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Abdominal cocoon in children: A report of four cases

Abdominal cocoon is a rare cause of intestinal obstruction. The authors report four cases (3 boys, 1 girl; age range, 6 to 8 years) that presented with features of intestinal obstruction. There was no history of previous surgery, peritonitis, or prolonged drug intake in any of these cases. One patient presented with acute intestinal obstruction and gangrene of bowel. The etiology, preoperative diagnosis, and management of this condition are discussed.

Twenty years' experience of steroids in infantile hemangioma - a developing country's perspective.

BACKGROUND Hemangioma is a common vascular tumor. Though it involutes spontaneously, results are unpredictable. Steroid therapy is an effective mode of its regression. We present our experience of largest series and possible recommendations for treatment. MATERIALS AND METHODS A total of 2398 patients were treated during the study period of 20 years. They were given oral prednisolone, intralesional triamcinolone, or combination of both as per the protocol and followed for the response. Response to the treatment was graded as excellent, good, poor, or no response. RESULTS The male-to-female ratio was 1:2.3. In 81% of patients, hemangioma was noticed within first month of life. The commonest site of involvement was head and neck (57%). The commonest clinical presentation was discoloration and swelling. Mean age and size were 8.43 +/- 7.04 months and 23.64 +/- 20.13 cm(2). Response rate was highest for superficial type using any modality of treatment. Patients younger than 1 year showed better response (90.3%) in comparison with children older than 1 year (80.8%). The specific complications occurring were infections in 249 (12.4%), cushingoid facies and growth delay in 62 (3.1%), and hypertension in 51 (2.5%) patients. CONCLUSION Steroid therapy either oral or intralesional as per the requirement is an easy and safe modality. Results are good to satisfactory in most patients. The complications are minimal. If treatment is needed, it should be used as a first-line therapy, especially when cost is an important concern.

Use of fibrin glue in preventing urethrocutaneous fistula after hypospadias repair

UNLABELLED Urethrocutaneous fistula is one of the most common complications after hypospadias surgery. The incidence of fistula development has varied from 4% to 20% in larger series. We sought to investigate the role of fibrin glue (Tisseel manufactured by Baxter India Pvt Ltd, Chennai, India) to reduce the chances of fistula formation in cases in proximal penile hypospadias. METHOD A total of 120 patients with proximal penile hypospadias (patients having urethral meatus at posterior third of penile shaft and at penoscrotal junction) were included in the present study. Patients were randomly allocated into 2 groups of 60 each by using Strata 9 software random number table. In group A, fibrin glue was used as a sealant after hypospadias surgery, whereas in group B, no sealant was used. All the operations were performed by single surgeon using transverse preputial tubularized island flap urethroplasty. RESULT Fistula formation occurred in 6 cases in group A (10%) and 19 cases in group B (32%) (P = .027). The fistulae observed in fibrin glue group A were single and small in size (<1 mm). Multiple (>or=2 fistulae) and larger fistulae (>2 mm) were observed in group B. Overall complication was significantly higher in group B (P = .006). CONCLUSION Fibrin glue in hypospadias repair does not eliminate fistula formation. However, it seems that it minimizes the incidence of fistula formation.

Conservative management of ulcerated haemangioma – twenty years experience

Ulceration is the most common complication of haemangioma and occurs in 5–15% of cases. The present study was carried out to evaluate the clinical features of ulcerated haemangioma and efficacy of the management protocol adopted by us over a period of 20 years. All patients with ulcerated haemangioma were evaluated on the basis of age at presentation, sex, rural or urban distribution and site of haemangioma. Treatment included application of topical antibiotic and systemic antibiotic and analgesic for pain. The total number of patients was 608. The male to female ratio was 1: 2·28. The rural:urban distribution was 2·43:1. The most common site of involvement was head and neck. Mean age of patients was 5·60 ± 2·44 months. Mean size of haemangioma and ulceration was 47·30 ± 20·67 cm2 and 7·49 ± 4·52 cm2, respectively. The mean time for ulcer healing was 40·06 ± 19·41 days. Ulcer size of more than 10 cm2 took more time to heal. Response to treatment was satisfactory. Ulcerated haemangioma usually occurs before completion of 1 year of age; hence, every patient with haemangioma needs careful attention. Adequate treatment and regular follow up brings satisfactory response in the patients.

Single-stage repair for rectovestibular fistula without opening the fourchette

BACKGROUND Anorectal malformations are one of the most common congenital defects. This study is conducted to demonstrate new technique for treatment of rectovaginal fistula without disturbing the fourchette through posterior sagittal approach. METHOD All the patients of rectovestibular fistula admitted after the neonatal age were treated with posterior sagittal anorectoplasty without opening the fourchette. The results were evaluated for cosmetic appearance and anal continence. RESULT A total of 40 patients were included in our study. All patients were more than 1 month old. Operative time ranges from 70 to 150 minutes. The cosmetic appearance was good. Anal continence was good in 72% cases and fair in 20% cases. Fifteen percent of patients had minimal constipation and 7.5% patients had mucosal prolapse. CONCLUSION Single-stage repair for vestibular anus through posterior sagittal anorectoplasty without opening fourchette has a good cosmetic appearance and good anal continence.

