Home | About Us | Current Issue | Ahead of print | Archives | Search | Instructions | Subscription | Feedback | Editorial Board | e-Alerts | Login 
Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
 Users Online:5515 
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size


 
Table of Contents   
ABSTRACTS
Year : 2020  |  Volume : 25  |  Issue : 7  |  Page : 1-99
 

Abstract



Date of Web Publication25-Jun-2020

Correspondence Address:
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions

 



How to cite this article:
. Abstract. J Indian Assoc Pediatr Surg 2020;25, Suppl S1:1-99

How to cite this URL:
. Abstract. J Indian Assoc Pediatr Surg [serial online] 2020 [cited 2020 Aug 4];25, Suppl S1:1-99. Available from: http://www.jiaps.com/text.asp?2020/25/7/1/287687





   Feasibility of pediatric day care surgery Top



   Category: UC Chakraborty Award Top


Sandeep Kumar, Amita Sen

Department of Paediatric Surgery, PGIMER and DR. RML Hospital, New Delhi, India.

E-mail: skjaglan2@gmail.com

Aims: To study feasibility,patient and parental satisfaction with pediatric day care surgery.

Methods: Type of study:A prospective observational study.Study was carried out in 120 patients with 60 patients as day care cases and 60 patients as inpatient care from 1st Feb 2018 to 28th Feb 2019.Feasibility of different pediatric surgical procedures,parental satisfaction with day care surgery(using COPD questionnaire)were studied.

Results: Male:Female ratio in case group was 7.5:1 and in control group was 4:1.Mean age in case group-6.28 yrs and in control group-5.37 yrs.Most common procedure in both groups was Unilateral herniotomy[Cases 38.3%(n=23),Control 46.7%(n=28).All procedures carried out under GA using propofol & desflurane.1 patient in case group had superficial wound infection in post operative period.Avg Likert score for parental satisfaction for cases-4.59/5,for controls-3.94/5 (p value= 0.00001).Mean stay for cases-16.27 hrs,for controls-118 hrs(p value =0.00001).

Conclusion: Day care pediatric surgery is feasible & satisfying to the parents.A wide array of pediatric surgical procedures can be performed on day care basis with a very low complication rate.


   Conjoined thoracopagus twins- Our experience and review of literature for outcome of surgical separation Top



   Category: UC Chakraborty Award Top


Rahul Saxena, Manish Pathak, Arvind Sinha, Mahaveer S Rodha, Biangchawadka Suchiang

Department of Paediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

E-mail: drrahulsaxena@gmail.com

Introduction: Conjoint twin is an extremely rare condition and requires a thorough knowledge of anatomy and a multidisciplinary approach is essential to successfully separate the twins. Thoracopagus are the twins attached by chest and umbilicus and are the commonest among all the varieties but carries a poor survival rate.

Materials and Methods: We describe our approach and experience of management of thoracopagus twins who were successfully separated at eighty-three day of life and were alive and well after more than 4 years of follow up. We have reviewed the English literature via PubMed, Google and Google scholar using keywords; Conjoined twins, Thoracopagus twins and Thoracoomphalopagus twins for outcome of thoracopagus twins.

Results: 118 thoracopagus sets were included from previous literature whose outcome was described. Out of 118 reported thoracopagus twin sets in literature, with M:F ratio of 1:3.4, thirty-nine sets were found to be non-operable and all subsequently expired; 55 sets were operated out of which 48 babies survived, suggesting overall surgical success rate of about 44%.

Conclusion: Thoracopagus twins have dismal prognosis and those with complex cardiac anomalies have almost 100 percent mortality. Most important decisive parameter for successful separation is the extent of sharing of organs between twins and dedicated multidisciplinary team support.


   The role of urinary biomarkers (IL-6, TGF B, MCP-1, E-CADHERIN) for monitoring the clinical course of patients with posterior urethral valves Top



   Category: UC Chakraborty Award Top


Priyanka Garg, Nitin J Peters, Ram Samujh, Sadhna Sharma

Department of Paediatric Surgery, PGIMER, Chandigarh, India.

E-mail: priyanka1986mittal@gmail.com

Aims: To measure the levels of IL-6, TGF-β, E-cadherin, and MCP-1 in cases of posterior urethral valves (PUV) and to observe trends in consequent follow ups and correlate them with established clinical, radiological and biochemical parameters of disease progression.

Methods: This prospective study was conducted on 42 patients of PUV, over a period extending from Jan 2018 to June 2019. Patients managed elsewhere and presenting for second opinion, refused consent and lost to follow up were excluded. In addition to evaluation as per standard institutional protocol, these biomarkers were measured in urine samples at time of admission, pre- fulguration and 3 months and 9 months post fulguration.

Results: All the biomarkers showed statistically significant trends when these values were compared on admission, post optimization (pre-fulguration), at 3 months and 9 months post-fulguration. On applying Pearson's correlations, E-Cadherin showed negative correlation with IL-6, TGFβ, MCP-1; which was statistically highly significant. None of the biomarkers showed significant correlation with RFTs. Spearman's Rho correlations were applied and E-Cadherin and TGFβ showed high statistical significance with USG KUB. On application of T-test; E-Cadherin, IL-6 and TGFβ showed significant correlation with MCU whereas only IL-6 showed significant correlations with DMSA. MCP-1 did not show any statistically significant correlation with USG KUB, MCU and DMSA.

Conclusion: This study concludes that E-Cadherin, IL-6, TGF-β can be promising urinary biomarkers to follow the first year outcomes of patients of PUV undergoing valve fulguration. MCP-1 may have more complex interactions with other pro and anti-inflammatory markers which warrants further research.


   Bracka urethroplasty with buccal mucosa graft; Ergonomic management of penile skin dartos in first stage to facilitate second stage neourethral coverage Top



   Category: UC Chakraborty Award Top


Gaurav Shandilya, SN Kureel, Archika Gupta, GP Singh, Anand Pandey, JD Rawat, Ashish Wakhlu

Department of Paediatric Surgery, King George Medical University, Lucknow, Uttar Pradesh, India.

E-mail: megauravshandilya@gmail.com

Aim: To report new technique of ergonomic penile skin-dartos management during buccal mucosa graft (BMG) to provide adequate penile skin-dartos for neourethral coverage at the time of second-stage tubularisation.

Materials and Methods: Ten proximal hypospadias with severe chordee underwent first stage surgery with new technique. Incision along the urethral plate margin and preputial edge used to split inner prepuce off preputial dartos and penile degloving leaving inner prepuce attached to corona. Urethral plate was divided in subfascial plane. Penile dartos was bisected in dorsal midline avascular plane. Distal half of penile skin-dartos bifurcated and joined to inner preputial edges. Mobilised and lateralised penile skin-dartos was sutured flanking edges of BMG. Second-stage tubularisation after 6-months provided neourethral double dartos coverage with eccentric suture lines.

Results: Adequate dartos for neourethral coverage during second-stage tubularisation was available in all. Subcoronal urethrocutaneous fistula occurred in one that was repaired.

Conclusions: Ergonomic management of inner-preputial skin and ventral transfer of penile skin-dartos helps in providing neourethral coverage during subsequent second-stage tubularisation to minimise the occurrence of complications.


   Comparison of high spermatic vessel ligation and low spermatic vessel ligation in undescended model of rat testis Top



   Category: UC Chakraborty Award Top


Murali Krishna Nagendla, Vishesh Jain, Sandeep Agarwala, MC Sharma, Surabhi Gupta

Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: krrishnany@gmail.com

Aim: To compare immediate and long-term outcomes after High spermatic vessel ligation (HSVL) and low spermatic vessel ligation (LSVL) in high undescended testis in rat model.

Methods: Prospective randomised controlled study conducted on 24 male Wistar rats. The rats were randomly divided into three groups. Each group was again divided into two sub groups. Group A underwent sham laparotomy and acted as control. Group B underwent HSVL of both testicular vessels. Group C underwent LSVL of both testicular vessels. Each sub groups underwent blood collection and testicular biopsy of both testes at 24 hours after procedure to demonstrate immediate changes. Other sub groups underwent blood sample collection and testicular biopsy of both testes at Day 50 following the procedure for hormonal changes and long-term changes.

Results: All the testes in HSVL showed atrophy (100%) on long term whereas LSVL showed atrpohy in 12.5% of testes, even though both groups showed adequate neovascularization. Testes in HSVL showed poor bleeding on incision at both 24 hours and at Day 50. On histology 75% of testes in HSVL showed complete necrosis and 50% in LSVL showed partial necrosis at 24 hours. On Day 50 all the testes in HSVL (100%) showed complete necrosis with dystrophic calcification, whereas all the testes in LSVL showed normal histology with good maturation of seminiferous tubules. There was no significant difference in testosterone levels in both groups.

Conclusion: HSVL associated with higher testicular atrophy rates than LSVL. LSVL can be preferred for management of high intra-abdominal testis.


   Assessment of distribution of Interstitial cell of Cajal like cell across upper urinary tract region in children with pelvic ureteric junction obstruction Top



   Category: UC Chakraborty Award Top


Kumar Ashish, Simmi K Ratan, Nita Khurana, Jyoti Kumar, Yogesh K Sarin

Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: dmcashish@gmail.com

Aims and Objectives: To study the distribution of Interstitial cell of Cajal like cell(ICC-LC) across upper urinary tract region in children presenting with PUJO and its association with age, renal functional and sonological parameters of patients.

Materials and Methods: Prospective study done on twenty children (excluding neonates) with primary PUJO undergoing dismembered pyeloplasty. All subject underwent renal sonography [anteroposterior diameter of pelvis(APPD), pelvicalyceal ratio(P/C ratio), Midpolar Renal parenchymal thickness(MPPD)] and functional imaging scan.

Three specimens were taken intra-operatively from above, at and below PUJ and were examined immunohistochemically using CD117 to count ICC-LC using standard criteria. ICC-LC distribution was correlated with above stated parameters and with age of the patients.

Results: The number of ICC-LC showed a continuous decreasing trend craniocaudally across PUJ. P/C ratio and APPD showed parallel trend with ICC-LC distribution across PUJ while split renal function(SRF) showed inverse relationship with expression of ICC-LC. Children > 3 months and group with lesser severity of obstruction (APPD <31.5mm, SRF>40%) showed uniform decreasing trend in number of ICC-LC craniocaudally across PUJ. More severely obstructed patients (APPD>31.5mm, SRF<40%) and younger infants had decreasing trend upto the level of PUJO followed by a sudden relatively increased expression of ICC-LC below PUJ.

Conclusion: Resurgence in the number of ICC-LC below PUJ in subjects with severely obstructed and in young infants hints at emergence of new pacemaker area below severely blocked PUJ akin to that seen in complete heartblock patients and deserve early attention.


   Role of abdominal leak point pressure in prediction of continence following surgery for unilateral ectopic ureter in girls Top



   Category: UC Chakraborty Award Top


Priyank Yadav, Anil Mani, Ravi Banthia, Naveen Kumar, Sarita Syal, MS Ansari

Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

E-mail: priyankmamc@gmail.com

Aim: Some case of unilateral ectopic ureter (UEU) in girls are associated with malformation of the bladder neck which may cause persistent incontinence after ureteric reimplantation alone. The aim of this paper is to use abdominal leak point pressure (ALPP) as a tool to predict such incontinence before undergoing ureteric reimplantation.

Methods: All girls operated for UEU between January 2009 to May 2018 were prospectively evaluated. History, preoperative imaging, preoperative urodynamics and intra-operative findings were recorded. Postoperative persistent incontinence were noted and the patients were divided into two groups A and B based on their status of continence. The preoperative findings were analysed and compared specifically for the group A patients to find significant factors.

Results: Twenty three girls were operated for UEU with their ureteric orifice at or distal to bladder neck with mean age of 10.9 ± 3.15 yrs. Six underwent nephroureterectomy and 17 had reimplantation/ureteroureterostomy. Nine (39.1 %, Group A) girls had varying degree of incontinence postoperatively and 14 (60.9%, Group B) were dry. In group A, cystometrogram had demonstrated abdominal leak point pressure (ALPP) < 60 cm of water in 7 patients with mean ALPP of 43.9 ±16.15 while only one patient in Group B demonstrated leak. Preoperative ALPP predicted leak with 90% PPV. Those who failed conservative management in Group A underwent bladder neck reconstruction or bulking agents.

Conclusion: Preoperative ALPP in girls with UEU is able to predict continence after ureteric reimplantation which can help in prognostication before surgery for probable need of secondary procedures.


   Mini-Perc for renal calculi in pediatric patients: A prospective randomised study Top



   Category: Swapna Dutta Award Top


Shrey Jain, MS Ansari, Priyank Y, Sarita

Department of Urology, SGPGI, Lucknow, Uttar Pradesh, India.

E-mail: shreyjain992@gmail.com

Aims: To assess the safety, efficacy, and stone-free rate (SFR) of Mini percutaneous nephrolithotomy (mPCNL) and compare it with conventional PCNL (cPCNL) in pediatric patients under 18 years of age.

Methods: 50 patients were prospectively randomised into two groups. Group A had 28 patients managed by mPCNL. Group B had 22 patients who underwent cPCNL. Unpaired t test was used to assess p value.

Results: Both groups were comparable for basic demographic profile and the stone characteristics. The mean operating time was statistically significantly longer in Group A (p=0.04). On first session of PCNL the SFR for m-PCNL was 93.31% and for cPCNL 94.2%, which was not significantly different. On re-look, SFR improved to 96.2% and 97.3% respectively. Episodes of haematuria were more in cPCNL [p=0.03]. Pain score on POD0 and POD1, need of analgesia, perinephric extravasation and nephrostomy site leak were all higher in cPCNL(p-<0.05). Although the hospital stay was longer in cPCNL as compared to mPCNL this was not statistically significant (p-0.244).

Conclusion: Mini-Perc offers good outcomes with lower complications rates compared to the conventional technique even for larger stones. Size of tract influences nature of complications such as higher rates of haematuria, lumbar pain and perinephric extravasation.


   Evaluation of surgical approaches, outcomes and prognostic factors of posterior urethral injuries in children Top



   Category: Swapna Dutta Award Top


Nidhi Sugandhi, Nidhi Sugandhi, Deepak Bagga, Sameer Acharya, Amit Jadhav, Narinder Teckchandani

Department of Paediatric Surgery, VMMC and Safdarjung Hospital, New Delhi, India.

E-mail: drnidhisugandhi@gmail.com

Aim: To evaluate the surgical approaches and outcomes of posterior urethral injuries in children.

Methods: Retrospective review of all children with posterior urethral injures undergoing delayed urethral repair.

Results: 48 children underwent surgery for posterior urethral injuries from 2000-2019. Transpubic repair (TPR) was done in 25, perineal repair(PR) in 19 and Anterior Saggital Transrectal Approach (ASTRA) in 3. End to end anastomosis (EEA) could be achieved in 42 patients.

Associated injuries were universally present in children undergoing TPR. Mean age of children undergoing TPR was 9 years compared to 4 years in PR. Assessment with RGU/MCU and EUA revealed urethral injury above the ischial spine and disrupted gap > 2.5 cm in all patients undergoing TPR. EEA could be achieved in all males but only in 25% of females. Postoperatively 3 patients with PR required dilatation. Stress incontinence and gait disturbance were noted in 2 patients each in TPR group.

Conclusion: Posterior urethral injuries are difficult to treat but satisfactory results can be achieved by correct surgery. TPR is more probable in patients with RTA , associated injuries, high and wide urethral disruption and in older children .EEA is more likely in male patients . Follow up surgeries are more likely after PR.


   Role of urinary tissue inhibitors of metalloproteinases-2 and bladder wall thickness in predicting the urodynamic profiles in operated patients of lumbo sacral meningomyleocele Top



   Category: Swapna Dutta Award Top


Shubhalaxmi Nayak, Monika Bawa, Ravi Kanojia, JK Mahajan, Ram Samujh

Department of Paediatric Surgery, PGIMER, Chandigarh, India.

E-mail: shubhi.shubha@gmail.com

Aim: To establish role of bladder wall thickness (BWT) and urinary-Tissue Inhibitors of metalloproteinases 2 (uTIMP-2) to predict urodynamic profile and upper urinary-tract damage in children operated for Lumbo-sacral Meningomyleocele(LSMMC).

Methods: Prospective study on 55 patients with 40 operated cases of LSMMC and 15 controls. All operated patients underwent cystometry. uTIMP-2 levels, Ultrasound-KUB for BWT was done in all patients and were correlated with cystometric findings and DMSA.

Results: Operated LSMMC patients were grouped into 3 based on cystometry - Group A(n-12)–without NB, Group B(n-14)–with NB on treatment,GroupC(n-14)–with NB, not on treatment. Group D (n-15)-controls. Average values of uTIMP-2 in group A to D were 386.35, 1515.14, 2953.54 and 201.93 pg/ml respectively (statistically significant in patients with NB and controls).Average BWT in Groups A to D were 2.07 mm, 2.32 mm, 2.36mm and 1.97 mm respectively(statistically insignificant). uTIMP-2 was found to be higher in patients with renal scarring(statistically insignificant).

Conclusion: uTIMP2 levels can be a promising replacement to UDS in assessment of bladder profiles in operated cases of LSMMC but cannot effectively predict scarring. However BWT does not effectively correlate with urodynamic findings.


   Comparative outcome analysis of onlay preputial flap and snodgraft urethroplasty in preservable narrow urethral plate hypospadias: A pilot study Top



   Category: Swapna Dutta Award Top


Rohit Kapoor, Archana Puri

Department of Paediatric Surgery, Lady Hardinge Medical College, New Delhi, India.

E-mail: puriarchana@hotmail.com

Aim: Hypospadias with narrow urethral plate poses a therapeutic challenge. This series aims to compare the outcomes and complications of Onlay preputial flap and Snodgraft urethroplasty in preservable narrow urethral plate hypospadias.

Methods: This prospective study included 28-patients of hypospadias (Distal: 10; Proximal: 18) with narrow urethral plate managed over last 2-years by a single surgeon. Narrow urethral plate (UP) was defined as maximum urethral plate diameter of <6mm. Based on operative procedures performed, patients were divided into 2 groups; Group I: Onlay preputial flap urethroplasty (n: 10) and Group II: Snodgraft urethroplasty (n: 18). Penile anatomical characteristics (meatal position, UP width, glans maximum transverse diameter and corpus spongiosum) were compared in the two groups and correlated with complications namely urethrocutaneous fistula and glans dehiscence. Data was analyzed using Chi-square test and Student t test with p<0.05 taken as statistical significance.

Results: Mean follow-up in the present study was 13±7.8 months. Both the groups were comparable as regards age at surgery, meatal position, urethral plate width (Mean UP- Group 1: 3.7± 1.4, Group II: 2.9 ± 1.4 mm) and glans maximum transverse diameter (median Group 1: 1.5, Group II: 1.3 cm). Well-developed corpus spongiosum was noted in 4 (40%) in Group 1 and in13 patients (72.2%) in Group II (p: 0.04). Urethrocutaneous fistula in two groups was 10% (n:1) and 27.7% (n:5) respectively (p>0.05), while glans dehiscence was noted in 1 patient in group II. All patients in group II who developed urethral fistula had UP < 4mm.

Conclusion: Onlay preputial flap urethroplasty gives better surgical results than Snodgraft urethroplasty in preservable narrow urethral plate hypospadias, more so in those with UP < 4 mm. However, the difference was not found to be statistically significant due to limited patient number and merits further investigation.


   Pippe salle clitoroplastyin congenital adrenal hyperplasia: Experience and mid-term results from an apex hospital Top



   Category: Swapna Dutta Award Top


Sidharth Tyagi, Prabudh Goel, Minu Bajpai

Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: docsidharth@gmail.com

Aim: To present our experience and mid-term-results withPippeSalle Clitoroplasty in patients with Congenital Adrenal Hyperplasia (CAH).

Materials and Methods: Prospective Study to present the results of Pippi Salle Clitoroplasty in 10 females with CAH done over the last three years. Observation parameters included age at surgery, indication, clitoral length at the time of surgery, post-operative complications and outcomes at discharge and in follow-up.

Results: The study protocol will be presented. Age at surgery varied from 4-18 years. Mean follow-up 2 years. Two patients have salt wasting variety of CAH. The mean Clitoral length is 3.2 cm (2.5-6cm). Two patients developed Surgical site infection. All patients are doing well at last follow up and on steroid supplemental drugs.

Conclusions: The purpose of this presentation is to discuss Gender Dysphoria, its incidences and treatment options available for CAH in literature and advantages of pippe salle clitoroplasty over resection clitoroplasty in dealing with gender dysphoria.


   Characteristics of the gonadal vessel and deep inguinal ring during laparoscopy in impalpable undescended testis. Also, it's relation with the macroscopy/microscopic finding on inguinal exploration Top



   Category: Swapna Dutta Award Top


M Aishwarya, Bikash Kumar Naredi, S Kumaravel, Bibekanand Jindal, G Krishna Kumar

Department of Paediatric Surgery, JIPMER, Puducherry, India.

E-mail: aishwaryamalla61@gmail.com

Aims: To find the characteristics of the testicular vessel and deep inguinal ring on laparoscopy; its relation with inguinal exploration and macroscopy/microscopy finding of the testis.

Materials and Methods: A retrospective study of all children with non-palpable undescended testes who underwent diagnostic laparoscopy between 2010- 2019 and vessel going through deep ring.

Results: We admitted 198 children with non-palpable undescended testis with an average age of 55 months. Out of 198 children 69 (45%), 91 (46%) and 38 (9%) were right, left and bilateral respectively underwent diagnostic laparoscopy. Seventy nine (51%) children had no testis in the abdomen, and the deep ring was closed in 70 and opened in 9. Among 70 children with deep ring closed blinding ending vas in 8,hypoplastic in 42 and normal looking vessel in 20. In 42 children with the hypo plastic vessel, nubbin testis was in 28 (67%) and fair size testis in 14 (33%). Moreover, in the normal vessel, nubbin testis was found in 13 (65%) and fair size in 7 (35%). Besides, among children with deep ring open 5 had hypoplastic with nubbin in 3, and 4 had normal vessels with nubbin in 2. 46 (58%) nubbin testis excised out of 79 children with no testis in the abdomen. Biopsy available for 39 of which 38 reported as vas ending in fibro collagenous tissue.

Conclusion: From our study, it can be concluded that inguinal exploration is essential in all children with absent testis in the abdomen. Also, there is no relationship with characteristic of the vessel and deep ring.


   To assess adequacy of bladder interventions by employing “catheter test” after valve ablation in patients with posterior urethral valves Top



   Category: Swapna Dutta Award Top


Mamta Sengar, Yousuf Siddiqui, Anup Mohta, Chhabi Ranu Gupta, Vivek Vishwanathan

Department of Paediatric Surgery, Chacha Nehru Bal Chikitsalya, New Delhi, India.

E-mail: rjainngmc@gmail.com

Aim: To assess adequacy of bladder interventions by employing 'Catheter test' after valve ablation in patients with Posterior urethral valves (PUV).

Materials and Methods: Study type-Prospective Study duration – July 2016 to June 2019 All consecutive patients with PUV aged less than 3 years, who were in regular follow up for at least one year after PUV ablation, were enrolled in the study. Catheter test was done in cases in whom nadir serum creatinine level of less than 0.6mg/dl could not be achieved within three months of valve ablation and anticholinergic therapy. Fall in level of serum creatinine by doing this test was considered as an indicator to employ further bladder management strategies.

Results: Of 90 enrolled patients, twenty four were subjected to catheter test. The fall in serum creatinine value was found statistically significant with P value of 0.024 in 22/24 patients.

Conclusion: Catheter test helps in early identification of need for bladder interventions in follow up of post PUV ablation patients.


   Vesicoscopic ureteric reimplantation: Comparison of laparoscopic and robotic approach Top



   Category: Swapna Dutta Award Top


Gursev Sandlas Bhushanrao Jadhav

Department of Paediatric Surgery, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.

E-mail: drgursev@gmail.com

Aim: Cohen's Trans Trigonal Ureteric Reimplantation has over the years proven to be the gold standard approach for the treatment of Vesico-Ureteric Reflux.

Since the dawn of the new millennium, the vesicoscopic approach has revolutionised the post operative morbidity in these patients, thus providing a viable alternative for approach to resolution of Vesicoureteral reflux.

Introduction of Robotics has added a new approach to the same surgical technique however with added burden of extra cost.

The aim of the study was to compare the two minimal access approaches to assess any significant advantages offered by the Robotic approach over Laparoscopic approach.

Methods: Retrospective analysis of a prospectively maintained database was done with respect to the following parameters.

  • Port placement time
  • Operative time
  • Post operative stay
  • Ergonomics using the REBA Score from ErgoPlus


Selection Criteria: Inclusion Criteria – Primary reflux needing operative correction

Exclusion Criteria – Secondary reflux due to any underlying condition.

Results: Criteria Laparoscopic Robotic

Average Age 3 yrs [ 1-4 yrs] 7.25 yrs [ 3-11 yrs]

Sex ratio [M:F] 6 Boys : 5 Girls 3 boys : 2 girls

VUR Primary Primary

Criteria Laparoscopic Robotic

Port placement time 20 min (15-35 min) 25 (20-40 min)

Operative time 125 min (90-145 min) 100 (87-113 min)

Post Operative Stay 2.7 days 2 days

Ergonomics [REBA SCORE] 13 5

Risk Index 3.25 1.25.

Conclusions: Laparoscopic equally competent except for ergonomics. Robotic surgery more ergonomic thus reduces the chances of errors due to surgeon fatigue during surgery.


   Study of renal scintigraphy and bladder dynamics in patients of posterior urethral valve with vescico-ureteral reflux Top



   Category: Swapna Dutta Award Top


Aboli Hukeri, Paras Kothari, Abhaya Gupta

Department of Paediatric Surgery, LTMMC, Mumbai, Maharashtra, India.

E-mail: abolihukeri@gmail.com

Aims and Objectives: 1. To study course of PUV having low grade VUR in terms of renal functions and bladder urodynamics.

2. To study effect of temporary urinary tract diversion surgeries on renal functions and bladder urodynamics in case of PUV with high grade VUR.

Methodology: The study was conducted retrospectively in 46(n) patients of 2-12 years age, with PUV with VUR, during January2008- December2018. Patients were categorized into 'PUV with low grade VUR group- Group 1, 'PUV with high grade VUR: - Group 2A with diversion and Group 2B without diversion'. All patients were treated with PUV fulguration and pharmacological treatment. Group 2A patients were additionally treated with temporary urinary tract diversion. Outcomes were evaluated on basis of follow up renal scintigraphy, urodynamic studies.

Results: In group 1, course was smooth and didn't deteriorate over duration. In Group 2A, diversion didn't alter scintigraphic changes. In group 2B, no. of renal units with cortical defects were increased (p= 0.03). While comparing urodynamics in group 2A and 2B, bladder compliance was found significantly better in 2A (p=0.00013).

Conclusion: Though there are many controversies in management of PUV with high grade VUR, temporary urinary tract diversion may help in gaining safer bladder with preservation of functional renal parenchyma.


   Comprehensive review of surgical management of disorders of sexual differentiation in children Top



   Category: Swapna Dutta Award Top


Taha Asif Daginawala, Shivaji B Mane, Prathamesh More, Hussain S Kotawala, Natasha Vageriya, Hemangi Athawale

Department of Paediatric Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India.

E-mail: taha.daginawala@gmail.com

Aims: To review outcomes of patients with disorders of sexual differentiation in 26 patients managed surgically.

Methods: Children who presented with disorders of sexual differentiation were retrospectively reviewed over a period of 3 years at JJ hospital Pediatric surgery department and were followed up. Relevant history, physical examination and investigations were analysed; endocrine workup and psychological counseling were done and appropriate surgical procedures performed. Cosmetic and functional (depending on age) outcomes and parental satisfaction for the same were evaluated.

