our experience with subcutaneoscopic excision of external angular dermoid cysts in pediatric patients using endoscopic instrumentation. Materials and Methods Retrospectively, we reviewed 11 cases, between the ages of 4 months and 3 years with external angular dermoid cysts. An incision is made on the scalp above the hairline, then a tunneled working space is created underneath the skin. 3 mm laparoscopy instruments were then used for providing excellent visualization and precise subcutaneoscopic dissection. Results There were no complications apparent in any of the 11 cases (except cyst rupture in one case), with mean procedure duration at 61 minutes. Final results at follow‐up revealed aesthetically pleasing and well‐healed skin incisions, hidden from view behind the hairline. Conclusion The subcutaneoscopic technique utilizing endoscopic instrumentation has the advantage of improved visualization of the cyst, greater precision of dissection, and excellent cosmesis. One disadvantage of this procedure is that this involves learning a new technique while the majority of surgeons are already comfortable with the open approach. Given the safety and efficacy observed for this subcutaneoscopic procedure, this technique can have tremendous possibilities.

Laparoscopic Gastroscopic Transgastric Cystogastrostomy and Cholecystectomy for Pseudopancreatic Cyst after Gallstone Pancreatitis in Children

A 15-year-old girl presented with gallstone pancreatitis. Subsequently, a pseudopancreatic cyst developed that was diagnosed on computed tomographic scan. She underwent a laparoscopic and gastroscopic transgastric cystogastrostomy. In the following report, we describe our novel approach and technique for the above condition.