V. Bhatnagar

Endoscopic treatment of tracheoesophageal fistula using electrocautery and the Nd:YAG laser

BACKGROUND Endoscopy is a well-established means of diagnosis in recurrent and congenital H-type tracheoesophageal fistulas. There is only limited knowledge of its role in the treatment using either electrocautery or laser. Laser application has not yet been reported in the treatment of recurrent tracheoesophageal fistula. METHODS From 1993 to 1997 five patients with tracheoesophageal fistula (two congenital H-type and three recurrent) were treated endoscopically using a rigid ventilating bronchoscope. The final diagnosis was made on bronchoscopic examination. In two of the patients with recurrent fistulas and one with congenital fistula, the mucosal lining was fulgurated with electrocautery via an insulated wire. In one patient each with recurrent and congenital fistula, the mucosal lining was vaporized with the Nd:YAG laser via a 600 microm bare quartz fiber. RESULTS Obliteration of the fistula was achieved in both the patients in whom laser was used, but it was unsuccessful in two of the three children in whom electrocautery was used. The obliquity of the congenital H-type fistula renders it more amenable to obliteration compared with the short and direct recurrent fistula. There was significant respiratory distress in the postoperative period after use of electrocautery. However, it was uneventful with the use of laser. CONCLUSIONS Endoscopic treatment of recurrent and congenital H-type tracheoesophageal fistula is technically easier than open surgical procedures and helps avoid the risks associated with the latter. The Nd:YAG laser is qualitatively better than electrocautery for the obliteration of the fistula.

Genitourinary tuberculosis in pediatric surgical practice

BACKGROUND Genitourinary tuberculosis (GUTB) has been reported to account for 20% to 73% of all cases of extrapulmonary tuberculosis in the general population but is much rarer in children. GUTB is a form of secondary tuberculosis with vague symptoms. Surgical intervention is required in a minority of cases. METHODS Nine cases of genitourinary tuberculosis (GUTB) were diagnosed and treated from 1988 to 1995. The age of the patients ranged from 5 to 12 years. There were five boys and four girls. Presenting features were diverse and included gross hematuria in 44% of cases and epididymoorchitis in 22% of cases. Rarer presenting features included acute renal failure, staghorn calculus, and pyonephrosis. Associated or past history of tuberculosis was present in three patients. Conclusive diagnosis was made on the basis of isolation of mycobacterium tuberculosis, histopathology, or cystoscopy in eight patients, whereas one patient was given a therapeutic trial based on clinical manifestations. RESULTS Response to antitubercular drug therapy was gratifying. Excisional surgery in the form of nephrectomy was needed in one patient, whereas another underwent bilateral ureteric replacement with ileal loops for multiple ureteric strictures. CONCLUSIONS The wide variety of presenting features and pathological lesions that result from GUTB are emphasized. The diagnosis of GUTB must be suspected in patients who present with hematuria (gross or otherwise), epididymoorchitis, and patients with long segment or multiple ureteric strictures. In view of the anticipated resurgence in tuberculosis caused by the prevalence of aquired immunodeficiency syndrome the pediatric urologist must be aware of the pathophysiology and clinical spectrum of this disease.

Functional outcome after pyeloplasty for unilateral ¶symptomatic hydronephrosis

Abstract. The functional outcome and factors influencing improvement after pyeloplasty for ureteropelvic junction (UPJ) obstruction are still debated. This retrospective study was aimed at evaluating the factors associated with functional improvement in symptomatic unilateral hydronephrosis (HDN). Patients (n=68) who underwent successful pyeloplasty for unilateral symptomatic UPJ obstruction without any other associated urological abnormality were included. Preoperative evaluation included a diuretic renogram (DR) to confirm obstruction and assess the split renal function (SRF). A follow-up DR was obtained 3 months and 1, 2, and 5 years postoperatively. An absolute increase in the differential function of the operated kidney by over 5% was considered significant; such kidneys were classified as improved (group A) and the others as unimproved (group B). The difference between the preoperative and 3-month SRF was highly significant (P < 0.001). Significant (P < 0.01) improvement in SRF continued until 1 year after pyeloplasty. Patients who presented with a mass had significantly greater improvement (P < 0.05) than those who presented with other clinical features. In group A, a significantly higher number of patients presented with a mass. It was also evident that patients aged less than 1 year showed significantly greater (P < 0.01) improvement in SRF than older patients. Thus, in unilateral symptomatic HDN with impaired function, patients who present with a mass or those in whom pyeloplasty was performed before 1 year of age showed significantly greater improvement.

