Samir Pandya

Pyloric Stenosis in Pediatric Surgery : An Evidence-Based Review

Pyloric stenosis is a common pediatric surgical problem that requires a combination of both medical and surgical attention. This article reviews the classical elements necessary to care for the patient in a safe and effective manner. A well-tested management approach that can be applied to the general surgical environment is described. Perioperative management of the patient is discussed and the currently used techniques are reviewed. Current recommendations include the routine use of ultrasonography for diagnosis, attention to the preoperative correction of electrolytes, and the use of minimally invasive techniques for treatment.

Laparoscopy and complicated meckel diverticulum in children.

Background and Objectives: Meckel diverticulum can present with a variety of complications but is often found incidentally during other surgical procedures. The role of laparoscopy in the management of Meckel diverticulum is established. We reviewed our experience with complicated cases of Meckel diverticulum in children managed with laparoscopy. Methods: A 15-year retrospective chart review revealed 14 cases of complicated Meckel diverticulum managed with laparoscopy. Incidentally found Meckel diverticulum and cases done by laparotomy were excluded. Ages varied from 2 years to 16 years old. There were 10 males and four females. Eight cases had small bowel obstruction; of those, three had extensive intestinal gangrene. Four cases had significant rectal bleeding, three had acute diverticulitis, and two had intussusception caused by the diverticulum. Results: Eleven cases were treated with laparoscopic Meckel diverticulectomy and three with laparoscopic-assisted bowel resection because of extensive gangrene of the intestine. Two of the three cases with significant intestinal gangrene returned several weeks later with small bowel obstruction secondary to adhesions. They were successfully managed with laparoscopic lysis of adhesions. There were no other complications. Conclusions: Laparoscopy is safe and effective in the management of complicated Meckel diverticulum in children. Most cases can be managed with simple diverticulectomy. Laparoscopy is useful when the diagnosis is uncertain. When extensive gangrene is present, laparoscopy can help to mobilize the intestine and evaluate the degree of damage, irrigate and cleanse the peritoneal cavity, and minimize the incision necessary to accomplish the bowel resection.

A meta-analysis of B-mode ultrasound, Doppler ultrasound, and computed tomography to diagnose pediatric ovarian torsion.

PURPOSE Ovarian torsion (OT) is a true surgical emergency that requires prompt diagnosis and therapy. There are conflicting reports on the accuracy of different imaging modalities for OT. In this study, we performed a meta-analysis of all the published studies on B-mode ultrasound (US, morphological criteria), Doppler US (DUS, flow criteria), and computed tomography (CT) for the diagnosis of OT. Methods: The medical literature from 1987 to 2013 was searched for studies that evaluated US, DUS, CT, or combination of these techniques to diagnose OT in children using PubMed/MEDLINE database. The studies were screened and included if the quality criteria were met. Data were extracted using a standardized form. Reported sensitivities and specificities were pooled with 95% confidence intervals using a RevMan version 5.1 software (The Cochrane Collaboration, Oxford, United Kingdom). RESULTS A total of 18 US studies with 716 combined patients were included, along with 15 DUS studies comprising of 1,021 patients, and 5 CT studies with a total of 107 patients. All studies reported sensitivities, while only few selected studies also reported specificities. Using morphological criteria on B-mode US (including absolute or relative ovarian size, echotexture, location, and configuration) yielded high sensitivity and specificity (average 92 and 96%, respectively); DUS was highly specific, but lacked sensitivity, while CT was the least sensitive test. CT specificities could not be calculated from the available data. CONCLUSION This study found considerable variability of the reported sensitivities and specificities for the diagnosis of OT across all evaluated imaging modalities. Interestingly, B-mode US was the most sensitive and specific examination to detect OT. Some authors reported high diagnostic accuracy of DUS as well, but these findings have not been universally reproduced. CT had low overall sensitivity and is not recommended for the workup of suspected OT.

Laparoscopic-assisted management of traumatic abdominal wall hernias in children: case series and a review of the literature.