Results: Congenital Adrenal Hyperplasia was the most common encountered disorder of sexual differentiation (36%), followed by Partial Androgen Insensitivity Syndrome, 5 α reductase deficiency, Ovotesticular DSD, Complete Androgen Insensitivity Syndrome, Mixed Gonadal Dysgenesis and Proximal biosynthetic defect. Surgical interventions were based on the gender of rearing, genital ambiguity, psychiatry brain imprinting and parental choice in collaboration with endocrinal workup. Some required isolated sigmoid vaginoplasty, gonadectomy and excision of mullerian structures; while others demanded in addition to above masculinizing genitoplasty with cordee/hypospadias correction with scrotoplasty in future males and clitoral recession with labioplasty and vaginoplasty in future females.

Conclusion: Management of patients with disorders of sexual differentiation when guided by proper biochemical, anatomical, psychosexual and parameters yields satisfactory outcomes in children when managed with a team of dedicated pediatric endocrinologist, psychiatrists and supportive parents and family.


   A comparative study of surgical procedures in neonatal intestinal atresia- Resection and anastomosis, Bishop Koop, Santulli,and Mikulicz procedure Top



   Category: KK Sharma Award Top


Aniruddha Basak, PK Mishra, DD Pramanik, Arindam Ghosh

Department of Paediatric Surgery, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India.

E-mail: aniruddhabasak52@gmail.com

Aim: The aim of this work was to assess the different surgical modalities in management of intestinal atresia especially in high risk neonates attempting to improve the morbidity and mortality rates in such patients.

Methods: During the period from January 2017 to January 2019, 50 neonates (35 males and 15 females) suspected to have intestinal atresia were referred to NRSMCH. All neonates presented with bilious vomiting and failure of passage of meconium. The 50 cases were classified according to the surgical technique into three groups: Group A included 14 patients who were treated with primary resection/ anastomosis or enterotomy with excision of the membrane (in type I atresia). Group B including 10 patient had undergone Bishop-koop technique and Group C included 10 patients who were treated with Santulli technique and Group-D included 16 patients who were treated with mikulicz procedure.

Results: In this study intestinal leak and delayed intestinal transit (DIT) were significant complication among group A and contributed more to septicaemia and dessiminated intravscular coagulopathy (DIC). The overall mortality were 15 cases; 6 cases from group A,5 cases from group B and 3 cases from group C, 1 case from group D. The improvement in group D was attributed to the low pressure anastomosis performed with less leakage problems. The early start of oral feeding and shorter duration of TPN usage in group D in relation to other groups helped in reducing the bacterial overgrowth in the gut and decreasing the sepsis rate.

Conclusion: Using mikulicz procedure in the current study has improved the survival of these patients and minimized the post operative complications.


   RNA sequencing reveals outcome specific gene expression of MMP7 and PCK1 in biliary atresia Top



   Category: KK Sharma Award Top


Ashitha K Unny, Priya Ramachandran, Deepak Balamurali, J John Peter, M Milner Kumar, Mohamed Safwan, Mukul Vij, Mohammed Rela, Sundarasamy Mahalingam

Department of Paediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India.

E-mail: ashitha.aku@gmail.com

Aims: The disease phenotype in Biliary Atresia (BA) is caused by a fibro-inflammatory process leading to destruction of cholangiocytes, obstruction of ductular pathways and eventual progression to liver cirrhosis. The first line of management is a Kasai portoenterostomy (KPE) followed by liver transplantation (LT) in some children. Several factors have been postulated to affect the outcome of KPE and/or the subsequent progression of liver disease. However, no biomarkers have been identified in the liver for BA. We aimed to address this defect.

Methods: Whole transcriptome mRNA sequencing was performed for 29 samples (25 BA and 4 controls) to identify the candidate genes predicting the prognosis of KPE. These results were further confirmed with quantitative Real-time PCR (qPCR).

Results: When BA group was compared against controls, certain genes like LAMC2, MMP7 and CLDN6 showed increased expression, while IGF1, CYP2C18, PRG2 AND EPX were downregulated. Analysis from RNA sequencing data identified matrix metalloproteinase7 (MMP7) and phosphoenolpyruvate carboxykinase (PCK1) as potential determinants of the outcome of KPE. MMP7 expression is significantly elevated in patients who failed to clear jaundice after KPE as well as in patients with End Stage Liver Disease. In contrast, PCK1 level was upregulated in patients who had successful KPE, while there was a significant down regulation in patients who failed KPE.

Conclusion: MMP7 and PCK1 expression patterns had an inverse relation to the outcome of KPE and hence could potentially be used as biomarkers to predict KPE outcome and disease progression, enabling clinicians to design new treatment strategies for BA.


   Intra-abdominal cystic lymphangiomas in children: A case series Top



   Category: KK Sharma Award Top


Pratik Raut, Saurabh Tiwari, Paras Kothari, Shalika Jaiswal, Abhaya Gupta, Vishesh Dixit

Department of Paediatric Surgery, LTMG Hospital, Mumbai, Maharashtra, India.

E-mail: pratikraut88@gmail.com

Background: Lymphangiomas are hamartomas of lymphatic vessels commonly arising in the head, neck, and axilla. Intra-abdominal cystic lymphangiomas are rare and are located in the retroperitoneum, the mesentery, omentum, or visceral organs. Radiological imaging in the form of ultrasound and computed tomography (CT) scan helps in preoperative diagnosis. The objective of this study is to present the management of children with intra-abdominal cystic lymphangioma in our institution.

Materials and Methods: Six cases of intra-abdominal cystic lymphangiomas comprising three males and three females, which presented over 15 months, were studied. Clinical presentation, location, mode of surgical intervention, and outcome were studied.

Results: The site of origin was retroperitoneum, omentum, and the mesentery, with two cases of each. Age of presentation ranged from 5 days to 7 years. Abdominal lump was the most common presenting feature. All the patients underwent complete surgical resection – four had open excision, one had a laparoscopy converted to open excision, and one had a complete laparoscopic excision. Postoperative recovery was uneventful in all of them, with no recurrence at 6 months follow-up.

Conclusion: Intra-abdominal cystic lymphangiomas in children are usually symptomatic. CT scan is more accurate than ultrasound to diagnose the lesion. Complete excision of the lesion with or without intestinal resection provides symptomatic relief and prevents recurrence.


   The outcome of critically ill neonates undergoing laparotomy in neonatal intensive care unit versus operation theatre: A 5-year review Top



   Category: KK Sharma Award Top


Abirami Krithiga, Harish Jayaram, Mainak Deb

Department of Paediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India.

E-mail: drabiramikrithiga@gmail.com

Aim: To evaluate outcomes in critically ill neonates with Necrotizing enterocolitis(NEC) and Spontaneous intestinal perforation(SIP) undergoing a laparotomy in the neonatal intensive care unit (NICU) and compare the outcomes with the newborns operated in theatre.

Methods: This is a retrospective study of neonates with NEC who underwent a laparotomy in NICU (Group A) and in Operating Room (Group B) between 2014 and 2019.

Results: Among 106 operated for NEC, 39 underwent laparotomy in NICU. Mean Gestational age in Group A 25.7weeks(23-35),Group B 30.7weeks(25-37). Mean age at surgery in group A in 14.6days and 25.87 days in group B. Mean operating time and blood loss in both the groups are comparable. 32 where in HFO in Group A, none in Group B were on HFO. In Group A 8 had NEC totalis. 13 stoma and 18 bowel resection and primary anastomosis. 13 infants remain alive at 1.4 (0.5–5.5) years in Group A.

Conclusion: Laparotomy for NEC in NICU is a treatment option for neonates who are too unstable to transfer to theatre. Performing major surgical neonatal procedures in the NICU is both feasible and safe without increasing surgical or anaesthetic difficulty.


   Local instillation of mitomycin-C at portal plate after Kasai porto-enterostomy in extra hepatic biliary-atresia: A pilot study Top



   Category: KK Sharma Award Top


Shailesh Solanki, Ravi P Kanojia, Sadhna Lal, Pramod Gupta, Manasa Reddy, Ram Samujh

Department of Paediatric Surgery, PGIMER, Chandigarh, India.

E-mail: drshaileshpgi@gmail.com

Aim: Extrahepatic biliary atresia (EHBA) is a disease with unclear etiology. Despite a lot of research, Kasai porto-eneterostomy (KPE) is the only available treatment before liver transplant. Even after KPE and initial bile flow, the prognosis is not same for all children due to ongoing sclerosis in the region of porta hepatis. Mitomycin-C (MMC) has anti-fibroblastic property and its instillation at portal plate could decrease/arrest this process and improves bile flow. We carried out a pilot study to establish technical feasibility and evaluate the effect of MMC in terms of bile drainage and nadir bilirubin levels. This under setting of future RCT to prove the effect.

Patients and Methods: Study was approved by IEC and registered in CTRI .Patients with EHBA were randomly allocated to Group-A (KPE only) and Group-B (KPE plus MMC) by block randomization. All children underwent standard KPE, in group-B additional placement of 5 Fr infant feeding (IFT) tube near the porta though the roux limb was done i.e. one end of tube (tip) was in close contact with porta and another end (hub) was outside the abdominal wall. Postoperative care and follow up was same for all patients, in group B children, instillation of MMC was done according to protocol.

Results: Total of fourteen patients were enrolled in study from April 2018 to August 2019. Six patients were in group A and 8 in group B with mean age at surgery was 85 days and 92 days respectively. At 3 months follow up, 4 children in group A and all in group B were passing normal color stool with significant decrease in their bilirubin level. In group A, there was one mortality and one child was passing clay color stool. At 1 year follow-up, 4 children in group B and 1 in group A had bilirubin <1.

Conclusion: Technical feasibility is possible for the procedure. The instillation of MMC was well tolerated by all patients. Early results are encouraging and study can be continued to get more insight information.


   Spleen preserving shunt in children with extra-hepatic portal vein obstruction Top



   Category: KK Sharma Award Top


Ruchira Nandan, Minu Bajpai, Prabudh Goel, Vishesh Jain

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: ruchira.nandan@gmail.com

Aim: To study the reversal of hypersplenism and regression of spleen size in children with EHPVO who underwent distal splenorenal shunt (DSRS).

Methods: Prospective study based on consecutive children with EHPVO who underwent DSRS after July 2011. Mean follow up of 2 years (6months-7years) was done. Hemoglobin, total leukocyte count, platelet count and spleen size in mid-clavicular line were recorded. Shunt patency was confirmed on USG Doppler ± CT portogram.

Results: Forty-five patients who underwent DSRS had mean age of 7.9 years (range: 6 years-15 years) and male to female ratio was 33:12. Decrease in splenic size was documented in all patients. Mean regression in spleen size was 2.5 cm (1.5-3.3 cm) at 3 months, 6.3 cm (4.8-8.8 cm) at 6 months and 12.4 (6.8-22) at 12 months. Reversal of hypersplenism was observed in 42 % (n=19) patients at 3 months and 91% (n=41) at 12 months.

Conclusion: DSRS reduces the portal pressure, thus decreasing the risk of variceal bleed. Reversal of hypersplenism and splenic size have been observed. It also has additional benefit of preserving the hepatopetal flow and spleen.


   Role of MRCP and intra operative choledochoscopy is to interpret anatomical variations in choledochal cyst: Do we know enough? Top



   Category: KK Sharma Award Top


Rupa Banerjee, Satish K Aggarwal, Aparajita Mitra, Gaurav Singh, Muni Varma, Garvita Singh

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: dctrrupa@gmail.com

Aims: The aim to this study is to clearly define the anatomy of the malformation by MRCP and then correlate it with choledochoscopic evaluation performed intra-operatively with the purpose of performing safe and optimum surgery. So, that the cyst can be excised completely without any remnants at the pancreatic end.

Methods: Records of all cases of choledochal cyst that underwent surgery between February 2016 and June 2019 were reviewed retrospectively with respect to demography, presenting symptoms, blood investigations, radiological investigations (USG, CECT abdomen and MRCP). Type of choledochal cyst and ductal anomalies including accessory hepatic duct, cystic dilatation of sectoral ducts, length of common channel, relation of cyst with main pancreatic duct (MPD) and calculus or sludge in common bile duct (CBD) and gall bladder, relation of hepatic artery with hepatic ducts and cystic duct opening on CBD. Intra operative findings, choledochoscopic findings were reviewed. Further post-operative complications and outcomes were recorded.

Results: A total of 31 cases were operated during this time. Age range was from 5 months to 8 years with mean age of 2.8 ± 2 years. Out of 31 cases 26 were girls and 5 were boys with male to female ratio of 1: 5. Most common presenting symptom was pain abdomen which was seen in 27 cases with mean duration of 6 months. Initial diagnosis was made on USG and specific anatomical details were studied on MRCP. Eleven cases had come with a CECT already performed elsewhere, and they were operated on that basis only. Ten cases had per operative cholangiogram. Twenty cases had intra-operative choledochoscopy as well. Anomalies delineated were: Right posterior sectoral duct opening into CHD (n = 11), Very low insertion of cystic duct into intrapancreatic CBD (n=4) and long common channel (n = 7).

Conclusion: Experience with choledochoscopy is scarce in children. This factor limits us from delineating the pathological anatomy in choledochal cysts to perform more safe and complete surgery.


   Role of MRCP and intra operative choledochoscopy to interpret anatomical variations in choledochal cyst: Do we know enough? Top



   Category: KK Sharma Award Top


Rupa Banerjee, Satish K Aggarwal, Aparajita Mitra, Gaurav Singh, Muni Varma, Garvita Singh

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: dctrrupa@gmail.com

Aims: The aim of this study is to clearly define the anatomy of the malformation by MRCP and then correlate it with choledochoscopic evaluation performed intra-operatively with the purpose of performing safe and optimum surgery. So, that the cyst can be excised completely without any remnants at the pancreatic end.

Methods: Records of all cases of choledochal cyst that underwent surgery between February 2016 and June 2019 were reviewed retrospectively with respect to demography, presenting symptoms, blood investigations, radiological investigations (USG, CECT abdomen and MRCP). Type of choledochal cyst and ductal anomalies including accessory hepatic duct, cystic dilatation of sectoral ducts, length of common channel, relation of cyst with main pancreatic duct (MPD) and calculus or sludge in common bile duct (CBD) and gall bladder, relation of hepatic artery with hepatic ducts and cystic duct opening on CBD. Intra operative findings, choledochoscopic findings were reviewed. Further post-operative complications and outcomes were recorded.

Results: A total of 31 cases were operated during this time. Age range was from 5 months to 8 years with mean age of 2.8 ± 2 years. Out of 31 cases 26 were girls and 5 were boys with male to female ratio of 1: 5. Most common presenting symptom was pain abdomen which was seen in 27 cases with mean duration of 6 months. Initial diagnosis was made on USG and specific anatomical details were studied on MRCP. Eleven cases had come with a CECT already performed elsewhere, and they were operated on that basis only. Ten cases had per operative cholangiogram. Twenty cases had intra-operative choledochoscopy as well. Anomalies delineated were: Right posterior sectoral duct opening into CHD (n = 11), Very low insertion of cystic duct into intrapancreatic CBD (n=4) and long common channel (n = 7). Therapeutic benefits of choledichoscopy were: crushing of stones at distal end, flushing sludge, dilatation of papilla, and intrahepatic washes.

Conclusion: Choledochoscopy is helpful in precise delineation of anatomy and it supplements MRCP in difficult cases. There are therapeutic benefits as well.


   Liver resections in children: Tips, tricks and overcoming the initial learning curve Top



   Category: KK Sharma Award Top


Nitin J Peters, Nitin James Peters, Muneer A Malik, Ram Samujh, Sandhya Yaddanapudi, Akshay Saxsena

Department of Paediatric Surgery, PGIMER, Chandigarh, India.

E-mail: nitinjamespeters@yahoo.com

Introduction/Background: Pediatric liver resections (PLR) are the mainstay for management of pediatric liver malignancies. Occasionally they may be required for non-oncological indications. These operations are usually confined to few advanced centres, and are significantly challenging in resource limited nations. Various tips, technical considerations the learning curve for a beginner are discussed in this paper.

Materials and Methods: We retrospectively evaluated the data of consecutive 9 patients who underwent PLR over a period of 21/2 years (January 2017 to June 2019). All patients underwent ultrasound abdomen, triple phase CECT abdomen and CT scan chest (for metastatic evaluation). Patient records, operative and anaesthesia notes and operative photographs were studied and analysed.

Results: The average patient age was 19 months (10-48 months) PRETEXT 2,3 and 4 were seen in 4, 2 and 2 patients respectively. One was a case of fungal mass. Five patients underwent left hepatectomy, 2 right and 1 patient underwent extended right hepatectomy. One patient was subjected to central hepatectomy. One patient who had previously undergone left hepatectomy relapsed with a lesion in segment 7 and was taken up for a non-anatomical resection after 1 year. The mean operating time was 165 minutes (60 -300 mins) and the average blood loss was 123 ml (40 ml -240 ml). IVC injury was noted in 2 patients, which was repaired. Parenchymal resection was carried out using harmonic scalpel, monopolar cautery and enseal in all cases. In three patients 'Hanging liver manoeuvre' was carried out to ease the parenchymal transection. Two patients were ventilated for 24-48 hours post operatively. One patient had post-operative bile leak which was managed conservatively. One patient succumbed on table with suspected air embolism and one died on post op day 13 after liver failure. Six patients are disease over a follow up of 3months to two years.

Conclusions: PLR is a technically challenging surgery. An exhaustive pre-operative work up, meticulous intraoperative steps and dynamic interaction with anaesthesiologists and radiologists and advanced energy sources aid in safe resections. Negative margins are achievable in most situations.


   Minimal invasive surgery for achalasia cardia- an early experience with complication and technical tips from a tertiary care center Top



   Category: KK Sharma Award Top


Bibekanand Jindal, Bikash Kumar Naredi

Department of Paediatric Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.

E-mail: drvjindal@gmail.com

Aim: To review our result of achalasia cardia operated via minimal invasive surgery (MIS), complications and technical appraisal.

Methods: A retrospective study of all children who underwent minimally invasive cardiomyotomy for Achalasia Cardia from 2014- till date.

Results: Four casesof Achalasia cardia were operated over the last 5 years. The age of the children ranges from 9 months to 8 years. Al the children were diagnosed on the basis of radiologic and endoscopic finding. Of these four cases, three were operated via laparoscopy and one via robotic assisted laparoscopy. Of the three operated by laparoscopy, two had conversion to open because of mucosal perforation during myotomy near gastroesophageal junctionboth in the early phase our experience. The one operated via robot assisted laparoscopy surgery was completed successfully. Both the two cases completed laparoscopic cardiomyotomy and Dor fundoplication were discharged early and are doing well successfully.

Conclusion: The myotomy near gastroesophageal junction is crucial where perforation is common. The robot assisted cardiomyotomy has an advantage over laparoscopy because of its three D visison and precise dissection which allow us to perform the cardiomyotomy with ease along with avoidance of energy in that area.


   ACE-inhibitors–Can it be used in treatment of infantile hemangioma Top



   Category: Experimental Long Oral Top


Archika Gupta, Gaurav Shandilya, Akhilesh Kumar, Anand Pandey, SN Kureel

Department of Pediatric Surgery, King George Medical University, Lucknow, Uttar Pradesh, India.

E-mail: drarchika2006@rediffmail.com

Aims: To report preliminary results of use of enalapril, an ACE-inhibitor, in treatment of Infantile hemangioma(IH).

Methods: This was a prospective study including 15 infants with IH admitted in the department of pediatric surgery. Baseline heart-rate(HR), blood-pressure(BP), ECG, 2-D ECHO, random blood sugar(RBS), and renal function test(RFT) were noted. Enalapril was started at dose of 0.1mg/kg orally 12-hourly with monitoring of HR, BP, RBS, RFT and occurrence of any side-effect. In the absence of any side-effect, dosage was gradually increased upto 0.5mg/kg 12-hourly over the period of 10-days but with monitoring of BP, HR, RBS and occurrence of any side-effect. If no side-effects were noted and patients were stable, they were discharged and followed up until 6-months after stopping treatment. During follow-up, response to treatment was documented clinically and photographically. Development of any side-effect was also noted.

Results: Complete response to enalapril therapy was noticed in 9 patients over 18-24 months. In five patients, complete response could be achieved only after increasing dose upto 1.0mg/kg 12-hourly. Remaining two showing no response required addition of propranolol/corticosteroid.

Conclusions: ACE-inhibitors may be potential treatment for IH. Further studies with higher doses under monitoring in large number of patients might prove its efficacy better.


   LED OT lights and per-operative burns: Clear and present danger! Top



   Category: Experimental Long Oral Top


Mainak Deb, Harish Jayaram, Abirami Krithiga

Department of Pediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India.

E-mail: mainakdeb@gmail.com

Aims: To report 3 cases of per-operative burns due to LED OT lights and discuss recommendations to prevent such injuries based on an experimental study.

Methods: Three infants who underwent major laparotomies developed second degree burns over the abdominal wall noticed immediately after surgery. It was hypothesized to be due to LED OT lights and hence an experiment was conducted to study the effect of LED light of different intensities (40000 lux to 2.6 lakhs lux) on generated temperatures over a period of 30 minutes at distances of 60 cms and 90 cms) from the operating field. A lux meter and a digital multimeter were used to record the findings.

Results: It was noted that at a lux levels of more than 93000, the temperatures reached unsafe levels of 40 degrees C and above in 30 mins. At an intensity level of 2.6 lakhs lux at a distance of 60 cms caused progressive raise of temperature from 28 to 48.1 C in 30 minutes.

Conclusion: LED OT lights though considered safe as an effective cold light can cause burn injuries in neonates and infants. It is recommended not to exceed 90000 lux of incident LED light where temperatures were recorded in unsafe levels.


   Evaluation of nebulized N-acetyl cysteine in outcome of esophageal atresia Top



   Category: Experimental Long Oral Top


Gurmeet Singh, Anand Pandey, Archika Gupta, Gaurav Shandilya, Jiledar Rawat, Ashish Wakhlu, SN Kureel

Department of Pediatric Surgery, King George Medical University, Lucknow, Uttar Pradesh, India.

E-mail: gurmeet.dr@gmail.com

Aim: To evaluate the role of nebulized NAC in liquefying the airway secretions and improving the outcome of patients of EA±TEF.

Methods: In this prospective case control study, 2ml of 10% NAC was given in a nebulized form (2:5 dilution, every 6 hourly) both pre and post-operatively along with regular suction of upper esophageal pouch. The group was compared with matched control, which comprised patients of EA-TEF not receiving NAC nebulization. The consistency of the secretions was compared by hand held consistometer in unit of time (seconds) required to cross a predetermined distance along gravity.

Results: Thirty patients each of cases and controls were evaluated for consistency of saliva. Cases showed a significant (p<0.05) decrease in consistency of secretions from controls after day 2 of NAC nebulisation. Discharge was significantly (p=0.01) earlier in cases as compared to controls. There was no significant (p>0.05) difference in mortality between cases and controls.

Conclusion: It appears that NAC has effect on liquefying the secretions in EA±TEF patients. The discharge time is earlier when it is used. Further studies with more patients may show additional beneficial effects on its use.


   Transanal endorectal pullthrough for Hirchsprung's disease: Results of 40 cases Top



   Category: GI Long Oral Top


Akshay Prasad, Dipak Ghosh, Janki Bisht, Kaushik Saha

Department of Pediatric Surgery, Nilratan Sircar Medical College, Kolkata, West Bengal, India.

E-mail: akshay.prasad@yahoo.co.in

Aims: TAERPT has drastically changed the treatment of HD.The aims of this study:

-To discuss technical refinements that has been introduced in this procedure

-Feasibility of TAERPT both in cases of lap assisted primary with frozen section and as definitive procedure in post colostomy biopsy proved HD cases

-Short and long term outcomes of TAERPT.

Methods: TAERPT was performed in between AUG 2017 to JUL 2019. Laparoscopy with frozen section was done in 5 and post colostomy biopsy definitive pull through procedure in 35 cases.Short rectal seromuscular sleeve(not extending >5cm) 2cm from dentate line was left.

Results: Early complications we encountered were perineal excoriation and stooling pattern takes around 3-6 months to come down from 15-20 per day to 3-4 per day which may require stool hardners,bowel management,etc.Late complications encountered were anastomotic stricture, retraction of pull through bowel, rectal prolapsed,etc. for which redo-exploration were done.

Conclusion: With the learning curve steadily progressing. Transanal endorectal pull through is expected to stand the test of time.


   Alimentary duplications-spectrum of presentations Top



   Category: GI Long Oral Top


Tanusree Kundu, PK Mishra, Kaushik Saha, Dipak Ghosh, Janki Bisht

Department of Pediatric Surgery, NIL Ratan Sircar Medical College, Kolkata, West Bengal, India.

E-mail: tandgreat@gmail.com

Aim: To study the different types of alimentary duplication and management.

Methods: Total number cases- 5 cases. period of study – 4 months. case 1 3 year old male presented to us with history of chronic abdominal pain since 1 year.contrast enhanced ct scan – revealed an omental cyst. case 2 22 days old female child presented with severe respiratory distress and regurgitation of milk after each feed. mri neck – possibility of esophageal duplication. case 3 7 days old male child presented with bleeding per rectum and abdomen distension. st x-ray abdomen – multiple air fluid level usg whole abdomen –ileocaecal intusussception. case 4 and 5 2 years and 3 years male child presented with abdomen distension and repeated episodes of billious vomiting. st x-ray abdomen – multiple air fluid level seen.

Results: Case 1 laparoscopy was converted to exploratory laparotomy and a duodenal duplicattion cyst was noted which was marsupialized. case 2 ligation and excision of the esophageal dulication cyst was done via cervical approach. case 3,4,5 exploratory laparotomy and resection anastomosis of caecal and ileal duplication cyst.

Conclusion: All the patients had an uneventful recovery. duplication cyst is an anomaly with varied presentations but mortality rate is very less with a satisfactory outcome.


   Study of different pathologies of secondary intussusception Top



   Category: GI Long Oral Top


Swetha Edamakanti, Sudhakar Jadhav, Santosh Patil

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: eswethareddy22@gmail.com

Aim: To study different pathologies of secondary intussusception.

Methods: This is a study of a series of 5 cases of secondary intussusception. All 5 Patients presented with pain in abdomen & vomiting; and 2 cases had blood in stools. USG abdomen revealed ileo-colic intussusception in 4 cases and jejuno-jejual intussusception in 1 case. Hydrostatic reduction was attempted but was not successful. Exploratory laparotomy revealed different pathologies : Meckel's diverticulum in 2 cases, Ileal Duplication cyst in 1 case, Jejunal duplication cyst in 1 case, and Lymphoma in 1 case.

Resection and anastomosis was done in all cases.

Results: The patients did well post operatively.

Conclusion: Secondary intussusception should be ruled out in every case of recurrent intussusception.


   Factors affecting survival in patients of esophageal atresia and tracheoesophageal fistula in a resource challenged setting Top



   Category: GI Long Oral Top


G Vidhya, Nitin J Peters Ram, Ram Samujh

Department of Pediatric Surgery, PGIMER Chandigarh, India.

E-mail: aanoor90@gmail.com

Introduction: Esophageal atresia with tracheoesophageal fistula (TEF EA) is an uncommon congenital anomaly with an incidence of about 1 in 4500. Various intrinsic and extrinsic factors affect the outcome, in terms of survival in these neonates despite the best possible surgical repair.

Aim: To analyse the factors predicting outcome of the EA patients, to validate the existing prognostic classification systems and to formulate a classification system for the patients managed in a resource limited setting.

Materials and Methods: This was a prospective observational study involving 80 consecutive neonates of EA treated in the Department of Pediatric Surgery at a referral teaching hospital, over a period of 2 years. The patients underwent primary trachea-esophageal repair or diversion procedures as indicated. All the possible factors which might affect the outcome were analysed in terms of survival and morbidity through multi variant analysis.

