Htut Saing

Early and late results of excision of choledochal cysts

BACKGROUND/PURPOSE Reports on the late results of choledochal cyst excision with hepaticojejunostomy in children are relatively few. METHODS Of the 84 patients who had choledochal cyst who came under our care, 79 have had definitive surgery, three are awaiting surgery, one is being observed with Carolis disease, and the parents of one child have refused surgery. Thirty-eight patients treated decades ago had internal drainage procedures. Since 1972, 41 patients have had cyst excision with hepaticojejunostomy using a 40-cm Roux loop without an antireflux procedure. Early complications in those who underwent cyst excision with hepaticojejunostomy included anastomotic leak in three patients who required reoperation, cholangitis in two, and fluid collection in the gall-bladder bed that required no intervention in one. RESULTS During a follow-up period ranging from 4 months to 17 years (mean, 8.5 years), anastomotic stricture, cholangitis, and intrahepatic stone formation developed in two children after being well for 8 years and over 11 years. These children required additional surgical procedures to overcome their problems. Asymptomatic intrahepatic stones 2 years after cyst excision with hepaticojejunostomy developed in a third child. There was no mortality in the entire group that underwent cyst excision and they are all enjoying a good quality of life. CONCLUSIONS Careful, long-term follow-up is important in children who have choledochal cyst excision with hepaticojejunostomy.

Management of choledochal cyst: 30 years of experience and results in a single center

BACKGROUND Choledochal cyst is usually diagnosed in childhood. Early treatment can prevent further complication. We report on our series of patients over the past 30 years. METHODS A retrospective study was performed on all pediatric patients who presented with choledochal cyst from January 1978 to December 2008. The main outcome measures recorded were the clinical presentation, management, and long-term outcome of the patients. RESULTS Eighty-three patients presented to us during the caption period with a mean age at diagnosis of 45 months (0 month to 16 years). Diagnoses were made antenatally in 15 patients. The most common symptoms were abdominal pain (n = 39) and jaundice (n = 35). Seventy-five patients had surgery, in which 72 patients had resection of the cyst and Roux-en-Y hepaticojejunostomy. Ten were performed by laparoscopic means. We categorized the cysts based on the Todani classification. There was no mortality. No malignant change was documented. For those 4 who had Caroli disease, 2 underwent liver transplantation and 2 had hepatectomy. Overall early complication rate was 5.3% (4/75). CONCLUSIONS Complete excision of cyst with Roux-en-Y hepaticojejunostomy is the treatment of choice, and the late result is good. Laparoscopic surgery is feasible. Long-term follow-up is necessary. There is no evidence to suggest that some type IV cysts are the result of disease progression from type I cysts.

Acute pancreatitis in children

Twenty-nine children with acute pancreatitis were managed during the period 1971 to 1983. Aetiology included trauma (5), mumps (5), drug therapy (4), biliary disease (1), and cystic fibrosis (1); 13 cases were classified as idiopathic. Diagnosis could be difficult, and unnecessary laparotomies were performed in 7 instances for suspected appendicitis. One patient, however, had a well-justified laparotomy revealing coexisting severe appendicitis and pancreatitis. Morbidity included relapses (7), pseudocysts (3), obstructive duodenal hematoma (1), and miscellaneous problems (4). Improvements in management included endoscopic retrograde cholangio-pancreatography (ERCP) to exclude anatomical anomalies in relapsing cases, ultrasonography for the diagnosis of pseudocysts and for follow-up measurements in two such cases successfully managed conservatively, and increasing use of total parenteral nutrition in cases with protracted disease or serious complications.

Childhood Intussusception: Ultrasound-Guided Hartmann's Solution Hydrostatic Reduction or Barium Enema Reduction?

A comparison was made of the efficacy of ultrasound guided Hartmanns solution hydrostatic reduction on 23 patients (US group) with the same number of consecutive patients in whom hydrostatic reduction was done by barium enema (BE group) under fluoroscopy for childhood intussusception. The US group was diagnosed by ultrasound scan and reduction was attempted under the guidance of ultrasonography with Hartmanns solution at 100 mm Hg pressure. Excluded were patients older than 12 years, patients in shock, patients with peritonitis, bowel perforation, and gross abdominal distension as well as recurrent intussusception of more than three episodes. There were three patients excluded in this group. The diagnosis of intussusception and complete reduction were confirmed by gastrografin enema. This US group had three recurrences (3 of 26, 11.5%), one lead point (1 of 23, 4.4%), and 19 successful reductions (19 of 26, 73%). Incidentally, there were also three patients excluded in this period of barium enema reduction. There was only one recurrence (1 of 24, 4.2%), one leadpoint (1 of 23, 4.4%), and 12 successful reductions (12 of 24, 50%) in these 23 BE patients. The success rates for the ileo-colic intussusceptions with Hartmanns solution reduction and barium enema reduction were 91% (19 of 21) and 55% (12 of 22), respectively (P = .00865). There was no complication in either group, and the accuracy of diagnosing a complete reduction was 100% in both forms of reduction. Hence, ultrasound-guided hydrostatic reduction for childhood ileocolic intussusception is preferred because it is safe, accurate, has a higher success rate, and can avoid radiation exposure risk.