BACKGROUND Traumatic abdominal wall hernia (TAWH) is defined as herniation through a disrupted portion of musculature/fascia without skin penetration or history of prior hernia. In children, TAWH is a rare injury. OBJECTIVE The objectives of this study were to report our experience with different management strategies of TAWH in children and to determine the utility of laparoscopy. DESIGN/METHOD A retrospective chart review of all children treated by pediatric surgery at our institution for TAWH in a 5year interval was performed. Data were collected on mechanism of injury, initial patient presentation, surgical management, and outcomes. RESULTS We present 5 cases of traumatic abdominal wall hernia; 3 were managed using laparoscopic assistance. One patient was managed nonoperatively. All patients recovered without complications and were asymptomatic on follow up. CONCLUSION Traumatic abdominal wall hernias require a high index of suspicion in the cases of blunt abdominal trauma. Laparoscopy is useful mainly as a diagnostic modality, both to evaluate the hernia and associated injuries to intraabdominal structures. Its use may facilitate repair through a smaller incision. Conservative management of TAWH may be appropriate in select cases where there is a low risk of bowel strangulation.

Noniatrogenic Neonatal Gastric Perforation: The Role of Interstitial Cells of Cajal

Noniatrogenic neonatal gastric perforation is a rare and life-threatening condition whose etiology is often unclear. Interstitial cells of Cajal act as gastrointestinal pacemaker cells and express the proto-oncogene c-Kit. Six new cases were identified at our institution which presented with no mechanical, pharmacologic, or otherwise medical-related intervention prior to rupture. The number of interstitial cells of Cajal in nonnecrotic muscularis propria from five random high-power fields per specimen was compared using immunohistochemical stains for c-Kit. The authors show that a lack of interstitial cells of Cajal in the stomach musculature may be implicated in the development of noniatrogenic gastric perforation (p = 0.008). Further large-scale studies, including molecular and genetic analysis, may help to better understand this phenomenon.

Ciliated Hepatic Foregut Cyst: Four Case Reports with a Review of the Literature

Ciliated hepatic foregut cysts (CHFCs) are rare congenital legions that arise from the embryonic foregut. The cysts are formed during fetal development by evagination from their respective portions of the foregut, and are characterized by a ciliated epithelial lining. Approximately 100 cases of CHFC have been reported, of which only 13 were in children. Although CHFC is typically benign, malignant transformation to squamous cell carcinoma (SCC) has been reported in 3 cases. Survival rate after progression to malignancy is poor, as SCC in this setting is biologically aggressive. We present 4 new cases of CHFC in children between 5 months and 17 years old. Our cases are unusual, as some of the cysts exhibit multilocularity and biliary communication, and 2 of our patients were diagnosed under the age of 1. Additionally, 1 of the cysts was 19.3 cm in diameter, making it the largest reported CHFC to our knowledge. Ciliated hepatic foregut cysts should be included in the differential diagnosis of hepatic lesions.

Cardiaplication: a novel surgical technique for refractory gastroesophageal reflux in the pediatric population.

INTRODUCTION We encountered 3 patients with severe gastroesophageal reflux disease and tubular stomachs precluding fundoplication. Here, we report the use of an innovative technique, cardiaplication, as an alternative approach for antireflux surgery. METHODS Three infants with medically refractory gastroesophageal reflux disease (GERD) were referred for fundoplication. In each case, the patients anatomy prevented a traditional fundoplication from being performed. A cardiaplication was performed by invaginating the cardia of the stomach at the angle of His and securing the invaginated tissue with interrupted silk suture. The plication tubularized the cardia of the stomach, essentially increasing the intra-abdominal portion of the esophagus and altering the angle of His. The imbrication also creates a flapper valve over the distal esophagus, further limiting potential reflux. The charts for the infants who received cardiaplication were reviewed. Radiographic studies and clinical notes for the presence of persistent reflux were evaluated. RESULTS Cardiaplication was completed in 3 patients with GERD. All cases were initiated laparoscopically and one was converted to an open procedure secondary to dense adhesive disease. Each child was initiated on feeds between postoperative day 2 and 3. Two of the 3 patients were tolerating goal feeds with-in 2 days. The third patient reached goal feeds on day 16. Postoperative imaging (upper gastrointestinal series [UGI]) was obtained in 2 of the 3 patients. At follow-up (13, 7, and 4 months), all 3 patients are clinically free of symptoms of GERD. Delayed radiographic imaging has confirmed that the patients are no longer refluxing. CONCLUSION Based on preliminary findings, cardiaplication appears to be a safe and effective surgical technique for the management of severe GERD in infants. We performed cardiaplication out of necessity; however, after further testing this may prove to be an optimal approach, as it can be performed without disruption of the hiatus.