Results: Survival was 70% in those who were operated. Antenatal diagnosis and early presentation did not show any added advantage in survival. Birth weight, ventilator requirement, SNAPPE score and associated congenital cardiac anomalies significantly affected the prognosis. Anastomotic tension affected survival, leak and stricture formation. Trans anastomotic tube helped in early feeding. Most minimal leaks healed with conservative treatment alone. 3 out of 5 postoperative stricture required dilatation. None required anti- reflux surgery for gastroesophageal reflux in the first year. A prognostic scoring system was formulated which showed 100% mortality when score was <2 as against 94% survival when score was >6.

Conclusion: Inherent risk factors like Birth weight, SNAPPE score, cardiac anomaly and requirement of ventilation affect the prognosis in operated patients of TEF EA. A novel scoring system is designed to prognosticate patients in a resource limited setting.


   Primary transanal endorectal pull through with anastomotic stenting Top



   Category: GI Long Oral Top


Amit Gupta, Partap S Yadav, Rajiv Chadha, Subhasis Roy Choudhury

Department of Pediatric Surgery, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India.

E-mail: amitpedsurgeon@gmail.com

Aim: Assess outcome of Primary Transanal Endorectal Pull Through with anastomotic stenting for short segment Hirschsprung's disease.

Methods: 7 patients were assessed prospectively in terms of age at diagnosis, preoperative preparation, perioperative course and postoperative outcome. Diagnosis was confirmed on contrast enema and rectal biopsy. The level of ganglionic bowel was confirmed with frozen section biopsy. The anastomosis was stented with a wide bore catheter in 5 patients to allow for decompression during immediate postoperative period.

Results: Mean age at diagnosis was 3 months, decompression of dilated ganglionic bowel was done using glycerine suppository, colonic wash and/or anal dilatation. 5 patients were < 6 months of age and 2 patients beyond 1 year of age. Total length of dissection varied from 15 cms to 21 cms. Postoperative delay in bowel function was noticed in 2 patients without stenting of anastomosis. One patient developed cuff/anastomotic narrowing at per rectal examination 2 weeks postoperatively requiring anal dilatation and one developed local perianal hematoma which resolved within 4 weeks.

Conclusion: All have normal bowel function at short term follow-up of at least 6 months without any visible scar. Negligible risk of abdominal adhesions and no stoma makes this procedure even more appealing.


   Early outcomes in children with anorectal malformations following single-staged abdomino-perineal pull-through by the hanging bowel technique Top



   Category: GI Long Oral Top


Teg Rabab Singh, Prabudh Goel, Abhimanyu Varshney, Minu Bajpai

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: tegrababsingh123@gmail.com

Aim: To describe early-and-mid-term results of Abdomino-Perineal Pull-Through (APPT) with Hanging Bowel Technique (HBT) in children with ano-rectal malformations.

Methods: Prospective review of our results of APPT with HBT (n=31, 3 days-7 years) over last four years. Study included 17 male and 14 female children with anorectal malformations. Spectrum of anomaly included recto-vesical fistula (n=4/12.9%), recto-prostatic-urethral fistula (n=8/25.8%), recto-bulbar-urethral fistula (n=3/9.6%), vestibular fistula (n=12/38.7%), pouch colon (n=4/12.9%) and rectal atresia (n=1/3.2%). Seventeen patients (17-of-31/54.8%) presented with a colostomy done elsewhere. Observation parameters: post-operative complications and continence status (anal caliber, puckering, squeeze and soiling).

Results: The surgical technique and its advantages over traditional approaches will be presented and discussed. Post-operative complications included superficial wound infection/ dehiscence (n=2) and gangrene of distal bowel (redo-pull-through n=1). Continence status was assessed with anal puckering (27/31, 83.9%), calibre (adequate n= 26/31, 87.1%), mucosal prolapse (7/31, 22.6%) and perianal excoriation (n= 10/31, 32.2%), voluntary squeeze present (25/31, 80.6%) and soiling (Gr 1 n=10, 32.2%; Gr2 n=5/31, 16.1%; Gr3 n=4, 12.9%).

Conclusion: APPT-HBT avoids colostomy and its myriad complications, avoids posterior sagittal incision, the sphincter is not incised, avoiding injury to neurovascular innervation, and can be done in neonatal period in males, promoting better continence rates. Anoplasty and its complications are avoided.


   Long-term follow up of gracilis muscle transposition in children with anal incontinence Top



   Category: GI Long Oral Top


Gaurav Singh, Satish Kumar Aggarwal, Aparajita Mitra, Rupa Bannerjee, Muni Varma, Garvita Singh

Department of Pediatric Surgery, Sir Ganga Ram Hospital,

New Delhi, India.

E-mail: gauravpsurg86@gmail.com

Introduction: Since the original description of gracilis transposition by Pickrell in 1952, there is a paucity of literature about its use and long term follow up. We report a long term follow up study of 21 children who underwent gracilis muscle transposition for anal incontinence.

Methods: Data of 21 children who underwent gracilis transposition between 2007 and 2018 were reviewed. Demography, etiology of incontinence, clinical profile and operative intervention were recorded. Continence status before and after gracilis transposition were assessed clinically. Long term follow up status was assessed either clinically or by telephonic conversations with the patients or care givers.

Results: 21 cases (16 boys and 5 girls) in the age range of 4-19 years (median 6.4) were studied. The etiology of incontinence was Ano rectal malformation in 16 and traumatic loss of external sphincter in 5 cases. Both gracilis muscles were used in 16 cases while single side was used in 4 cases. Technique of gracilis transposition was as per Pickerell's description. All cases were performed under covering colostomy except for one. All attained social continence, only two patients have natural bowel movements and are continent. All others required bowel management program.

Conclusion: Gracilis transposition provides passive outlet grip that prevents leakage, therefore improving social continence. It can't substitute the normal sphincter mechanism. Bowel management program is still required for diaper free life.


   Puestow procedure in chronic pancreatitis: An institutional experience Top



   Category: GI Long Oral Top


Apoorv Singh, Minu Bajpai, Prabudh Goel, Aparajita Mitra, Vishesh Jain, Devasenathipathy Kundasamy

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: dr.singhapoorv@gmail.com

Aim: To present our experience with lateral pancreatico-jejunostomy (Puestow Procedure) for chronic pancreatitis.

Methods: Prospective study based on consecutive patients of chronic pancreatitis who underwent Puestow's Procedure at our centre over 5 years. Observation parameters included patient demographics, presenting symptoms with a particular emphasis upon the duration, radiologic findings, surgical procedure, intraoperative events, postoperative recovery and time to resolution of pain.

Results: There were 7 patients (M:F – 6:1) operated at our centre in the last 5 years with a mean age of presentation 12.4 years.

The surgical technique with technical nuances will be described and the results based on observation parameters will be presented. Resolution of pain was not instantaneous; the time taken for pain to resolve varied from 10 months-23 months with a longer duration in those who had symptoms for a longer duration.

Conclusion: The department has witnessed satisfactory results with Puestow's procedure in chronic pancreatitis. There is a direct correlation between the duration of symptoms and the time required for resolution of symptoms post surgery.


   Profile of Ileal perforation in children – 5 years audit from a tertiary referral centre Top



   Category: GI Long Oral Top


Simmi K Ratan, Ravinder Naik Noonavath, Anju Verma, Shasank Sekhar Panda, Sujoy Neogi, Satish Agarwal

Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: drjohnsimmi@yahoo.com

Aim/Purpose: To evaluate the clinical profile, treatment and histological profile of children managed for ileal perforation.

Methods: The hospital records of 56 children (New-born to 12yrs) managed for ileal perforation over 5yrs (2015 to 2019) were scrutinized.

Results: Incidence of ileal perforation was comparable among males (29 pts, 51.7%) and female (27 pts, 48%). All patients presented with acute abdomen, fever and pneumo-peritonium; 8 with shock. Blood counts were raised in 24 patients and 70% had correctable metabolic acidosis. Five children presented with blunt abdominal trauma while fifteen had enteric fever. Most common site of perforation was distal ileum within 20 cm of ileo-cecal junction (64%). Primary repair done in children with enteric and posttraumatic perforation (n= 20) while resection anastomosis (16%) was done with less contaminated peritoneal cavity. Diverted ileostomy following resection done in 50% and of these 5 had worm obstruction. Proximal loop ileostomy with primary repair of ileal perforation (n= 7) for perforation located close to IC junction. Four patients needed re-exploration and of these two were neonates. Histopathology revealed nonspecific inflammation in 45 pts, tuberculosis 8 pts, enteric 3 pts and fungal 0. One third grew E.Coli on peritoneal fluid. There was no mortality or significant morbidity.

Conclusion: Ileal perforation is acquired condition in children with good outcome.


   Retrospective study of series of cases of Acute presentation of Koch's abdomen in children Top



   Category: GI Long Oral Top


Rishabh Jain, Niyaz Ahmed Khan, Chhabi Gupta, Mamta Sengar, Parveen Kumar

Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalya, New Delhi, India.

E-mail: rjainngmc@gmail.com

Aim: Retrospectively to analyze our experience with demography of acute presentations of abdominal tuberculosis (TB) in children at our institute and its course in terms of surgery or conservative management.

Materials and Methods: From Jan 2016 to August 2019 , available electronic and operation theatre (OT) records of 50 patients with confirmed diagnosis of abdominal TB were analysed retrospectively. Parameters reviewed were age, sex, presentations, diagnostic investigations, surgery/intervention performed, final outcome and follow-up.

Results: Out of 50 patients 32 underwent surgery where patients had presented with acute abdomen due to intestinal obstruction and diversion was made in form of ileostomies.5 patients had developed enterocutaneous fistula post surgery but were managed conservatively with support of total parenteral nutrition and antitubercular drugs. 13 patients had presented with pain in abdomen, fever and loss of appetite, Ascites, abdominal mass, Alternate bowel habits and were diagnosed with help of radiological(Xray abdomen and Ct Abdomen and Pelvis) and blood investigations (CBNAAT,Ascitic fluid for AFB and ADA levels) and proven on histopathology and managed with antitubercular drugs alone.

Conclusion: Abdominal TB can be of various forms like peritoneal TB, tuberculous lymphadenopathy, gastrointestinal TB and visceral TB. Though gastrointestinal TB usually involves the ileocaecal region, it can virtually affect any part of GI tract. The symptoms of abdominal TB can be nonspecific. Various imaging features and radiological signs are useful in making a diagnosis of abdominal TB. Recurrent bowel obstruction or anastomotic disruptions also give clues of its diagnosis. A careful history of illness, high index of suspicion, ascitic fluid adenosine deaminase needed for early diagnosis. Prompt minimal surgical interventions, preferred diversion over primary anastomosis, early antitubercular treatment required for success in acute crisis.


   An alternative to frozen section for intraoperative biopsy for Hirschsprung's disease Top



   Category: GI Long Oral Top


Ashutosh Pandey, Piyush Kumar, Vinni Tondon

Department of Pediatric Surgery, Vivekanand Polyclinic and Institute of Medical Science, Lucknow, Uttar Pradesh, India.

E-mail: ashu_pandey66@yahoo.co.in

Aim: To study the efficacy of rapid microwave desication as an alternative to frozen section biopsy for intraoperative assesment of ganglionic cells during pullthrough procedure.

Methods: 14 patients of hirschsprung's disease were included in the study from 2014 to 2018. 12 were male and 2 were female. Age ranged from 8 days to 14 years.

Initial diagnosis was made by barium enema and rectal mucosal biopsy. 8 patient underwent primary colostomy and subsequent pullthrough. Primary pull through was done in 6 patients. Serial seromuscular biopsies were taken from all of these patients, intraoperative determination of extent of aganglionic zone was done by an alternative method involving rapid tissue dessication by microwave and subsequent staining by H & E. The terminal end of pullthrough colon was later subjected to normal histopathopogy to compare with the intraoperative hitopathology.

Results: There was 100% correlation between intraoperative rapid biopsy and standard Histopathological material examination performed later. All of these children are defecating normally so far.

Conclusion: Repid dessication and H & E staining is a useful alternative to frozen section for intra operative determination of aganglionosis & deciding about lavel of resection.


   Twenty years of esophageal substitution: What have we learnt? Top



   Category: GI Long Oral Top


Deepak Kumar Kandpal, SK Chowdhary, DK Kandpal, A Sibal, S Balan, V Gupta, N Jerath

Department of Pediatric Surgery, Indraprastha Apollo Hospital, New Delhi, India.

E-mail: sujitchowdhary@hotmail.com

Aim: To report twenty-year experience with esophageal substitution in children and determine long-term outcomes with risk stratification into different perioperative groups.

Patients and Methods: The records of all the children who underwent esophageal substitution from 1998 onwards were retrospectively studied. Those who underwent laparoscopic esophageal substitution were prospectively recruited into the study.

The patients were classified in three groups; group I were those with esophageal atresia without TEF. Group II were failed esophageal surgery with mediastinal complications and group III constituted corrosive strictures. The clinical parameters were analysed for each group and compared.

Results: There were a total of 30 patients. There were 11, 9 and 10 patients in group I, II and III respectively. The operative time and hospital stay were significantly longer in the group II and III patients. There was no difference in the duration of postoperative ventilation. The major postoperative complications requiring more than 12 months of treatment or additional surgical intervention were seen in 0% in group I, 13% in group II and 11% in group III patients.

There was no mortality in this series. All but one (1/30) are on solid diet, and postoperative success has been achieved in 96% patients with major morbidity in 20% and minor morbidity in 64% patients.

Conclusion: The MIS for esophageal substitution is ideally suited for patients in group I. Those in group II and III require significantly higher level of operative experience and intensive care. In the long term follow-up, similar results are achievable in all groups.


   To study if gallbladder hypo motility is one of the causes for nonhaemolytic gallstones in children Top



   Category: Hepatobiliary Long Oral Top


Subash Chandra Subudhi, Tarun John Kochukaleekal Jacob, Jujju Jacob Jurian

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India.

E-mail: subashsubu@gmail.com

Aim: Is hypomotility of the gall bladder commonly associated with non haemolytic gall stones?

Methods: A pilot study was done on 19 patients with non haemolytic gallstones who had presented to OPD. Those with haemolytic gallstones were excluded. All the patients underwent blood tests, USG and Hepatobiliary scan. Those with Ejection fraction less than 35% in HIDA were considered to have gallbladder dyskinesia. Those who underwent Laparascopic Cholecystectomy were followed up. The histopathological features were correlated to rule out any hypertrophic nerve bundles or muscular abnormalities.

Results: 14 were reported to have GB hypomotility as per HIDA scan. Not all these patients underwent surgery. 5 of them underwent Laparascopic Cholecystecomy. The histopathological features these did not have any features of hypertrophic nerve bundles or muscular abnormality.

Conclusion: Gallbladder stones in children occurs due to a dyskinetic or poorly contracting gall bladder. Haemolytic disease accounts for some gall stones - other causes like drugs or starvation are described but rare. There is a large group where the cause is unclear (Idiopathic) - we believe poor contractility of the GB wall can cause this. This study can help form the basis of further tests on GB contractility and physiology.


   A novel risk prediction scoring system to predict the outcomes of children with biliary atresia post Kasai portoenterostomy Top



   Category: Hepatobiliary Long Oral Top


Shruti Tewari, Rajeev Redkar, Vinod Raj, C Swathi, Rahul Sharma, A Sushma, Shirin Joshi

Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India.

E-mail: shruti.t18@gmail.com

Aim: To find association between liver function, liver biopsy and TORCH titre with outcomes of biliary atresia following Kasai Portoenterostomy.

Materials and Methods: Retrospective study of children who underwent Kasai Portoenterostomy (KPE) at single institute by single surgeon. Data collected was blood reports and histopathology reports. Patients were followed up monthly for 3 months, 3 monthly for first year and yearly thereafter till10 years. Successful KPE was jaundice clearance within 3 months post procedure. Outcomes recorded as alive and jaundice free, alive but jaundiced, and deceased.

Results: 149 children operated between January 2000 to December 2018. Of these, 26 children fulfilled criteria of study. Parameters assessed were percentage of direct bilirubin, ratio of Aspartate transaminase (AST) to Alanine transaminase (ALT), the ratio of Gamma glutamyl transferase (GGT) to AST, the ratio of GGT to ALT and Aspartate transaminase to platelet ratio index (APRI). In histopathology, grade of fibrosis and bile ductular size were noted. 16 children are alive and 10 are deceased. Among 16 alive, all are jaundice free. The ratio of AST to ALT, APRI and grade of fibrosis were found statistically significant. An AST to ALT ratio of less than 2.1, APRI less than 1.8 and grade of fibrosis less than 4, irrespective of age at surgery, had 96.2 % probability of successful KPE. Based on these observations, a scoring system and a risk prediction model were constructed which are first of its kind in the management of biliary atresia.

Conclusion: Biliary atresia children once diagnosed can be subjected to the scoring system and risk prediction model and a KPE can be performed in children who have a score less than 7 out of 20 and can be offered to children who have a score of 8-16 out of 20.


   Pancreatico-biliary malunion: A possible cause of acquired Type IIIa biliary atresia Top



   Category: Hepatobiliary Long Oral Top


Bikasha Bihary Tripathy, Manoj Kumar Mohanty, Subrat Kumar Sahho, J Narahari

Department of Pediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.

E-mail: pedsurg_bikasha@aiimsbhubaneswar.edu.in

Aims and Objectives: Pancreatico-biliary malunion (PBM) is common in choledochal cyst (CDC), but only few reports in literature document its association with biliary atresia (BA). This is an instance of acquired type IIIa BA associated with PBM.

Methods: A 68 days male with moderate conjugated hyperbilirubinemia and elevated liver enzymes with USG documenting 0.7mm CBD and 1.8cm GB (with partial contraction after feeding) was admitted for evaluation. Previously left inguinal herniotomy was done on day 33 at our centre. Previous USG depicted normal CBD and GB.

Results: HIDA scan on day 72 revealed preserved hepatic function without enteric drainage. Per-operative cholangiogram on day 85 confirmed type IIIa BA with PBM. Fluid aspirated from GB showed significant lipase level. Portal plate dissection didn't reveal any significant bile leak. Kasai procedure was done. Histopathology revealed insignificant inflammation in GB, mild fibrosis with wide denudation of epithelium in CBD and predominantly lymphocytic infiltration without any ductular remnants in the portal plate. Postoperatively he was not free from jaundice and was referred for liver transplantation.

Conclusion: In this case due to PBM the CBD and GB (which are constantly exposed to pancreatic juice) remained patent while the intrahepatic bile duct and hepatic duct became constricted and closed.


   Early diagnosis of choledochal cyst prevents metaplasia leading to cholangiocarcinoma Top



   Category: Hepatobiliary Long Oral Top


Abhishek Anand, AK Basu, TJ Banerjee, Kuntal Bhaumik

Department of Pediatric Surgery, Institute of Child Health, Kolkata, West Bengal, India.

E-mail: pandeyabhi16@gmail.com

Aims: To study histopathology of cyst wall at the site of anastomosis after excision of cyst for any metaplastic change. Patients have been followed up for maximum upto two decades for complication.

Materials and Methods: Data of 92 cases of choledochal cyst were reviewed. Hepaticodochojejunostomy was performed in 24 cases and hepaticodochoduodenostomy in 68 cases. Biopsies taken from the site of ananstomosis and liver and they were reviewed.

Results: Metaplasia was not seen in any case. Liver biopsy showed features of infantile obstructive cholangiopathy. Short term complication includes anastomotic problem and cholangitis. No patient develop late stricture or cholangiocarcinoma. Longest follow-up is 18 years.

Conclusion: In our series none of our patient had metaplasia in biopsy. Patient was followed upto 18 years and no evidence of Cholangiocarcinoma was found.


   IHPS beyond laparoscopic pyloromyotomy – combating complications Top



   Category: Laparoscopy Long Oral Top


Balamourougane Paramasamy

Department of Pediatric Surgery, Apollo Children's Hospitals, Chennai, Tamil Nadu, India.

E-mail: bala_sowba@rediffmail.com

Aims: To report on the lessons learnt in Laparoscopic Pyloromyotomy.

Methods: All babies with non bilious vomiting evaluated and confirmed to be IHPS by USG were considered for Laparoscopic treatment. The babies were kept nil orally. Dehydration and electrolyte abnormalities were corrected prior to surgery. They were subjected to surgery with 3 port technique.

Results: 2 cases with perforation were found in our series. One was a delayed perforation and one identified intra op. The management is discussed. There was no case of Incomplete myotomy needing re- surgery.

Conclusions: Laparoscopy is simpler and safer to perform in IHPS and results in shorter hospital stay and lower pain scores. However we need to be vary of the possible complications and be able to identify and manage the same.


   A comparative study between open herniotomy and single port percutaneous internal ring suturing in female inguinal hernia Top



   Category: Laparoscopy Long Oral Top


Arka Chatterjee, Ramesh Chand Tanger, Rahul Gupta, Arun Kumar Gupta

Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India.

E-mail: arka.jimhendrixwasagod@gmail.com

Aims: aims of this study are to compare time of surgery recurrence, cosmetic result between open herniotomy and single port laparoscopic PIRS in female patients.

Introduction: Open inguinal herniotomy is universally preferred surgery in inguinal hernia. Recently, laparoscopic repair gained acceptance in pediatric patients. Percutaneous internal ring closure suturing (PIRS) performed with one umbilical port and puncture to skin in groin, with no inguinal incision.

Materials and Methods: Between January 2017 and June 2019 all female patients of inguinal hernia included. 44 patients underwent open herniotomy and 37 PIRS. Mean operative time , complication ,recurrence and final scar in both techniques compared.

Results: 35 patients of PIRS went home scar less 2 patients, PIRS converted to open procedure due to presence of sliding hernia Small haematoma developed in 2 cases managed conservatively Suture granuloma in one, scar hypertrophy in one case of open herniotomy Hernia recurrence in two patients of PIRS - one managed with open herniotomy and other with PIRS.

Longest follow-up is 2years.

Conclusion: In the era of minimal invasive surgery the PIRS technique is safe, simple ,effective & scarless.


   Robotic surgery in pediatrics- Our initial experience and modifications for children Top



   Category: Laparoscopy Long Oral Top


Arvind Sinha, Rahul Saxena, Manish Pathak, Ayushi Vig

Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

E-mail: drrahulsaxena@gmail.com

Aim: The popularity of Robot assisted surgeries has accelerated since its advent in 1990's as it offers highly precise and lesser dissection and thus decreased overall patient morbidity. Recently we procured Da Vinci surgical system in our institution and here we present our initial experience of first few Robot assisted Urological surgeries at our hospital.

Materials and Methods: We recorded the demographic data, indication of surgery, port placements and its variation, docking time, operating time, role of assistant surgeon, outcome of surgery and hospital stay.

Results: We performed three pyeloplasty; 2 right side and one left; 2 males and one female, 3 Ureteric Reimplantation; all males, 1 Bladder diverticulum excision in male and one Choledochal cyst excision with hepatoduodenostomy in female child successfully with robot assistance and one of our patient with right sided phaeochromocytoma was converted to open procedure.

The age ranged from 4-17 years with average of 10.375 years. The mean operating time for pyeloplasties was 120min and hospital stay was 3 days; for ureteric reimplantation mean operating time is 200min; bladder diverticulum excision was 350min and that of choledochal cyst excision was 150min.

Conclusions: The operative duration of the cases were less than the standard laparoscopic techniques. The docking time is reduced with expertise of supporting staff. Port placement in children is different for every patient and has to be individualized. Robotic surgery is safe and feasible in pediatric population and has good post operative outcomes.


   Role of laparoscopy in management of complicated appendicitis in children: A critical appraisal Top



   Category: Laparoscopy Long Oral Top


Arun Chauhan, Archana Puri, Sahej Prajapati

Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India.

E-mail: puriarchana@hotmail.com

Aim: Role of laparoscopic appendectomy in uncomplicated appendicitis is universally acceptable; however it's utility in managing complicated appendicitis (those with appendicular perforation, abscess, lump) remains controversial. This study aimed to study the feasibility, safety and efficacy of laparoscopic appendectomy in complicated appendicitis in children.

Methods: This is a retrospective analysis of prospectively collected data of 32 patients of complicated appendicitis (AAST grading II-V) over a period of 2-years. Medical records were scrutinized to record mean age at presentation, severity of appendicitis, Paediatric appendicitis score (PAS), duration of symptoms, symptomatology, presence of appendicular lump and ultrasonographic findings. Laparoscopic findings, post-operative course, length of hospital stay and complication if any were noted. Mean, median and standard deviation were calculated for various variables.

Results: Mean age at presentation was 8.5±3.7 year with median duration of illness being 3days. Gangrenous appendicitis (AAST II, n:2), perforated appendicitis with abscess (AAST III, n:16), with loculated pyoperitoneum (AAST IV, n:12), and with generalised peritonitis (AAST V, n:2)were noted. PAS varied from 8-10 and appendicular lump was noted in 26 patients. Median appendicular wall diameter on USG was 9mm, while free fluid with internal echoes and free lying appendicolith was noted in 13 and 2 patients respectively. Laparoscopic trocar ports varied according to the site of lump and appendicular position (Retrocecal: 2, paracaecal: 3, postileal: 9, preileal: 9 and pelvic: 9). Tips and tricks of port positioning and technical details shall be discussed in presentation. Mean operative time was 70±20.6 minutes. None of the patients had wound infection, residual abscess or needed readmission for subacute intestinal obstruction. One patient developed enterocutaneous fistula which was managed conservatively. Mean duration of hospital stay was 9.5±4.8 days.

Conclusion: Laparoscopic appendectomy is feasible and safe for complicated appendicitis, presenting even with lump in children.


   Management of intra-abdominal tumors by laparoscopic approach Top



   Category: Laparoscopy Long Oral Top


Suramya Anand, Prabudh Goel, Minu Bajpai,Kanika Sharma

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: suramya.anand@gmail.com

Aim: To assess the feasibility of laparoscopic surgery as a viable option in the management of intra-abdominal tumours in paediatric population.

Methods: Prospective study from July 2013 onwards including all patients with intra-abdominal solid malignancies less than 14 years old . Locally advanced tumors with dense intra-abdominal peri-tumoral adhesions or with any other contraindication to laparoscopy were excluded. 3 or 4 port technique of laparoscopy was used and dissection done using harmonic scalpel. Parameters including conversion rate, intraoperative blood loss and duration were noted.

Results: 21 children(16-males, 5 females) with intraabdominal tumours in the age range of 10 months to 14 years were included. Wilms tumor(62%) formed the majority of the cases. Other tumors included neuroblastoma(14%) , phaeochromocytoma (10%), CCSK(5%), adrenal cortical tumor (5%) and ovarian tumor (5%) .Tumor rupture occurred in one(5%) case. Tumors were retrieved via extended lumbotomy incision(n=13), lumbotomy(n=6), Pfannensteil incision( n=1) and inguinal incision(n=1).Conversion rate was nil. Average intra-operative blood loss was 50 ml and duration of surgery ranged from 120 min to 360min. Two patients (one Wilm's tumor and one neuroblastoma) had a local recurrence and one had a port site recurrence.


   Robotic surgery in children: Beginner's perspective Top



   Category: Laparoscopy Long Oral Top


Rajat Piplani, Manish Kumar Gupta, Enono Yhoshu

Department of Pediatric Surgery, AIIMS, Rishikesh, Uttarakhand, India.

E-mail: rajatpiplani@yahoo.co.in

Aims: To study the utility of Robot assisted surgery in Paediatric Minimal Invasive Surgery (MIS).

Minimally invasive surgery in children has been the cornerstone of Paediatric surgery. Use of Robots in paediatric MIS has been an advantage for not only the patient but also for the surgeons. As the number of paediatric surgeons are interested in robotic training and its use in their clinical practice, we present the difficulties faced before and during robot assisted laparoscopic surgery from the beginner's perspective. We also highlight the tips and the tricks that can be used in a small child undergoing a robotic surgery.

Methods: Prospective one-year observational study including all cases operated with Robotic (Da Vinci Xi) assistance.