A study of pre-antibiotic bacteriology in 125 patients with necrotizing enterocolitis

Over a five‐year period, 125 newborns with necrotizing enterocolitis (NEC) were managed by us. Their mean birthweight was 1700 g and mean maturity was 32 weeks. Before commencement of antibiotics, routine septic work‐up was done in order to define the bacterial spectrum and antibiotic sensitivity. The study includes aerobic and anaerobic cultures of gastric and pharyngeal aspirates, blood cultures, umbilical swabs and culture of umbilical catheter tips in relevant cases. Peritoneal swab results were also analyzed if laparotomy was performed. Positive cultures were present in 45 patients (36%) with 55 positive specimens. Fifteen types of organism were isolated: the commonest was Enterobacter (29%), followed by E. coli (14.5%) and Klebsiella (13%). They were resistant to ampicillin and first‐generation cephalosporin. These organisms were usually opportunistic pathogens. Overgrowth of them may be the cause of NEC. Regular review of the antibiotic sensitivity of these organisms allows prompt and appropriate choice of antibiotics. At the same time, antibiotic sensitivity for these organisms was analyzed to guide us in the choice of antibiotic therapy.

Case report: Lingual thyroid, a cause of neonatal stridor

Stridor implies partial airway obstruction, resulting from intrinsic or extrinsic abnormalities of the upper respiratory tract. In a neonate whose airway is small, soft and easily occluded this may be potentially life threatening. Its immediate diagnosis with prompt therapy is a rewarding challenge. When stridor occurs in a neonate with congenital hypothyroidism, surgically amenable cause of obstruction due to an ectopic thyroid or thyroglossal cyst has to be seriously considered. We report a case of neonatal stridor caused by a lingual thyroid, and discuss the imaging approach.

A prospective randomized study of wound approximation with tissue glue in circumcision in children

Objective: Bleeding and wound infection are the most common complications of circumcision. Cyanoacrylate tissue glue has been claimed to have the advantage of being haemostatic, bacteriostatic and easy to use. The purpose of this study is to assess the feasibility of using the tissue glue in approximation of circumcision wound in children.

The Involvement of Two or More Systems and the Severity of Associated Anomalies Significantly Influence Mortality in Esophageal Atresia

PURPOSE The aim of this study was to examine the influence of associated anomalies in babies born with esophageal atresia (EA). METHODS A retrospective review of the records of 41 consecutive cases of esophageal atresia managed over an 11-year period was undertaken. RESULTS A higher incidence of associated anomalies was seen in those babies with lower birth weights. Although all five (100%) babies with EA who weighed less than 1,800 g had associated anomalies, those who weighed 1,800 to 2,500 g and more than 2,500 g were associated with 67% (10 of 15) and 43% (9 of 21) anomalies, respectively. The most common system in which anomalies occurred was the cardiovascular system (37%) followed by gastrointestinal (24%), musculoskeletal (17%), genitourinary (7%), chromosomal (5%), and others (12%). All 17 (41%) babies with no associated anomalies survived. Four of the 10 babies who had two or more systems involvement died, whereas only one of 31 babies with less than two systems involvement died; the difference between these two groups was highly significant (Fishers Exact test, P = .009). The overall mortality rate was 12%. Three of the deaths were associated with severe anomalies that were incompatible with life such as bilateral renal agenesis, trisomy 18, and complex cardiac anomalies. CONCLUSION The association of two or more system anomalies and the severity of associated anomalies influence mortality in esophageal atresia.

Surgical management of choledochal cysts: A review of 60 cases

Sixty cases of choledochal cysts in children are reviewed. The series comprises 55 cases of Alonso-Lej. Type 1 cysts, two cases whose cysts were infraduodenal and retropancreatic in position, and three cases of choledochal cysts with both proximal and distal atresia of bile ducts. The following five types of operative procedures were employed for the 58 cases: (1) Choledochocystoduodenostomy in 12; (2) Partial excision, choledochorraphy and choledocho-duodenostomy in six; (3) Cyst excision, portal dissection and portojejunostomy in three; (4) Choledochocystojejunostomy Roux-en-Y in 20; and (5) Cyst excision with hepaticojejunostomy Roux-en-Y in 17 cases. Two patients did not receive definitive surgical treatment. Early complications included six cases of leakage, of which one died; and four cases of cholangitis and septicemia, resulting in fatality in all. The overall operative mortality was 5/58 (8.6%). This review, though retrospective in nature, further supports the more recent trend that radical cyst excision with hepaticojejunostomy is the treatment of choice. This procedure carried no mortality and low morbidity. All 17 patients treated in this manner are well and free from jaundice and recurrent cholangitis. Cyst excision eliminates the reservoir for bile stasis, biliary obstruction, cholangitis, and biliary cirrhosis. It also removes the possibility of malignant change in the cyst and spontaneous rupture.

Liver transplantation in infants

PURPOSE In view of the earlier reports that children below 1 year of age constitute a high-risk group for liver transplantation, the authors reviewed their experience in performing orthotopic liver transplantation in this age group. METHODS The records of 9 children aged less than 1 year who underwent 6 living-related liver transplants and 3 reduced-size liver transplants between December 1993 and June 1997 were reviewed. RESULTS Five reexplorations were required for 3 children who had 1 or more of the following early complications: bleeding from hepatic vein to inferior vena cava anastomosis (n = 1), right hepatic vein stump bleeding (n = 1), intraabdominal hematoma (n = 2), jejuno-jejunostomy leakage (n = 1), and colonic perforation (n = 1). Late complications include stricture at the biliary-enteric anastomosis requiring percutaneous balloon dilatation (n = 3) and hepatitis of undetermined etiology requiring retransplantation (n = 1). There was no hepatic artery thrombosis despite the small arteries available for anastomosis. Follow-up ranged from 19 to 61 months (mean, 40 months). Patient survival rate was 100%, and graft survival with good liver function was 89%. All living donors, 2 fathers and 4 mothers, are well. CONCLUSIONS Liver transplantation in infants less than 1 year of age is technically demanding but feasible and still can be performed with a good outcome. Age alone (under 1 year) should not be considered as a contraindication for liver transplantation.