A histopathological study of esophageal atresia and tracheoesophageal fistula.

BACKGROUND/PURPOSE Histopathologic examination of the esophagus has not been reported often in esophageal atresia (EA) and tracheoesophageal fistula (TEF). Abnormal esophageal motility has been reported after successful repair of EA and TEF, although the exact etiology of this motility disorder remains unclear. Histological evaluation of the fistulous portion of the esophagus has been performed to document any abnormality that may be responsible for the abnormal motility. METHODS Histopathological study of fistulous segment of esophageal atresia and distal TEF was conducted on 65 patients, which included autopsy material from 3 patients in whom the entire esophagus was examined by serial section. Special stains were administered to each specimen to look for tracheobronchial remnants and the arrangement of muscle fibers. Clinical evaluation was performed in 27 patients who were available for review 6 months to 9 years after successful surgical treatment. These patients were categorized into 3 groups according to their clinical status. RESULTS These findings showed that the majority of these patients have tracheobronchial remnants in the esophagus in the form of abnormal mucous glands and ducts, abnormal mucin secretion, presence of cartilage, and a disorganized muscle coat. CONCLUSIONS The presence of abnormal mucous glands and abnormal mucin secretion has not been highlighted before. Although tracheobronchial remnants and a disorganized muscle coat are common findings in the fistulous portion of the esophagus, these may not reflect the structure of the remaining esophagus.

The role of DMSA scans in evaluation of the correlation between urinary tract infection, vesicoureteric reflux, and renal scarring.

Abstract The correlation between urinary tract infection (UTI), vesicoureteric reflux (VUR) and renal scarring was studied in 89 patients (177 renal units; 1 solitary kidney) during the period 1997–2000. There were 63 males and 26 females; ages ranged from neonates to 14 years. UTI was diagnosed on the basis of a positive urine culture, VUR was diagnosed and graded by micturating cystourethrogram (MCU), and renal scarring was assessed by technetium 99 m Tc-dimercaptosuccinic acid (DMSA) scan. Ultrasonography (US) was done to evaluate renal tract dilatation and other structural abnormalities. A follow up DMSA scan was performed approximately 6 months after the initial scan. VUR was present in 106 of the 171 renal units in which it was studied and absent in 65 units. The majority of the VUR was grade V. Renal scars were seen in 90 of 177 renal units at presentation and in 72 of the 163 renal units studied at follow-up. Some information was lacking in 31 patients; hence, the correlation between UTI, VUR, and renal scarring was done in 58 patients. The majority of the suspected scars at presentation were not seen at follow-up, but most of the established scars persisted. Only 2 renal units showed scars for the first time on follow-up. On US, approximately 50% of normal kidneys showed either suspicious or established scars on DMSA scan, and patients with bilateral abnormality on US showed renal scars. Renal scars were seen in 15 of 23 children without VUR, 17 of 18 with unilateral VUR, and 16 of 17 with bilateral VUR. Thus, there is a cause-and-effect relationship between UTI and renal scarring that is made worse by VUR. DMSA scans have been shown to be the most reliable method of assessing renal scarring, and an abnormal US scan showing upper-tract dilatation or a structural abnormality may have a predictive value in the detection of renal scarring.

Ectopic pancreas associated with a choledochal cyst and extrahepatic biliary atresia.

Abstract. Two children with incidentally-diagnosed ectopic pancreatic tissue in the jejunum at surgery for extrahepatic biliary atresia (EHBA) and choledochal cyst (CC) are reported. No case has been reported in the literature describing the association of a CC with ectopic pancreas, and only one case of EHBA associated with ectopic pancreas has been reported. We believe that incidentally-detected ectopic pancreatic tissue should be excised, even though the patient is symptom-free, in order to prevent the risk of serious complications due to either the mass effect or the potential for acute pancreatitis, cystic degeneration, or malignant transformation at a later date.

Crossed fused renal ectopia: Challenges in diagnosis and management.

