Devendra Kumar Yadav

Enteric Duplication Cysts in Children: A Clinicopathological Dilemma.

AIM Enteric duplication cysts are rare and uncommon congenital malformations formed during the embryonic period of the development of human digestive system and are mainly encountered during infancy or early childhood, but seldom in adults. The clinical presentation is extremely variable depending upon its size, location and type. We present six cases of enteric duplication cysts with diverse clinico-pathological features. MATERIALS AND METHODS This study was carried out in the Department of Pathology and Department of Paediatric Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India for a period of 2 years (January 2013 - December 2014). We retrospectively analyzed six patients of enteric duplication cysts based on data obtained, which consisted of patients age, sex, clinical presentation, radiological features, operative findings and histopathology report. The data collected was analyzed by descriptive statistics. RESULTS Six children between age range of 3 days to 10 years had enteric duplication cysts. Two had ileal and one each were of pyloroduodenal, colonic and rectal duplication cyst. In one patient a presumptive diagnosis of enteric duplication cyst was made. Radiology played an important contributory role in diagnosis of these cysts in all the patients but histopathology proved to be gold standard for its confirmation. All these patients were managed by surgical excision. The postoperative and follow up period in all the cases was uneventful. CONCLUSION It is important to be aware and make a definitive diagnosis of this rare congenital anomaly as they can present in various clinical forms and can cause significant morbidity and even mortality if left untreated by causing life threatening complications.

Peripherally inserted central venous lines versus central lines in surgical newborns — A comparison

ObjectiveTo compare the insertion characteristics, utilization profile, life span and the complication rates of Central lines (CL) and Peripherally inserted central lines (PICL).MethodsA prospective study of all CL or PICL insertions during January 2007 to September 2007 in the Neonatal Surgical Intensive Care Unit of a tertiary care center was done. The number of attempts, procedure time, duration of catheter stay, number of dressing done, complication during insertion and maintenance and cause of removal were noted and the differences analyzed statistically using Pearson chi square / t test. P value. 0.05 was considered significant.ResultsNinety two neonates were included in the present study of whom 60 were PICL insertions and 32 CL insertions. The two groups were comparable in terms of age, weight and the use of total perental nutrition (TPN) through the catheters. On comparing the PICL and CL groups, the number of attempts for successful insertion (p=0.003), the time taken (p=0.005), the number of dressing changes required during the indwelling period (p=0.005) and the overall complication rates (p=0.002) were significantly less in the PICL group. The PICL could be maintained for longer periods of time (p= 0.005) and only in 11.5% of the patients it had to be removed before completion of therapy as compared to 37.5% early removals for CL (p=0.02)ConclusionPICL is a safe, effective and reliable method of providing prolonged IV access in newborns. It also has the least incidence of complications during insertion and maintenance over prolonged period of time when compared to CL and should be recommended for routine use in neonatal surgical patients.

Hepatopulmonary fusion: a rare and potentially lethal association with right congenital diaphragmatic hernia.

Hepatopulmonary fusion is an extremely rare accompaniment of right congenital diaphragmatic hernia. It is associated with abnormal systemic arterial supply and venous drainage of the right lung along with congenital heart disease. Children with this condition have a comparatively poor prognosis. We report a case of right congenital diaphragmatic hernia with hepatopulmonary fusion along with review of the literature with stress on diagnosis and management.

Does Pneumomediastinum and Pneumoretroperitoneum Always Necessitate Surgical Treatment

To the Editor: A seven-year old girl, having history of accidental ingestion of button battery, presented to our emergency department with pain in the chest, nausea and vomiting after feeds for the last 3 h. On examination, the general condition of the child was well preserved and her systemic examination was unremarkable. A chest radiograph (Fig. 1a) at initial presentation revealed button battery impaction at lower-third of the esophagus. Rigid esophagoscopy confirmed the presence of button battery with the impaction site (anterior wall of distalthird of esophagus) revealing a grade 3 injury [1]. The child followed an unremarkable course throughout the procedure and battery was removed with minimal insufflation. Although the child remained asymptomatic, chest and abdominal radiographs after 4 h (Fig. 1b) revealed pneumomediastinum and pneumoretroperitoneum. She was kept nil per oral and an expectant management was followed. Serial radiographs after 48 h showed resolution of free air. The child was discharged uneventfully on day 5 of admission after resumption of feeding. Free air inside the body cavities depicts injury to the lung or hollow viscus. Its management mainly depends on presence of symptoms and vicinity to vital structures [2]. Unlike pneumothorax, therapy for isolated pneumomediastinum is generally conservative. Surgery is limited to life-threatening mediastinitis, tension pneu-

Caecal volvulus with intestinal malrotation: need for caecopexy?

