Digamber Chaubey

Antireflux status post Roux-en-Y anastomosis: An experimental study for optimal antireflux technique

Background: Roux-en-Y hepaticojejunostomy has been a gold standard to establish biliary-enteric anastomosis for various surgical indications, but associated with variable incidences of cholangitis. This experimental study was conducted to report a modification in Roux-en-Y anastomosis for possible better alternative to provide antireflux procedure after Roux-en-Y biliary-enteric anastomosis with the aim to minimize the possibility of reflux and its consequences. Materials and Methods: For experimental study, the required fresh segment of Lambs small intestine was procured. Three sets of Roux-en-Y anastomosis were created for each experiment. In set 1, there was simple Roux-en-Y anastomosis. In set 2, Roux-en-Y anastomosis along with 4–5 cm long spur between the hepatic and duodenal limbs was created. In set 3, in addition to Roux-en-Y with creation of spur, additional antireflux mechanism was created at the junction of upper two-third and lower one-third of the hepatic limb. Saline mixed contrast was infused by infusion pump to raise the intraluminal pressure to more than 10 cm of H2O. X-ray was taken at that time. Results: In set 1, all preparations demonstrated reflux of contrast in the hepatic limb. The set 2 also demonstrated the same findings of 100% reflux in the hepatic limb. In set 3, No reflux was observed in 8 (80%) preparations while remaining 2 (20%) preparations reveal partial reflux. Conclusion: This experimental study suggests that the provision of spur and additional valve may be able to decrease the possibility of reflux in Roux-en-Y biliary-enteric anastomosis.

Technique of antireflux procedure without creating submucosal tunnel for surgical correction of vesicoureteric reflux during bladder closure in exstrophy

Aim: To report the clinical application of the new surgical technique of antireflux procedure without creating submucosal tunnel for surgical correction of vesicoureteric reflux during bladder closure in exstrophy. Materials and Methods: Based on the report of published experimental technique, the procedure was clinically executed in seven patients of classic exstrophy bladder with small bladder plate with polyps, where the creation of submucosal tunnel was not possible, in last 18 months. Ureters were mobilized. A rectangular patch of bladder mucosa at trigone was removed exposing the detrusor. Mobilized urteres were advanced, crossed and anchored to exposed detrusor parallel to each other. Reconstruction included bladder and epispadias repair with abdominal wall closure. The outcome was measured with the assessment of complications, abolition of reflux on cystogram and upper tract status. Results: At 3-month follow-up cystogram, reflux was absent in all. Follow-up ultrasound revealed mild dilatation of pelvis and ureter in one. Conclusions: The technique of extra-mucosal ureteric reimplantation without the creation of submucosal tunnel is simple to execute without risk and complications and effectively provides an antireflux mechanism for the preservation of upper tract in bladder exstrophy. With the use of this technique, reflux can be prevented since the very beginning of exstrophy reconstruction.

Lipoencephalocele in a Child: An Uncommon Swelling in the Occipital Region

Neural tube defects are common congenital malformations of the central nervous system. The 3 most common neural tube defects are anencephaly, myelomeningocele, and encephalocele. Lipoencephalocele is an extremely uncommon entity with sporadic reports in the literature. We treated a 4-year-old gild with occipital lipoencephalocele. This report presents the clinical presentation and management of the patient along with a review of the relevant literature.

Type V congenital pouch colon: An extremely rare variant of anorectal malformations

Type V is the rarest form of congenital pouch colon with only four cases reported till date. We report this anomaly in a 6-month-old boy. He was managed successfully with excision of distal pouch and coloplasty of proximal pouch along with abdominoperineal posterior sagittal anorectoplasty. We recommend preservation of proximal pouch in such cases.

Spontaneous bladder rupture: unusual presentation in a haemophilic child

A 4-year-old boy child presented with abdominal pain, haematuria, lower abdominal mass and urinary retention. There was no family history of bleeding. Ultrasound abdomen revealed an intravesical blood clot, rupture of the anterior bladder wall and perivesical haematoma. Contrast-enhanced CT (CECT) confirmed the findings. The child had a history of previous gum bleeding which prompted work-up for coagulation disorder. Investigations confirmed haemophilia. Following clotting factor replacement, surgical exploration was done. Intraoperatively, a 3 cm extraperitoneal, longitudinal tear on the anterior bladder wall was found along with haematoma in the bladder and perivesical space. Evacuation of the haematoma and repair of the bladder tear was performed. Postoperative period was uneventful, and the child was asymptomatic at 6-month follow-up. To the best of our knowledge, spontaneous bladder rupture has not been reported in a haemophilic child.

Two Cases of Massively Prolapsed Patent Vitellointestinal Duct

Patent vitellointestinal duct (PVID) is a benign congrnital anomaly ususally presenting with fecal discharge from the umbilicus. In this report, we describe two cases of PVID presented with massive bowel prolapse through the PVID and signs of intestinal obstruction. Surgery revealed prolapse of the ileal intussusceptum through the PVID. Both of the babies were sucssesfully managed with surgery.

Sewing Needle Penetration into Thorax: What Might be the Cause?

A 10-month-old male baby presented with irritability and inconsolable cry for last two weeks which increased on touching the chest. There was no history of fever, respiratory symptoms, or any accident. On examination, an indurated tender nodule over right lower chest was present. Chest x-rays showed a metallic foreign body at right lower chest extending from skin to pleural cavity (Fig.1A,1B). Foreign body was removed under anesthesia. It was a two inches long sewing needle. Child was discharged on day three of hospitalization after information to authority for further action.

A Rare Case of Split Notochord Syndrome

We treated a one day old baby presenting with an extensive lumbosacral deformity, hydrocephalus and apparent enteric segments in the dorsal midline with abnormal genitalia, accompanied by an enteric fistula and imperforated anus. The malformation fits into split notochord syndrome. The baby died as a result of sepsis before surgical treatment could be attempted. Patient was full term caesarian delivery of twin pregnancy. The other baby was a normal live male. There was no history of exposure to teratogenic agents or family history of congenital defects. On admission, the patient was cold, lethargic and tachycardiac. Baby had enlarge head with bulging fontanelle, dorsal midline spinal defect with prolapsing bowel loops (Fig.1). Anal opening was not present and baby had abnormal genitalia, which was extensively shifted dorsally with bifid scrotum, peno-scrotal transposition with right gonad not palpable. There was no leakage of cerebrospinal fluid or visible exposure of neural tissue elements. He could move his lower limbs. Neither urinary retention or dribbling nor a palpable bladder was present. The cranial ultrasound showed type II Arnold Chiari malformation, hydrocephalus, and cerebral cortex abnormal development. The baby was expired on day 3 of life before planning further investigations and surgical interventions due to sepsis.