Saurabh Garge

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.

Orchidopexy san ligation technique of orchidopexy

Pediatric hernia surgery is the most common operation done by pediatric general surgeons and it is a core competency for general surgeons in the developing world. Herniotomy is performed for the surgical repair of hernia and along with orchiopexy for the closure of associated patent processus vaginalis. Traditionally, ligation of hernial sac during orchiopexy is considered mandatory to prevent postoperative development of hernia. The present report was designed to study the results of non-ligation of the hernial sac during orchiopexy. It was found that non-ligation has no untoward effect on early complications and recurrence rate on long-term follow-up. It is suggested that it is not necessary to ligate the hernial sac during orchiopexy in children.

Sternal cleft repair: A report of two cases and review of literature

A cleft sternum is a rare congenital anomaly often diagnosed as asymptomatic at birth. Clinical outcome may be unfavourable when an associated anomaly, particularly, an intra cardiac anomaly coexists with the defect. Primary repair should be employed in the neonatal period because the flexibility of the chest wall is maximal and thus the compression of underlying structures is minimal. However, patients with sternal cleft may even present late in the childhood or adolescence period. We herein report two cases of successful repair of sternal clefts with review of the available literature.

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.

Rare association in a female DSD case of phallus, accessory phallic urethra, perineal lipoma and anterior ectopic anus

Disorders of sex differentiation (DSD) are a heterogeneous and broad spectrum group of diseases with a varied appearance. Presence of an accessory phallus with a phallic urethra in association with a normal vagina in a female is an extremely uncommon anomaly. We present a rare case of a genotypically female child with a normal urethra and vagina in association with a phallus, accessory phallic urethra, perineal lipoma and anterior ectopic anus.

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.

Saxophone penis due to primary lymphoedema

Congenital lymphoedema is a rare disorder that may result in disfiguring edema of the male genitalia. The treatment of persistent lymphoedema is surgical and consists of meticulous excision of all subcutaneous layers of the affected skin, combined with reconstruction of the penis and or scrotum.

Undiagnosed ureteroinguinal hernia with solitary kidney in a child with ureteric injury during herniotomy.

Iatrogenic ureteric injuries are an uncommon but difficult problem to manage. Although ureteric injury has been reported during hernia surgery in adults, it has not been reported in children during herniotomy. An 18-month-old male child underwent repair of an inguinal hernia and developed postoperative anuria. Investigations revealed that the patient had a solitary kidney and had injury to the solitary ureter. We successfully managed this patient using the vermiform appendix to replace a segment of the injured ureter. The possible mechanism of injury and the relevant literature are discussed.

Role of feeding jejunostomy in major anastomotic disruptions in esophageal atresia: A pilot study

Aims: To investigate the role of feeding jejunostomy (FJ) in patients of esophageal atresia with anastomotic leak (AL) to decrease the degree of gastroesophageal reflux (GER) and its effect on anastomotic healing. Materials and Methods: Twenty neonates, with major AL and severe GER after primary repair were managed with decompressing gastrostomy and transgastric FJ and analyzed prospectively. Results: Male to female ratio was 1.7:1. Mean birth weight was 2.2 kg. Anastomotic gap ranged from 0 to 4 cm. The amount of leak was more than 20% of nasogastric feeds. Gastrostomy and FJ was done on an average of the 12 th postoperative day, after observing the general condition, chest tube output, lung expansion, and ventilatory requirement. There was a drastic reduction in chest tube output and lung expanded in all patients. Average hospital stay was 36 days (8-80 days). Sixty percentage patients were discharged successfully on FJ. Esophagogram demonstrated healing and leak free patency after an average of 1.5 months. GER was noted in seven patients, four developed stricture, and one had pseudodiverticulum in follow-up. Conclusion: Decompressing gastrostomy and FJ can be an alternative to managing major ALs. It helps in healing of anastomotic dehiscence and in preserving the native esophagus.