Results: Around 30 paediatric surgical cases has been operated in our institution using robot since its inception over a year with fairly good results.

Conclusion: Robotic Surgery is the new dimension in Paediatric MIS and has been an asset in difficult situations along with the ergonomic advantages to the surgeon.


   Role of Ipsilateral ureteroureterostomy in management of megaureter in functional ureteric duplication in children –Our institutional experience Top



   Category: Laparoscopy Long Oral Top


Aishwarya M, Bibekanand Jindal, Bikash Kumar Naredi

Department of Pediatric Surgery, JIPMER, Puducherry, India.

E-mail: aishwaryamalla61@gmail.com

Aim: To present our experience on open and robotic ipsilateral ureterouretrostomy in children with ureteric functional duplication and megaureter.

Materials and Methods: A retrospective study of all children who underwent ureteroureterostomy for megaureter in ureteric duplication from 2013 to 2019 in department of Pediatric Surgery, JIPMER.

Results: Total four female children were subjected to ipsilateral ureteroureterostomy during this study period. Age group ranging from 11months to 48months (mean-26months).Two were antenatally diagnosed with hydroureteronephrosis, three had recurrent urinary tract infection and two had dribbling of urine. Three children had a unilateral duplex and one child had a bilateral duplex. Upper moiety obstructive megaureter was noted in three cases, whereas one child had obstructive and refluxing lower moiety. Two children underwent open ureteroureterostomy, of which one child underwent bilateral ureteroureterostomy. The mean operating time and hospital stay for open and robotic ureteroureterostomy were 277mins, 10days and 197mins, 5days respectively. Follow up range from 2months to 69months with no complications postoperatively.

Conclusion: We conclude that ipsilateral uretroureterostomy is a safe and effective technique in the management of ureteric functional duplication anomalies. Moreover, minimally invasive surgery is a better option with excellent cosmesis, less hospital stay, operative time with success comparable to open approach.


   Diversity of spectrum and management of animal inflicted injuries in pediatric age-group: A prospective study from a pediatric surgery department catering primarily to the rural population Top



   Category: Miscellaneous Long Oral Top


Rafey Abdul Rahman, Umesh Gupta, Shashank Agrawal, Prabudh Goel

Department of Pediatric Surgery, Uttar Pradesh University of Medical Sciences, Saifai, Uttar Pradesh, India.

E-mail: dr.rafeyaiims@gmail.com

Introduction: Animal inflicted injuries continues to be a major health problem worldwide. In developing countries, the outcome of such injuries especially in children may be poor.

Aim: To evaluate diversity of spectrum and management of animal inflicted injuries in pediatric age-group.

Materials and Methods: This was prospective study on animal inflicted injuries in children between 1 to 15 years of age over a period of 12 months. Data on various parameters like age and sex, animal species involved, provoked/unprovoked, mechanism of injury, time of injury, pre hospital care, injury-arrival interval, admission hemodynamic parameters, pattern and type of injury, trauma score, body region injured, treatment given, complications and outcome were collected and analyzed.

Results: 52 children with animal inflicted injuries were included, constituting < 1 % of all trauma cases seen during the study period [M:F=2:1]. Mean age of cohort was 9.65 years. Domestic animals were accountable in 41 (78.84%) and wild animals in 11 (21.16%). Dog bite was most common and seen in 30 (57.69%). Penetrating injury was seen in 40 children (76.9%) and blunt injury was seen in 12 children (23.1%). Musculoskeletal system was the most common organ-system injured affecting 36 children (69.23%). 35 children (67.3%) after minor treatment were discharged. 17 children (32.7%) required admission. 34 children (65.38%) underwent surgical procedures. Wound debridement was the commonest procedure done in 16 children (47.05%). Wound infection was seen in 20 children (38.46%) and was significantly higher (P<0.01) in delayed presenters. Length of hospital stay for the admitted children ranged from 3 days to 28 days.

Conclusion: Animal inflicted injuries are rare in children and have wide spectrum of presentation. Severe injuries require extensive resuscitation and expert surgical care. Mild injuries can be managed conservatively with use of proper dressings, antibiotics and analgesics.


   Common cloaca- An uncommon entity posing diagnostic and management challenges: Our experience with nine cases Top



   Category: Miscellaneous Long Oral Top


Santosh Kumar Dey, V Shankar Raman

Department of Pediatric Surgery, Army Hospital, Pune, Maharashtra, India.

E-mail: santodey@gmail.com

Introduction: Cloacal anomalies are the severest and most complex of all anorectal malformations (ARM). They require careful evaluation and meticulous surgery tailored to suit each variant. We present our experience in a series of nine cases.

Materials and Methods: Prospective and retrospective review of 9 cases of cloaca managed at a tertiary care centre between 2015-2019.

Results: Associated anomalies were seen in 44% cases.The definitive surgery was done at a mean age of 15.2 months (10 months -19 months). The definitive surgery being rectal separation with total urogenital mobilization. The common channel as measured during panendoscopy was upto 3 cm in 7 patients (78%) and only 2 patients had a common channel of more than 3 cm (22%). Out of the 34 procedures that these nine patients underwent, we had four complications (12%). The median follow up period in our study after stoma closure was 18 months (5-32 months) and the mean age of our patients at last follow up was 38 months (22-48 months) . Five children (63%) had spontaneous voiding and remained dry in the intervening period. Three patients (37%) had poor urinary stream with dribbling and high post void residue requiring clean intermittent catheterisation (CIC). Six patients had fecal soiling (66%); four had daily soiling and two had occasional soiling. Four patients had constipation (44%). Seven patients (77%) require daily enemas for bowel evacuation and to remain dry.

Conclusion: Cloacal anomalies are rare and complex anorectal malformations. Satisfactory urinary and bowel continence rates can be achieved even in these complex anomalies.


   Quality of life in children with Spina Bifida in South East Asia need not to be gloomy -as generally believed Top



   Category: Miscellaneous Long Oral Top


Shruti Tewari, Santosh Karmarkar, Vinod Raj, Rahul Deo Sharma, Shirin Joshi, DA Sushma

Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India.

E-mail: shruti.t18@gmail.com

Aim: Assess quality of life in SB children were treated at a single centre.

Methods: Out of 100 SB patients 50 were selected randomly and questionnaires sent to them. 39 patients/families replied. Questionnaire included information about socio-economic status, patient's education status, quality of treatment, personal and social life. Score was assigned to each question and the total score was tabulated and analysed for assessing the QOL.

Results: N=39, F=23, M=16, <10Y=6, 10-20 Y=23, >20Y=10, Results summary of QOL questionnaire: Rural Urban LI MI HI WCB AWS A Treatment quality 76% 88% 75% 87% 92% 86% 87% 87% Educational level 52% 85% 50% 82% 92% 77% 77% 88% Social life 67% 82% 58% 75% 92% 74% 74% 87% Personal life 62% 79% 54% 82% 83% 70% 73% 86% LI-low income MI-middle income HI- high income WCB- Wheel chair bound AWS-Ambulatory with support A-Ambulatory.

Conclusions: QOL in wheel chair bound SB was as good as others. The quality of treatment and the personal lives in SB individuals in rural areas was as good as those in urban areas. However, the educational level and social life in SB in rural area was slightly inferior to those in urban area. The QOL in SB individuals is co-related with incomes as can be expected. Thus, we conclude that the QOL of SB individuals in SEA need not to be gloomy- as generally believed in this part of the world.


   Spectrum of Neo- vaginoplasties in children: Our experience Top



   Category: Miscellaneous Long Oral Top


Venkatesh Kolla, Gowri Shankar, Narendra Babu, S Ramesh

IGICH, Department of Pediatric Surgery, Bangalore, Karnataka, India.

E-mail: kolla.venkatesh@gmail.com

Aims: To describe our experience with various alternative for vaginoplasty done in children.

Methods: This is a retrospective study of thirteen children aged 10 months to 16 years, who underwent vaginoplasty over a period of 8 years (2011-2018). The indications of vaginoplasty included cloaca (n=2), vestibular fistula associated with vaginal atresia (n=5) and vestibular fistula with Mayer-Rokitansky-Kuster-Hauser syndorme(MRKH)(n=2) and MRKH(n=2) pure vaginal atresia (n=1). The tissue used for vaginoplasty included include sigmoid colon (n=5 ileum(n=2)peritoneum(n=2),rectum (n=3)andureter(n=1).

Results: Bowel vaginoplasty was done for ten patients. Two patients underwent peritoneal vaginoplasty. One had vaginal stenosis child kept on regular dilatation and one patient it is a failure. One patient underwent ureteral vaginoplasty. One patient had mucosal prolapse of the neovagina. 12 patients have neovagina, cosmetically acceptable to the parents. One patients had vaginal stenosis and excessive mucus discharge, during follow-up visits. One child with ileal bowel vaginoplasty developed stones which were retrieved under genitoscopy guidance. One child developed pyometra after menstruation which was drained under ultrasound guidance.

Conclusions: Though Bowel vaginoplasty is a safe and acceptable procedure to treat the pediatric patients of uterovaginal agenesis and cloaca. Alternatives such as megaureter can be used as replacement. Peritoneum can also be tried.


   Pilot study of pediatric blunt abdominal trauma Top



   Category: Miscellaneous Long Oral Top


Gali Divya, Vijay Kundal, Amita Sen

Department of Pediatric Surgery, PGIMER and DR. RML Hospital, New Delhi, India.

E-mail: galidivya55@gmail.com

Aim: Pilot study of Pediatric Blunt Abdomianl Trauma.

Methods: We have prospectively studied 20 patients of Blunt Abdominal Trauma referred to us from emergency, below 12 years of age, from Septmber 2018 to July 2019. Demographic data-age,sex,mode of injury,place of injury,time taken to seek medical management was taken.Thourough clinical examination and close monitoring was done.Management outcomes are studied.

Results: Male:Female ratio 7:3.Mean age of presentation was 6.6 years.Most common type of injuries are fall& Road Traffic Accidents.17 cases presented with in 1 hour,Retroperitoneal injuries presented late .19 patients required blood transfusion.2 cases required laparotomy.Most commonly injured organs-liver(40%),spleen(30%),kidney(20%).Each one case of Bowel injury,Pancreatic injury &Retroperitoneal hematoma.More than one abdominal organ injury is observed in 3 cases.Multiple system involvement is seen in 50% of cases.Most common associated injuries include blunt trauma chest,Extremity injury and head injury.Average hospital stay – 7 days.

Conclusion: Multiple system involvement is common in Pediatric Trauma because of their small size hence detailed examination is required.Eventhough conservative management is gold standard, close monitoring helps in appropriate decision making.


   Analysis of results in Fowler Stephen staged procedure: 7-year study Top



   Category: Miscellaneous Long Oral Top


Arun T Sen, Aswathy Ravikumar

Department of Pediatric Surgery, Government Meddical College, Thiruvananthapuram, Kerala, India.

E-mail: aruntsen1@gmail.com

Aim: Analyse the results of two staged Fowler Stephen procedure in cases of undescended testes and assessment of size of testes in follow up.

Materials and Methods: Retrospective study which includes 60 cases which undergone fowler Stephen staged procedure in year 2102 – 2018.

Results: Total 60 cases , 8 cases were b/l , 28 acses left amnd 24 cases right sided. Mean age is 4.8yrs. 15 cases were above 7yrs of age. In follow up of min 6 months , position of testes was intrascrotal in 49 cases , 10 cases at root of scrotum , 1 case was atrophic. Preop size almost same size as opposite side testes in 10 cases , half or smaller in size in 50 case. Postop size , 1 became atrophic , 26 cases testes was smaller than opposite side and 33 cases had comparable testicular size. In all the cases except one that became atrophic , there was no postop decrease in size of testes.

Conclusion: Fowler Stephen staged surgery is a safe and effective operative procedure with good results.


   A fool with a tool is still a fool, what if an intellect possess it Top



   Category: Miscellaneous Long Oral Top


Prabhu Karaunakaran, Sheik Uduman Ali, Satya Kaliki

Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India.

E-mail: k.prabhucr@gmail.com

Aim: Augmenting the efficacy of the physician using technology.

Methods: Mobile Application –with four components.

Active book- a similar context of working in whats up and telegram groups, where in all the discussion are undiluted and is retrievable on all possible headings

Alarm- activating the alarm-will lead to altering your colleagues on and off duty depending the nature of patient violence, including nearby police station

Loop- Helps in clinical decision making of the doctors by getting help from the seniors after leaving the place of qualification, both online and offline opinions, keep the physicians updated with the academic activity, also help in real time communication with colleagues

Log book- Could help managing personal patient data, with specific follow up Buzz to the patient and physician.

Results: Currently app is close to completion and will plan launching of this application in our prestigious IASPCON 2019 and Golden jubilee of AIIMS- Pediatric surgery department and presence of great teachers from the lengths and breaths of the country.

Conclusion: This is need of hour application of the physician, by the physician and for the physician with one of the world's best software team who made Lorenzo (software used by NHS) possible.


   Rising disgruntlement against healthcare service providers in India: Binary perspectives Top



   Category: Miscellaneous Long Oral Top


Prabudh Goel, Aparajita Mitra, Minu Bajpai

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: aparajita270@gmail.com

Aim: To identify the causes of parents' (of patients) dissatisfaction in a pediatric surgery ward of a tertiary care institute by a nurse-based survey and to generate insights on those issues from the perspectives of resident doctors and parents/ attendants independently.

Materials and Methods: A preliminary survey was conducted on 15 nurses posted in the pediatric surgery ward of a tertiary care institute and a list of common grievances of parents (wherein they feel that the doctor was the cause) was drawn. The list was converted into a google-form-based questionnaires and presented independently to the resident doctors of the same ward (n=15) and the parents/ attendants of children admitted to the ward for at least 10 days (n=30). The responses were analysed to generate insights into this aspect of healthcare.

Results: The preliminary survey identified a list of 15 questions. When the same questions were presented to the resident doctors, the analysis of their perception of the problem was in striking contrast to the perception generated from the parents/ attendants.

Conclusions: The difference in binary perspectives to similar situations is indeed an important cause of disgruntlement and a possible solution to such problems will be presented for open contemplation.


   Outcome of antenatally diagnosed gastroschisis from a single institution Top



   Category: Neonatal Long Oral Top


Vikram Khanna, Subhasis Roy Choudhury, Rohit Kapoor, Amit Gupta, Partap Singh Yadav, Rajiv Chadha

Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, India.

E-mail: vikramaiims@gmail.com

Objective: To study the outcome of antenatally diagnosed gastroschisis from a single institution.

Methods: Review of antenatally diagnosed gastoroschisis patients enrolled in our Fetal Medicine Clinic from Dec.2016 till July.2019.

Results: Eight patients with antenatally diagnosed gastroschisis were prospectively enrolled in the study period. Seven patients (3 term & 4 pre-term) were delivered in our hospital while one was delivered elsewhere. All patients were LBW and had spontaneous normal vaginal delivery. All 7 patients underwent surgery on day 1 of life and received NICU care. One patient delivered elsewhere died on Day 1 of life itself without surgery as confirmed telephonically. In one patient only, immediate bedside reduction of the contents and skin flap closure was possible while the patient was on ventilator. In 2 patients, Silo was created and sheath closure was subsequently done after 7 days. Skin flap closure was done in 4 patients and two of these patients had associated jejunal atresia which was repaired in second surgery. One patient with associated atresia went LAMA after the second surgery. 6/7 (85%) operated antenatally diagnosed gastroschisis were alive and feeding well at discharge.

Conclusion: Immediate management of the newborn delivered in a tertiary care institution following antenatal diagnosis of gastroschisis, a skin flap closure and NICU care have led to improved outcomes.


   Septic screening of neonatal abdominal surgery and their outcomes Top



   Category: Neonatal Long Oral Top


Ritesh Kumar, Amita Sen, Nandini Duggal

Department of Pediatric Surgery, PGIMER and DR.RML Hospital, New Delhi, India.

E-mail: ritesh.mgims@gmail.com

Aims:

  1. To study neonatal abdominal surgery and sepsis screening pre and post operatively.
  2. To study morbidity and mortality in neonatal surgical sepsis.


Methods: Thirty consecutive neonatal cases with surgical abdomen from March 2018 to February 2019 included in this study. septic screening was done in all neonates on day 0, 1, 3 ,7 and 14 day of surgery with serum procalcitonin, CRP, TLC, I/T ratio, and micro ESR. Septic screening was correlated with sepsis and analysis was done.

Results: Total 30 neonates of abdominal surgical cases were included consequently out of which male were 57 % and female were 43% . Maximum no of cases of CDH 20% ,then ARM 16.7%. Total 70 % neonate were septic screening positive . In 30 % of neonate septic screening was negative. 50% neonates diagnosed to have sepsis so sensitivity and specificity of septic screening was 93.33% and 40 % respectively. There was total 30 % mortality in this study.

Conclusion: Septic screening is an early diagnostic marker which helps in early diagnosis and timely intervention for positive outcome is my take home message.


   Germ cell tumour: A clinico-pathological study and outcomes Top



   Category: Surgical Oncology Long Oral Top


Ritesh Kumar, Pinaki R Debnath, Vijay Kundal, Atul Meena, Shalu Shah, Amita Sen

Department of Pediatric Surgery, PGIMER and DR. RML Hospital, New Delhi, India.

E-mail: ritesh.mgims@gmail.com

Aims: The aim was to study clinical presentation,pathological types and outcomes of management of different germ cell tumours in pediatric patient.

Methods: This is retrospective study done over 10 yrs from 2009 to 2019 and 26 patients of germ cell tumors included .Clinical features, imaging and laboratory studies, surgical approach , as well as pathological diagnosis were recorded.

Results: There were total 26 cases of germ cell tumour. Female were 57.69 % and male 42.30% .Most common germ cell tumour was sacrococcygeal teratoma( 53.84 %) and followed by ovarian germ cell tumour (11.53 % ), gastric tumour ,testicular and retroperitoneal germ cell tumour was 7.6 % each. Most patients presented with lump and one patient of SCT presented with altered bowel habit and pain abdomen. AFP was raised in 46.15 %.Neoadjuvant chemotherapy was given in 2 patients . complete excision was done in 88.46 % cases and partial excision was done in one case .There was 4 mortalities in this series.

Conclusion: – GCTs in children have various pathological types, as well as clinical manifestations and most of them benign tumours with good long term outcome following complete excision but poor if malignant, is my take home message.


   The outcome of operated neonates with isolated congenital diaphragmatic hernia in a limited resource scenario: A critical analysis Top



   Category: Neonatal Long Oral Top


Nibi Hassan, Vivek P Sarma

Department of Pediatric Surgery, Government Medical College, Thiruvananthapuram, Kerala, India.

E-mail: nibihassan@gmail.com

Aims: To analyze the outcome of operated neonates with isolated CDH , where a standardised protocol of management was followed.

Methods: A thorough retrospective analysis of the antenatal, preoperative and postoperative records of all neonates with CDH operated during 2015-18 in a tertiary teaching institute. Nonoperated cases of CDH, CDH with multiple major associated anomalies, syndromic cases and cases presenting beyond newborn period were not included in the analysis. The standard protocol followed consisted of mandatory intubation in all antenatally detected cases and those cases with early onset respiratory distress; preoperative stabilization; selective use of HFOV and Sildenafil and planned surgery with optimal postoperative ventilation and medical management.

Results: The total number of operated cases during this period was 40.The average duration of preoperative stabilisation was 3 days.The average age at surgery was postnatal day 3. Mortality was 5 out of 40 cases(12.5%).All mortalities occurred during postoperative period after day 3 due to respiratory failure.

Conclusion: Many neonates with CDH are treated in public health hospitals where facilities are limited for advanced therapies due to constraints. Therefore optimisation of resources and therapy is vital for maximizing survival.


   Differentiated thyroid carcinoma in paediatric and adolescent age group: A 12-year institutional experience Top



   Category: Surgical Oncology Long Oral Top


John K Thomas, JJ Kurian, AJ Cherian, MJ Paul, DT Abraham, J Hephzibah

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India.

E-mail: drjohntk@gmail.com

Objective: This study was done to assess the clinicopathological profile, aggressiveness and response to treatment of paediatric Differentiated Thyroid Carcinoma.

Materials and Methods: All the patients below 18 years who were diagnosed with Differentiated Carcinoma Thyroid(DTC) during January 2006 to June 2018 and underwent their therapy and follow up in a tertiary care hospital in India were included in this study. All data were collected and analysed retrospectively.

Results:- Out of 87 patients, 64 were girls and 23 were boys. The median age of presentation was 15 years. The youngest child was 6 years. The most common presentation was solitary nodule (52.87%). FNAC was diagnostic only in 52.87% of patients. 13 patients had distant metastasis at presentation. 86 patients underwent total thyroidectomy, while one patient underwent hemithyroidectomy. Lymph node dissection was done for 42 patients. 70.1% of patient had a multifocal disease, and 57.47 % of patients had Lymph node metastasis. The most common postoperative complication was hypocalcemia (46.12%). 75 patients received postoperative radioiodine therapy. 53 patients are disease-free on median follow up of 48 months.

Conclusion:- When compared to adult disease, DTC in children are aggressive at presentation, in terms of local and distant spread. But they have a better response to treatment.


   Functional bladder outcomes in patients with bladder and bladder/prostate rhabdomyosarcoma Top



   Category: Surgical Oncology Long Oral Top


M Varunkumar, Aprajita Mitra, Vishesh Jain, Anjan Dhua, Sameer Bakhshi, Manisha Jana, Devasenathipathy Kandasamy, Ahitgani Biswas, V Bhatnagar, S Agarwala

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: drvarunkumar999@gmail.com

Aim: To study the functional outcomes in relation to bladder and upper tracts in survivors of bladder and bladder/prostate RMS(RMS-BP).

Materials and Methods: Long-term survivors of RMS-BP, treated from 1998 till 2016, with native bladders preserved were included. Urinary symptoms and signs were noted. Upper tract was evaluated with ultrasound and Dimercapto-succinic-acid scan(DMSA) and lower tracts with micturating cysto-urethrogram and urodynamic studies. Glomerular Filtration rate was derived using Tc99m-DTPA(diethylenetriaminepentacetate).

Results: Among 19 patients included, 17 were males. Three(16%) had undergone partial cystectomy, while the other 16(84%) had achieved complete response with chemotherapy+radiation. Follow-up after completion of treatment ranged from 2-22 years(median 11). Six of 19(31.5%) were asymptomatic. The symptoms among 13(68.5%) symptomatic children included frequency(4), dribbling(3), hematuria (4), nocturnal enuresis(5), dysuria (1), and straining(2). Urodynamic studies in symptomatic cases showed 6(50%) had reduced bladder capacity for which they were on imipramine. One child required urethral dilatation. One with low capacity high pressure bladder with falling GFR (52ml/min/1.73m2) had undergone augmentation colocystoplasty with Mitrofanoff. The GFR of this child improved to 71ml/min/1.73m2.

Conclusion: Patients with conserved urinary bladders following RMS-BP treatment persist to have abnormalities which need to be followed up and appropriately treated to prevent deterioration of the renal functions.


   The hidden prognostic factors in neuroblastoma affecting the outcome Top



   Category: Surgical Oncology Long Oral Top


Ruchira Nandan, Devendra Yadav, Shilpa Sharma, Minu Bajpai, Prabudh Goel

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: ruchira.nandan@gmail.com

Aim: To study the effect of nutritional status on outcome in patients of neuroblastoma.

Methods: Anthropometry [height, weight, weight for height (in <5yrs), mid-arm circumference (MAC) (in <5yrs], hemoglobin level, serum protein level of patients of neuroblastoma were correlated with outcome and complications (like neutropenia).

Results: Twenty-four NB patients, 16 male, 8 females with mean age 42.7 months were treated and followed up over period of 0.03 to 67.97 months. Height(H)-3 of 24(12.5%) had H<2SD, of which 1 survived [stable disease(SD)-1]. All had neutropenia. Weight(W)-9 of 24(37.5%) had W<2SD, of which 6 survived [complete response(CR)-1, partial response(PR)-1, progressive disease(PD)-2, SD-2] . 6 of 9(67%) had neutropenia. Weight for height(WH)-7 of 20(35%) had WH below 2SD, of which 4 survived [CR-1,PR-1,PD-1,SD-1]. 5 of 7(71.4%) had complications. MAC-3 of 19(15.8%) had MAC below 2SD, of which 1 survived[PD-1]. 2 had neutropenia. Anemia-15 of 24(62.5%) had anemia, of which 9 survived[CR-3,PR-1,PD-3,SD-2]. 14 of 24(58.3%) had complications(p=0.001). Hypoproteinemia- 5 of 24 pts had hypoproteinemia, of which 3 survived[PD-2,SD-1] . 4 of 5(80%) had neutropenia.

Conclusion: Neuroblastoma has poor outcome in Indian children and nutrition plays an important role in determining the clinical outcome such as treatment response, quality of life and prevention and efficient management of infections.


   Extragonadal germ cell tumors in children Top



   Category: Surgical Oncology Long Oral Top


Narahari Janjala, Narahari Janjala, Santosh Kumar Mahalik, Mukund Sable, Sonali Mahapatra, Akash Bihari Pati, Kanishka Das

Department of Pediatric Surgery, AIIMS, Bhubaneswar, Odisha, India.

E-mail: narahari.janjala@gmail.com

Aim: Retrospective review of the clinicopathological profile and management of extragonadal germ cell tumors (GCT) at a tertiary teaching centre.

Materials and Methods: Clinical details, tumour markers, pathology and management details of all extragonadal GCT managed between 2016-2019 were collated and analysed.

Results: Fourteen cases are detailed. The mean age was 12 months (12 days - 12 years), most were males (M: F=8:6). The primary site was retroperitoneum (7/14), others included stomach (2/14), sacrococcygeal (3/14), supra renal (1/14) and gluteal region (1/14). Two sacrococcygeal teratomas were diagnosed antenatally. Besides the common clinical presentations (abdominal mass, pain, bowel obstruction), one had Currarino syndrome with discharging sacral sinus.13/14 had elevated serum alfafetoprotein levels .At histopathological examination, 12/14 were benign (mature - 7 , immature – 5 with Norris grade 2 to 3) while 2 were malignant yolk sac tumors. The benign cases were managed with surgical excision; the two malignant ones are on neo-adjuvant chemotherapy and await surgery. At a median follow-up of 2 years, all postoperative cases are well and asymptomatic.

Conclusion: Paediatric extra gonadal GCTs are uncommon with diverse clinical, radiological and histological features. The outcome is favourable in the benign majority, an occasional one presents a diagnostic or therapeutic dilemma.


   Chest wall tumors in children: Surgical challenges and short-term outcomes Top



   Category: Surgical Oncology Long Oral Top


Nitin J Peters, Nitin James Peters, Muneer A Malik, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: nitinjamespeters@yahoo.com

Background/Aim: Chest wall tumors (CWT) constitute 1.8% of all childhood cancers and ~45% include sarcomas. We studied the challenges, surgical approach and peri-operative events in resection of CWT in children.

Materials and Methods: A retrospective analysis of patients operated for chest wall tumors, from January 2017 to May 2019 was done. Data on presentation, radiological and histological diagnosis, neoadjuvant therapy, surgery, and immediate post operative events was analyzed.

Results: There were 12 patients, 9 boys and 3 girls between the ages of 1 to 12 years. Various presentations included respiratory distress, chest pain and fever. Tissue diagnosis showed 9 cases were of Ewing's sarcoma (ES), 2 Rhabdomyosarcoma (RMS) and 1 Neurofibroma. All patients with malignant disease underwent neoadjuvant chemotherapy followed by surgical excision. None of the patients required artificial chest wall reconstruction. Important structures like brachial plexus, diaphragm and spinal canal were in close proximity of resected margins. Three patient required excision of a part of lung parenchyma to achieve en-bloc resection. Six patients required peri-operative blood transfusion. Two patients required post-operative ventilation. HPR showed negative margins in 8 patients of ES. One patient has had of ES had recurrence after 8 months and died. The patient of neurofibroma had R2 debulking and is on adjuvant radiotherapy. Rest all others are disease free over a period 3 months to 2 years. Radiotherapy was given in 7 patients of ES and 2 of RMS and is awaited in one patient.

