Katragadda L.N. Rao

Dose-response study of intrathecal fentanyl added to bupivacaine in infants undergoing lower abdominal and urologic surgery.

Background:  Intrathecal (IT) adjuncts often are used to enhance the duration of spinal bupivacaine. Fentanyl is a spinal analgesic that could be a useful adjunct, and enhances the duration and quality of sensory block in adult surgical and obstetric population. However, no data exist to assess the dose–response characteristics of IT fentanyl when added to bupivacaine in infants.

Meckel’s diverticulum with segmental dilatation of the ileum: radiographic diagnosis in a neonate

We report a neonate with segmental dilatation of the ileum and a Meckel’s diverticulum that was diagnosed preoperatively on the plain abdominal radiograph.

Comparison of low-dose ketamine to midazolam for sedation during pediatric urodynamic study

Aim of sedation during pediatric urodynamic studies (UDS) is a calm and cooperative child while not affecting measurements. We compared the effectiveness of midazolam to low‐dose ketamine infusion for sedation and their impact on urodynamics.

Novel association of VACTERL, neural tube defect and crossed renal ectopia – Sonic hedgehog signaling: A point of coherence?

The present case report describes two patients with a novel combination of VACTERL (vertebral, anorectal, cardiac, tracheoesophageal, renal, limb), neural tube defect and crossed renal ectopia. Though cases of VACTERL associated with crossed renal ectopia have been described, the present case report is the first to describe its combination with neural tube defect. The cases reported here are significant because central nervous system manifestations are scarce in VACTERL syndrome. The role of sonic hedgehog pathway has been proposed in VACTERL association and neural tube defects. Axial Sonic hedgehog signaling has also been implicated in the mediolateral positioning of the renal parenchyma. With this knowledge, the etiopathogenesis of this novel combination is discussed to highlight the role of sonic hedgehog signaling as a point of coherence.

Tracheobronchial Foreign Body Aspirations: Lessons Learned From a 10-year Audit.

Background Foreign body aspirations (FBA) in the tracheobronchial tree must be suspected in children who present with a witnessed history of choking or respiratory distress of sudden onset and asymmetric breath sounds, even in the absence of pathognomonic radiographic findings. This study reviews our experience with a variety of FBA and outlines the salient differences in the literature. Methods One hundred eighty-four consecutive children with a history suggestive of FBA undergoing bronchoscopy over a period of 10 years were reviewed. In all of the cases, rigid bronchoscopy was performed under general anesthesia using a Storz ventilating bronchoscope with the aid of optical forceps. Results In 166 (90.21%) patients, a foreign body (FB) was discovered, whereas in 18 (9.78%) children, no FB could be found. The highest incidence of FBA (126/166, 75.9%) was found in the age group between 1 and 5 years. FBA of organic origin were more common (77.77%) in the younger patients (<3 y) as compared with the older patients (12.23%, >3 y) (P<0.0001). The radiographs were suggestive in 90% of the children >5 years of age (P<0.0063). Seven patients had a delay in the diagnosis and were being treated for various medical ailments. The incidence of FBA was almost double (64.83%) during the winter months as compared with rest of the year (34.17%). Pen cap aspirations were seen in 7 patients, and 6 of them could be extracted successfully with bronchoscopy. Two patients died. Conclusions Bronchoscopy can be a life-saving procedure and is safe even when no FB is found. The parameters of the history of witnessed choking, respiratory distress of sudden onset, and the asymmetric breath sounds are used in the decision making to perform a bronchoscopy. Radiographs are less helpful in younger patients. Nonorganic FBA is more common in older children. There may be seasonal variations and more attention should be given to small children during the times of high incidence.

