Geeta Kekre

Thoracoabdominal pseudocyst of pancreas: An rare location, managed by retrocolic retrogastric Roux-en-Y cystojejunostomy

Pseudocyst formation is a common complication of acute and chronic pancreatitis. Most common site of pseudocyst is lesser sac; mediastinal extension of pseudocyst is rare. Other possibilities of posterior mediastinal cyst must be considered. This patient presented with computed tomography abdomen with thorax showing a large thoraco-abdominal pseudocyst with right sided pleural effusion. It was confirmed to be pancreatic pseudocyst by analyzing fluid for amylase and lipase during surgery. In our patient, the pseudocyst was accessible transabdominaly. Cystogastrostomy was not possible as it was causing twisting of cardio-esophageal junction; we did retrocolic and retrogastric Roux-en-Y cystojejunostomy. Only two such cases were reported in literature.

Immediate and long-term outcome analysis of lipomeningomyelocele repair in asymptomatic infants in a tertiary care center.

Objective: To analyze immediate and long-term results of lipomeningomyelocele (LMM) repair in asymptomatic patients. Materials and Methods: Seventeen patients of LMM presented to Department of Paediatric Surgery over a period from 2011 to 2015 were evaluated preoperatively by magnetic resonance imaging of whole spine, and pre- and post-operative Ultrasound of kidney, ureter, bladder, and neurosonogram. Surgical procedure involved total excision of lipoma in 15 patients and near total excision in 2 patients. Division of filum terminale could be done in 15 out of 17 patients. Follow-up varied from 1 to 3.5 years (mean 1.9 years). Results: This study included 10 (58.8%) patients of lumbosacral LMM, 5 (29.4%) patients of sacral, and 2 (11.7%) patients of thoracolumbar LMM. About 13 (76.4%) patients were operated before 3 months of age, 2 (23.5%) patients were operated between 3 and 6 months, and two patients were operated between 6 and 11 months. None of the patients had bladder/bowel dysfunction preoperatively. Preoperative lower limb power was normal in all patients. Objective improvement in lower limb motor function was observed in 3 (17.6%) patients and three patients had decreased lower limb power. Two patients developed altered sensations and weakness of lower limb about 2.5-3 years after initial LMM repair. They needed repeat detethering of cord. Two patients had fecal pseudoincontinence, whereas one patient developed constipation. Bowel dysfunction was managed by rectal washouts, and oral laxatives were added if required. One (5.8%) patient of lumbosacral LMM and 1 (5.8%) patient of sacral LMM had urinary incontinence postoperatively. This was managed by clean intermittent catheterization with continuous overnight drainage. Conservative management of bladder and bowel dysfunction was effective in all patients till the last follow-up. Two patients developed hydrocephalus after LMM repair for which low-pressure ventriculoperitoneal shunt was inserted. Wound infection occurred in 1 (5.8%) patient, whereas 7 (41.1%) patients developed seroma in wound which responded to repeated aspirations under aseptic precautions. Conclusion: With total excision of lipoma and division of filum terminale satisfactory outcome for asymptomatic patients of LMM can be achieved. Authors recommend early surgery for LMM even in asymptomatic patients. Patients with residual lipoma and undivided filum terminale should be observed closely for the development of progressive neurological changes.

Complete sternal cleft - A rare congenital malformation and its repair in a 3-month-old boy: A case report.

Complete midline sternal cleft is a rare congenital anomaly resulting from failed midline ventral fusion of the sternal bars. Very few cases of complete sternal cleft have been described in literature. We present a case of complete sternal cleft in a 3-month-old child. The patient underwent primary closure of the defect using stainless steel wires.

Undetected duplex moiety with ureteropelvic junction obstruction: A case report

Although ureteropelvic junction obstruction and duplex kidney are common anomalies in child age group, the combination of these two anomalies is a rare association and infrequently reported. A 2 month old male patient antenatally diagnosed as having hydronephrosis of right kidney, was brought to us for follow up. Renal scans and ultrasonography suggested ureteropelvic junction obstruction. It was only intra-operatively, at the time of pyeloplasty that we found he had duplex system of the same side, not picked up in any of the earlier investigations. Pyeloplasty was done over a double J stent. Patient was discharged and called for follow up.