Conclusions: Rib and chest wall resections, with adequate margins is the crux in the treatment of CWT. Surgical planning includes accurate preoperative radiology assessment, aggressive surgical approach and adequate pulmonary toilet and pain relief in the post-operative period. Short term outcomes are encouraging in the era of multimodality treatment.


   Rare presentations of chest trauma in children Top



   Category: Thoracic Long Oral Top


Tanusree Kundu, Dipak Ghosh, Janki Bisht, Kaushik Saha

Department of Pediatric Surgery, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India.

E-mail: tandgreat@gmail.com

Aim: To study the rare cases of chest trauma in children and their management.

Methods: Total no of cases taken: 3 mode of injury: penetrating and blunt. case 1 history of overrun by tractor. presented with respiratory distress. on examination: tachypnea, left sided air entry decreased. diagnosis: chest x-ray pa view showed multiple air fluid level. diagnosis: left sided traumatic rupture of diaphragm.

Case 2 history of overrun by autorickshaw. presented with respiratory distress. on examination: tachypnea, left sided air entry decreased.

DIAGNOSIS: Chest x-ray pa view showed multiple air fluid level in left hemidiaphragm. diagnosis: left sided traumatic rupture of diaphragm.

Case 3 asymptomatic history of penetrating injury to the chest with iron rod. on examination: bilateral air entry was equal. chest x-ray showed foreign body in right hemithorax.

Results: Case 1 repair of left sided traumatic rupture of diaphragm was done with mersilk 2-o. case 2 repair of left sided central tendon repair was done using prolene 2-0. case 3 removal of the iron rod was done after right sided thoracotomy.

Conclusion: Case 1 and case 2 patients were put on elective ventilation for 48 hours with proper sedation.both the patients had an uneventful recovery. case 3 –patient had an uneventful recovery in the post-operative period. traumatic rupture of diaphragm though has a prevelance of less than 1 % among thoracic injuries it has a very good prognosis. take home message: don't forget the chest while you are lost in the abdomen.


   Thoracoscopic protocol to esophageal atresia with unfavourable anatomy: A novel approach to long gap esophageal atresia Top



   Category: Thoracic Long Oral Top


Prabudh Goel, Minu Bajpai, Rahul Anand

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: prabudh.aiims@gmail.com

Objective: Presenting our early study in a prospective study-based-protocol to address long-gap esophageal-atresia, while preserving the native esophagus.

Materials and Methods: Prospective study over twenty-two months on seven patients of long-gap esophageal-atresia [male:female=5:2; mean birth weight=1.85 kg; mean gestation at birth=34 weeks].

Neonates with long-gap esophageal-atresia and fit for thoracoscopy were included in this study. The protocol will be discussed in detail.

Results: The study protocol will be presented in detail. With this protocol, a delayed primary anastomosis over a #6 infant feeding tube was possible in 6/7 (85.7%) neonates after a mean waiting period of 9 weeks (8.5-10.5 weeks). Per-oral dye study performed ten days after repair excluded any leak in each of these patients with no hold-up of contrast. Two patients presented with anastomotic narrowing three and five months post-repair and responded to antegrade dilatation.

All six patients are doing well in follow-up (3 mths – 18 mths).

Conclusions: The authors continue to evaluate this protocol based on encouraging results in the initial cohort.


   Rare Type II variant of congenital bronchopulmonary foregut malformations (esophageal lung): A case series Top



   Category: Thoracic Long Oral Top


Rujuta Shah, SV Parelkar, BV Sanghvi, RK Gupta, KP Mudkhedkar, DP Makhija, MP Khobragade, S Soundharya

Department of Pediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India.

E-mail: rujutas84@gmail.com

Introduction: Congenital Bronchopulmonary Foregut Malformations (CBPFMs) represent a spectrum of malformations, of which esophageal lung is a very rare variant. Embryologically, it represents a persistent communication between the respiratory and alimentary system due to faulty separation of tracheal and oesophageal tissue during development. Though a handful of case reports have been published so far, due to its rare incidence and lack of a single institution study of a large number of cases, there is no set protocol for the management of CBPFMs. This has given rise to multiple different approaches in management of the same disease entity.

Description: We present a case series of two patients of this rare variant of CBPFM(esophageal lung). One of them was a previously operated Tracheo-oesophageal fistula, managed by thoracotomy and lower lobectomy while the other patient underwent 3-D Thoracoscopic Pneumonectomy. This also marks the second case of thoracoscopic pneumonectomy for CBPFM in an infant and the first using 3D technology, according to a review of literature.


   Sharp foreign bodies of the digestive tract- Tips and tricks for unpredictable trajectories Top



   Category: Thoracic Long Oral Top


Tanvi Goel, Aparajita Mitra

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: aparajita270@gmail.com

Aims: Sharp foreign bodies in the oesophagus and stomach may present as an entirely asymptomatic child with only radiological evidence but require emergent surgical management. Safety pins, razor blades, needles and decorative hair pins are a few of the sharp objects that we have encountered. Many methods and instruments have been used over the years for their removal. This presentation will focus on innovative methods to tackle unique objects lodged in difficult orientations.

Case Report: Index Case 1: One-year old boy with an open safety-pin lodged in the upper esophagus. The technique of removal of the pin by the Kangaroo technique, along-with the mechanics of enpouching the foreign body is described. Index Case 2: Eight years old boy with accidental aspiration of a razor blade. Removed from the trachea by the Kangaroo technique. Index Case 3: A child with accidental ingestion of a metallic hair ornament leading to gastric impalement. Removed with minimally invasive surgery coupled with endoscopy.

Conclusion: The use of the pediatric bronchoscope, specific extraction techniques (“Kangaroo technique”-published data) and the addition of minimal access surgery for dangerous gastric impalement, allow one to address forbidding situations with success and minimal morbidity.


   Assessment of long-term outcomes in males with disorders of sex development Top



   Category: Urology Long Oral Top


Vivek Kumar Singh, Shilpa Sharma, M Bajpai

Department of Pediatric Surgery, Command Hospital (SC), Pune, Maharashtra, India.

E-mail: singhvivec@yahoo.co.in

Abstract: Introduction: DSD patients most of the times present with ambiguous genitalia. There is paucity of data in the literature about long term outcome in DSD patients with male genitoplasty with very few reports from India. Therefore, we investigated the long-term physical, functional and psychosexual outcomes in males with disorders of sex development.

Methods: This is a descriptive observational study on a retrospective cohort conducted at AIIMS, Delhi.

Results: 10 out of 12 (83.33%) patients had 46 XY karyotype. All the patients were comfortable with their sexuality. Most of the patients were satisfied with their voiding. All these patients had expressed heterosexual inclination. 4 out of 12 (33.33%) are sexually active, with 3 of them married and one of them has fathered a child. 7 out of 12 (58.33%) were able to ejaculate sufficient quantity of sample to be analysed. All those patients with sperms had asthenozoospermia. Majority of them had normal hormonal level.

Conclusion: Most DSD patients may have male sexual potential and male sex identity without need of any hormonal therapy, if testicular tissues are preserved. Multidisciplinary team approach involving pediatric surgeons, endocrinologists, geneticist and psychologist are required for appropriate assistance and better management.


   Penile anthropometry in outcome after hypospadias repair: An appraisal Top



   Category: Urology Long Oral Top


Nitin Sharma, M Amin Memon, Shipra Sharma, JL Patel

Department of Pediatric Surgery, DKSPGI and Associated Pt JNM Medical College, Raipur, Chhattishgarh, India.

E-mail: nitinsharma4you@gmail.com

Aims: To compare the outcome in hypospadias with respect to preoperative penile anthropometry.

Materials and Methods: Prospective study between feb2016-sep2017. All underwent TIP urethroplasty. Stent were kept for 10 days and the final outcome was assessed at the time of stent removal or during first OPD visit. Those not giving consent, stent came out before 10 days, requiring staged repair, where measurements could not be taken or outcome could not be recorded were excluded. The penile measurements used were Maximum Glans width(<14mm and >14mm) and urethral plate width(<10mm and >10mm). The outcome parameters considered were Urethrocutaneous fistula, meatal stenosis/neourethral stricture, skin necrosis, wound dehiscence.

Results: 55 of 60 cases operated formed the study group. Mean age at surgery was 4.69 years. Types of hypospadias operated were distal (25/55, 45.5%), mid penile (18/55, 32.7%) and proximal penile hypospadias (12/55, 21.8%) respectively. Urethrocutaneous fistula rates were higher in cases with low gans width(p=0.02) and narrow urethral plate(p=0.03). Meatal stenosis/neourethral stricture was significantly associated in cases with low glans width (p=0.01). Skin necrosis was not associated with the glans width (p=0.9) and urethral plate width(p=0.1).

Conclusion: Penile anthropometry could be used as a guiding factor in predicting the outcome and preoperative patent counseling.


   Effect of preoperative parenteral testosterone on vascularity and lymphocyte infiltration of penile skin and correlation with outcome of urethroplasty in pediatric proximal hypospadias: A randomized controlled study Top



   Category: Urology Long Oral Top


Md Mokarram Ali, Prema Menon, Sailesh Solanki

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: mohdmokarramali1990@gmail.com

Introduction: Severe or proximal hypospadias is associated with paucity of local tissue and small phallus size. Pre-operative androgens have been used to improve the same but there are very few randomized studies on its role in proximal hypospadias.

Aim: To assess the effects of preoperative intramuscular (IM) testosterone on proximal penile hypospadias in terms of morphology, post operative complications and tissue characteristics of penile skin.

Methods: Twenty seven patients of proximal penile hypospadias with or without chordee were prospectively enrolled from June 2017-July 2018 and randomized into study group A (pre operative IM testosterone) and control group B ( no testosterone). Outcomes were analysed in terms of vascularity and lymphocyte infiltration of prepucial skin, penile dimensions and post-operative complications.

Results: Preoperative testosterone caused significant increase in stretched penile length from mean 3.058cm (±0.691) to 3.9 cm (±0.875) [P= 0.002], penile circumference from mean 4.142cm (±0.772) to 4.667cm (±1.174) [P= 0.029] and glans width from mean 1.225cm (±0.245) to 1.750cm (±0.571) [P= 0.002] . There was higher mean vessel density(MVD) in the preputial skin of group A [mean 12.212 (±4.745) blood vessels/ HPF] compared to group B [8.867 (±3.258) blood vessels/HPF] [P= 0.043]. However, fistula formation, meatal stenosis and urethral stricture was higher in group A compared to group B, though statistically not significant.

Conclusion: Preoperative testosterone in proximal hypospadias cause significant changes in penile dimensions and tissue characteristics. However, wound healing complications and fistula formation is noted to be higher after its use.


   Rectus abdominis muscle flap cover instead of pubic approximation in the repair of exstrophy – Epispadias Top



   Category: Urology Long Oral Top


Usha Gajbhiye, Usha Gajbhiye

Department of Pediatric Surgery, Matruchhaya Hospital and RRSH, Amravati, Maharashtra, India.

E-mail: ushagajbhiye@gmail.com

Aim: To assess the efficacy of using the left lower rectus abdominis muscle (RAM) as a vascularised flap cover for repaired exstrophy-epispadias instead of pubic bone approximation (PBA) in providing a sound repair with minimal complications.

Materials and Methods: During the period from 2010 to 2019, 4 cases of primary Exstrophy epispadias complex aged 1 month to one year underwent the RAM flap method of exstrophy Epispadias reapir. All the cases were primary repair which includes of bladder turn in, epispadias repair in males, and mobilization of the RAM flap. No attempt at PBA was done but the RAM flap was turned across the lower abdomen and penopubic area to cover the repaired bladder, bladder neck and penopubic junction.

Results: The outcome in all Four patients were good, that means the bladder was closed well, no dehiscence of the bladder at all, good epispadias repair and bladder capacity is ok , one child has got partial opened epspadias repair.

Conclusion: The RAM technique is an easy technique providing tension free cover to repaired Exstrophy-Epispadias. In our experience the RAM technique has given a more reliable repair than the traditional PBA technique. It also allows safe concomitant reconstructive surgery.


   DSD management - 30 years experience of a single tertiary care centre in North India Top



   Category: Urology Long Oral Top


Ravi Banthia, Priyank Yadav, Sarita Sayal, MS Ansari

Department of Urology, SGPGI, Lucknow, Uttar Pradesh, India.

E-mail: drravivbanthia@gmail.com

Aims: Disorder of sexual development is a major cause of psycho-social anxiety both to patient and parents if not managed properly. Our experience in management of sexual development disorder patients is being presented here.

Methods: We retrospectively reviewed clinical records of all patients with disorder of sexual development managed surgically at our institute in last 30 years between December 1989 and June 2019. Relevant history, clinical examination, investigations and surgical procedures performed were recorded and analysed and results were assessed in terms of cosmetic, functional and psychosocial and sexual outcomes.

Results: A total number of 126 patients were retrospectively analysed.

Age of diagnosis ranged from new born to 32 years. Most common cause of genital ambiguity in our patients was 46 XX DSD. Masculinizing and feminizing genitoplasty was done according to gender of rearing, genital anatomy, and parental choice. among 64 patients diagnosed as 46 X XDSD 54 patients (84.37%) reported satisfactory cosmetic outcome and 48 patients (75.00 %) had satisfactory functional outcome on long term follow-up. Among the 37 patients diagnosed as 46 XY DSD 31 (83 .78 %) patient have reported satisfactory cosmetic outcome and 27 (72.9 %) have reported satisfactory functional outcome. In patients with mixed gonadal dysgenesis and ovotesticular DSD satisfactory cosmetic and functional outcome was seen in 68 % patients.

Conclusion: Managing disorder of sexual development according to gender of rearing, genital anatomy and parental choice mostly carries a good prognosis in terms of cosmetic, functional and psychosocial and sexual outcome.


   Comparison of outcomes in ectopic versus intravesical ureterocoeles Top



   Category: Urology Long Oral Top


Suramya Anand, Vishesh Jain, Sandeep Agarwala, Anjan Dhua, Aparajita Mitra, Divya Murali, Deepak Mittal, Devasenathipathy Kandasamy, Manisha Jana, Rakesh Kumar, Veereshwar Bhatnagar, CS Bal

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: suramya.anand@gmail.com

Aim: To compare treatment outcomes in patients with ectopic ureterocoeles and intravesical ureterocoeles.

Methods: Retrospective study design including patients with ureterocoele treated from January 1992 to June 2018.Demographic profile, presentation, renal function , type of ureterocoele and procedure performed were noted. Categorical data was analysed using Chi-square test.

Results: Forty-seven patients were included , of whom 28 (60%) were males. Four(8.5%) had bilateral ureterocoeles resulting in a total of 51 renal units being studied. Of these 51 units, 16(32%) had ectopic ureterocoele of which 10(63%) were in Duplex system and 6(37%) in single system. Of these 16, nine(56%) underwent heminephrectomy/nephrectomy (5 in Duplex; 4 in single system) either upfront or after cystoscopic decompression. Intravesical ureterocoele was present in 35 renal units(68%) of which 21(60%) were in Duplex and14(40%) in single system. Of these 35, only 2 (5.7%) underwent heminephrectomy/nephrectomy(2 in Duplex ; none in single system). This difference in the incidence of requirement of heminephrectomy/nephrectomy was statistically significant (p<0.001).

Conclusions: Ectopic ureterocoeles are more commonly associated with poorly functioning or non-functioning renal units and more often undergo heminephrectomy/nephrectomy as compared to intravesical ureterocoeles(p<0.001).


   Modified Durham Smith two stage urethroplasty for proximal hypospadias- our experience Top



   Category: Urology Long Oral Top


Ravinder Naik Noonavath, Simmi K Ratan, Shasank Shekhar Panda, Sujoy Neogi

Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: nravindernaik6@gmail.com

Aim/Purpose: To present our experience in modified two stage Durham Smith technique in repair of proximal hypospadias.

Methods: All patients of proximal hypospadias with narrow urethral plate or chordee were included in the study. Durham Smith staged urethroplasty was done in all cases. Thiersch Duplay urethroplasty with both tunica vaginalis and dartos flaps cover was done after 6 months of the primary surgery; catheter removal on 10th post-operative day. All patients underwent weekly urethral calibrations for 3 months after the second stage surgery. These patients were assessed at the time of catheter removal, after 3 months and 6 months in terms of complications and ease of procedure and cosmesis. PPPS (Pediatric Penile Perception Score) score was used to assess the cosmetic outcome.

Results: From May 2016 to December 2018, 35 patients were operated and enrolled for this study. Age range of patients was between 1-11years. Three patients developed fistula at the time of catheter removal; one of them healed spontaneously and other two are waiting for fistula closure. Three patients developed local edema after that resolved spontaneously. Penile torsion and glans dehiscence seen in one patient each; no patient had skin dehiscence. All patients had wide meatus at tip of the glans with good stream. Cosmetic results were very good (score 3).

Conclusion: Our initial experience shows that Durham Smith staged repair is a good technique. It gives good cosmetic results with meatus at the tip of glans and has relatively shorter learning curve.


   Interstitial cells of cajal like cells in children with pelviureteric junction obstruction-the missing link Top



   Category: Urology Long Oral Top


Ruchira Nandan, Vishesh Jain, Sandeep Agarwala, Devendra Yadav, Prasenjit Das

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: ruchira.nandan@gmail.com

Aim: To evaluate the interstitial cells of Cajal-like cells (ICC-LC) in pelviureteric junction obstruction (PUJO) and correlate ICC-LC at distal margin of resected specimen with outcome.

Methods: A prospective study was conducted over a period of 2 years. PUJO patients who underwent Anderson-Hynes pyeloplasty were included in the study group and Wilms tumor patients were included in control group. ICC-LC were semi quantified after staining with c-kit antibodies as follows: score 0: 0-1 ICC-LC; score 1+: 2-5 ICC-LC; score 2+:6-10 ICC-LC and score 3+ : >10 ICC-LC. The number of ICC-LC at PUJ in study group were compared with PUJ of control and resected distal margin of study group. Postoperative outcome was evaluated with USG and RDS at 3 months.

Results: Study group had 37 patients and control group had 13 patients. The density of the ICC-LC at PUJ in study group was lower as compared to that of the control group (p=0.001). The density of ICC-LC was higher at resected margin compared to PUJ in study group (p=0.001). There was no correlation between the ICC-LC grading at resected margin with outcome.

Conclusion: A significant decrease in number of ICC-LC at PUJ in children with PUJO can have a role in etiopathogenesis of disease.


   Modified Jone's approach ensuring safe testicular mobilisation in redo orchiopexy for failed undescended testis Top



   Category: Urology Long Oral Top


Archika Gupta, Archika Gupta, SN Kureel, Kanoujia Sunil

Department of Pediatric Surgery, King George Medical University, Lucknow, Uttar Pradesh, India.

E-mail: drarchika2006@rediffmail.com

Aims: For undescended testis, redo orchiopexy after failed primary orchiopexy poses challenge of preservation of testicular vessels, vas and testis. We report modified Jone's approach in redo orchiopexy enabling preservation of structures yet adequate mobilisation.

Methods: In last five-years, seven failed orchiopexy underwent redo orchiopexy by modified Jone's approach. Access gained via inguinal scar of previous surgery. Testis was trapped in scarred tissue in inguinal canal. External-oblique-aponeurosis was opened above the location of testis. Upper-flap raised to expose conjoint tendon and internal oblique that were split. Exposed peritoneum incised and bowel packed off. Under direct vision of retroperitoneal testicular vessels and vas, peritoneum was incised and raised to mobilise testicular vessels from origin upto testis releasing it off surrounding fibrous adhesions. Mobilised testis placed in scrotum without tension. Layered closure completed.

Outcome measurement; 1) ability to place testis in scrotum without tension and vascular damage, 2) testicular viability on follow-up color-doppler.

Results: In all patients, testes could be placed in scrotum without injury to cord structures. Follow-up color-doppler at six-months revealed viable testis in scrotum in all.

Conclusions: For earlier failed orchiopexy with fibrosis around testis, modified Jone's approach for redo orchiopexy is safe procedure for salvaging of testis.


   Modified Snodgrass urethroplasty with substitution glansplasty: A simple solution to a difficult problem Top



   Category: Urology Long Oral Top


Rohit Kapoor, Archana Puri

Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India.

E-mail: puriarchana@hotmail.com

Aim: Narrow urethral plate and small glans often coexist and pose a formidable therapeutic challenge to hypospadiologists. This study aims to evaluate the outcome of modified Snodgrass urethroplasty with Byar's flap substitution glansplasty in this difficult clinical scenario.

Methods: This is a retrospective analysis of prospectively collected data of 31-patients of hypospadias presenting with preservable narrow urethral plate (≤6mm) and small glans (≤1.4 cm). All of them had undergone modified Snodgrass urethroplasty with wide skeletonization of urethral plate including shiny, hairless penile skin along with Byar's flap substitution skin glansplasty over a period of 42 months (February 2013 to August 2016).Technical details of the procedure will be presented. Meatal position, urethral plate (UP) width, glans size and development of corpus spongiosum were recorded along with complications and final surgical outcome. Based on meatal position, patients were divided into 2 groups: Group I: Distal and mid-penile hypospadias (n: 15) and Group II: Proximal penile hypospadias (n: 16). Data was analyzed using Chi-square test and Student's t test with p<0.05 taken as statistical significance.

Results: Mean age at surgery and follow-up was 45 ± 37.1 and 56.16 ± 12.95 months respectively. Both the groups were comparable as regards age at surgery, glans size, corpus spongiosum and urethral plate width (Median UP group I: 6, Group II: 5 mm). Urethrocutaneous fistulae were observed in three (20%) patients in group I while meatal stenosis was seen in two (12.5%) patients in group II. Overall urethrocutaneous fistula and metal stenosis with this procedure was 9.7 and 6.5% respectively. Three patients had splaying of urinary stream.

Conclusion: Modified Snodgrass urethroplasty with substitution glansplasty is an easy and versatile procedure both for distal and proximal hypospadias. It gives good functional results with nominal complications (<10%).


   Experience with single-staged trans-vestibular foleys-assisted female epispadias repair and bladder neck tightening – Furthering experience with our cohort Top



   Category: Urology Long Oral Top


Kanika Sharma, Minu Bajpai, Prabudh Goel

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: kanika_medico@yahoo.com

Aim: To report the results of single-staged trans-vestibular foleys-assisted female epispadias repair and bladder neck tightening.

Methods: Prospective study based upon 9 patients of female-incontinent-epispadias with patulous bladder neck over the last 4 years. Mean age at surgery 8 years and follow up of 1yr 5months. Observation parameters were urinary continence, dribbling, post void residue(PVR), micturating cystourethrogram, GFR and DMSA.

Results: The surgical technique will be described in detail. The short female epispadiac urethra and coexisting pubic diastasis facilitated the subpubic dissection and easy access to bladder neck. The bladder neck plication and lengthening of urethra provides adequate resistant for continence. The post-operative complications were not significant. Continence status: 8 girls voids with good stream with no dribbling, one patient has intermittent episodes of dribbling, while one is incontinent. Preoperatively vesicoureteric reflux was absent in all cases, however one case had unilateral post-operative reflux after surgery. The upper tracts were well preserved in all cases, except in one where there was pre-operative unilateral scarring. Significant PVR was noted in one patient.

Conclusions: With this single stage perineal procedure, we were able to achieve good post-operative continence, avoid the laparotomy scar and preserve the virginity of the abdominal-domain.


   Dorso-ventral transfer of preputial tube – A novel urethroplasty technique for single-staged fistula-free hypospadias repair Top



   Category: Urology Long Oral Top


Ruchira Nandan, Minu Bajpai, Prabudh Goel

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: ruchira.nandan@gmail.com

Aim: To describe our short-to-mid-term results with the Dorso-Ventral Transfer of Preputial Tube - a novel urethroplasty technique for single-staged fistula-free hypospadias repair.

Methods: Prospective study reporting upon 62 consecutive patients of hypospadias (scrotal n=15, proximal and mid penile n=31 and distal penile n=6) repair with the DVTPT over the last thirty months. Urethroplasty was performed over #6-8 Infant Feeding tube depending upon age. Stent was removed on POD10.

Results: Mean age of patients was 3.5 years (range- 1.8-12.6 years). All patients were operated under general anaesthesia with caudal block (0.25%ropivacaine+morphine). Mean operative time was 2.1 hrs (range 1.5-4.5 hrs). Blood loss was not more than 15 ml in any case.

Complications developing post operatively were urethra-cutaneous fistula (1 of 62; 1.6%), proximal anastomotic narrowing (9 of 62; 14%) of which 6 responded to calibration and 3 required dilatation under anesthesia, meatal stenosis (4 of 62; 6%) and urethral diverticulum. (2 of 62; 3%). Residual chordee and torsion of penis were seen in none of the patients.

Conclusions: DVTPT is applicable over the wide spectrum of hypospadias severity. Although technically demanding, it provides good results with low complication rates. Chordee correction, urethroplasty and correction of penoscrotal transposition can be achieved in a single stage.


   Vesico-ureteral reflux and bladder dysfunction – Does UDS have a role in decision making? Top



   Category: Urology Long Oral Top


Muni Varma, Satish Aggarwal, Aparajita Mitra, Gaurav Singh, Sugandh Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: drmunivarma@gmail.com

Aim: Bladder dysfunction in Primary VUR is a poorly understood component. There is limited data available. The indications for surgery in VUR ( as per standard guidelines) do not include bladder dysfunction in any criteria. We, as a part of an ongoing project, have done UDS in 23 cases of Primary VUR, the data of which will be presented with specific reference to finding any impact of UDS data on decision making.

Methods: Data of UDS done in cases of primary VUR from February,2017 to June,2019 was retrieved. Analysis of 23 UDS studies revealed 2 cases with a low capacity, high pressure bladder. Decision for surgery in both cases was delayed and the patients were put on anti-cholinergics. Five cases were found to have impending myogenic failure due to load of extra urine on the bladder as a result of high grade VUR. Surgery in such cases was advised to prevent further myogenic damage.

Results: Decision making was influenced by UDS data in 7 out of 23 cases.

Conclusion: UDS may have an important role to play in decision making for anti reflux surgery. More experience is required.


   Twenty year experience in management of duplex renal system in children from a single centre Top



   Category: Urology Long Oral Top


KV Satish Kumar, Udaya Samarakkody, Jitoko Cama, Stephen Adams, Sridharan Jayarathnan, Askar Kukkady

Department of Pediatric Surgery, Baptist Hospital, Bengaluru, Karnataka, India.

E-mail: satishpushpa33@gmail.com

Aims: There is no universal consensus on optimal management of duplex renal systems (DRS). This study aimed at various management methods in children presenting with duplex renal systems and assess their outcome.

Methods: This is a 20-year (1996 to 2016) retrospective review of all patients with confirmed DRS presenting to paediatric surgery department at Waikato hospital, New Zealand. Patients with duplex pelvis and in those with follow up less than 6 months were excluded. Following parameters were assessed- Antenatal / Postnatal ultrasound features, Demographics, investigations, surgical procedures, complications and follow up.

Results: Sixty-one patients were confirmed to have DRS and 50 patients were included. 28 (56%) patients were diagnosed antenatally and 22 patients presented symptomatically. 30 (55%) patients needed surgical intervention. Secondary procedures were needed in 4 patients (13.7%).

Conclusions: Surgical intervention was needed in 55 % of patients with DRS who were symptomatic, found to have obstructive features or had high grade Vesico Ureteric Reflux. Obstructing ureterocele of the upper pole moiety and gross reflux involving the lower pole moiety were the commonest indications for surgery. Surgical management provides satisfactory outcome, which may need to be tailored to individual case to preserve renal function and minimize secondary surgical procedures.


