K. L. N. Rao

Side-to-side lienorenal shunt without splenectomy in noncirrhotic portal hypertension in children

Noncirrhotic portal hypertension is a common cause of upper gastrointestinal bleeding in infants, children, and adolescents in India. More than one major bleeding episode, severe hypersplenism, presence of fundal varices, rare blood group, remoteness from the hospital, and patient noncompliance to sclerotherapy formed the main indications for shunt surgery. One hundred four cases of noncirrhotic portal hypertension (age range, 18 months to 20 years) underwent side-to-side lienorenal shunt (SSLR) without splenectomy in a period of 15 years. Splenic veins varying in diameter from 4 to 18 mm and in length from 3 to 4 cm were skeletonized through the root of transverse mesocolon and a shunt of at least 1.5 cm in diameter was constructed. At a mean follow-up of 54 months, 87% of shunts were patent, 13% of shunts were blocked, and 2% were inadequate. Ten percent of the children had rebled, all of whom had a blocked shunt. Growth and development was normal and no patients developed encephalopathy. There was a good correlation between shunt patency on splenoportography and endoscopic disappearance of varices, reduction in the size of spleen and splenic pulp pressure, and improvement of hypersplenism.

Effect of propranolol vs prednisolone vs propranolol with prednisolone in the management of infantile hemangioma: a randomized controlled study.

AIMS AND OBJECTIVES The purpose of this study was to compare the efficacy of orally administered propranolol versus prednisolone versus both in the treatment of potentially disfiguring or functionally threatening infantile hemangiomas. MATERIAL AND METHODS A prospective study of 30 patients aged 1 week-8 months was randomized into three equal groups. These were as follows: A, propranolol (2-3 mg/kg/d); B, prednisolone (1-4 mg/kg/d); and C, receiving both for a minimum duration of 3 months. Dimensions, color, consistency, ultrasonography, photographic documentation based on Visual Analogue Scale (VAS) were recorded before and periodically after starting treatment. A minimum 75% improvement was considered as success with no regrowth up to 1 month of stopping treatment. RESULTS Mean initial response time (days) in A (4.1±3.3 SD) and C (4.7±3.4SD) was significantly lower than B (9.78±7.8SD) (p<0.047). Significant change in consistency was noted very early in A (24 hours) compared to B and C (8 days). VAS results are as follows: (a) color fading--significant reduction in A within 48 hours compared to B and C (p=0.025), (b) flattening--more significant and earlier in A and C than B (p<0.05), and (c) mean reduction in size: significant in A and C at 3 months (p=0.005, p=0.005), 6 months (p=0.005, p=0.008), 12 months (p=0.005, p=0.008), and 18 months (p=0.02, p=0.04), whereas in B, it was seen only at 6 months (p=0.008). CONCLUSIONS Propranolol had a consistent, rapid therapeutic effect compared to prednisolone. A combination of the two had a comparable but not higher efficacy than propranolol alone. Prednisolone was associated with a higher number of complications, thereby decreasing patient compliance.

Beware of neonatal appendicitis

We report a neonate with acute appendicitis who was mistakenly diagnosed and treated initially as neonatal necrotizing enterocolitis. The diagnostic dilemma of this rare and life-threatening condition in premature babies and newborns is underlined. Awareness of this rare condition and possible differential diagnosis in this age group is also discussed.

CT virtual bronchoscopy: New non invasive tool in pediatric patients with foreign body aspiration

A 2-year-old girl presented with recurrent cough, wheese and breathing difficulty. Her imaging (CT and virtual bronchoscopy) revealed a foreign body in tracheobronchial tree, that was removed by rigid bronchoscopy.

Gastric augmentation in isolated congenital microgastria

A 10-month-old boy with isolated congenital microgastria is reported. This is an extremely rare condition with only 2 previous similar case reports. The patient was treated successfully with early gastric augmentation. Although the embryologic origin of this anomaly was widely believed to be in the fourth week of gestation, the anatomic features in the current case point to the arrest of development at least after the eighth week of fetal life.

Esophageal perforations due to foreign body impaction in children.

AIMS The treatment of perforating esophageal foreign body impaction (FBI) is complex and unclear. We present the outcome of surgical treatment of esophageal perforations due to FBI in children along with a management algorithm. METHODS During a period of 7 years, 7 cases of esophageal perforations due to foreign body (FB) ingestion were referred to our unit. We analyzed the FB types, lodging duration and location, complications, and the surgical approaches. RESULTS There were 4 male and 3 female patients. Mean age was 28 months (5 months-6 years). Six patients had metal FBs of variable shapes and 1 had glass marble. Three patients had witnessed history of FB ingestion. Duration of ingestion was variable and unknown in half of the patients. The site of impaction was cervical (1) and thoracic (5) esophagus. One patient had a marble as FB in the superior mediastinum. One patient manifested with features of perforation after removal of the impacted FB and 5 patients presented with perforations. Two patients presented with subcutaneous emphysema. One patient had trachea-esophageal fistula (TEF) after disc battery ingestion. Rigid esophagoscopy failed in 4 out of 6 patients. Five patients underwent thoracotomy, and repair with a pleural patch reinforcement. One patient had lateral esophagotomy in the cervical esophagus for removal of the impacted FB. Mediastinal FB was removed without opening the esophagus. All the patients were discharged uneventfully. CONCLUSIONS Esophageal perforation following FBI is rare and requires prompt treatment. Surgical treatment tailored to the needs of individual patients is associated with a successful outcome and decreased morbidity.

