Katragadda Lakshmi Narasimha Rao

Multidetector CT angiography in pulmonary sequestration

Purpose: To evaluate the role of multidetector CT angiography in the diagnosis and preoperative assessment of pulmonary sequestration with angiographic or surgical correlation. Methods: Eight patients (5 males, 3 females) in the age range of 2 days to 35 years suspected of having pulmonary sequestration on the basis of clinical history and chest radiographs were included in the study. All patients underwent CT angiography (4 or 16 slice) and MPVR, MIP and 3D volume rendered images were generated. The axial images were also reviewed at soft tissue and lung window settings to evaluate the parenchymal changes. Results: CT angiography showed five pulmonary sequestrations on the left and three on the right, located in the basal segments (n = 7) or paravertebral region (n = 1). Aberrant systemic arterial supply was demonstrated in all cases: from the descending thoracic aorta (n = 2); abdominal aorta (n = 3) and celiac axis (n = 3). Venous drainage into inferior pulmonary veins was demonstrated in 4 patients. The angioarchitecture depicted on CT angiography was confirmed on surgery in five patients and by DSA in two patients who subsequently underwent embolization using PVA particles and/or coils. Conclusion: The ability of CT angiography to simultaneously image the arterial supply, venous drainage and parenchymal changes in a single examination makes it the imaging modality of choice for the diagnosis and preoperative assessment of pulmonary sequestration.

Addition of midazolam to continuous postoperative epidural bupivacaine infusion reduces requirement for rescue analgesia in children undergoing upper abdominal and flank surgery

STUDY OBJECTIVE To investigate the effect of adding midazolam to continuous epidural infusion of bupivacaine for postoperative analgesia in children. DESIGN Prospective, randomized, double-blind, controlled study. SETTING Tertiary-care center. PATIENTS 44 ASA physical status I and II children in age groups of two to 10 years, undergoing elective upper abdominal and flank surgery. INTERVENTIONS At the end of surgery, patients were randomly allocated to receive epidural infusion of 0.125% bupivacaine alone (Group B) or with 20 microg/kg/hr midazolam (Group BM) for 12 hours at the rate of 0.2 mL/kg/hr. MEASUREMENTS Pain, motor block, and sedation were assessed at predetermined times over 24 hours. Intravenous fentanyl was used as rescue analgesic for the first 12 hours, and tramadol for next 12 hours. Patients were followed at one week, one month, and one year for any neurological deficits. MAIN RESULTS The number of patients requiring rescue analgesia during infusion was significantly lower in Group BM (7 vs. 17 in Group B; P < 0.001). Time to first rescue analgesia was significantly prolonged in Group BM compared with Group B (P < 0.001). Frequency of fentanyl (P < 0.001) and tramadol (P = 0.001) administration as rescue analgesia was significantly less in Group BM. Significantly lower median pain scores were obtained in Group BM than Group B at all time intervals (P < 0.05). Greater sedation scores were noted in Group BM at all time intervals postoperatively except at 4 hours (P < 0.05). No motor block was observed in any child during the study. No neurological deficit was reported in any child in the one year of follow-up. CONCLUSION Addition of 20 microg/kg/hr of midazolam to postoperative continuous epidural infusion of 0.125% bupivacaine reduces the requirement for rescue analgesia in children following upper abdominal and flank surgery.

Mature gastric teratoma: recurrence in adulthood

A case of mature gastric teratoma developing recurrence after 2 decades after complete excision during infancy is being reported. The patient was successfully managed by surgical resection. Pathologic examination confirmed it to be a mature teratoma.

Duplicated gall bladder with duodenal duplication cyst

A four year old boy with a duplicated gall bladder communicating with a duplication cyst of the duodenum is reported for the first time in the literature. It is also reported for the absence of any connection with the biliary system.

Vesicoureteral reflux: Endoscopic therapy and impact on health related quality of life.

Aim: To evaluate the health related quality of life (HRQOL) after endoscopic injection treatment for vesico ureteral reflux (VUR) in children. Materials and Methods: Fifty four children received treatment and were prospectively evaluated for their quality of life scores, according to resolution of reflux on cystograms and status of renal scars. Results: Of the 81 refluxing units, 72 (89%) had resolution of reflux whereas 9 (11%) did not resolve. The total average QOL was higher for the patients in the resolved group as compared to the non resolved group. Comparison of pre and post procedure renal DMSA scans in 44 patients showed status quo in 26, regression of scars in six, progression in two and formation of new scars in 6. The total increase in HRQOL was highest in regression group (67.91), and lowest in progression group (36.45). Conclusions: Successful endoscopic treatment of VUR is associated with improved quality of life, as indicated by higher HRQOL scores in the resolved group.