   Clinical aspects and management outcome in pediatric biliary calculus disease Top



   Category: GI Short Oral Top


Rajasekhar Addagatla, Anil Taneja, Amita Sen

Department of Pediatric Surgery, RML Hospital, New Delhi, India.

E-mail: rajasekharaddagatla51@gmail.com

Aim: To study the clinical and management aspects of biliary calculus disease (BCD) in children.

Methods: Prospective observational study comprising 26 children with BCD, from February 2018 to April 2019, detailed clinical history was documented, calculated Body mass index (BMI) and screened for hemolysis. Drug induced stones were kept on conservative management, rest were operated by laparoscopy or open technique. Stones were sent for qualitative biochemical analysis.

Results: 26 children were included with age ranging from 2.5 years to 13 years (mean 9.2 years), 9 (34.6%) were females and 17 (65.4%) were males. Risk factors encountered were Ceftriaxone therapy (n=1) and ileal resection (n=1). Children presented with right upper quadrant pain (n=26), Typhoid (n=1), calculus cholecystitis (n=5), and jaundice (n=2). Mean BMI was 13.9 kg/m2 (range 10.4 to 26 kg/m2). All were negative for hemolytic screening. 23 underwent surgery (laparoscopy n=22, open n=1), 3 were converted to open. Pigment (n=14), cholesterol (n=4), and mixed (n=5) were among type of stones.

Conclusion: For pediatric BCD obesity and hemolytic diseases do not seem to be risk factors in Indian scenario where etiology could be idiopathic is our take home message.


   Laparoscopic and robotic management of achalasia cardia: Experience with five cases Top



   Category: GI Short Oral Top


Shaswati Behera, Ravi Prakash Kanojia, Monika Bawa, Sadhna Lal, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: drshaswati67@gmail.com

Aim: Achalasia cardia (AC) is a relatively uncommon condition in pediatric age group. We present our experience with cases of AC treated by MAS including robotics. The technique and outcome are discussed.

Patients and Methods: Their predominant clinical presentation was dysphagia to solids with off and on vomiting. Three patients had severe weight loss. All patients had contrast esophagogram. Esophageal manometery was done in 2 patients. All patients were under long term treatment with pediatric gastroenterologist and underwent multiple esophageal dilatations. Patients underwent laparoscopic/robotic Heller's esophagomyotomy (LHE) with Do'r fundoplication. The patients were followed clinically in post-operative period. A radio nuclide GER scan was done only if the patient was symptomatic for reflux.

Results: 5 patients (3 females) were studied. Mean age 5.5 years. Esophagogram showed bird's beak appearance in all patients. Esophageal manometery was done in 2 patients by treating physician which showed high pressure LES zone and failure of relaxation. First 2 patients underwent LHE. Later 3 patients underwent the same procedure robotically. A long myotomy was done after esophageal mobilization. Post operatively patients tolerated oral feeds from day 2 onwards. Mean follow up duration is 2 years. One patient had intraoperative esophageal perforation during the myotomy. No follow up GER nuclear scan was done as the patients were not clinically symptomatic for reflux.

Conclusion: LHE is ideal for Achalasia cardia. Use of robot further simplifies the procedure. Once effective myotomy is done these patients do well in long term with no requirement for dilatation.


   Primary psarp in the management of high arm: Challenges and outcome Top



   Category: GI Short Oral Top


Nitin Sharma, M Amin Memon, Shipra Sharma

Department of Pediatric Surgery, DKSPGI and Pt JNM Medical College, Raipur, Chhattisgarh, India.

E-mail: nitinsharma4you@gmail.com

Aims: To analyze the outcome in High ARM managed by Primary PSARP.

Methods: Cases from june 2014 to May 2019 were included. Those with no associated anomaly, comorbidity and no spine abnormality were considered. Rectal pack was kept around flatus tube for four days. All the patients were followed up on 15 day, 1 month and 3 monthly till a minimum of 2 years. Those with incomplete follow up and pouch colon were excluded. Outcome was analyzed as immediate outcome in terms of duration of surgery, duration of post operative stay; infection, dehiscence and local excoriation. Long term outcome was analyzed using krickenbeck's criteria.

Results: Forty seven of 69 cases were included. The average age at surgery was 34 hours(Range:24-120 hours). The average duration of surgery was 2.15 hours(Range:1.30-3.15 hour). The average duration of hospital stay was 7 days(Range:5-14 days). Rectourethral fistula was present in 41. Local wound infection was present in 6. Two required diversion. Four required abdominoperineal approach for high pouch. Perineal excoriation was present in 17. Grade1 soiling was present in four. Grade 1 Constipation was present in 6 and grade2 in 2.

Conclusion: Primary PSARP can be offered in High ARM. This has equally good results.


   Martin's modification in the era of two stage Duhamel's pull through: Pros and Cons Top



   Category: GI Short Oral Top


Nidhi Sugandhi, V Himanshu, B Amit, Sameer Acharya, Amit Jadhav, Narinder Teckchandani, Deepak Bagga

Department of Pediatric Surgery, VMMC and Safdarjung Hospital, New Delhi, India.

E-mail: drnidhisugandhi@gmail.com

Aim: Comparison of outcomes of Martin's v Non- Martin's modification in two stage Duhamel pull through for Hirschprung disease (HD).

Materials and Methods: Children undergoing 2 stage Duhamel pull through were randomized into Group I( Martin's modification ) and Group II ( Classical Duhamel). The operative time , immediate and delayed complications were compared.

Results: 30 children (21males and 9 females) underwent 2 stage Duhamel surgery with 15 in each group. The mean operative time was 210 minute in Group I vs 150 minutes in Group II (p<0.05). 5/15 (33%) in group I had wound infection vs 1/15(6.5%) in group II (p<0.05). 2/15(13%) in group I developed small fecal fistula , one of which required formal surgical closure vs none in Group II (p<0.01). 2/15(13%) in Group II had perforation of Hartmann' s stump vs none in Group I (p<0.01). 4/15 (25%) in Group II had persistent constipation , two of whom required revision surgery and two required regular bowel washes(p<0.05).

Conclusion: In two stage Duhamel pull through Martin's modification entails a longer operative time and higher rates of wound infection and fecal fistula. However classical Non- Martin's Duhamel has higher incidence of Hartman's stump perforation and post-operative constipation.


   Antegrade stomal dilator in distal loop – Effective way to localise and facilitate surgery of rectal atresia Top



   Category: GI Short Oral Top


Nidhi Sugandhi, Deepak Bagga, Goutam Chakraborty, Gunjan Shoor, Sameer Acharya, Amit Jadhav, Narinder Teckchandani

Department of Pediatric Surgery, VMMC and Safdarjung Hospital, New Delhi, India.

E-mail: drnidhisugandhi@gmail.com

Aim: Description of technique and outcomes of using antegrade stomal dilator to assist in localizing the atretic segment and anastomosis in surgery for rectal atresia by the posterior saggital (PS) approach.

Materials and Methods: All infants with rectal atresia on colostomy underwent a definitive end to end anastomosis(EEA) by PS approach. Preoperatively, a Hegar's dilator was introduced in the distal stoma leaving it amenable to intra-operative manipulation. Through the PS approach, the anal canal was incised in midline and simultaneously the dilator was pushed down , thus bringing the atretic segment under vision easily without excessive dissection. The blind ending upper segment was then incised and EEA completed circumferentially between the upper and lower segment mucosa under vision. The post operative stricture and continence rates were noted.

Results: 9 children with rectal atresia underwent surgery with the above technique from 2009-2019. The mean length of atretic segment was 2cm and mean distance from the anal verge was 3.5cm. At 6months post surgery, all patients were completely continent and none of them had anastomotic stricture.

Conclusion: In rectal atresia , antegrade stomal dilator is an easy and effective method to localize the upper segment avoiding excessive dissection for its localisation and facilitating safe EEA.


   Surgical intervention in children with foreign body ingestion Top



   Category: GI Short Oral Top


D Swetha, Anil Balraj

Department of Pediatric Surgery, Osmania Medical College, Niloufer Hospital, Hyderabad, Telangana, India.

E-mail: d.swethavarma@gmail.com

Aim: To evaluate and manage cases of foreign body ingestion in children that needed surgical intervention.

Methods: 5 cases of foreign body ingestion in children who presented with either acute abdomen or intestinal obstruction or with history of retained foreign body for prolonged period were admitted and evaluated. All the 5 cases had routine blood investigations done and x-ray abdomen was done.After resuscitation and high risk consent, cases were posted either for elective or emergency surgery.Post-operative management was done.All 5 cases were discharged uneventfully.

Results: All 5 cases with foreign body ingestion were managed appropriately with surgery and discharged.

Conclusion: Not all cases of foreign body ingestion needs surgical intervention but those that need intervention have to be identified promptly and acted accordingly.


   Compare suction rectal biopsy with full thickness rectal biopsy in suspected cases of Hirschsprung's disease Top



   Category: GI Short Oral Top


Shruti Tewari, Rajeev Redkar, C Swathi, Vinod Raj, A Susg

Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India.

E-mail: shruti.t18@gmail.com

Aim: To compare suction rectal biopsy (SRB) with full thickness rectal biopsy (FTRB) in suspected cases of Hirschsprung's disease (HD).

Methods: Between 2014 and 2018, we enrolled 41 consecutive children with suspected HD. Data regarding sex, age and clinical presentation were analysed. All the children had undergone X-ray of abdomen and pelvis and contrast enema (CE). All of them have undergone both SRB and FTRB and their results were compared.

Results: Out of 41 children, 26 were male and 15 females. The Children were aged from 5 days to 12 years of age. Children had delayed passage of meconium, abdominal distension and severe constipation and/or could not be weaned off from laxative treatment. The sensitivity and specificity of SRB is 80.95% and 90.00% respectively. The sensitivity and specificity of FTRB is 100% and 100% respectively.

Conclusion: FTRB is the gold standard test for diagnosing HD. SRB may be a good screening test in suspected HD cases but it is not equal and effective to FTRB for diagnosis of HD.


   Prospective comparative cohort study of operated cases of choledochal cyst underwent hepaticodudenostomy and hepaticojejunostomy Top



   Category: GI Short Oral Top


Murali Krishna Nagendla, Shilpa Sharma, DK Gupta, MC Sharma, Rohan Malick

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: krrishnany@gmail.com

Aim: To compare outcomes of hepaticoduodenostomy and hepaticojejunostomy in children operated for choledochal cyst.

Methods: Prospective comparative study conducted on retrospective cohort of patients who underwent surgery for choledochal cyst between January 2000 and December 2017. All the clinical data regarding post-operative complications and episodes of cholangitis were noted. Patients participated in the study underwent clinical assessment for gastritis, assessment of duodeno-gastric reflux (DGR) by Upper GI endoscopy (UGIE), HIDA scan and antral biopsy.

Results: Total of 38 patients participated in the study. Post-operative leak was present in 15.7% cases of HD. Late complications like stricture, cholangitis was not present in both groups. Symptoms of gastritis present in 52.63% cases of HD and none with HJ. On post-operative HIDA, DGR was present in 78.94% patients of HD group and none with HJ. On UGIE 73.68% of patients had visible gastritis with DGR. Whereas 10.52% cases of HJ had visible gastritis without DGR. All the patients having gastritis on UGIE were confirmed on histopathology.

Conclusion: Easier reconstruction, physiologic drainage, single anastomosis favours HD. However, with evidence of more chances of bile leak, presence of DGR and biliary gastritis, HJ may be favoured. The relevance of subclinical gastritis during a shorter follow up following hepatico-duodenostomy remains subjected to further assessment.


   Appendicitis in preschool children: A clinical challenge Top



   Category: GI Short Oral Top


Abirami Krithiga, Harish Jayaram, Mainak Deb, Jyoti Bothra

Department of Pediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India.

E-mail: drabiramikrithiga@gmail.com

Aim: Appendicitis is the most common surgical abdominal emergency in the pediatric population, but is uncommon in children less than 5 years of age. Aim of this study is to compare the clinical profile, investigations, intraoperative finding, postoperative recovery and incidence of complications in children < 5 years with older children.

Methods: 245 children, between 2015 to 2019 were operated for appendicitis, were retrospectively analyzed. They were divided into two age groups: >5 years (209) and <5 years (36). 36 children less than 5 years comprised 14% of all children with appendicitis in this series. The demographics, hematological, radiological investigations, the intraoperative and postoperative outcomes were documented and compared.

Results: The most common presenting symptoms were pain (196), vomiting (144), fever (87), diarrhea (17),anorexia (14) and shock(4). Parent delay were more in children <5 years of age (17/36) than in older children (24/209). In group 2 laparoscopic appendectomy was performed in 35, open surgery in 1, laparoscopic abcess drainage done in 2 children and a drain was placed in 12. children in group 2 had more complications like appendicular perforation(28), appendicular abcess(2) and longer hospital stay than in group 1.

Conclusion: Although appendicitis is uncommon in this age group, it should be considered in children with lower abdominal pain under the age of 5 years.


   Single-port single-instrument laparoscopic cholecystectomy: Evolving experience of 6 years Top



   Category: GI Short Oral Top


Ankur Bhardwaj, Prabudh Goel, Minu Bajpai

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: ankur.sprout@gmail.com

Aims: To present the technique of single-port single-instrument laparoscopic cholecystectomy (SPSILC) for gall-stone disease and evaluate the learning curve of a single surgeon.

Methods: Prospective study on consecutive children (n=39) who underwent SPSILC for uncomplicated gall-stone disease over a 6-years.

Observation parameters included operating time, blood loss, intra-or-post-operative complications, time to resume soral feeding, duration of hospital stay and final outcomes.

Results: The technique of surgery will be described. Thirty-nine children (M:F=20:19) were included. Mean age at surgery was 10.3 years. Dividing the cohort into two groups of initial 19 and later 20, the mean operating time was observed to decrease from 80 to 72 minutes. There was minimal blood loss (not more than 20 ml in any case). Time to oral feeds decreased from 32 to 24 hours. Duration of hospital stay decreased from 3 days to 2 days. One patient in the latter group developed a bile leak (presented one week after discharge with pain abdomen); was managed conservatively with pigtail drainage.

Conclusion: SPSILC is a simple, easy to learn, cosmetically acceptable technique of cholecystectomy which has a short learning curve and excellent results.


   Ultrasound-guided hydrostatic reduction of intussusception in paediatric age group in a tertiary care centre: A retrospective analysis Top



   Category: GI Short Oral Top


S Soundharya, Sandesh V Parelkar, Beejal V Sanghvi, Rahul K Gupta, Kedar P Mudkhedkar, Rujuta Shah, Deepa Makhija

Department of Pediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India.

E-mail: soundharya.s@gmail.com

Aims: To assess the efficacy of USG-guided Hydrostatic reduction using normal saline in intussusception.

Methods: All patients who had undergone USG guided hydrostatic reduction of intussusception between Jan 2016 to Dec 2018 were enrolled. Patients presenting with symptoms of more than 72 hours, signs of perforation peritonitis, USG abdomen showing free fluid were excluded from the study.Criteria for successful reduction was – 1. Disappearance of target sign 2. Detection of ileocaecal valve 3. Visualization of fluid reflux into distal ileum Number of patients=103, using formula for determination of sample size in an observational cross sectional study.

Results: Study objectives assessed as follows: 1. Assessment of the number of patients who underwent USG-guided reduction successfully, the number of patients who needed multiple trials and the number of patients in whom non-operative management failed. 2. Assessment of duration of symptoms, site of intussusception and length of intussusception and its relation with the success of USG-guided reduction. 3. Assessment of correlation between length and site of intussusception with number of attempts required for reduction. Final outcome was analysed based on the assessment of all parameters like age, sex, length of intussusception, success of reduction, need for surgery, recurrence were studied. Statistical testing was done with SPSS Statistics 23.0.

Conclusion: USG guided hydrostatic reduction is a safe and efficient approach for the management of intussusception.


   Patterns and outcomes of splenic injury from blunt abdominal trauma in children- preliminary experience from the trauma centre of a tertiary care hospital Top



   Category: GI Short Oral Top


Dhruv Mahajan, Prabudh Goel, Anjan Dhua, Minu Bajpai, Rajesh Malhotra

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: 280691dhruv@gmail.com

Aim: Management of splenic injuries in children is not a replication of adult protocols. In the absence of well-developed guidelines in favour of Non operative management(NOM) of splenic injuries in children, the decision has to be customized on case-to-case basis.

To study the role of NOM over Splenectomy in blunt trauma abdomen(BTA) leading to splenic injuries in children.

Materials and Methods: Prospective review of modality of injury, clinical presentation, work-up &amp; management and outcome in children (&lt;14 years of age) after BTA leading to splenic injury (n=20). Parameters studied included mechanism of injury, time of presentation after injury, hemodynamic parameters, radiological findings, associated injuries, average hospital stay and other complications.

Results: Mean delay in presentation after injury: 1.5 hrs (0.5-48 hrs). Trial of NOM was successful in all 20 patients (including n=7, grade IV/V injury).

Difference in average hospital stay between isolated splenic injury (n=3, 4.6 days) and multi-system injury (n=17, 10.7 days) was significant. Chest (n=10; 50%) and liver (n=7; 35%) injuries were commonly associated.

Conclusions: Splenectomy for splenic injuries following blunt abdominal trauma is seldom necessary (irrespective of Grade of injury) in children subject to hemodynamic stability. A larger study is needed to frame guidelines on such management.


   Antroplasty as a definitive procedure for antral stricture and congenital antral web: A case series Top



   Category: GI Short Oral Top


Rupa Banerjee, Gaurav Singh, Muni Varma, Satish K Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: dctrrupa@gmail.com

Aims: We report 2 cases of gastric outlet obstruction due to antral web, one congenital and the other post corrosive. In both these cases antroplasty was performed. Case 1 A 5 year old boy presented with recurrent vomiting, poor oral intake and failure to thrive since birth. He was diagnosed with pyloric stenosis on endoscopy and had been on repeated balloon dilatation for two year without any significant improvement. CECT abdomen showed a possible antral web in addition to a thick pylorus. Endoscopy revealed very narrow opening at the pyloric antrum, scope could not be passed. He underwent laparotomy, antroplasty and pyloroplasty. Post – operative dye study showed passage of dye to the duodenum and jejunum. He is tolerating solid feeds and has gained weight on 3 months follow up. Case 2 A 4 years old boy, a case of gastric outlet obstruction secondary to acid ingestion, underwent FJ as repeated attempts for pyloric dilatation were unsuccessful. After nutritional rehabilitation, dye study revealed antral stricture. After 3 months he underwent laparotomy, antroplasty and Heineke Miculicz pyloroplasty. He tolerated feeds well in 3 months follow up.

Conclusion: We conclude that antroplasty should be the choice of surgery in cases of congenital antral web and antral stricture post corrosive injury.


   Microbial drug resistance and surgical site infections: Experience of a tertiary care centre with paediatric emergency laparotomies Top



   Category: GI Short Oral Top


Rishabh Jain, Mamta Sengar, Chhabi Ranu Gupta, Niyaz A Khan, Parveen Kumar

Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalya, New Delhi, India.

E-mail: rjainngmc@gmail.com

Introduction: Recommended antibiotics in acute surgical gastrointestinal (GI) conditions are a combination of cephalosporins, aminoglycosides and metronidazole. Microbial resistance to these antibiotics might prolong the recovery in these cases.

Aim: To know the incidence and pattern of drug resistance in children who underwent emergency surgeries for infective acute surgical GI conditions.

Methodology: Study type – Retrospective Study Place – Tertiary care Paediatric Surgery Centre

Duration - July 18 to July 19 Patient Profile- Patients that underwent surgery for acute, infective GI conditions and whom culture and sensitivity of peritoneal fluid was done during the same admission.

Results: Significant number of cases had growth of gram negative organisms which were resistant to all drugs except colistin.

Conclusion: Resistance of organisms to first line antimicrobials is exhibiting a rising trend and is a major contributory factor for surgical site infections. Judicious use of antibiotics and adherence to antibiotic policy is recommended to control the rising incidence of antimicrobial drug resistance.


   Minimally invasive management of pancreatic pseudocyst: Tips and tricks in technique Top



   Category: GI Short Oral Top


Gaurav Singh, Rupa Banerjee, Aparajita Mitra, Neeraj Dhamija, Satish Kumar Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: gauravpsurg@gmail.com

Aim: The minimally invasive management of pancreatic pseudocyst is well established in adults. Experience in the paediatric age age group is limited. An insight into technique is discussed here.

Methods: Two girls (ages 7 and 11 years) were evaluated at our institution for recurrent pain abdomen for varying time frames. Both were investigated and found to have large pancreatic pseudocysts as consequences of chronic calcific and acute necrotising pancreatitis respectively.

Both the cases were planned for laparoscopic cystogastrostomy . Three ports (10 mm at umbilicus and 5mm in midclavicular line above the umbilicus on either side. After anterior wall gastrostomy, stapled cystogastrostomy was created between the common wall of stomach and cyst. The collected fluid and debris with the necrotic material were removed. Anterior gastrostomy was closed with PDS 3-0 interrupted. Leak test was negative. Hemostasis was achieved and ports were closed. The older girl required post operative transfusion of albumin in view of low serum protein. Feeds were instituted on post operative day 1. They were discharged on post operative day 3 and 5 respectively.

Conclusion: A few modifications in technique including the use of anterior gastric wall suspension sutures, use of the harmonic scalpel and an endostapler for cystogastrosallowed us to keep port number to minimum. Hence, minimally invasive management of pseudocyst of pancreas ensures early ambulation, least complications and minimal hospital stay.


 Budd-Chiari syndrome More Details in children">   To study the etiology, clinical presentation and the management strategies of Budd-Chiari syndrome in children Top



   Category: Hepatobiliary Short Oral Top


Shruti Tewari, Rajeev Redkar, Vinod Raj, C Swathi, Rahul Sharma, A Sushma, Shirin Joshi

Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India.



E-mail: shruti.t18@gmail.com

Aim: Define selection criteria and evaluate outcome of venoplasty in children with Budd Chiari Syndrome and construct algorithm for management.

Materials and Methods: The patient's age at procedure, liver function tests, complete blood counts, histopathology reports were collected. Management form as open surgical shunt or venoplasty was recorded. Liver biopsy was also done. Data was analyzed with importance to number of hepatic veins blocked, route of venoplasty, anticoagulation protocol used and follow up anticoagulation protocol. Presence or absence of cirrhosis in liver biopsy was noted.

Results: 35 patients were included in study . These were managed with balloon venoplasty initially. It was successful in 20 of them and opened atleast one blocked hepatic vein. Among 35, 14 are alive and symptom free, 10 are deceased while 11 are lost to follow up. Four of them had portosystemic shunt surgeries for failed venoplasty, of them 3 are deceased and one lost to follow up. All patients were put on heparin post venoplasty and then later changed to low molecular weight heparin on follow up.

Conclusion: Early and aggressive use of interventional radiological procedure may achieve successful diagnosis and recanalization in most children. If access for balloon angioplasty is difficult through IJV, it can be aided by transfemoral or transhepatic approach.


   Robot assisted deroofing and excision of contents for a large sub-diaphragmatic hydatid cyst liver Top



   Category: Hepatobiliary Short Oral Top


Rajat Piplani, Manish Kumar Gupta, Sunil Kumar Singh Gaur, Gyanendra

Department of Pediatric Surgery, AIIMS, Rishikesh, Uttarakhand, India.

E-mail: rajatpiplani@yahoo.co.in

An 8 year old boy presented with an asymptomatic progressively increasing hepatomegaly since 5 months. On investigations a large well defined space occupying cystic lesion occupying most of the right lobe of liver in the sub-diaphragmatic location of about 14x12x10cm in size and about 1200cc in volume suggestive of hydatid cyst without calcification. Child underwent Robot assisted followed percutaneous aspiration, injection of scolicidal agent and reaspiration (PAIR) followed by deroofing and excision of laminated membranes. Postoperative period was uneventful. At three months follow up child is asymptomatic and there is no evidence recurrence or residual cyst.


   Laparoscopic “steering wheel” derotation technique for midgut volvulus in children with intestinal malrotation Top



   Category: Laparoscopic Short Oral Top


Vikesh Agrawal, Abhishek Tiwari, VK Raina, H Acharya, D Sharma

Department of Pediatric Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India.

E-mail: drvikeshagrawal@gmail.com

Aims: Since the first description by William Ladd, the Ladd's procedure has been the surgery of choice for the correction of malrotation. Various techniques of the Ladd's procedure have been described but none of them describes the stepwise technique for derotation of volvulus which is the most difficult and confusing part of the surgery. We describe 'steering wheel' technique for easy derotation of volvulus associated with malrotation.

Methods: A total of 62 patients were diagnosed to have an intestinal malrotation between 2010 and 2017. All cases which had complete non-rotation with a midgut volvulus were reviewed. Out of these, 48 patients were operated with open technique and 14 patients were subjected to the laparoscopic correction.

Results: Of 62 patients diagnosed with malrotation, 14 (22.6%) patients underwent the laparoscopic Ladd's procedure. The mean age was 26 + 8 months, mean weight was 10 + 2 kg and included eight males (57%) and six females (43%). There was only one (7.14%) conversion to open technique, due to a huge dilatation of duodenum causing difficulty in dissection in a patient with malrotation without volvulus. The laparoscopic Ladd's procedure took an average time of 70 ± 15 min.

Conclusion: The laparoscopic 'steering wheel' derotation technique is easy and provides a stepwise description of the laparoscopic derotation of volvulus associated with malrotation in children.


   Laparoscopic hybrid pyloromyotomy for infantile hypertrophic pyloric stenosis: A simplified technique Top



   Category: Laparoscopic Short Oral Top


Vikesh Agrawal, Abhishek Tiwari, VK Raina, H Acharya, D Sharma

Department of Pediatric Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India.

E-mail: drvikeshagrawal@gmail.com

Aim: Laparoscopic pyloromyotomy (LP) has become a preferred approach for treatment of infantile hypertrophic pyloric and has advantage of smaller incisions, faster recovery, reduction in wound related complications and better cosmesis. Various laparoscopic knives and spreaders have been used for LP but they do not provide the depth and tissue perception as in open surgery.[4] We describe the laparoscopic hybrid pyloromyotomy[LHP] which makes procedure simple and safe without the requirement of any special instrument.

Methods: This prospective observational study was conducted over a period of 2 years in a tertiary teaching hospital in Central India. All patients with infantile hypertrophic pyloric stenosis diagnosed on the basis of clinical history, examination and ultrasonography (US) were included in the study. Patients with aspiration pneumonia were considered unfit for pneumoperitoneum were excluded from the study.

Results: Twenty five patients underwent laparoscopic hybrid pyloromyotomy [LHP]. Mean age was 50+12 days and mean weight was 2.7+1 kilos. One patient required conversion to standard three port pyloromyotomy due to mucosal perforation while overzealous separation of muscles at duodenal end which was our 3rd case. Mean operative duration was 21+7 minutes. None of the patient developed recurrence and required any redo surgery.

Conclusion: Laparoscopic hybrid pyloromyotomy is a simplified approach which is easy to learn and teach, improves safety and accuracy of the procedure.


   Appendicitis in preschool children: A clinical challenge Top



   Category: Laparoscopy Short Oral Top


Abirami Krithiga, Harish Jayaram, Mainak Deb, Jyoti Bothra

Department of Pediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India.

E-mail: drabiramikrithiga@gmail.com

Aim: Appendicitis is the most common surgical abdominal emergency in the pediatric population, but is rarely considered in children less than 5 years of age.

Methods: In last 5 years 27 children less than 5 years old comprised 2.3% of all children with appendicitis in this series. The most common presenting symptoms were vomiting (27), fever (23), pain (21), anorexia (15), and diarrhea (11). The average duration of symptoms was 3 days, with 4 or more days in 9 children. 14 were initially treated for an upper respiratory tract infection or a urinary tract infection.

Results: Perforated appendicitis was found in all 27 patients. An laparoscopic appendectomy was performed in 23, open surgery in 1, laparoscopic abcess drainage done in 2 children and a RLQ drain was placed in 18.