Caecal volvulus accounts for 30% of all colonic volvulus.1 It occurs due to torsion or hyperflexion of an enlarged, poorly fixed hypermobile caecum. It manifests in two forms: axial rotation of the caecum and the ileum around the mesentery and the less common caecal bascule, where the bowel folds up on itself.2 Intestinal malrotation occurs due to incomplete or faulty rotation and fixation of the gut during the 5th to 11th week of fetal life. A combination of both is rare. A 10-year-old boy presented with the complaints of right lower quadrant pain, bilious vomiting and non-passage of stools since 2 days. On examination, the child was dehydrated, had tachycardia, had low-volume pulse, had blood pressure …

Management of long segment congenital esophageal stenosis: A novel technique

Congenital esophageal stenosis (CES) is a rare cause of dysphagia in children. Diagnosis is often apparent on esophagogram. Surgical treatment for the subtype with tracheobronchial remnants (TBR) includes resection and anastomosis of the stenosed segment, myectomy, enucleation of cartilage, etc., These procedures are not suitable if the stenosed segment is long. We present a case of a 5-year-old boy who was diagnosed as CES and was successfully managed with stricturoplasty with some innovative modifications.

Cap of Pen Aspiration Causing Multiple Lung Lesions.

To the Editor: Foreign body aspiration generally leads to unilateral radiological finding in the form of localized bronchiectasis, collapse or hyperinflation. We report an older child (aged 12 y) in whom radiological changes involving both sides of the lung were due to unusual foreign body (cap of pen) in the left lingular lobe. A 12-y-old girl presented with recurrent cough, fever and breathlessness, for last one and half year, requiring hospitalization twice and was treated with multiple courses of antibiotics and antituberculosis drugs. There was no history of recurrent wheeze, pneumonia or foreign body aspiration in the past. On examination, there was no clubbing, breath sounds were decreased in right infra-scapular region and crepitations were heard on left side of the chest. Other systemic examinations were within normal limit. Chest radiograph revealed right lower lobe collapse. CT chest showed multifocal atelectasis and air trapping (Fig. 1). On flexible bronchoscopy, an unusual foreign body (cap of a pen) was found impacted in left lingular bronchus. Foreign body removal was attempted by rigid bronchoscopy using different types of forceps but failed as it was densely impacted. Thus, removal had to be performed by open left posterolateral thoracotomy and left lingular segment bronchotomy. Patient was discharged after 10 d. Other possible causes of multifocal lung involvement were investigated by appropriate tests and causes such as tuberculosis, primary and secondary immune deficiencies, allergic bronchopulmonary aspergillosis, cystic fibrosis, and primary ciliary dyskinesia were ruled out by appropriate investigations (Results not shown). Foreign body aspiration is a life threatening medical emergency and is relatively common in preschool children. Our patient had unusual findings in the form of older age (12 y) with aspiration of unusual FB (pen cap) that remained without diagnosis for more than 1.5 y, removed from lingular segment (very rare site) and which caused multiple segmental atelectasis and bronchiecatsis. Foreign body aspiration is most common in 1–3 y age group and peanut is the most common foreign body followed by vegetable seeds and is commonly seen in right main bronchus [1]. Pen cap is an unusual foreign body in the airways of children. In a study, the median age of presentation was 8.7 y with male to female ratio of 7.8:1. Time interval between foreign body aspiration and removal ranged from hours to 6 y, but 75 % cases were seen within 1 wk [2]. Foreign body in the lingular segment is rarely found due to anatomical reasons and has been reported in an adult patient (dental piece) [3]. Radiological findings on chest radiograph are due to indirect signs of foreign body aspiration because most of the foreign bodies are radiolucent. In our case radiological findings are multifocal areas of atelectasis and air trapping with bronchial narrowing. Bilateral multifocal radiological findings due to foreign body in airways are rarely reported [4]. These findings can be explained by mobile foreign body; initially it lodged in the right bronchus leading to collapse of the right * Sushil K. Kabra skkabra@live.in