Aim: Crossed fused renal ectopia is a rare congenital malformation, which is reported to be usually asymptomatic but may have varied presentations. This survey was conducted to study the clinical profile and the challenges posed in the management of this entity. Materials and Methods: Retrospective analysis of 6 patients diagnosed to have crossed fused renal ectopia during 1997-2010. The diagnosis was confirmed during surgical exploration in one patient. In one patient it was detected on antenatal ultrasonography and in the other 4 patients it was detected during investigations for abdominal pain, abdominal mass, anorectal malformation and urinary tract infection. Results: The left moiety was crossed and fused with the right moiety in 4 cases. Ultrasonography was found to be a good screening investigation with useful diagnostic contributions from CT scans, radionuclide scintigraphy and magnetic resonance urography. Micturating cystourethrography revealed presence of VUR in 4 cases, 3 of whom have undergone ureteric reimplantation. Two patients required pyeloplasty for pelviureteric junction obstruction; in one of these patients the upper ureter was entrapped in the isthmus. In one patient, a non-functioning moiety resulted in nephrectomy. All children were asymptomatic at last follow-up with stable renal functions. Conclusions: Crossed fused renal ectopia was detected in most patients during investigation for other problems. It was found more commonly in boys. The left moiety was crossed to the right in the majority of cases. Associated urological problems were found in most cases and required the appropriate surgical management.

Respiratory distress in neonates

Respiratory distress due to either medical or surgical causes occurs commonly in neonates. It is the most common cause of admission to a neonatal surgical intensive care facility in a tertiary care hospital. The distress can be caused by a variety of clinical conditions; common conditions treated in medical intensive care units are transient tachypnea of the new born, respiratory distress syndrome, pulmonary air leak and pneumothorax. In surgical causes of respiratory distress in neonates the underlying mechanisms include airway obstruction, pulmonary collapse or displacement and parenchymal disease or insufficiency; the common causes are congenital diaphragmatic hernia, congenital cystic adenomatoid malformation, congenital lobar emphysema and esophageal atresia with or without tracheo-esophageal fistula. Obstructive lesions of the new born airway include choanal atresia, macroglossis, Pierre-Robin syndrome, lymphangioma, teratoma or other mediastinal masses, cysts, subglottic stenosis and laryngo tracheomalacia. Imaging plays a very major role in the pre-operative diagnosis of these conditions and proper pre-operative resuscitation helps in improving the results of surgery dramatically.

Congenital hepatoportal arteriovenous fistula: Report of a case

Fistulae between the hepatic artery and portal vein, known as hepatoportal arteriovenous fistula (HPAVF), most commonly occur secondary to trauma or malignancy. Congenital HPAVF is an extremely rare anomaly and only 11 pediatric cases have been documented to date HPAVF causes portal hypertension with the reversal of flow in the portal circulation, leading to hyperemia and congestion of the bowel, causing severe ascites, gastrointestinal bleeding, anemia, and malabsorption. The diagnosis is first made by Doppler sonography, then confirmed by angiography. HPAVF is most effectively treated by performing either ligation of the hepatic artery or percutaneous transcatheter embolization. We describe herein the case of an 8-month-old boy diagnosed to have congenital HPAVF by duplex Doppler sonography and confirmed by digital subtraction angiography, who was successfully managed by percutaneous transcatheter embolization of the feeding right hepatic artery. A review of the previously reported 11 cases of infants with this unusual anomaly, examining presentation, management, and outcome, is also presented.

Fulguration of posterior urethral valves using the Nd:YAG laser

Abstract Endoscopic management is the accepted form of treatment for posterior urethral valves (PUV) . The Nd:YAG laser has been in clinical use for many decades, but has been used only sporadically for ablating PUV. In this study, PUV were diagnosed by micturating cystourethrogram (MCU). In the 9-month period beginning March 1997, 23 boys 3 months to 9 years of age underwent endoscopic Nd:YAG laser surgery for PUV using a 600 quartz bare fibre through the catheter channel of an 8.5 F cystoscope. The laser power and total energy delivered ranged from 20 to 50 W and 50–1085 J, respectively. Type I PUV were present in 20 boys; 1 had type III, and in 1 boy each there were residual valves and a urethral stricture from a previous electrocautery ablation. All operations were done with the patient under general anaesthesia supplemented by caudal morphine. Routine postoperative cystoscopy was done in the first 5 cases only. All patients had a good stream of urine without bleeding or any other complication after valve ablation. Mucosal tags seen on follow-up cystoscopy in 5 patients were fulgurated by laser. In 4 other patients recystoscopy was required for deterioration of the urinary stream and persistent posterior urethral dilatation on MCU; residual valves were refulgurated by laser. An indwelling catheter was left in only 4 patients, 2 of whom were primarily operated and 2 following refulguration. All except the first 2 were treated as out-patients. Application of the Nd:YAG laser has added a new dimension for treating PUV. The initial experience has been very encouraging: the destruction of valves is precise, there are no complications, and it can be practised on a day-care basis without indwelling catheterisation. The bare fibre can be used repeatedly, thus reducing the cost of treatment.