Laparoscopic Surgery for Acute Appendicitis in Children With Cancer.

Introduction: Abdominal pain during cancer chemotherapy may be caused by medical or surgical conditions. A retrospective review of 5 children with cancer who had appendicitis while receiving chemotherapy was performed. Case Descriptions: Three had acute lymphoblastic leukemia, and 1 each had T-cell lymphoblastic lymphoma and rhabdomyosarcoma. Two of the patients had a Pediatric Appendectomy Score of 6, and 1 each had a score of 7, 5, and 2. All had evidence of appendicitis on computed tomography. Laparoscopic appendectomy was performed without any perioperative complication. Discussion: Appendicitis is an important diagnosis in children with cancer, and laparoscopic appendectomy is safe and the procedure of choice.

International teleconsultation on conjoined twins leading to a successful separation: a case report:

Conjoined twins are identical twins that have incompletely separated in utero. The prognosis for conjoined twins is poor and management in a skilled tertiary care centre is paramount for definitive care. We describe our experience with a telemedical consultation on conjoined twins in The Dominican Republic from our eHealth centre in Valhalla, NY. The patients were two month old, female, pygopagus conjoined twins. A multidisciplinary teleconference was initiated with the patients, their family, the referring paediatrician and our team. Based on this teleconsultation, the team felt as though the twins may be amenable to a surgical separation. They presented to our centre in Valhalla, NY, for a detailed physical examination and series of imaging studies. Soon after, the patients underwent a successful 21 h separation procedure and were discharged 12 weeks later. To our knowledge, this is one of the first reports of an international teleconsultation leading to a successful conjoined twin separation procedure.

Recurrence of Diaphragmatic Hernia After Thoracoscopic Repair With Strattice Patch

Introduction: Thoracoscopic repair of congenital diaphragmatic hernia has increased with the use of prosthetic material. When the defect cannot be repaired primarily, a variety of materials have been used. The ideal prosthetic material has not been identified yet. The use of biologic tissue matrix prosthesis is appealing because this material may serve as a framework to support the patient’s own tissue regeneration. We report on 2 newborns with congenital diaphragmatic hernia repaired by thoracoscopy with placement of a Strattice patch (LifeCell, Branchburg, New Jersey). The hernia recurred in both cases. Case Description: Two neonates born at term, weighing 3.5 kg and 4.0 kg, had left-sided congenital diaphragmatic hernias repaired by thoracoscopy with a Strattice patch. The repairs were performed at 1 and 4 days of age after a period of stabilization. There were no other congenital anomalies. There were no operative complications. The neonates recovered uneventfully and were discharged in good condition. Recurrence of the diaphragmatic hernia was identified by chest radiographs at routine follow-up visits 16 and 22 months postoperatively. One patient had mild abdominal pain and increasing shortness of breath, whereas the other patient was asymptomatic. One patient had an abdominal open primary repair of the recurrent diaphragmatic hernia, whereas the other patient had a laparoscopy-assisted repair with AlloDerm patch (LifeCell). They both recovered uneventfully. Discussion: Postoperative follow-up at regular intervals is extremely important after repair of diaphragmatic hernia, especially when prosthetic material is used, because of the high incidence of recurrence. We do not recommend the repair of diaphragmatic hernia with the Strattice patch at this time.