Juvenile polyposis in a tropical country

The clinical profile, malignant potential, and management of 17 children with juvenile polyposis (more than five juvenile polyps) were evaluated clinically and endoscopically. Colonoscopy and polypectomy were done three weekly until colonic clearance was achieved, and thereafter two yearly. All polyps were subjected to histological examination. Mean age was 7.7 years, with a male preponderance (3:1). Presentation was with rectal bleeding (94%), pallor (65%), stunted growth (53%), and oedema (47%), and the mean (SD) duration of symptoms was 33 (27) months. None had a positive family history or any congenital anomaly. Two children had six polyps up to the transverse colon; the rest had numerous polyps all over the colon. All children had juvenile polyps on histology and 10 (59%) had adenomatous changes (dysplasia). Total colectomy was done in six for intractable symptoms. Colon clearance was achieved in eight after an average 3.4 polypectomy sessions, and three were still on the polypectomy programme. In conclusion, juvenile polyposis is commonly associated with low grade dysplasia. Serial colonoscopic polypectomy is effective but colectomy is required for intractable symptoms and when clearance of the colon is not possible.

Management of esophageal atresia with a tracheoesophageal fistula complicated by gastric perforation

PurposeGastric perforations generally develop in neonates with esophageal atresia (EA) and a tracheoesophageal fistula (TEF), requiring preoperative mechanical ventilation. To the best of our knowledge, spontaneous gastric perforation in patients who have not been treated with mechanical ventilation has not been described in the literature. There is also no current consensus or treatment protocol available for the management of these patients.MethodsOver a period of 6 years, six patients with EA and TEF presented with gastric perforation at our center. We studied the clinical presentation, initial resuscitation, surgical management, and outcome of these six patients.ResultsOut of the six patients, five were treated with initial flank drain insertion for peritoneal decompression. In all of the patients, a thoracotomy was performed first, followed by a laparotomy for closure of the stomach perforation. Four of the six patients survived and were discharged uneventfully. Two patients died of sepsis. Early feeding was established in all of the patients.ConclusionsSpontaneous gastric perforation can occur in patients with EA and TEF even without mechanical ventilation. Initial stabilization with peritoneal drain insertion and subsequent thoracotomy for esophageal anastomosis followed by laparotomy for stomach repair, both done in a single sitting, should be the ideal management of such patients.

Transcatheter coil embolization of a traumatic intrahepatic arterioportal fistula

Traumatic arterioportal fistulas are rare lesions in the pediatric age group. This case highlights the safe and effective management of intrahepatic arterioportal fistulas by transcatheter coil embolization.

Endoscopic management of post laparoscopic cholecystectomy bile leak in a child

A 9-year-old boy was referred to us 6 days after LC. The child had 3 episodes of biliary colic during a period of 6 weeks prior to LC and US showed gallstones. During LC the surgeon thought that the cystic duct was edematous and inflamed. The procedure was completed and a drain was placed in the subhepatic area. Thereafter the child developed fever and abdominal pain, and daily output from the drain was 200 to 300 mL bilious fluid. On examination he was febrile, the abdomen was tender on palpation and there was free fluid. US showed free fluid in the abdomen but the biliary tree was normal. At ERCP contrast-free selective cannulation of common bile duct was achieved using a method described previously.3 The cholangiogram disclosed a large leak from the cystic duct stump (Fig. 1A). A 7F nasobiliary drain (NBD) was placed in the bile duct. The daily output of bile through the NBD was 400 to 600 mL. The child was treated with antibiotics according to the results of culture and sensitivity of the ascitic fluid. Following NBD placement, output from the subhepatic drain gradually subsided and the drain was removed on the seventh day of admission. Repeat US (on the tenth day after NBD placement) showed 2 loculated fluid collections instead of free fluid in the abdomen. From 1 collection 20 mL bilious fluid was aspirated under US guidance. A cholangiogram 12 days after NBD placement demonstrated closure of the leak (Fig. 1B). The NBD was removed on the twenty-second day. Repeat US did not show a fluid collection in the abdomen. The child was discharged after 28 days in hospital. At discharge and 1 month thereafter he was asymptomatic.

Blunt injury of the abdomen: a plea for CT

Abstract A 3-year-old boy was brought to the emergency unit 1 h following a deceleration injury. On clinical examination there were no signs of injury and US showed only free intraperitoneal fluid. The following morning, contrast-enhanced CT showed the right kidney did not enhance and delayed scans showed contrast medium in the renal vein. This is an indirect sign of post-traumatic renal artery occlusion. Failure to recognise this sign may have disastrous consequences in a patient with solitary kidney or bilateral renal artery occlusion. Contrast-enhanced CT scan remains the most widely available investigation for accurate staging of blunt renal trauma.