Foreign body oesophagus in a neonate: A common occurrence at an uncommon age

Neonatal ingestion of foreign body is a very uncommon occurrence. We describe a 25-day-old neonate who had a large-sized stone impacted in the cervical oesophagus. The stone was accidently lodged by one of the elder siblings while playing. The stone, after failure to be retrieved endoscopically, was successfully removed by open esophagotomy. The case describes the unusual occurrence at a very uncommon age. It also re-affirms the successful role of open surgery in such situations, which are otherwise commonly treated endoscopically.

Congenital pouch colon associated with anorectal agenesis (pouch colon syndrome)

Dear Sir, The review article by Rajiv Chadha on ‘‘Congenital pouch colon associated with anorectal agenesis’’ (Pediatr Surg Int 2004; 20:393–401) was interesting. We would like to mention the following observations regarding this disease. Four types of congenital pouch colons (CPC) have been described [1]. In type I, the entire colon is converted into a pouch; in type II, the caecum enters into a pouch; and in type III, at least 10–15 cm of normal colon is present proximal to the pouch. In a type IV pouch colon, only the terminal portion of the colon, i.e. rectum and sigmoid, is transformed into a pouch. The author states that only 7.8% cases of CPC have been reported outside India. We are of the opinion that the incidence in the West is much higher than the one quoted, as many cases of type IV CPC are being inappropriately labelled as rectal ectasia/megarectum-megasigmoid. The case reports of Cloutier et al. [2], Peña et al. [3], and several others are a case in point [4–9]. Children who continued to suffer from severe constipation and overflow incontinence following previous surgery for low/intermediate anorectal malformations (ARM) were referred to these authors. There was no anal stricture, and all children had normal sphincter contraction and sensation. Contrast enemas showed massive stool-filled rectosigmoid with abrupt transition to normal-sized proximal colon. Following excision of the dilated bowel, all the children improved. This abrupt change in the diameter of the bowel is a classical feature of CPC [1]. Girls with anovestibular fistula may not decompress well despite an adequate anal opening. To avoid the abovementioned problem, we routinely perform a barium enema prior to anorectoplasty to rule out a CPC. Over the years, we have observed a striking trend of reducing severity of pouch colon—e.g. from type I towards type IV—in our part of the world. Although only one case of type IV CPC was seen out of a total of 56 cases between 1968 and 1984, the figure rose to 46 out of a total of 81 cases between 1985 and 1999 [10]. A study from another tertiary centre in India also showed that out of 41 cases of CPC, 51% were type IV pouch colon [11]. Whether this change is due to improving nutrition in the community or diminishing effect of the causative agent is unknown. The cases reported in the Western literature also appear to be corresponding to type IV pouch, which is usually associated with low/intermediate ARM. Increased awareness of this entity is essential to avoid postoperative problems of severe constipation in this subgroup of patients with ARM as exemplified in the reported cases [2–9]. Excellent results can be obtained by complete excision of the pouch in all cases of type IV CPC prior to anoplasty.

Surgical management and outcome analysis of stage III pediatric empyema thoracis.

Aim: Report of 125 pediatric patients of empyema thoracis treated by open decortication, highlighting the presentation, delay in referral, operative findings, the response to surgical intervention and follow-up. Materials and Methods: All the children who underwent open decortication for stage III empyema thoracis during the study period were included. Preoperative workup included hemogram, serum protein, chest radiographs and contrast-enhanced computed tomographic (CECT) scan of the chest. Results: One hundred and twenty-five patients (81 males, 44 females) (age 3 months–12 years, mean 4.9 years) were operated during a 4.5-year period. Among them, two children underwent bilateral thoracotomies. Also, 81.6% patients were referred 3 weeks after the onset of disease (mean duration 9 weeks). Intercostal chest drainage (ICD) had been inserted in (119) 95% cases. Thickened pleura, multiloculated pus and lung involvement were invariably seen on CECT scan. Bronchopleural fistula was present in 10 patients and empyema necessitatis in 2. Decortication, removal of necrotic tissue and closure of air leaks was performed in all the patients. Necrotizing pneumonia was seen in (35) 27.5% cases. Mean duration of postoperative ICD was 7 days. Follow-up ranged from 3 months to 4 years (mean 12 months). There was no mortality. Six patients had proven tuberculosis. Conclusions: The duration of the disease had a direct relationship with the thickness of the pleura and injury to the underlying lung. Delayed referral causes irreversible changes in the lung prolonging recovery. Only 18% presented within the early period of the disease. Meticulous open surgical debridement gives gratifying results. The status of the lung at the end of surgery is a major prognostic factor.

Segmental dilatation of ileum: an unusual cause of severe malnutrition.

Segmental dilatation of the ileum causing blind loop syndrome was seen in a 6-year-old boy presenting with nonspecific symptoms and severe malnutrition. Barium meal was characteristic. Resection of the affected segment and an end-to-end anastomosis was curative and restored normal bowel function. Clinicians’ awareness of this entity would help in appropriately managing such cases.