Brice Antao

Management of rectal prolapse in children.

PURPOSERectal prolapse in children is not uncommon and usually is a self-limiting condition in infancy. Most cases respond to conservative management; however, surgery is occasionally required in cases that are intractable to conservative treatment. This study was designed to analyze the outcomes of rectal prolapse in children and to propose a pathway for the management of these cases in children.METHODSA retrospective analysis of all cases of rectal prolapse referred to our surgical unit during a period of five years was performed. End point was recurrence of prolapse requiring manual reduction under sedation or an anesthetic. Results are presented as median (range) and statistical analysis was performed using chi-squared test; P < 0.05 was considered significant.RESULTSA total of 49 children (25 males) presented with symptoms of rectal prolapse at a median age of 2.6 years (range, 4 months –10.6 years). All children received an initial period of conservative treatment with watchful expectancy and/or laxatives. Twenty-five patients were managed conservatively without any additional procedures (Group A), and 24 patients had one or more interventions, such as injection sclerotherapy, Thiersch procedure, anal stretch, banding of prolapse, and rectopexy (Group B). Management of rectal prolapse was successful with no recurrences in 24 patients (96 percent) in Group A vs. 15 patients (63 percent) in Group B at a median follow-up period of 14 (range, 2–96) months. An underlying condition was found in 84 percent of patients in Group A vs. 54 percent in Group B (P = 0.024). The age at presentation was younger than four years in 88 percent of patients in Group A vs. 58 percent in Group B (P = 0.019).CONCLUSIONSRectal prolapse in children does respond to conservative management. A decision to operate is based on age of patient, duration of conservative management, and frequency of recurrent prolapse (>2 episodes requiring manual reduction) along with symptoms of pain, rectal bleeding, and perianal excoriation because of recurrent prolapse. Those cases presenting younger than four years of age and with an associated condition have a better prognosis. The authors propose an algorithm for the management of rectal prolapse in children.

Diagnostic Difficulties in the Management of H-type Tracheoesophageal Fistula

Purpose: To evaluate the diagnostic difficulties and pitfalls in establishing the diagnosis of congenital H-type tracheoesophageal fistula. Material and Methods: A retrospective review of all cases of H-type tracheoesophageal fistula that were diagnosed in a single unit over a 6-year period. The variables assessed were age at presentation, presenting symptoms, time to diagnosis, investigations, and time to surgical repair of H-type fistula. The investigations leading to a definitive diagnosis are assessed and discussed. Results: Between 1998 and 2004, five cases of H-type tracheoesophageal fistula presented to our unit. All cases had an upper gastrointestinal contrast study/tube esophagogram. In addition, four cases had a chest radiograph, three cases had a bronchoscopy, and one case an esophagoscopy. The median delay from the time of first presentation to diagnosis of H-type tracheoesophageal fistula was 14 days (7–58 days). Median age at surgery was 15 days (8–60 days). Conclusion: Although symptoms are usually present from birth, the diagnosis of H-type fistula is difficult and often delayed. The various diagnostic techniques are not entirely reliable and fistula identification can be elusive. The authors present recommendations for the diagnostic work-up, which may increase the diagnostic potential and avoid unnecessary delays in the diagnosis and management of H fistula.

Factors affecting the outcome of foreskin reconstruction in hypospadias surgery

OBJECTIVE Despite ongoing refinement of numerous techniques, the incidence of complications following hypospadias repair is still significant. The aim of this study is to evaluate the factors that affect the success in childhood of foreskin reconstruction with hypospadias repair. MATERIALS AND METHODS A retrospective study was carried out of all primary hypospadias repairs with foreskin reconstruction (n=408) over the last 23 years. The hypospadias was coronal in 160 (39%), glanular in 114 (28%), subcoronal in 78 (19%) and distal penile in 56 (14%) cases. Foreskin reconstruction was included in 362 cases suitable for a meatal advancement (191) or distal urethral tubularization (171), and 46 cases for a flip-flap procedure (37 Mathieu, nine Barcat). Outcome analysis was of foreskin-related complications post surgery. RESULTS Foreskin repair was successful in 333 cases (92%) that underwent meatal advancement/distal urethral tubularization, and 33 (72%) that underwent a flip-flap operation. Complications related to the foreskin occurred in 10% of the whole group with a urethral fistula rate of 8%. The median age at surgery was 13 months (2-120 months), and the median follow-up period was 11 months (1-100 months). CONCLUSIONS A good cosmetic and functional outcome can be achieved with foreskin reconstruction combined with a variety of hypospadias repairs. The outcome in this series was better in cases of distal hypospadias using interrupted polyglactin sutures.

Foreign body ingestion causing gastric and diaphragmatic perforation in a child

Foreign body ingestion is a common problem in children. Most ingested foreign bodies pass through the gastrointestinal tract without difficulty once they reach the stomach. Perforation of the gastrointestinal tract very rarely occurs. This case report discusses the clinical presentation and management of a very unusual case of an eyeliner pencil ingested by a child that perforated the stomach and diaphragm, causing empyema.

