Kamalesh Pal

Congenital hernia of the umbilical cord associated with extracelomic colonic atresia and perforation of gut in a newborn

Congenital hernia of the umbilical cord (CHUC) is a rare congenital entity compared to more common post-natally occurring umbilical hernia. Although recognized as a distinct entity since 1920s, CHUC is often misdiagnosed as a small omphalocele, resulting in its underreporting. We present the first case report of CHUC associated with extracelomic colonic atresia, complicated by perinatal perforation in a newborn. We also discuss the differentiating features from other anterior abdominal wall defects such as omphalocele and gastroschisis including its embryogenesis.

Effect of lidocaine-prilocaine eutectic mixture of local anaesthetic cream compared with oral sucrose or both in alleviating pain in neonatal circumcision procedure

Background: Neonatal circumcision is one of the oldest and most frequently performed surgical procedures on males. Newborns demonstrate strong endogenous reaction to pain and therefore modalities are being explored for optimum pain relief during circumcision. Pediatric nurses have a vital role for the use of these modalities and minimising the pain response during the neonatal minor procedures. Aim: The aim of this study was to assess the effectiveness of eutectic mixture of local anaesthetic (EMLA) cream compared with oral sucrose and both in alleviating pain in neonatal circumcision. Materials and Methods: This study was conducted in the Day Care Surgery Department of Maternity and Children Hospital, Dammam City, KSA. 90 full-term newborn males who underwent circumcision were divided randomly into three groups (30 each). Each group was assigned to receive a different type of analgesics such as EMLA cream (Group A), oral sucrose (Group B) or combination of EMLA cream and oral sucrose (Group C). Neonatal pain agitation and sedation scale (N-PASS) was used 5 min before, during and 5 min after the circumcision procedure to assess the neonatal response to pain. Results: N-PASS scores were significantly lower in Group C (median Group C = 5.2, Group A = 5.8, Group B = 8.5; P< 0.001). The endogenous response to pain in terms of escalation of heart rate and reduction in O 2 saturation were minimal among Group C (P < 0.0001). Duration of crying was comparable among all the groups. Conclusion: The combination of sucrose and EMLA cream revealed a higher analgesic effect and minimal adverse response to pain than either EMLA cream or sucrose alone during neonatal circumcision.

Laparoscopy in the management of emphysematous cholecystitis and secondary appendicitis in an 11-year-old child with insulin-dependent diabetes mellitus

Acute abdomen in a diabetic child may cause diagnostic dilemma. Acalculous emphysematous cholecystitis (EC), although reported among critically ill or diabetic adults, is an uncommon occurrence in the children. It may complicate the presentation due to its varied manifestations; especially when associated with other concomitant intra-abdominal inflammatory pathologies. We encountered a rare concurrence of acute EC complicated with pericholecystic fluid collection and secondary appendicitis causing non-specific acute abdomen in an 11-year-old obese boy with insulin-dependent diabetes mellitus. Laparoscopy proved to be a highly useful tool in the diagnosis and treatment of this surgical dilemma.

Granulomatous appendicitis in children: A single institutional experience

Background: Granulomatous appendicitis (GA) is a rare entity, mostly mentioned in adults. There have been anecdotal case reports describing GA in the paediatric population. This study was aimed at reviewing the cases of appendectomies to assess the incidence and characteristics of GA in children in a tertiary care University hospital. Materials and Methods: Records of children (<13 years age) with biopsy proven granulomatous lesions in the appendectomy specimen, treated during 1991-2011, were analysed. Data regarding demography, clinical presentation, radiological findings, intra-operative finding, histology, diagnosis and follow-up were recorded and descriptively analysed. Results: Twelve out of 1150 (1.04%) appendectomies were biopsy proven GA. Male to female ratio was 8:4. Four had Yersinia enterocolitis, two had Crohn′s disease (CD; one isolated Crohn′s Appendicitis, one Ileo-cecal Crohn′ with appendicitis) and five were idiopathic. Remaining one case, initially diagnosed as idiopathic GA, developed full blown ileo-cecal CD at 2 nd month post-operative. Age ranged between 4 and 11 years with inflammatory bowel disease (IBD) affecting older children and Yersinia, seen in younger children. Majority (10/12) remained asymptomatic at a maximum of 5 years of follow-up. Two patients had recurrent symptoms; one with sub-acute obstruction (2 years follow-up) and another with flaring of Crohn′s ileitis (2 months follow-up). Conclusions: GA in children is a rare entity, with incidence of 1.04% and male preponderance in our series. Idiopathic causes were the most common followed by Yersinia enterocolitis and CD. Although majority remained asymptomatic, IBD should be ruled out in case of recurrence of pain or alteration of bowel habit. Therefore, a long-term follow-up (at least for 5 years) of idiopathic GA is suggested in children.