Conclusion: Perforated appendicitis was found in all children less than 5 years old, resulting in very high morbidity, which may be attributed to the 3–5-day delay in diagnosis. Although appendicitis is uncommon in this age group, it should be considered in the differential diagnosis of children under the age of 5 years who present with the triad of abdominal pain, tenderness, and vomiting.


   Simplified laparoscopic suture rectopexy for idiopathic rectal prolapse in children: Technique and results Top



   Category: Laparoscopy Short Oral Top


Md Imran, Vaibhav Pandey

Department of Paediatric Surgery, IMS, BHU, Varanasi, Uttar Pradesh, India.

E-mail: drimran05@gmail.com

Background: Laparoscopic suture rectopexy is safe and effective treatment option for paediatric rectal prolapse. We performed this study to compare the outcome of modified laparoscopic suture rectopexy (MLSR) versus Classical Laparoscopic suture rectopexy (CLSR).

Materials and Methods: The study was conducted between June 2015 to May 2019 including all the patients with persistent rectal prolapse who underwent surgery managed by either MLSR (Group A) or CLSR (Group B). The groups were compared for constipation, operative time, blood loss, length of stay, postoperative complications.

Results: 19 patients from Group A and 22 patients from group B were evaluated. The mean operative time in Group A was 41.58±6.248minutes which was significantly lesser than Group B with a mean operative time of 78.64±14.24 (p= 0.001). The blood loss was also less in group A compared to Group B (p=0.013). At three months of follow up, the constipation was less in Group A compared to Group B (p=0.041).

Conclusion: The modification makes the procedure technically easy, minimises the chances of complications and retaining all the advantages of suture rectopexy.


   Laparoscopic approach to management of varicocele: A series of four cases Top



   Category: Laparoscopy Short Oral Top


Nitin Vyas, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: nitintg@gmail.com

Aim: Laparoscopic approach to management of varicocele- a series of 4 cases.

Methods: This is a study of 4 male children, all above 10 yrs of age, who presented with swelling and dragging sensation in either scrotum, three on left and one on right side. The average duration of symptoms was 10 days. On examination in standing position, Bag of Worms like appearance was seen near the root of scrotum, with raised local temperature, suggestive of varicocele, which was confirmed on scrotal ultrasound. One case had testicular atrophy. Laparoscopic ligation of testicular vessels was done in all the cases. All patients had uneventful recovery.

Results: All patients did well post-operatively.

Conclusion: Laparoscopic approach to management of varicocele is safe.


   Impalpable undescended testis: Can we avoid the open inguinal exploration altogether? Top



   Category: Laparoscopy Short Oral Top


Biangchwadaka Suchiang, Manish Pathak

Department of Pediatric Surgery, AIIMS, Jodhpur, Rajasthan, India.

E-mail: dbbcc17@gmail.com

During Diagnostic Laparoscopy for impalpable testis, if testicular vessels and vas are found to course into the inguinal canal through the closed ring, recommendations are to go for an open inguinal exploration to look for inguinal testicular tissue. This requires an additional inguinal incision. To avoid inguinal incision, here we describe the technique of laparoscopic exploration of the inguinal canal. Peritoneum around the closed internal inguinal ring is incised to open the deep inguinal ring. Mobilization of the testicular vas and vessels is done all around, without applying any tuck or traction on the cord. After reaching the distal inguinal canal, assistant is asked to gently push the ipsilateral hemiscrotum towards the inguinal canal. This maneuvers helps in delivering the testicular tissue into the abdominal cavity. Depending on the status of the testicular tissue, we can decide whether to preserve the testis or excise the atrophied testis or testicular nubbin.


   Laparoscopic pyelo-ureteric anastomosis of retrocaval ureter Top



   Category: Laparoscopy Short Oral Top


Manasa Reddy, Prema Menon, Shailesh Solanki, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: docmanasareddy@gmail.com

Background: Retrocaval ureter is a rare congenital anomaly of the urinary tract. We present the management of the same in an 8-year girl.

Case Report: An 8-year girl presented with history of vague dull-aching periumbilical pain for one year. There was no fever, vomiting, burning micturition or hematuria. Physical examination was unremarkable. Ultrasonography revealed right hydronephrosis and proximal hydroureter. Blood urea and serum creatinine were 31 mg/dl and 0.44 mg/dl respectively. On CT urography, the right ureter was seen looping behind inferior vena cava with a prominent proximal part and normal distal course. A diagnosis of symptomatic right retrocaval ureter with hydronephrosis was made. There were no other congenital anomalies. Laparoscopic repair was undertaken for the same. After adequate mobilization and precaval transposition of ureter, pyelo-ureteric anastomosis was performed over double J ureteric stent. Post-operative period was uneventful and the child was discharged after 2 days with stent in-situ. The stent was removed after 4 weeks. Currently, the patient is asymptomatic on follow-up.

Conclusion: Laparoscopy is a safe and feasible modality to repair retrocaval ureter.


   New novel method of laparoscopic herniotomy-hernial orificial mobilisation and sealing Top



   Category: Laparoscopy Short Oral Top


TV Sathappan

Department of Pediatric Surgery, Tamilnadu Dr.MGR Medical University, Chennai, Tamil Nadu, India.

E-mail: drtvstnj@gmail.com

Aim: Hernia is the commonest surgical problems in children.Clinically most of the times,it presents as unilateral disease,but readmission for contralateral involvement is quite frequent with lot of displeasure from parents for the unexpected additional expenditure and surgery and unwanted discomfiture for the surgeon.Though laparoscopic method of herniotomy prevents this,the techniques employed such as extra corporeal knotting(SEAL) or intra corporeal knotting with purse string stitch closure or inversion herniotomy are slightly complicated in nature and time consuming.I've devised a novel technique of herniotomy -HOMAS(Hernial Orificial Mobilisation And Sealing) which even the novice in the laparoscopy can perform it easily with minimal time consumption and minimal scarring.

Methods: 3-port technique Camera port-5 mm hidden within umbilicus. Left 3 mm port.Right 5 mm port.Port closure with interrupted buried subcuticular sutures with postoperative Steroid cream application for elimination of the scar.

Age group:Females –all age group including new born

Males-all except infants

Study duration :6 years-2014 to 2019.

Total number of cases: 176

Technique(VIDEO):Internal hernial orifice separated from cord structures for 1-2 cm-the orifice sealed within 1 cm with 100% protection to vas without any lateral thermal effects.

Results: This method helped to recognise contralateral disease in the same sitting in all cases.Bilateral procedure completed within 20 minutes.No recurrence.Scar disappeared after 6 months.

Conclusion: This novel technique of laparoscopic herniotomy of HOMAS can be performed by a novice in laparoscopy with wonderful outcome.


   Sexual assault in children: A major emerging threat in Indian society Top



   Category: Miscellaneous Short Oral Top


Saurav Srivastava, Samir Kant Acharya, Deppak Bagga, Nidhi Sugandhi, Amitkumar Jadhav, Narinder Teckchandani, C Goutam, Anand Dixit, Gunjan Shoor, B Amit, Himanshu, Anjana Sreedharan

Department of Pediatric Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

E-mail: amit5249@yahoo.co.in

Aim: To evaluate initial presentation, treatment and outcome of sexual assault in children.

Materials and Methods: All the referred and primarily admitted cases of sexual assault, from 2014 – 2019 were evaluated. All patients were received in EMR and primary survey followed by secondary survey was done and the injuries noted. The child was stabilized, resuscitated if required and then taken to Emergency OT for Examination under anaesthesia (EUA). All the injuries were noted and appropriate repair of the perineal tear done with covering colostomy if indicated. Colostomy closure was done in the follow up period.

Results: 8 such cases were noted in which all of the accused were either known to or relative of the victim. In 1 case, the accused was the father himself. Out of 8 children, 6 were female and 2 were male. Average age of presentation was 7 years. The entire 8 sexual assault victims needed EUA. Apart from perineal repair/ repair of local tear, 6 out of 8 children all of which were female needed colostomy which was later closed within 3 months. 5 girls had 3° perineal tear, 1girl had 2° perineal tear and 2 boys had anal lacerations. The children were supported with medical and Psychiatric support and appropriate ART cover was given as indicated.

Conclusion: In recent times, sexual assault in children is a major emerging threat in Indian society and such patients should be looked after very well with proper medical, surgical, mental and social support.


   Therapeutic approaches for vascular malformations and their outcome Top



   Category: Miscellaneous Short Oral Top


Rajasekhar Addagatla, Amita Sen

Department of Pediatric Surgery, RML Hospital, New Delhi, India.

E-mail: rajasekharaddagatla51@gmail.com

Aim: To study the outcome of various therapeutic approaches for the management of vascular malformations.

Methods: We restrospectively reviewed 52 patients of vascular anomalies treated with oral Propranolol, intralesional therapy [Sodium tetra decyl sulfate (STD) and Polidocanal (PDCL)] and observation alone from February 2017 to April 2019. Response to therapy was measured in terms of reduction in the size of lesions by clinical examination with serial photographs and by color Doppler initially and 6 months of after starting therapy.

Results: 52 children of age from 1month to 10 years were included [(venolymphatic n=2), (retroperitoneal cavernous hemangioma [RCH] n=1), (liver hemangioma n=2), (infantile hemangioma n=47)]. Treatment was given with oral Propranolol (n=33), intralesional STD (n=2), PDCL (n=3), observation alone (n=13), and direct excision [RCH (n=1)]. Response to therapy was graded into 4 groups. Excellent response [(>80% reduction) n=4], Good response [30-80% reduction), n=30], Minimal response [(upto 30% reduction), n=11], No response [n=6].

Conclusion: Oral Propranolol is safe, non-invasive and effective treatment modality for vascular malformations in children. Grading of clinical response to therapy will guide in planning further management. Propranolol therapy requires 2D echography for cardiological evaluation, hence possible only in tertiary care center is our take home message.


   Morbidity in surgical patients with malnutrition Top



   Category: Miscellaneous Short Oral Top


Ashitha K Unny, Lakshmi Sundararajan

Department of Pediatric Surgery, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India.

E-mail: ashitha.aku@gmail.com

Aims: Nutritional status is an important and independent factor influencing postoperative outcome of elective and emergency surgical procedures. We assessed the influence of nutritional status on postoperative complications in our pediatric surgical patients.

Methods: Retrospective study of surgical patients with poor nutritional status, who underwent elective and emergency surgeries between 2015-2018(4 years) in our hospital was done. Demographic data like age, sex, anthropometric measures like weight and biochemical parameters like hemoglobin, albumin, and electrolytes were collected. Post-operative complications like wound dehiscence, wound infection, respiratory tract infection, sepsis, and need for ICU care and prolonged hospital stay were determined.

Results: 20 patients in the study period were found to be below 10 percentile of body weight. They had high rate of postoperative complications like wound dehiscence (35%), need for ICU care (35%) and sepsis (20%). They also had prolonged hospital stay average of around 2.5 months.

Conclusion: Nutrition status is an important factor determining postoperative outcomes. Hence steps should be taken to optimize nutrition in pediatric children undergoing surgery and close monitoring of biochemical and clinical parameters needed to identify complications in children with malnutrition postoperatively.


   Outcome of antenatally detected abdominal wall malformations Top



   Category: Miscellaneous Short Oral Top


Amit Gupta, Partap Singh Yadav, Vikram Khanna, Manisha Kumar, Subhasis Roy Choudhury, Rajiv Chadha

Department of Pediatric Surgery, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India.

E-mail: amitpedsurgeon@gmail.com

Aim: 1. To study the outcome of antenatally detected abdominal wall malformations managed at same centre. 2. To assess the effect of minimising the co-morbidity inherent to out-born referrals i.e. hypothermia, dehydration, dyselectrolytemia, hypoglycaemia, sepsis and associated congenit al anomalies.

Methods: 15 fetuses with abdominal wall malformation registered at fetal clinic were managed between December 2016 to May 2019. MTP in 3 patients, 1 omphalocele with major cardiac anomaly and 1 gastroschisis. Out of 12 liveborn patients, 1 omphalocele major succumbed to associated cardiac anomaly and rest 11 survived. 8 had gastroschisis - all low birth weight, primary closure in 2 and staged correction in remaining 6 due to large defect (silo/skin flap closure) or associated bowel atresia (n=2). 1 omphalocele minor and 2 hernia of umbilical cord underwent primary closure.

Results: 11/12 liveborn babies survived. The complications during treatment were very less which decreased the hospital stay. This is significantly good outcome in comparison to out-born referrals, especially in gastroschisis.

Conclusion: Counselling at fetal clinic created necessary awareness in parents regarding need for availability of both obstetric and pediatric surgical care in the same hospital to manage such a complicated anomaly. This resulted in a much better outcome.


   Patterns and primary management of perineal injuries in children Top



   Category: Miscellaneous Short Oral Top


Saurav Srivastava, Nidhi Sugandhi, Saurav Srivastav, Anand Dixit, S Anjana, Sameer Acharya, Amit Jadhav, Narinder Teckchanadani, Deepak Bagga

Department of Pediatric Surgery, VMMC and Safdarjung Hospital, New Delhi, India.

E-mail: drnidhisugandhi@gmail.com

Aim: To evaluate the patterns and primary management of perineal injuries in children and assess the adequacy of genital injury score.

Materials and Methods: Prospective review of all cases of perineal injuries in last 1 year. Severity grading was done using Onen's genital injury score.

Results: 29 children ( 20 females and 9 males) presented with perineal injuries resulting from sexual assault (11), RTA (7), fall (8) , and deliberate harm (3). 25 patients underwent EUA and 23 underwent additional surgery. 9/11 ( 90%) of assault patients had grade 3 or higher injuries. Stoma was required in 6/11( 50%) of assault and only 15% ( 3/18 ) of other injuries. Though all patients who required stoma had grade 4 or 5 injuries but major reconstructive procedures were needed in 9 children classified as grade 2/3 injuries .On follow up no patient has any functional or cosmetic deficit.

Conclusion: Increased perineal injuries in children, specially due to assault is a worrying trend. EUA is essential to assess the severity and perform reconstructive procedures. Assault injuries have more severe injuries and are more likely to require colostomy. Existing grading system may underestimate the severity of injury especially due to high impact RTA.


   Antenatally diagnosed neck masses- Prognosis and outcome Top



   Category: Miscellaneous Short Oral Top


Saswati Behera, Monika Bawa, Ravi P Kanojia,Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: drshaswati67@gmail.com

Aim: To study the prognostic markers and outcome of antenatally detected neck masses.

Methods: Antenatally detected neck masses over a period of two years were prospectively studied in terms of nature, laterality, size, and associated anomalies. A regular follow up in the antenatal and postnatal period was done to assess their outcomes.

Results: Seven out of 626 antenatal cases were detected with neck masses. Maternal age of conception was below 30 years in all the cases. First trimester USG showed increased nuchal translucency with cystic hygroma in only 3 cases (42%), second trimester USG was positive in another three (85%). Postnatally, 5 neonates (70%) have been managed with Injection bleomycin and have achieved more than 90% resolution. One patient was lost to follow up and another opted for termination. One patient had associated pericardial effusion, ascites and skin edema and is doing well in the follow up.

Conclusion: Antenatally diagnosed cervical masses are rare anomalies which need close observation during pregnancy. Use of serial high resolution obstetric USG with MRI helps in early diagnosis and proper prognosis. An institutional delivery improves the postnatal care. Majority of the patients respond well to Bleomycin and surgical intervention is usually not needed.


   A study of nutritional status of pediatric surgery patients with stoma and without stoma Top



   Category: Miscellaneous Short Oral Top


Gurmeet Singh, Rahul Kumar Rai, Vipul P Bothara, Akhilesh Kumar, Nitin Pant, Ashish Wakhlu, Jiledar Rawat, SN Kureel

Department of Pediatric Surgery, King George Medical University, Lucknow, Uttar Pradesh, India.

E-mail: gurmeet.dr@gmail.com

Aim: To compare the nutritional status of children with intestinal stomas (ileostomy/colostomy) with those without stomas.

Methods: Case-control study over 14 months duration. Cases (n=60) were pediatric patients < 10 years with stoma (Colostomy/Ileostomy). Controls (n=60) were pediatric surgical patients < 10 years admitted for elective surgery without stoma. Nutritional history (Subjective Global Nutritional Assessment protocol) , Anthropometric assessment (Z score in WHO Anthro ® software), Haemoglobin, Serum Ferritin, Serum Albumin and Serum calcium were assessed.

Results: Cases had a higher incidence of weight loss following stoma formation. Moreover, ileostomy patients had greater weight loss in 2 weeks as compared to colostomy. Nausea, vomiting, anorexia and malnutrition was significantly (p<0.05) higher in cases. Most of the assessed anthropometric parameters were significantly (p<0.05) lower in cases than controls. Hemoglobin, serum albumin, ferritin and calcium were significantly lower in cases than controls. Hemoglobin and serum albumin were lower in patients with ileostomy than colostomy.

Conclusion: In patients with intestinal stomas, nutritional assessment is required to ensure early detection and prompt management of malnutrition of paediatric surgical patients considering malnutrition has adverse effects on tissue healing, surgical outcome and long term growth.


   Knots that can give nightmares-hazards of frequently used tubes and stents Top



   Category: Miscellaneous Short Oral Top


Goutam Chakraborty, Nidhi Sugandhi

Department of Pediatric Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

E-mail: drgoutam83@yahoo.com

Aim: To emphasize on unanticipated complications/morbidities associated with rampant use of different tubes(NG,RT,etc) & simple measures to avert those.

Methods: Case details pertaining to the above mentioned complications were collected.Sequence of events were analysed to point out what may go wrong with frequent use of these tubes.

Case One: 7yrs old child referred to us with corrosive stricture of esophagus.UGI endoscopy f/b RT insertion done in the first hospital.We did dilatation under GA & while attempting removal of the RT,we found remarkable resistance.RT would not come out & it later required gastrotomy and retrieval.

Case Two: 3yrs old child underwent unilateral ureteric re-implantation for intractable VUR.While removing the ureteric stent,it snapped at the parietal level.Later,cystoscopic removal of the retained stent done.

Case Three: 3 months old child of ileostomy closure(K/C/O Ileal duplication cyst on DB stoma) had acute retention of urine on POD 1 for which No.5 IFT introduced as PUC.It could not be removed later.X-ray KUB revealed knotted IFT in UB.Required cystotomy & IFT removal subsequently.

Results: Not applicable.

Conclusion: DO NOT TAKE LIGHTLY-POTENTIALLY MORBID,CAN BE AVOIDED

  1. Judicious use of tubes/stents/drains
  2. Remember the basic-Measure required length of RT,put it,confirm position.Donot push extra.
  3. IFT when used as PUC to be strapped securely externally at the minimum length which drains the bladder.
  4. Tie snuggly inside,secure tightly outside.
  5. Remove as early as possible.



   Utility of involvement of custom-designed smartphone application and other modes of digital technology in the organization of national conference of pediatric surgery Top



   Category: Miscellaneous Short Oral Top


Apoorv Singh, Apoorv Singh, Prabudh Goel, Ajay Verma, Minu Bajpai

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: dr.singhapoorv@gmail.com

Aim: To present our experience with the use of custom-designed smartphone application and other modes of digital technology in the organization of national conference of Pediatric Surgery.

Methods: During the organization and conduct of IAPSCON-2019, the organizers have employed the use of digital technology in the form of a custom-designed smartphone application (IAPSCON-2019), google forms, google cloud, google mail and wix-based web-platform (for creation of a website with online and mobile versions). Our experiences with the novel-GST framework will also be shared.

Results: The experiences with use of digital technology, cost-and-infrastructure-implications, advantages and limitations will be discussed. Suggestions for future conferences will be raised for open contemplation.

Conclusion: Incorporation of advanced forms of digital technology eases out on the organization process. However, setting up the digital platform is a task and coupled with the limitations imposed upon the elderly members of our community, a balance has to be set-up between novelty and tradition.


   Post tracheo-esophageal fistula repair refractory anastomatic site strictures with endoscopic dilation, outcome and alternative managements Top



   Category: Neonatal Short Oral Top


AB Jagadeesh, S Ramesh, M Narendra Babu, Gowri Shankar

Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India.

E-mail: abjagadeesh44@gmail.com

Aim: “To study the outcomes of endoscopic dilation in anastomatic strictures of esophagus after TEF repair”.

Patients and Methods: - Retrospective longitudinal study carried out in tertiary referral hospital from May 2011 to April 2018.

Results: - In the present study - 46/139 (33.09%) developed anastomatic stricture which is significant and comparable with the studies in the literature. The percentage of responders(R) and non-responders(NR) are - 26/46 (56.52%) and 20/46 (43.47%) is noticed in current study respectively. In patients 40/46 (86.95%), required initial onset of upper GI dilatation at age <1year. In majority of non-responder group patients required procedures like Fundoplication – 3/46 (6.52%), Gastrostomy – 4/46 (8.69%) and esophageal replacement – 2/46 (4.34%) over a period of time.

Conclusion: Anastomatic stricture (AS) is the most common morbidity associated with post TEF repair. Defining clear outcome goals will help in the management of strictures. The prompt identification and differentiation between responders and non-responders is required for early alternative and aggressive intervention in later group.


   Ano rectal malformations: Earlier the diagnosis better is the outcome Top



   Category: Neonatal Short Oral Top


Manasa Reddy, Monika Bawa, Ravi P Kanojia, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: docmanasareddy@gmail.com

Aim: - To compare the outcomes of early versus delayed presentation of neonates with Ano-rectal malformations (ARM).

Methods: Prospective observational study over a period of one year on fifty- four neonates with ano-rectal malformations. Patients were grouped into two categories- Group A (n-28) - presented within 48 hours of birth and Group B (n-26) -presented later. Various parameters were compared amongst the two groups.

Results: - No significant difference was noted in the two groups in terms of place of delivery, breast feed attempts, sepsis. However significant difference was observed in terms of abdominal distension (p= 0.05), hours required for resuscitation (18 vs 24), requirement of inotropes (0 vs 5, p= 0.015). Difference was also noted in time taken for stoma to function (6 vs 24 hours, p=0.0001), time taken to start feeds and establish full feeds (p = 0.0001), and wound infection (p= 0.006). Overall morbidity was higher in Gr B.

Conclusion: Delay in diagnosis of ano-rectal malformations affects the results of this otherwise good outcome disease. Medical and paramedical staff working at peripheral centers should not miss on clinical examination of neonate.


   Role of transanastomotic tube feeding in the management of congenital duodenal obstruction in resource- limited nations Top



   Category: Neonatal Short Oral Top


Praveen Jhanwar, Praveen Jhanwar, Rajiv Chadha, Archana Puri

Department of Pediatric Surgery, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India.

E-mail: jhabbuu@gmail.com

Aim: Evaluating the role of Transanastomotic Tube (TAT) feeding in the management of congenital duodenal obstruction in centers lacking facilities for administration of strict Total Parenteral Nutrition (TPN).

Methods: A prospective study was conducted for the period of 18 months. Consecutive cases of congenital duodenal obstruction were included in the study after appropriate consent and explanation. Cases were divided into two groups randomly, Group A was managed with Duodeno-duodenostomy with TAT and Group B includes patient managed with Duodeno-duodenostomy without TAT.

Results: Total 14 cases were included in the study period, 6 in group A and 8 in group B, comparable to each other with reference of gestational age and weight vat presentation. Institution of enteral feeding, need of re-exploration, associated complication outcome were significantly better in group A as compare to group B but difference in time to reach the full enteral feed, start of breast feed and total duration of hospital stay were not found statistically significant.

Conclusion: Study underlines the value of insertion of a TAT during primary surgery to early institution of enteral feeding. In patients in whom TAT was not inserted primarily, its use is even more important if redo-surgery needs to be performed. Insertion of a TAT was not associated with significant complications.


   Mediastinal fore gut cysts in neonates: Challenges in management Top



   Category: Neonatal Short Oral Top


Manasa Reddy Vadhi, Nitin J Peters, Ram Samujh, Sandhya Yadanapuddi

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: docmanasareddy@gmail.com

Aim/Background: Mediastinal cysts presenting with respiratory embarrassment at birth are rare. More and more cases are being diagnosed antenatally. We present series of three cases and discuss the management options.

Materials and Methods: We report a series of 3 cases managed over 2 years from June 2017 to June 2019. The case records were reviewed. We analyzed the antenatal and post-natal presenting symptoms, immediate post-natal management, radiology, intraoperative findings and outcomes.

Results: Out of the three neonates two were antenatally diagnosed as cases of mediastinal cysts. All three patients presented with respiratory distress at birth. Ultrasound and CECT were suggestive of large cystic lesion the mediastinum ranging between 5.2 x 3.3 cms to 2.0x2.5 cms. In view of poor ventilatory compliance and circulatory collapse, all three underwent USG guided aspiration of cyst initially. After initial stabilization, all of them underwent thoracotomy and cyst excision. Two patients were extubated successfully on POD 2 and 3 respectively, however one patient succumbed on POD 6 due to florid gram-negative septicemia. Both patients are stable during follow up over a period of 1-2 years.

Conclusion: Management protocols for neonates with large mediastinal masses depend upon severity of the symptoms, size of the mass & physiological derangements. A staged approach of aspiration followed by definitive surgery is a sound treatment protocol, in cases with respiratory distress.


   Use of vacuum dressings for difficult wound management in neonates and older children Top



   Category: Neonatal Short Oral Top


Kant J Shah, Hema Rane, Anand Rane, Piyush Shah, Alan Perreira, Ratna Sharma, Mamta Manglani

Department of Pediatric Surgery, Cloudnine Hospital, Mumbai, Maharashtra, India.

E-mail: kantshah@gmail.com

Aim: To study the impact of Vacuum dressings on outcomes of complicated wounds in Neonates and Children.

Methods: A retrospective review of prospectively collected data on all children with complicated wounds was done from June 2017 – May 2019.

Results: Five children with complicated wounds were identified, Two neonates with necrotising fasciitis of back and scalp, one child with cellulitis of left arm, two immunocompromised children with leukaemia and aplastic anaemia. All children presented with sepsis and local necrotic wounds. In all children, rapid surgical intervention with once or twice daily debridement was done. When debridement was deemed adequate, vacuum dressings were applied to all the wounds. For neonates the pressure was kept at 50 mm Hg and for older children, 70-80 mmHg pressure was used. The child with aplastic anaemia succumbed to systemic infections before adequate local wound management could be completed. The two neonates and two older children had healthy granulation tissue at the end of first dressing change at 7 days and two needed one more week of vacuum dressing to fill up the defect completely. The plasma loss was minimal and pain was adequately managed with paracetamol. Skin grafting was avoided in all children due to adequate tissue margins available and secondary suturing was done.

Conclusions: Although there are few reports on pressures and duration of vacuum dressings in neonates and children, this method is most suitable for them as it provides a sealed dressing with minimal plasma loss, rapid granulation tissue formation and adequate skin closure.


   Gastroschisis repair using amnion flap: A novel approach compared to conventional management with silo application Top



   Category: Neonatal Short Oral Top


Umesh Bahadur Singh, Tapashya Pandita

Department of Pediatric Surgery, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India.

E-mail: singhub.2008@gmail.com

The most commonly adopted method for management of large sized abdominal wall defects like gastroschisis is silo application that allows gradual reduction in size of the defect followed by delayed closure and subsequent ventral hernia repair. We compared this conventional technique to a novel technique of amnion flap cover in similar group of patients with large gastroschisis defects, not amenable to primary closure. In our experience, the amnion flap cover is a feasible method with better results compared to silo application as it provides a natural and more stable barrier to exposed viscera, allowing better adaptation and growth of abdominal domain to accommodate the exposed viscera.


   Sacrococcygeal teratoma: Retrospective analysis Top



   Category: Surgical Oncology Short Oral Top


Priya Shalini Lakra, KS Basu, K Saha, PK Mishra

Department of Pediatric Surgery, NRS Medical College, Kolkata, West Bengal, India.

