Rajendra K Ghritlaharey

Ventriculoperitoneal shunt complications needing shunt revision in children: A review of 5 years of experience with 48 revisions

BACKGROUND The aim of this study was to review the management of ventriculoperitoneal (VP) shunt complications in children. PATIENTS AND METHODS During the last 5 years (January 1, 2006 to December 31, 2010), 236 VP shunt operations were performed in children under 12 years of age; of these, 40 (16.94%) developed shunt complications and those who underwent VP shunt revisions were studied. RESULTS This prospective study included 40 (28 boys and 12 girls) children and required 48 shunt revisions. Complications following VP shunts that required shunt revisions were peritoneal catheter/peritoneal end malfunction (18), shunt/shunt tract infections (7), extrusion of peritoneal catheter through anus (5), ventricular catheter malfunction (4), cerebrospinal fluid (CSF) leak from abdominal wound (4), shunt system failure (2), ventricular end/shunt displacement (2), CSF pseudocysts peritoneal cavity (2), extrusion of peritoneal catheter from neck, chest, abdominal scar and through umbilicus, one each. Four-fifth of these shunt complications occurred within 6 months of previous surgery. Surgical procedures done during shunt revisions in order of frequency were revision of peritoneal part of shunt (27, 56.25%), revision of entire shunt system (6, 12.5%), extra ventricular drainage and delayed re-shunt (5, 10.41%), shunt removal and delayed re-shunt (5, 10.41%), opposite side shunting (2, 4.16%), cysts excision and revision of peritoneal catheter (2, 4.16%) and revision of ventricular catheter (1, 2.08%). The mortalities following VP shunt operations were 44 (18.64%) and following shunt revisions were 4 (10%). CONCLUSIONS VP shunt done for hydrocephalus in children is not only prone for complications and need for revision surgery but also associated with considerable mortality.

Exploratory laparotomy for acute intestinal conditions in children: A review of 10 years of experience with 334 cases

AIM The aim of this study was to review 10 years of experience in the management of children with acute intestinal conditions requiring exploratory laparotomy. PATIENTS AND METHODS This retrospective study included 334 children (244 boys and 90 girls) who underwent laparotomy for acute intestinal conditions between Jan 1, 2000 to Dec 31, 2009. Patients were grouped into two categories: group A (n = 44) included patients who needed laparotomy with terminal ileostomy and group B (n = 290) included patients who needed laparotomy without terminal ileostomy. We excluded neonates and patients with jejunoileal and colonic atresias, anorectal malformations, congenital pouch colon, neonatal necrotising enterocolitis, Hirschsprungs disease, appendicitis, abdominal trauma and gastrointestinal tumours. RESULTS During the last 10 years, 334 laparotomies were performed in children under 12 years: 59.88% for intestinal obstruction and 40.11% for perforation peritonitis. Causes in order of frequency were: ileal perforations 34.13%; intussusceptions 26.34%; Meckels obstruction 10.17%; congenital bands and malrotation 6.88%; postoperative adhesions 5.98%; miscellaneous peritonitis 5.68%; miscellaneous intestinal obstructions 4.79%; abdominal tuberculosis 4.19% and roundworm intestinal obstruction 1.79%. Ileostomy closures (n = 39) was tolerated well by all except one. The mortalities were 28 (8.38%) in group B and 6 (1.79%) in group A. CONCLUSIONS The need for re-exploration not only increases the morbidity but also increases mortality as well. Diverting temporary ileostomy adds little cumulative morbidity to the primary operation and is a safe option for diversion in selected cases. The best way to further reduce the mortality is to create ileostomy at first operation.

Omphalopagus parasite: A rare congenital anomaly

Omphalopagus parasite is a very rare congenital anomaly. Presented here is a case in which an extra truncus was attached to an infant in the region of the epigastrium. The truncus had well-formed extremities, an abdomen, and a hypoplastic thorax. The infant had a small omphalocoele in addition to the truncus. Surgery performed in the neonatal period helped to achieve a successful separation of the truncus from the host.