A treatise on intestinal duplications

Duplications of the alimentary tract are unusual congenital anomalies that often present a diagnostic, as well as therapeutic challenge to the treating surgeon. These lesions occur infrequently and are often not suspected until encountered intraoperatively. Due to the complicated anatomy and involvement of the adjacent bowel, appropriate management requires familiarity with the anatomy and clinico-pathological characteristics. This review article is a treatise on intestinal duplications which addresses the current understanding, their epidemiology, classification, etiogenesis, management options and prognosis.

Esophageal lung resection and prosthesis placement in a preterm neonate

This report describes a successful outcome in a preterm baby with an esophageal atresia and tracheo-esophageal fistula, who initially underwent a primary esophageal repair; but a persistent nonexpanding lung on the side of surgery led to further investigations. A further diagnosis of an esophageal lung resulted in pneumonectomy and prophylactic placement of an intra-thoracic prosthesis to prevent post-pneumonectomy syndrome. To the best of our knowledge, this is the first report of a prophylactic placement of an intra-thoracic prosthesis in a neonate with the condition of esophageal atresia and tracheo-esophageal fistula and associated esophageal lung.

Outcome of a standardized technique of preputial preservation surgery for phimosis: A single institutional experience

Introduction: Pathological phimosis or preputial stenosis is a distressing problem in children leading to recurrent balanoposthitis, ballooning of prepuce, and rarely back pressure changes in the urinary tract. Circumcision has been the standard of care for such situations, although recently, various alternatives to circumcision have been reported in the literature. Most of these techniques are often complex and are met with poor acceptance. Moreover, besides personal preferences (in Hindus), advantages of preputial preservation is increasingly being realized recently. Materials and Methods: A prospective study was carried out in which a simple standardized technique of preputioplasty (dorsal slit) was used in 40 pediatric preputial stenosis cases. The outcome of this procedure including cosmesis and parental satisfaction was evaluated. Results: The average duration of this procedure was from 10 to 25 min with no intraoperative complications. The cosmetic outcome was good in 62.5%, satisfactory in 30%, and poor in 7.5% of cases. All of the boys had retractable prepuce with no functional problems. There was 100% parental satisfaction. None of the patients required a redo procedure or circumcision. Conclusion: A dorsal slit of adequate length i.e.; 1/3 rd the length from the corona to the tip leads to a satisfactory cosmetic outcome in more than 92% of cases. Preputioplasty is a safe and simple alternative to more radical procedure of circumcision.

Management of associated anomalies of oesophageal atresia and tracheo-oesophageal fistula

Tracheo-oesophageal fistula (TEF)/oesophageal atresia is one of the most common and serious congenital malformation. Despite progresses made in the field of early diagnosis, surgical techniques, ventilatory support and control of chest infections; morbidity and mortality still remains quite high and differs a lot from one to another centre particularly in the developing countries; as the availability and the level of neonatal care facilities are different. Associated anomalies play a significant role in dictating the outcome, timing of intervention and even the approach to management. The objectives of this review article is to outline the spectrum of associated anomalies, emphasise need of standardised system of documentation of anomalies, prognosis and management issues that would influence timing and approach of TEF repair.

Primary torsion of the omentum mimicking acute appendicitis in a female child: Case report and review of literature

Primary torsion of the omentum is an unusual cause of an acute abdomen and commonly mimics acute appendicitis. A case of primary omental torsion seen in a seven-year-old girl is discussed. All the signs and symptoms mimicked acute appendicitis. The patient underwent emergency laparotomy in which a normal appendix and serous fluid in the pelvis were observed. The pathological diagnosis was a primary torsion of the omentum which was excised. This case helps to emphasize the importance of a routine exploration of the abdomen when finding a normal appendix at the time of laparotomy.

Phlegmonous appendicitis and mobile cecum syndrome simulating ileal duplication cyst in a 9 year old girl.

Mobile cecum syndrome is a rare entity that produces recurrent lower abdominal pain mimicking appendicitis. Appendicitis developing in a mobile cecum at an abnormal location eludes the clinical diagnosis and confuses the clinicians unless a high index of suspicion is harbored. We present an unusual case of phlegmonous appendicitis in a mobile cecum masquerading as duplication cyst of ileum in a 9 years old girl.