Covered Exstrophy: A Rare Variant of Classical Bladder Exstrophy

Covered exstrophy is an extremely rare variant of exstrophy-epispadias complex. It is less distressing and easier to manage than classical exstrophy of the bladder. We report three cases of this entity, two associated with anorectal malformation and one with unilateral renal agenesis, along with a review of the literature.

Pediatric carcinoma of rectum - Varanasi experience

BACKGROUND Primary gastrointestinal system malignancies constitute approximately 2% of pediatric neoplasm and of these; colorectal carcinoma is the second most common malignancy. This is one of the rarer diseases in children. AIM We reviewed our records to study the clinical features, outcome and the follow-up of this condition with evaluation of the prognostic factors. SETTINGS AND DESIGN Tertiary care Pediatric Surgery centre. Retrospective study. MATERIALS AND METHODS The data of all patients with diagnosis of colorectal carcinoma from January 1986 to January 2006 were reviewed. The confirmation of the diagnosis was by biopsy from the lesion. The age, sex, family history, clinical features, response to the treatment and follow-up were studied. RESULTS There were four male patients. All had bleeding per rectum as the presenting complaint. Three patients had advanced disease at presentation. All the patients had signet cell adenocarcinoma. The two patients expired and one was lost to follow-up. One patient is alive after one year of follow up and is receiving treatment. CONCLUSION Colorectal cancer in children though rare can be a reality, hence any children presenting with pain in abdomen along with doubtful history of constipation and rectal bleeding should be examined carefully with special emphasis on digital rectal examination.

Long-term follow up of mesenchymal hamartoma of liver- Single center study

Background/Aim: Mesenchymal hamartoma of liver (MHL) is a rare liver tumor of childhood. About 200 cases have been reported till now. Most of the work on MHL is limited to case reports and there are not many long term follow-up studies. We present our 20 years of experience with this uncommon entity. This study aims to highlight clinical features, diagnosis and treatment of MHL. Materials and Methods: All patients with a diagnosis of MHL in last 20 years were included in this retrospective study. The patients were evaluated clinically, radiologically and pathologically. Results The total number of patients with a diagnosis of MHL was nine. Mean age of the patients was 19.89 ± 2.75 months. Right lobe was involved in eight patients. The prominent clinical features were distension of abdomen and anorexia. Surgical options used were hepatic lobectomy, wedge resection and enucleation. Histopathology of the specimens showed cysts of variable size with normal hepatocytes, bile ducts and connective tissue stroma. Overall mortality was one (11.11%). Conclusion: MHL is a benign tumor that can present with various clinical features. It should be differentiated carefully from other liver masses especially malignant ones. The diagnosis can be made with the help of radiology and histopathology. Adequate resection is curative in most of the cases and long-term follow up is satisfactory.

Surgical considerations in pediatric necrotizing fasciitis.

Background: Necrotizing fasciitis (NF) is a serious infection of soft tissues. This paper presents experience with pediatric NF and suitability of conservative surgery in its management. Materials and Methods: In this retrospective study, 70 patients of NF were managed during the study period of eight years. The study was divided into two time periods- first period (June 1998 to June 2001- group 1) and second period (June 2001 to June 2006- group 2). The parameters studied were age, sex, site of involvement and treatment. The treatment included intravenous antibiotics, supportive therapy and either aggressive (group 1) or conservative surgery (group 2). Results: Age of presentation ranged from 10 days to 11 years. Male to female ratio was 1.69:1. Back was the commonest site to be involved. Culture reports were polymicrobial in 70% with predominance of Staphylococcus species. Predisposing factors included malnourishment, boils, scratch injury, intravenous cannulation and injections. Conservative surgery had better outcome in terms of hospital stay, complications and cost of treatment. Conclusion: NF is a serious and disease which requires immediate and all out attention. Early diagnosis, aggressive supportive treatment and conservative surgery improve survival.

Placement of the Peritoneal End of a Ventriculoperitoneal Shunt in the Suprahepatic Space: Does It Improve Prognosis?

Introduction: Hydrocephalus is a common pediatric problem. Ventriculoperitoneal shunts (VPS) are the most frequent operative procedures used to treat hydrocephalic children. The peritoneal end is usually placed in the general peritoneal cavity. We present an alternative site of peritoneal end placement in the suprahepatic space in an attempt to reduce the abdominal complications. Material and Methods: All patients with a diagnosis of congenital hydrocephalus were included in the study. In group 1, the lower end of the VPS was placed in the suprahepatic space. Patients were evaluated for abdominal complications like pseudocyst formation, intestinal obstruction and blockage of the lower end of the VPS. The data were compared with those patients in whom the peritoneal end was placed in the general peritoneal cavity (group 2). Results: The total number of patients in groups 1 and 2 was 133 and 175, respectively. Complications in group 1 were dislodgement of the shunt in the general peritoneal cavity in 28 (21.05%), suprahepatic pseudocyst formation in 2 (1.5%) and blocked lower end in 2 patients (1.5%). In group 2, complications noted were pseudocyst formation in 5 (2.8%), blocked lower end in 25 (14.2%), intestinal obstruction in 9 (5.1%), inguinoscrotal migration in 10 (5.7%) and perforation of viscera in 6 patients (3.4%). The overall follow-up period ranged from 1 to 7 years. Conclusions: Placement of the lower end of the shunt in the suprahepatic space can be advantageous to placing it in the general peritoneal cavity. The procedure is simple and results can be rewarding.