Gonadoblastoma in patients with 45,X/46,XY mosaicism: A 16-year experience.

BACKGROUND It is recognised that individuals with a 45,X/46,XY karyotype, known as Turner mosaic syndrome with Y chromosome material (TMSY), have an increased risk of developing gonadoblastoma (GB), which may then devolve into one of a number of germ cell malignancies. Hence, children with TMSY are usually recommended to undergo prophylactic gonadectomy. OBJECTIVE We designed this study to describe the phenotypic features of our series of children with TMSY who underwent prophylactic gonadectomy in order to evaluate the prevalence of GB and germ cell malignancies in their resected specimens. STUDY DESIGN This is a retrospective case series wherein we comprehensively reviewed the clinical, histological, and cytogenetic features of all patients who underwent prophylactic gonadectomy at three tertiary paediatric referral centres over 16 years. Cases were identified from surgical logbooks and through the institutional histopathology database. Data were collected with particular reference to clinical phenotype, predominant karyotype cell line, operative management, anatomical findings and the presence of neoplastic changes. RESULTS Fourteen children ranging in age at the time of surgery from 2 weeks to 17 years were included in the series. Eleven children were reared as females. The three children who were reared as males had severe penoscrotal hypospadias. The 46,XY cell line was the predominant cell line in seven (50%) cases in blood lymphocytes. The resected specimens from four patients (28.6%) contained GB, with three patients having bilateral GB. This sub-group of patients with GB were aged 5 months, 48 months, 71 months, and 13 years. GB arose in one patient with and three patients without genital virilisation. There was no focus of invasive germ cell tumour in any specimen. DISCUSSION GB may be present in infants with TMSY as young as 5 months, even with low levels of Y chromosome material. The prevalence of GB in prophylactic gonadectomy specimens is similar to many previously reported series, although the absence of dysgerminoma in our series is reassuring. The exclusive presence of GB in intra-abdominal gonads is in keeping with the findings of several other series. CONCLUSION Owing to the presence of gonadoblastoma in the gonads of children with TMSY as young as 5 months, we recommend that all patients with intra-abdominal gonads in the context of TMSY should duly undergo prophylactic gonadectomy, although the timing of such surgery can be discussed with parents during counselling regarding the risk of malignancy.

Congenital intestinal fistula with exomphalos minor.

Minor degrees of exomphalos have been known to be associated with vitellointestinal duct anomalies. The most frequent association is Meckel’s diverticulum. It is unusual for a fistula to be communicating directly with the exomphalos sac. We report five neonates that presented with a fistula on the exomphalos sac over a 10-year period. The different variants of patent vitellointestinal duct in these cases have been discussed with a review of the literature.

H‐type tracheoesophageal fistula masquerading as achalasia cardia in a 13‐year‐old child

Abstract:  H‐type tracheoesophageal fistula is rare. Although symptoms are present from birth, its rarity and overlap of symptoms with other respiratory conditions makes diagnosis difficult and delayed. We report a case of H‐type fistula in a 13‐year‐old girl that was detected incidentally during investigations for achalasia cardia.

H-type tracheoesophageal fistula with type III laryngotracheoesophageal cleft

H-type tracheoesophageal fistula and laryngotracheoesophageal cleft are both rare anomalies. Laryngotracheoesophageal clefts are identified as a part of Opitz-Frias syndrome. We report a neonate with this combination of rare congenital anomalies. These associated malformations can have major implications in terms of resuscitation, diagnosis and surgical management, which are discussed.

Congenital Middle Mesocolic Hernia: A Rare Cause of Neonatal Intestinal Obstruction

Congenital mesocolic hernia is an extremely rare, but serious cause of intestinal obstruction in children. Given the rarity of this condition, delays in diagnosis and management can have catastrophic consequences. Congenital mesocolic hernias are usually caused by an abnormal rotation of primitive mid-gut and are divided into left and right congenital mesocolic hernias. We report and discuss the clinical and radiological features and management of a neonate with an extremely rare variant, congenital middle mesocolic hernia along with a literature review of this rare condition.

Pneumoperitoneum: a rare air leak in an infant with bronchiolitis and high-frequency oscillatory ventilation

A 4-month-old male infant developed respiratory distress, respiratory synchitial virus bronchiolitis with bilateral segmental collapse consolidation of upper zones requiring intraosseous vascular access with left tibial fracture, intubation and difficult mechanical ventilation. He was being treated in paediatric intensive care unit for the past 10 days and required antibiotics, dexamethasone, ribavirin, nitric oxide and high frequency oscillatory ventilation. He then developed abdominal distention, but was tolerating feeds and passing normal stools. His abdomen was soft, non-tender, bowel sounds were normal and all laboratory investigations including inflammatory markers were within normal …