Twenty-Four Hour pH Study and Manometry in Gastric Esophageal Substitutes in Children

Purpose Studies on the physiology of the transposed stomach as an esophageal substitute in the form of a gastric pull-up or a gastric tube in children are limited. We conducted a study of motility and the pH of gastric esophageal substitutes using manometry and 24-hour pH measurements in 10 such patients. Methods Manometry and 24 hour pH studies were performed on 10 children aged 24 to 55 months who had undergone gastric esophageal replacement. Results Six gastric tubes (4, isoperistaltic; 2, reverse gastric tubes) and 4 gastric pull-ups were studied. Two gastric tubes and 4 gastric pull-ups were transhiatal. Four gastric tubes were retrosternal. The mean of the lowest pH at the midpoint of the substitute was 4.0 (range, 2.8–5.0) and in the stomach remaining below the diaphragm was 3.3 (range, 1.9–4.2). In both types of substitute, the difference between the peak and the nadir pH recorded in the intra-thoracic and the sub-diaphragmatic portion of the stomach was statistically significant (p<0.05), with the pH in the portion below the diaphragm being lower. The lowest pH values in the substitute and in the remnant stomach were noted mainly in the evening hours whereas the highest pH was noted mainly in the morning hours. All the cases showed a simultaneous rise in the intra-cavitatory pressure along the substitute while swallowing. Conclusion The study suggested a normal gastric circadian rhythm in the gastric esophageal substitute. Mass contractions occurred in response to swallowing. The substitute may be able to effectively clear contents.

Use of fibrin sealant and tunica vaginalis flap in the repair of urethro-cutaneous fistulas: experience in a tertiary care centre

Urethro-cutaneous (UC) fistula is one of the most common and also the most frustrating complication after hypospadias surgery. The fact that it occurs and recurs has potential physical and psychological consequences to the patient and his family. The general reported rate of UC fistulas is around 0-30% depending on severity of hypospadias, surgical technique and experience of operating surgeon. Attempting to close the fistula without understanding the failure mechanisms can be dangerous. Factors influencing fistula repair are number, size and location of fistulas, condition of local tissue and time after hypospadias repair. Different techniques of hypospadias have different rates of fistula formation. The most commonly used techniques of hypospadias repair in our institute are Snodgrass tubularised incised urethroplasty (TIP) repair, Byar’s staged repair and the island onlay repair.

Aphallia (Penile agenesis): A preliminary report of three cases

Aphallia (penile agenesis) is an extremely rare abnormality with the reported incidence of 1 in 30 million births. The cause of this anomaly is associated with no genital tubercle formation or its development impairment. The majority of patients have 46XY Karyotype. The scrotum, testes and testicular function are usually normal. We report the preliminary experience with 3 cases of aphallia in different age groups along with a review of the literature.

Unusual presentation of metanephric stromal tumor in a neonate

Metanephric stromal tumor (MST) of kidney is an under-reported benign stromal specific renal neoplasm with good prognosis. This tumor is to be differentiated from congenital mesoblastic nephroma and clear-cell sarcoma of the kidney. In this case report, we describe the imaging, gross, and microscopic features of MST with ischemic left kidney in a 1-month-old child and discuss treatment with relevant literature.

Congenital facial teratoma in a neonate: Surgical management and outcome.

Teratomas are among the most common tumors of childhood, but craniofacial teratomas are rare. They can be diagnosed antenatally. Craniofacial teratomas may cause airway obstruction in the newborn. We present a case of a newborn male child who was diagnosed to have a facial tumor in the 8th month of gestation. He was delivered normally and had no respiratory or feeding difficulties. He was also found to have a cleft palate. Serum alpha fetoprotein levels were normal. He underwent excision on day of life 9. At 11 months follow-up, he is well with no evidence of recurrence and good functional outcome.

Use of composite mesh in gastroschisis: A unique approach

Gastroschisis is a congenital defect of the abdominal wall involving evisceration of abdominal contents. Initial surgical treatment of this condition depends on the size of the defect, size of the abdominal cavity and amount of bowel exposed. Various techniques described are primary closure, use of the skin flap and silo bag application, followed by fascial closure. Here we present a case wherein even after 7 days of silo bag application, fascial closure was not possible, and a composite mesh was used to cover the bowel until further repair could be attempted.