Monika Bawa

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.

The role of preoperative CT scan in patients with tracheoesophageal fistula: A review

PURPOSE The morbidity and mortality associated with esophageal atresia with or without a fistula make it a challenging congenital abnormality for the pediatric surgeon. Anatomic factors like inter-pouch gap and origin of fistula are not taken into consideration in various prognostic classifications. The preoperative evaluation of these cases with computerized tomography (CT) has been used by various investigators to delineate these factors. We reviewed these studies to evaluate the usefulness of this investigation in the intra operative and post operative period. MATERIALS AND METHODS A literature search was done on all peer-reviewed articles published on preoperative computed tomography (CT) in cases of tracheoesophageal fistula using the PUBMED and MEDLINE search engines. Key words included tracheoesophageal fistula, computerized tomography, virtual bronchoscopy, and 3D computerized tomography reconstruction. Further, additional articles were selected from the list of references obtained from the retrieved publications. A total of 8 articles were selected for analysis. RESULTS In most of the studies, comprising 96 patients, observations noted in preoperative CT were confirmed during surgery. In a study by Mahalik et al [Mahalik SK, Sodhi KS, Narasimhan KL, Rao KL. Role of preoperative 3D CT reconstruction for evaluation of patients with esophageal atresia and tracheoesophageal fistula. Pediatr Surg Int. 2012 Jun 22. [Epub ahead of print]], in 6 patients the fistula could not be identified pre-operatively by CT. One study found a difference of 0.43 cm in the intraoperative gap length compared to that given by CT when compared to +/- 2 mm shown by another [1. Mahalik SK, Sodhi KS, Narasimhan KL, Rao KL. Role of preoperative 3D CT reconstruction for evaluation of patients with esophageal atresia and tracheoesophageal fistula. Pediatr Surg Int. 2012 Jun 22. [Epub ahead of print], 3. Ratan SK, Varshney A, Mullick S, Saxena NC, Kakkar S, Sodhi PK. Evaluation of neonates with esophageal atresia using chest CT scan. Pediatr Surg Int. 2004 Oct; 20(10):757-61.]. Only three studies showed surgical utility of pre-operative CT, and the surgical plan changed based on the CT findings. CONCLUSION The usefulness of pre-operative computerized tomography in cases of tracheoesophageal fistula is controversial. The safety of this technique is questionable due to limited facilities and associated radiation hazards. Further, limited information obtained which may help in changing the surgical plan can easily be managed intra-operatively by careful and meticulous surgery. Overall, the safety concerns outweigh its efficacy. Thus, the use of pre-operative CT scan cannot be generalized and protocolized as a standard of care in the management of tracheoesophageal atresia.

Mayer-Rokitansky-Kuster-Hauser syndrome with H-type anovestibular fistula

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is characterized by Mullerian duct structures agenesis. Anorectal malformations are uncommonly associated with MRKH syndrome, and among them, rectovestibular fistula and cloacal malformations have been commonly described. H-type of anovestibular fistula associated with MRKH syndrome has not been reported previously. One such case along with its treatment is reported.

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.

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.

Transanal Swenson's operation for Recto-sigmoid Hirschsprung's disease

BACKGROUND Transanal Swensons operation is a relatively new single-stage procedure for Hirschsprungs disease. The results of this procedure at our centre are presented. PATIENTS AND METHODS Seventeen patients of recto-sigmoid Hirschsprungs disease underwent single-stage transanal Swensons procedure. The diagnosis was based on the evidence of a transition zone on barium enema examination. A full thickness incision was made on the rectal wall posteriorly, 0.5 cm above the dentate line. The mobilised segment was resected about 5 cm above the transition zone. Frozen sections were performed whenever the transition zone was not clearly seen intra-operatively. The operation was completed by full thickness colo-anal anastomosis. RESULTS There were fourteen male and three female patients. The ages of the patients ranged from two months to eight years (median 14 months). The median hospital stay was four days (range four to seven days). Two patients required additional abdominal mobilisation. The anatomical transition zone as seen intra-operatively correlated with the pathological transition zone in all the cases. Two patients had episodes of post-operative enterocolitis and the other two patients developed stricture of the anastomosis. The follow-up period ranged from six to 45 months (Mean 35.4 months). Post-operative soiling was observed in all the patients and lasted from two to six weeks (Mean 3.4 weeks). There were no injuries to the surrounding structures. No patient had voiding disturbances and post-void residual urine was normal in all the patients. Initial increased frequency of bowel movements had settled to one to three per day. CONCLUSIONS Transanal Swensons pull through not only avoids laparotomy, but also the problems associated with the muscular cuff of transanal endorectal pull-through. The anatomical transition zone can be safely utilised to decide the resection limits. By a meticulous technique of dissection, injury to the surrounding structures can also be avoided.

Idiopathic simultaneous intussusceptions in a neonate

Multiple simultaneous intussusception is a peculiar variety of intussusception. The condition is reported in older children and adults. The occurrence in neonates is an interesting situation. We present one such neonate who had a simultaneous ileo-colic and ileo-ileal intussusception without any specific cause. A review of existing literature revealed only three neonates. The terminology and various aspects of the condition are discussed.

A rare case of isolated Cushing syndrome in a 3-month-old boy.

Abstract Adrenocortical carcinoma (ACC) is a rare malignancy in children. Most of these are endocrinologically active tumors, with virilizing features being typically dominant. Its presentation with isolated Cushing syndrome is rare. We report a 3-month-old infant with Cushing syndrome without the clinical features of androgen or mineralocorticoid excess consequently diagnosed with ACC. We discuss the different presentations, diagnosis, and management of this rare tumor with a rarer presentation.

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.

Mini-vesicostomy in the management of PUV after valve ablation

AIM To determine the usefulness of infra-umbilical mini-vesicostomy in infants with posterior urethral valves (PUV), in developing countries. This new technique facilitates clean intermittent catheterization (CIC) and overnight bladder drainage, which have been effectively used for the treatment of valve bladders in the developed world. METHODS A retrospective analysis of the records of three infants who underwent a mini-vesicostomy between 2005-2009 was done. All were put on CIC in the neonatal period. Monitoring of renal parameters, bladder function and structural changes in the bladder was done before and after 4 years of CIC. RESULTS All three showed a decrease in upper tract dilatation, improvement in cortical function and improvement of bladder compliance at the end of 4 years. Two patients are on CIC through vesicostomy and can pass a good stream of urine per urethraly, and in one the vesicostomy has been closed. CONCLUSION Mini-vesicostomy is a useful option to allow CIC on a long-term basis in children with PUV. There were no complications with this technique in this small group of patients, and it has been well accepted by their families.