Risk of surgical site infection in paediatric herniotomies without any prophylactic antibiotics: A preliminary experience

Background: Different studies underline the use of pre-operative antibiotic prophylaxis in clean surgeries like herniotomy and inguinal orchiopexy. But, the meta-analyses do not recommend nor discard the use of prophylactic pre-operative antibiotics. The scarcity of controlled clinical trials in paediatric population further vitiates the matter. This study assessed the difference in the rate of early post-operative wound infection cases in children who received single dose of pre-operative antibiotics and children who did not receive antibiotics after inguinal herniotomy and orchiopexy. Materials and Methods: This randomised prospective study was conducted in Paediatric Surgery department of PGIMER Chandigarh. Out of 251 patients, 112 patients were randomised to the case group and 139 were ascribed to the control group. The patients in control group were given a standard regimen of single dose of intravenous antibiotic at the time of induction followed by 3-4 days of oral antibiotic. Case group patients underwent the surgical procedure in similar manner with no antibiotic either at the time of induction or post-operatively. Results: The incidence of surgical site infection in case group was 3.73 % and that in control group was 2.22%. The observed difference in the incidence of surgical site infection was statistically insignificant (P value = 0.7027). The overall infection rate in case and control group was 2.89%. Conclusions: Our preliminary experience suggests that there is no statistically significant difference in the proportion of early post-operative wound infection between the patients who received single dose of pre-operative antibiotics and the patients who received no antibiotics after inguinal herniotomy and orchiopexy. The risk of surgical site infection in paediatric heriotomies does not increase even if the child′s weight is less than his/her expected weight for age.

Caecal duplication cyst mimicking intussusception

Cystic caecal duplication is a rare congenital anomaly. We report a case of an infant, who presented with bilious vomiting and abdominal distension. On ultrasonography, intussusception with a cyst as a lead point was present in the right iliac fossa. On exploration, there was no evidence of intussusception, only caecal duplication cyst was found. To date, only three cases of caecal duplication which mimicked intussusception have been reported in the English literature.

Position of a sigmoid colon in right iliac fossa in children: A retrospective study

Aim: The aim was to identify the position of sigmoid colon in children and discuss its clinical significance. Materials and Methods: Ninety-one contrast enema studies were retrospectively evaluated and the position of sigmoid colon categorized as below: Left lower quadrant, right lower quadrant, midline, and indeterminate. Results: The position of sigmoid colon in the right lower quadrant, left lower quadrant, midline, and indeterminate was 32 (35.16%), 33 (36.26%), 12 (13.19%), and 14 (15.38%), respectively. There was no statistically significant difference in mean age (P = 0.87) or gender prevalence (P = 0.49) for different positions of the sigmoid colon. Conclusion: The sigmoid colon occupies the right lower quadrant in a large number of children. Awareness of this finding is of crucial importance in correct interpretation of abdominal radiographs in the emergency room.

Biliary Fasciola gigantica infestation in a nonendemic area — An intraoperative surprise

A 7year old girl infected with the zoonotic trematode, Fasciola gigantica is reported because of the extreme rarity of this condition in our region. Because of the overlap in symptomatology and radiological features, the more common amebic/pyogenic liver abscess in the initial hepatic migratory phase and later choledochal cyst/biliary ascariasis when the parasite was finally located in the extrahepatic bile ducts, were thought of delaying effective treatment. The diagnosis was confirmed only by surgical exploration. The characteristic contrast enhanced computed tomography scan features retrospectively identified were multiple clustered hypodense lesions in the liver with peripheral enhancement in the acute hepatic migratory phase, and periportal tracking in the previously affected areas of the liver with biliary dilatation and a linear hypointense lesion within the common bile duct in the chronic phase. Although a known association, she did not have eosinophilia. This child, who became symptomatic at the age of 5.5years, also appears to be one of the youngest patients reported with Fasciola gigantica.

Long segment jejuno-ileal duplication cyst with ectopic gastric mucosa detected on 99mTc-pertechnetate scintigraphy

Enteric duplication cysts (EDC) are uncommon congenital anomalies that may occur anywhere along the digestive tract. Ectopic gastric mucosa (EGM), another rare condition, is usually present as short segments in the small intestine and may be associated with EDC. Abdominal scintigraphy with 99mTc pertechnetate may be useful in the diagnosis, since the radiotracer is concentrated by functioning gastric mucosa. In this case report, the authors describe a child with a 150 cm long jejuno-ileal duplication cyst containing EGM identified by intense 99mTc pertechnetate uptake on scintigraphy without any pharmacological intervention.