Experience with 40 cases of congenital pouch colon

Aim : The aim of this study was to analyze the clinical and management aspect of congenital pouch colon. Materials and Methods : This retrospective study was carried out on 40 cases of congenital pouch colon managed in the department of paediatric surgery from 01, January 2000 to 31, December 2005. Results : The incidence of congenital pouch colon (CPC) in the present study was 11.290 % (40 of 354) of all anorectal malformations (ARM) and 19.60% (40 of 204) of high ARM. Of these 40 cases of CPC included in the study, 82.5% were male and 17.5% were female. The average age of presentation to hospital was 3.36 days with a range of 1-11 days; of these 25% patients were admitted with poor general condition. Preoperative diagnosis of CPC was possible in 75% of cases in our study. 60% ( n =24) of cases had incomplete pouch colon (Type III and IV) while 40% ( n =16) had complete pouch colon (Type I and II). Right transverse colostomy was done in 16 patients and colostomy at descending colon just proximal to pouch in two patients for incomplete (Type III and IV) CPC as a primary initial procedure. Ileostomy was done in 14 patients and window colostomy in three patients for complete (Type I and II) CPC. As definitive procedures, pouch excision and abdomino-perineal pull-through of colon was done in 17 patients, coloplasty and abdomino-perineal pull-through of coloplasty colon was done in four patients and pouch excision and abdomino-perineal pull-through of terminal ileum in four patients in our series. None of our patients underwent primary single stage procedure. Conclusion: (1) CPC comprises 11.290 % of all ARM and 19.60% of high ARM. (2) Right transverse colostomy was opted for incomplete pouch colon, while Ileostomy and window colostomy were opted for complete pouch colon as initial surgical procedures. (3) Staged surgical procedures for management of CPC were well tolerated in our series.

Tube thoracostomy: primary management option for empyema thoracis in children.

AIM The aim of this study was to review our experience with tube thoracostomy in the management of empyema thoracis in children. PATIENTS AND METHODS This retrospective study included 46 children (26 boys and 20 girls) who were admitted and managed for empyema thoracis, between January 1, 2010 and December 31, 2010 at the authors department of paediatric surgery. RESULTS During the last 12 months, 46 children aged below 12 years were treated for empyema thoracis: Five (10.86%) were infants, 22 (47.82%) were 1 to 5 years and 19 (41.30%) were 6 to 12 years of age. All the patients presented with complaints of cough, fever and breathlessness of variable durations. Twenty three (50%) children had history of pneumonia and treatment prior to development of empyema. Thirty five (76.08%) children had right-sided and 11 (23.91%) had left-sided empyema. Thirty nine (84.78%) children were successfully treated with tube thoracostomy, systemic antibiotics and other supportive measures. Seven (15.21%) children failed to respond with above and needed decortications. Most commonly isolated bacteria were Pseudomonas (n = 12) and Staphylococcus aureus (n = 7). The average length of hospital stay in patients with tube thoracostomy was 15.35 days, and in patients who needed decortications was 16.28 days following thoracotomy. There was no mortality amongst above treated children. CONCLUSIONS Majority of children with empyema thoracis are manageable with tube thoracostomy, antibiotics, physiotherapy and other supportive treatment. Few of them who fail to above measures need more aggressive management.

Embryonal rhabdomyosarcoma tongue in a male child

We report a two and half years old male child, who at the age of 2 years developed a small 3 x 3 cm, reddish lesion on his right side of dorsum of tongue. There was a history of bleeding from the lesion, off and on. There was no family history of malignancy or history of exposure to radiation, etc to the child. Incision biopsy was done on July 2005 and the histological findings were consistent with an embryonal rhabdomyosarcoma. Parents of the child were reluctant for any further treatment. He was re-admitted in September 2005 with a massive growth over the tongue, protruding from the mouth [Figure 1]. The child was unable to close his mouth and was also unable to swallow solid food. He was accepting liquids only in small amounts. The growth was arising from the anterior part of tongue and extending up to the base of it. On examination, the growth was 8x6x10 cms, red, bosselated, with nodular ulcerated surface, well defined margins and was hard in consistency. Lower lip was ulcerated and compressed. There was no cervical lymphadenopathy. Other systemic examinations were normal. Skiagram of mandible and chest and ultrasonography of abdomen were normal. The patient was assigned a clinical stage 1 and international rhabdomyosarcoma study (IRS) Group III. Near total excision of mass was done [Figure 2]. Histopathological examination showed embryonal rhabdomyosarcoma. He received one cycle of combination chemotherapy (vincristine, actinomycin D & cyclophosphamide). The child is now able to swallow liquids as well as solids and he is on regular follow-up for chemotherapy and is doing well.

Giant retroperitoneal cystic lymphangioma in a seven-months-old girl

A seven-month-old girl presented with complaints of gradually increasing abdominal lump for four to five months. Clinical examination revealed grossly distended abdomen with an ill-defined nontender, cystic lump, 30 × 15 cm, involving the entire abdomen more on the left side with a positive transillumination test and fluid thrill [Figure 1]. Other systemic examinations and routine laboratory investigations were within the normal limits.

Prune belly syndrome associated with incomplete VACTERL

A Prune Belly syndrome with VATER/VACTERL association is an extremely rare. They are either stillborn or die within few days of life, only few such cases have been reported in literature. We are presenting here a male neonate of Prune Belly syndrome associated with incomplete VACTERL with brief review of literature.

C S F pseudocysts peritoneal cavity following V P shunt surgery: Report of three cases in children and review of literature

Abdominal cerebrospinal fluid (CSF) pseudocyst is an uncommon complication following ventriculo-peritoneal (VP) shunt. The following reports our experience with three cases of CSF pseudocyst in children. VP shunt was done earlier for communicating hydrocephalus following tubercular meningitis (TBM) in all cases. Clinical presentation was with progressive abdominal distension and features of intestinal obstruction. Clinically we were able to diagnose all cases as CSF pseudocyst peritoneal cavity. Ultrasound examination confirmed the clinical findings in all. CT scan of abdomen and pelvis showed a large unilocular CSF pseudocyst with shunt catheter within it on one patient (case 3). Ultrasound guided aspiration of cyst was done in case 1 alone, but failed to resolve the symptoms. All patients needed formal exploration. Near total cyst excision, adhesiolysis and relocation of peritoneal end of VP shunt catheter in right supra hepatic space was done in all. Two patients who developed shunt tract infection needed shunt removal. The follow up period is 6-8 months.

Two-staged management for all types of congenital pouch colon.

Background: The aim of this study was to review our experience with two-staged management for all types of congenital pouch colon (CPC). Patients and Methods: This retrospective study included CPC cases that were managed with two-staged procedures in the Department of Paediatric Surgery, over a period of 12 years from 1 January 2000 to 31 December 2011. Results: CPC comprised of 13.71% (97 of 707) of all anorectal malformations (ARM) and 28.19% (97 of 344) of high ARM. Eleven CPC cases (all males) were managed with two-staged procedures. Distribution of cases (Narsimha Rao et al.′s classification) into types I, II, III, and IV were 1, 2, 6, and 2, respectively. Initial operative procedures performed were window colostomy (n = 6), colostomy proximal to pouch (n = 4), and ligation of colovesical fistula and end colostomy (n = 1). As definitive procedures, pouch excision with abdomino-perineal pull through (APPT) of colon in eight, and pouch excision with APPT of ileum in three were performed. The mean age at the time of definitive procedures was 15.6 months (ranges from 3 to 53 months) and the mean weight was 7.5 kg (ranges from 4 to 11 kg). Good fecal continence was observed in six and fair in two cases in follow-up periods, while three of our cases lost to follow up. There was no mortality following definitive procedures amongst above 11 cases. Conclusions: Two-staged procedures for all types of CPC can also be performed safely with good results. The most important fact that the definitive procedure is being done without protective stoma and therefore, it avoids stoma closure, stoma-related complications, related cost of stoma closure and hospital stay.