E-mail: preahlakra@gmail.com

Aim: To evaluate clinical presentation, histopathology and management of sacrococcygeal teratoma.

Materials and Methods: This is an observational study in which patients diagnosed as sacroccoygeal teratoma were studied in NRS Medical College Kolkata ( the oldest Paediatric surgery center in Eastern India) between June 2017 to June 2019.

Results: Total of 15 patients were studied. Patients were aged between 2days to 5 years. Out of these 6 were male and 9 female. Associated congenital anomalies was seen in one patient. Our findings according to the American Academy of Pediatrics (Altman's) classification, 20% of cases were Type I, 33.33% Type II, 26.66 % of cases Type III and 6.67% were for Type IV. All of them underwent management accordingly.

Conclusion: As sacrococcygeal teratoma has potential to become malignant, meticulous search for the malignant component is required for histopathological categorization and further management. A prenatal diagnosis is essential for reducing morbidity and mortality. Follow-up of patients by clinical examination, ultrasound and tumor markers should be mandatory to look for any recurrence.


   Evaluation and management of a case of bilateral Wilms tumour Top



   Category: Surgical Oncology Short Oral Top


Shruti Tewari, Rajeev Redkar, Preeti Mehta, Vinod Raj, A Sushma, Shirin Joshi

Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India.

E-mail: shruti.t18@gmail.com

Aim: Evaluation and management of a case of bilateral Wilms tumour.

Methods: Fourteen month male patient from Ghana, history of abdominal distension since 9 months of age, diagnosed with bilateral Wilms tumour and brought to India for further management. No gross renal functional anomaly upon evaluation. Renal scan reported non-functioning right kidney with functional renal mass in antero-medial portion of left kidney. CT showed few reactive lymph nodes but no involvement of ureters or bladder, extension into IVC or metastasis to liver and lungs. Diagnosis was Wilms tumour stage five with single partly functioning kidney and preserved renal function.

Results: Pre-operative chemotherapy was given for 12 weeks with Vincristine, Actinomycin and Doxorubicin. Right nephrectomy was followed by 2 cycles of adjuvant chemotherapy. Biopsy reported stromal predominant tumour, no anaplasia and lymph nodes negative for tumour. CT was repeated with 3D reconstruction to delineate the tumour on the left side. Left nephron sparing partial nephrectomy with “ice dam” technique was performed. The second biopsy reported it as classic triphasic Wilms tumour. Currently patient's renal function is preserved and he is on post-operative chemotherapy.

Conclusions: Bilateral Wilms tumour incidence is 10%, mostly presents with metastasis and has syndromic associations. Multi-disciplinary approach is required for treatment as we need to strike a balance between chemotherapy and surgical resection. Preservation of renal function should be kept in mind while deciding the type of surgical technique. Long term follow up is required as need for renal transplant can develop.


   Extensively metastatic adrenocortical tumour- case for the option of “nonintervention” Top



   Category: Surgical Oncology Short Oral Top


Simmi K Ratan, Prashant K Zulpi, Anju Garg, Shasanka Panda, Sachin Bansal

Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: drsimmiratan@gmail.com

Adrenocortical carcinoma is most malignant and rare carcinoma of the adrenal gland with incidence of 1 to 2 per million annually. Here is a 7yr old male child presented with abdominal pain and distention since 1 week with abnormal growth of facial hairs since 2 months. On examination found to have large right sided, firm abdominal mass crossing the midline and extending to the left hypochondriac region measuring around 15cmx11cm. On evalution with CECT abdomen and chest found to have rapidly spreading right sided adrenocortical tumour with bilateral extensive lung metastasis. Child also having cushingoid features, hirsutism and precocious puberty (development of facial hair, pubic hairs and enlargement of genitalia). Child had persistent high blood pressure which was controlled with labetalol infusion. Blood analysis revealed increased levels of adrenocortical hormones (cortisol- 60mic gram/dl, Testosterone – 3400ng/dl). Though surgery is the mainstay of treatment and mitotane is the drug of choice in the event of metastasis. However in the scnerio of extensive lung metastasis the decision was taken against any chemotherapeutic intervention both because of heavy cost of drug and its prominent side effect as leucopenia and also a rapid enlargement of tumour was noted. Extensively metastatized adrenocortical tumour in pediatric age group forms one of the few areas where non treatment may turn out to a better option and requires proper counselling of the parents.


   Papillary carcinoma thyroid in children: Aggressive surgery is the better option Top



   Category: Surgical Oncology Short Oral Top


Manoj Kumar Mohanty, Bikasha Bihary Tripathy, Subrat Kumar Sahho, J Narahari

Department of Pediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.

E-mail: pedsurg_manoj@aiimsbhubaneswar.edu.in

Aims and Objectives: Papillary Thyroid Carcinoma (PTC) in children is a rare and indolent disease. The optimal surgical strategy is not established yet. Aggressive surgery in the form of Total thyroidectomy (TT), with therapeutic comprehensive compartment oriented cervical lymph node di ssection (LND) is challenging in a low volume set up. We prospectively evaluated the local tumor control and postoperative morbidity in this study.

Methods: 2 cases of PTC (11 years male & 10 years female) were considered. Both presented with asymptomatic neck mass without any predisposing factors. The female child was having bilateral multiple palpable cervical lymphadenopathy. USG in both showed multifocal tumor with bilateral cervical lymphadenopathy. FNAB also suggested PTC in both.

Results: We did TT with LND in both cases preserving recurrent laryngeal nerve and parathyroids. Both had uneventful postoperative recovery. Histopathology report confirmed PTC with Lymph Node metastasis. Both were subjected to postoperative radiotherapy and are on regular follow up.

Conclusion: Currently a consensus is emerging that aggressive resection for differentiated thyroid cancer in children is the better surgical option. We have demonstrated that TT, with LND is not only associated with better local control of the tumor but also insignificant postoperative morbidity even in low volume surgical setup.


   Mesenchymal hamartoma of liver: Outcomes of surgical management Top



   Category: Surgical Oncology Short Oral Top


Mehak Sehgal, S Agarwala, M Jana, D Kandasamy, V Jain, A Dhua, P Goel, DK Yadav, M Srinivas, V Bhatnagar, M Bajpai

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: mehak.sehgal91@gmail.com

Aim: To evaluate the presentation, diagnosis, and outcome of surgical management of mesenchymal hamartoma (MH) over 13 years.

Methods: Retrospective analysis of children with a diagnosis of MH from January 2007 to 2019.

Results: Thirteen patients with a diagnosis of MH of liver were included in the study. There were 7 (54%)males and 6 (46%)females. Mean age was 22.8 months(range 15 days to 96 months). While one (8%) was antenatally diagnosed, two (15%) were diagnosed incidentally, remaining 10 (77%) were diagnosed on investigations for abdominal distention. Three (23%) had preoperative respiratory distress and underwent ultrasound guided drainage of the largest cystic space. Right lobe was involved in 92% children. All underwent surgical resection: Non-anatomical in 5 (39%) and anatomical resection in 8 (61%; right hepatectomy in 6 and extended-right hepatectomy in 2). Post-operative complications were observed in 2(15%;bile leak and bleeding in one each). Two children had gross residual lesion after non anatomical resection and one had a recurrence 1 year after surgery. Histopathology was confirmatory of MH in all patients.

Conclusions: Most children with MH present with abdominal distention and liver resection was curative in majority, with recurrence noted only in one (7.6%). The long term outcome is good.


   A Journey from neurology to surgery: Opsoclonus myoclonus ataxia syndrome experiences from a tertiary care center Top



   Category: Surgical Oncology Short Oral Top


Md Mokarram Ali, Nitin J Peters

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: mohdmokarramali1990@gmail.com

Introduction: Opsoclonus-myoclonus ataxia syndrome (OMAS) is a rare entity characterized by irregular and abnormal jerky eye and limb movements with gait imbalance and extreme irritability and behavioral changes. It is seen in children diagnosed with neuroblastoma.

Materials and Methods: This was a retrospective analysis of cases managed in the department over 2.5 years from January 2017-June 2019. The data was analyzed in terms of clinical features, radiology, neurology management, surgical findings, histopathology and outcomes.

Results: A total of four patients with a diagnosis of opsoclonus-myoclonus were admitted over a period of 2 years. The median age at presentation was 21 months. Male to female ratio was 1:1. The duration of symptoms at the time of presentation was in the range of 1-3 months. Opsoclonus and myoclonus were present in all four of them, irritability was present in three and sleep disturbances were present in two of them. On evaluation with imaging (CECT abdomen, PET CT and MRI), they were found to have abdominal neuroblastoma [two left suprarenal, one upper retroperitoneal and one at aortocaval bifurcation region]. After receiving medical management in the form of IVIG, ACTH therapy and chemotherapy, all underwent laparotomy and excision of tumor. Three of these patients received injection ACTH alone, one received IVIG along with ACTH and one received only chemotherapy prior to surgery. Post operatively the symptoms improved and they were discharged in satisfactory condition. surgery, they were discharged in good health. On a one year follow up two patients died due to pneumonia and acute diarrheal disease. Two others are surviving and doing well.

Conclusions: OMAS syndrome is a complex clinical entity and require a multimodality treatment approach. High suspicion is required for diagnosis. Medical management followed by surgical excision is adequate in most patients for resolution of symptoms.


   Pediatric abdominal teratoma at unusual sites Top



   Category: Surgical Oncology Short Oral Top


Sidharth Tyagi, Anjan Dhua, Prabudh Goel,Vishesh Jain, Devendra Yadav, Sandeep Agarwala, Veereshwar Bhatnagar

Department of Pediatric Surgery, All India Institute of Medical sciences, New Delhi, India.

E-mail: docsidharth@gmail.com

Objectives: To highlight three rare cases of abdominal teratoma arising at unusual sites.

Cases Report: Case 1 & 2: Two patients (2 & 2.5-years-old-girls, respectively) presented with abdominal lump since birth. On examination, there was a mobile, globular lump in the upper abdomen in both the patients. Contrast-enhanced CT scan (CECT) of the abdomen showed that the mass was originating from the hepatoduodenal ligament (HDL) with features of fat attenuation and calcification along with cystic areas suggestive of a mature teratoma in both. Serum αFP was normal in both. Excision was performed in both. Case 2 had an intra-operative common bile duct injury but was repaired primarily. Recovery was uneventful in both cases.

Case 3: A 14-year-old girl was found to be having a left adrenal mass during workup for pain in the abdomen. No lump was palpable clinically. CECT confirmed it as a teratoma. Serum αFP was normal. At laparotomy, the tumor was found to be encapsulated with a variegated consistency and arising from the left adrenal. Recovery was uneventful.

Results: In all cases, recovery is uneventful and presently doing well.

Conclusion: Three teratomas arising from unusual abdominal sites are reported. Pre-operative anatomical localization helped achieve an uncomplicated course.


   Gastric teratoma in infants Top



   Category: Surgical Oncology Short Oral Top


Garvita Singh, Satish Kumar Aggarwal, Rupa Banerjee, Gaurav Singh, Muni Varma

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: garvitasingh429@gmail.com

Aims and Objectives: Teratomas are embryonal tumors arising from totipotent cells containing elements from all 3 germ layers (i.e. ectoderm, endoderm and mesoderm). Gastric teratoma, being a rare tumor accounts for <1% of all teratomas in infants. Teratomas growing into the lumen and causing gastro intestinal bleeding are even rarer. we present two such cases who presented with large abdominal mass and GI bleeding.

Case Report:

  1. A 6 weeks old baby boy presented with progressive abdominal distension, black stools and vomiting for one week. clinically there was a large epigastric mass and the child was pale. CT showed large heterogenous complex solid cystic mass invading gastric wall near gastroesophageal junction, and expanding into gastric lumen. He underwent laparotomy, resection of tumor, partial gastrectomy and reconstruction of GE junction by a spiral flap from greater curvature. He recovered well post operatively. Histopathology revealed of grade 2 immature teratoma.
  2. An 8 months old boy presented with black stools, vomiting and fever for 3 months. He had a lump in epigastrium. CT revealed a mass infiltrating lesser curvature of stomach and growing within the lumen. There was a large area of contact with liver ?local infiltration. Upper GI endoscopy showed a bleeding lesion along lesser curvature. Resection of tumor with partial gastrectomy and non-anatomical liver resection was done. Histopathology revealed of immature teratoma.


Conclusion: Gastric teratoma mostly presents as an abdominal mass in children. CECT helps in planning the surgery. Primary objective of surgery is complete resection of tumor. it may require partial gastrectomy and non-anatomical liver resection to deal with local infiltration. Further therapy depends on histology. Both our patients did not require chemotherapy.


   Series of five rare cases of adenocarcinoma colon in children in last 5 years Top



   Category: Surgical Oncology Short Oral Top


Niyaz Ahmed, Chhabi Gupta, Parveen Maan, Mamta Sengar, Rishabh Jain

Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalya, New Delhi, India

Body of abstract (250 words only) Series of Rare 5 cases of adenocarcinoma colon presenting in children.

Aim: To present a series of 5 cases of rare Adenocarcinoma colon in children under 10 years of age.

Introduction: Colorectal carcinoma (CRC) in children, although rarely discovered, comprises approximately 1% of pediatric neoplasms. It is also the most common primary gastrointestinal malignancy in children.Carcinoma of the colon is usually associated with conditions such as familial adenomatous polyposis, and ulcerative colitis. Primary carcinoma of the colon is very rare in children. A series of five children with primary carcinoma of the colon is presented. Methodology: From January 2016 to December 2018, five patients with histopathologically confirmed colorectal carcinoma were treated in the Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya , Delhi. Age, sex, presenting symptoms, location of the primary tumor, serum CEA level, treatment modalities and outcomes were evaluated.

Results: There were four male and one female patients and age ranged from 6.5 to 10.5 years. Rectum(2 patients) and rectosigmoid (3 patients) were the most common primary sites. Serum carcinoembryonic antigen level was obtained in six patients and in only one patient the level was raised markedly (137ng/ml). None of the patients had familial adenomatous polyposis. Histopathologically, poorly differentiated adenocarcinoma was noted in five patients with one signet ring cell type Only one patient was surviving at the last follow up. This is a series of 5 cases from year 2016 to 2018 in which 5 pts of paediatric age group have been diagnosed with adenocarcinoma colon. Out of these 5 cases ,1 patient died due to advanced stage of the disease,2 patients lost to follow up due to limitations of radiotherapy , 2 patients underwent complete course of FOLFOX chemotherapy and are still following up for surveillance .

Discussion: Colorectal tumour is a tumour of older adults ;Its frequency peaks at age 65 years. Because CRC is rare in children and adolescents, it is frequently overlooked in the differential diagnosis of abdominal pain ,weight loss and anemia .Male preponderance is of 2:1 and are usually diagnosed in 2 nd decade of life. Data from surveillance ,Epidemiology suggest that CRC has a similar natural history in younger indiviuals as in adults,However many small series just like this suggest that children are likely to present at a later stage when the disease has advanced unfavourable tumour histology and a poor outcome.


   Acquired tracheo-esophageal fistula in children: Our clinical experience in diagnosis and mangement Top



   Category: Thoracic Short Oral Top


Shreya Krishnamurthy, Rahul Saxena, Manish Pathak, Arvind Sinha

Department of Pediatric Surgery, All India Institue of Medical Sciences, Jodhpur, Rajasthan, India.

E-mail: drrahulsaxena@gmail.com

Aim: To discuss various clinical presentations, diagnosis and management of acquired TEF in children admitted in our institute in last 3 years.

Materials and Methods: Between 2015-2018, 4 patients with acquired TEF were admitted in our institute. In this regard, the aetiology, clinical presentation, initial management, diagnosis of acquired TEF, surgical management and post-operative outcomes were studied.

Results: 4 cases, three girls and one boy with median age of 59 months (range-9-204 months) were included. The presenting symptoms were recurrent coughing on taking feeds (n = 2), persistent vomiting (n=2) and feeding difficulty (n=1) with median duration of 58 days (range 7-180 days). The aetiologies were disc battery ingestion (n = 2), Organophosphorus ingestion and tracheostomy (n = 1) and post-operative complication of Bronchogenic cyst excision(n=1).

Initial management included NG feeds(n=2), Feeding Gastrostomy(n=1) and Feeding Jejunostomy(n=1). Bronchoscopic TEF obliteration was attempted in one patient with fibrin glue but it was not successful.

Diagnosis of TEF was made initially by upper GI study and definitively by esophagoscopy. CECT was done for confirming the location of fistula and preoperative planning. The patients were variously managed: primary repair of TEF (n=3), 2 by cervical approach and 1 by thoracotomy and 1 retrosternal Gastric pull-up was done. Complications included post-operative local abscess, pneumonia, intussusception (n=1).

Conclusion: Acquired TEF is rare in pediatric population with diverse etiology and clinical presentations. We conclude that the definitive surgical management should be individualised to each of these and needs appropriate initial management for better patient care.


   Results of closure of broncho-pleural fistula using muscle flap in children Top



   Category: Thoracic Short Oral Top


K Vinay Kumar, Narendra Babu

Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India.

E-mail: vinaykonammek@gmail.com

Aims: Bronchopleural fistula is a serious complication of several pulmonary and postoperative conditions, as it carries a high morbidity and mortality. It is associated with prolonged hospital stay and high resource consumption. This study evaluates the use of muscle flap to reinforce the bronchus in pediatric patients.

Methods: This was a retrospective study. Nine patients with BPF who underwent muscle flap closure during the operation were studied. IMF and SA muscle flaps were used for the closure of the fistula. Data was collected and analysed on SPSS 2014.

Results: Range of children was from 3-10 years. Six patients had Grade II-III empyema. Two patients had necrotizing lung disease. One of the patients had chronic spontaneous BPF; another had a large lung cyst. Eight patients received IMF and 1 received SA. The mean duration for ICD removal and hospital stay postoperatively was 6+/-1 days and 7 +/- 1 days respectively. There was immediate or early stoppage of air leak after the intervention in 8 children. One child had persistent air leak for 2 weeks. One child had lung collapse due to bronchial obstruction by muscle flap, requiring bronchoscopic trimming of the muscle flap using cautery.

Conclusions: Surgical closure of BPFs with proper vascularized tissues is an effective technique associated with low cost and lower hospital stay.


   Esophageal button battery in the pediatric population: Recent experience from a tertiary care center Top



   Category: Thoracic Short Oral Top


Sachit Anand, Vishesh Jain, Anjan Kumar Dhua, Devendra Kumar Yadav, Sandeep Agarwala

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: kanu.sachit@gmail.com

Objectives: To highlight different patterns of clinical presentation and outcomes in children following button battery ingestion.

Methods: Single center descriptive cohort study (w.e.f. January 2014 to December 2018). All children with button battery ingestion were included. Data pertaining to the circumstances and duration of exposure, grading of injury, complications and outcomes was recorded. Contrast esophagogram was performed for assessing esophageal emptying and detecting sequelae.

Results: Fifty-two children, of whom 60% (31/52) were males,with median age at presentation of 42 (24-66) months were included in the study. Median (IQR) duration of exposure was 10.5 (6-21) hours. Most common source of battery was a remote (50%) and common symptoms at presentation were vomiting and dysphagia. During endoscopy, majority (60%) of the batteries were lodged in the upper esophagus. Grade 3 and grade 2 injury was detected in 59% and 41% cases respectively. Five children developed complications and two (1- tracheoesophageal fistula, 1-aorto-esophageal fistula) of them died. While contrast esophagogram was normal in all survivors, self-limiting symptoms like mild chest pain and cough were observed during follow-up.

Conclusion: Accidental button battery ingestion can be life-threatening. Despite having significant esophageal injury at the time of endoscopic removal, no long-term sequelae (clinical or radiological) were observed in our study.


   Thoracoscopic plication for cases of diaphragmatic eventration in children Top



   Category: Thoracic Short Oral Top


Gurmeet Singh, Rahul Kumar Rai, Gaurav Shandilya, Nitin Pant, Ashish Wakhlu

Department of Pediatric Surgery, King George Medical University, Lucknow, Uttar Pradesh, India.

E-mail: gurmeet.dr@gmail.com

Aim: To present outcome of thoracoscopic repair in children with Eventration of Diaphragm(ED)

Methods: Records of cases of ED repaired thoracoscopically over a period of 10 years were retrieved. Three port technique was used. Plication of diaphragm was done by intracorporal knotting using a single proline suture. The data was analysed with respect to demography, clinico-radiological presentation, operative technique, intraoperative time, operative/ postoperative complications and outcome.

Results: Twenty-four patients, 22 boys and 2 girls. Patients included were neonates (n=8), post neonatal infants (n=12) and more than 1 year (n=4). In 19 cases ED was left sided while it was on the right side in 5 cases. There was no per operative complication and none of our patients required conversion from thoracoscopy to open. Immediate postoperative complication were subcutaneous emphysema (n=1), Hydrothorax (n=1). Patient were discharged on an average 7.5 days (3-22 days) after surgery. Two patients presented with recurrence in follow up. There was no mortality.

Conclusion: - Thoracoscopic plication for repair in cases of ED is feasible and safe in children including neonates. Further prospective study in this regard will substantiate our efforts.


   Short and long-term results of oesophageal replacement with ISO-peristaltic gastric tube Top



   Category: Thoracic Short Oral Top


Suramya Anand, Minu Bajpai, Prabudh Goel

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: suramya.anand@gmail.com

Aim: To assess the long- term outcomes of patients undergoing oesophageal replacement by iso-peristaltic gastric tube(IGT) at our centre.

Materials and Methods: Prospective study n=35(<14 years) with non-existent/damaged oesophagus over last 13 years. Observation parameters: symptoms of reflux, need for oesophageal dilatation and barium swallow studies were documented.

Results: Thirty-five patients underwent oesophageal-replacement [males: 26(74.3%); females: 9(25.7%)]. Etiology: corrosive injury (22/35; 62.9%) and diverted atresia (13/35; 37.1%). IGT was performed in 34/35(97%); one patient has a severe-scarred-stomach. Mean age at surgery: 55-months (11 months-13 years) and mean follow-up: 48-months (3 months to 11 years). Complications: one(2.9%) patient died of respiratory complications, neck-leak(11 of 35; 31.4%) of which 7 (20%) were minor and managed conservatively while 4(11.4%) were major leaks requiring diversion in the form of window oesophagostomy. The oesophagostomy closed spontaneously in 2 of 4 patients. Partial-graft necrosis 1 of 35(2.9%). Dysphagia: 7of 35(20%) patients and reflux related symptoms in 1 (2.9%). The results of cine-esophagogram, oesophageal manometry, 24-hr pH manometry and Tc99 scan will be presented.

Conclusions: Oesophageal replacement remains a major challenge in children. The gastric tube has a reliable blood supply and can bridge long gaps also. Long-term results with IGT at our centre have been encouraging.


   Postnatal management of prenatally diagnosed bilateral pelvi-ureteric junction obstruction Top



   Category: Urology Short Oral Top


Ramesh Babu

Department of Pediatric Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India.

E-mail: drrameshbabu1@gmail.com

Aims: To retrospectively audit our experience of Bilateral pelvi-ureteric junction obstruction (PUJO) over the past 15 years.

Methods: Among patients who were treated for PUJO following antenatal diagnosis, only those with bilateral grade 3-4 PUJO were included. and analyzed.

Results: Between 2003-2018, a total of 1410 patients were evaluated following antenatal hydronephrosis (ANH) and 224 (15%) were diagnosed to have a PUJO. A total of 28 patients (M: F = 26:2) had bilateral PUJO (12% of all PUJO; 2% of all ANH).

Among the 28 patients 6 had bilateral grade 4 hydronephrosis with a palpable mass (group 1); 10 had bilateral grade 4 hydronephrosis without a mass (group 2) and 12 had grade 3/grade 4 hydronephrosis (group 3). All patients in group 1 underwent neonatal intervention (4 bilateral pyeloplasty; 2 unilateral pyeloplasty with contra-lateral stenting). All patients in group 2 underwent unilateral pyeloplasty of worse side first followed by elective contra-lateral pyeloplasty after 2 months. Patients in group 3 underwent unilateral pyeloplasty of the worse side and were followed up with repeat renogram for 2-5 years. 9/12 did not require any intervention while remaining 3 deteriorated on contra-lateral side warranting a pyeloplasty.

Conclusions: 1. Bilateral pyeloplasty is feasible and successful in infants; 2. Contra-lateral improvement is noted following unilateral pyeloplasty in patients with bilateral PUJO. 3. Contra-lateral stenting/nephrostomy can be effective to prevent loss of function in those elected for unilateral pyeloplasty.


   The effect of early upper tract diversion and delayed undiversion on renal function in megaureters secondary to PUV Top



   Category: Urology Short Oral Top


Prathap Somnath, Arun Ajay

Department of Pediatric Surgery, Government Medical College, Kozhikode, Kerala, India.

E-mail: dr.arunajay@gmail.com

Aim: To assess the renal status by evaluation of glomerular filtration rate[GFR] in PUV patients with secondary megaureters presenting in renal failure/urosepsis treated by our institutional protocol(singlecentre study) of early supravesical diversion by Prathap Somnath's partially diverting reduction ureterostomy(PSPDRU) and delayed undiversion. PUV fulguration is generally done in all cases within one month of age and fulguration is completed by 3-6 months of age.

Methods: GFR for each renal unit in patients who underwent PSPDRU is assessed at various stages like prediversion/1week post diversion/3 months post diversion/3 years post diversion and 3 months post undiversion based on their case records.

Results: GFR improved in all cases immediately post diversion. This improvement was maintained until 3 years post diversion. In cases which underwent undiversion GFR has decreased but only slightly and has not deteriorated to the prediversion values.We have observed that this advantage is less or lost if the diversion was delayed.We have also observed that 129 children who underwent 241 such surgeries(PSPDRU) over the last 10 years have shown comparable height and weight for age as of normal children.

Conclusion: Early supravesical(PSPDRU) and delayed undiversion is an effective method to preserve renal function in patients with megaureters secondary to PUV presenting with renal failure/urosepsis.


   Comparison of outcomes between a 2 week and 4 week stenting in pediatric pyeloplasty: A single centre observational study Top



   Category: Urology Short Oral Top


Shankar Raman, Santosh Dey

Department of Pediatric Surgery, Army Hospital, Pune, Maharashtra, India.

E-mail: shankyafmc@yahoo.com

Aim: To compare the surgical outcomes, improvement in renal function and complications between early stent removal (2 weeks) and late stent removal (4weeks) after pediatric open pyeloplasty.

Materials and Methods: A total of 72 open Pyeloplasty were included in the study. 43 underwent late stent removal at 4 weeks (Group1) and 29 underwent early stent removal at 2 weeks( Group 2). Diuretic renography and ultrasonography of kidney, ureter and bladder (USG-KUB) was done in follow up for outcome of surgery. Pre-operative and post-operative follow up data were compared.The complications between the two groups were also compared.

Results: Out of the 72 pyeloplasty, 43 were in Group 1 and 29 in Group 2. Preoperative mean split function in Group 1 was 42%(26-54%) while it was 39%(19-42%), p=0.37 in Group 2. Post operative improvement in drainage pattern was seen in overall 69 out of 72(96%) patients; 41out of 43(95%) in Group 1 and 28 out of 29(97%) in Group 2. Improvement in split function occurred in 35 of 38(97%) in Group 1 and 23 of 26(88%) patients in Group 2, p= 0.51. Overall 91% patients showed improvement in split function. Complication was seen in 9/72(12.5%) patients. Incidence of complication in Group 1 was 7/43(16%) and Group 2 was 2/29(7%), RR= 2.36.

Conclusion: A shorter duration of DJ stenting (2 week) is as effective as a longer stenting period (4 weeks) in terms of surgical success outcomes and improvement in split renal function along with a decreased risk of stent related complications.


   Evaluation of the outcome of pyeloplasty in children with poorly functioning kidneys due to unilateral ureteropelvic junction obstruction Top



   Category: Urology Short Oral Top


Rohit Kapoor, Rajiv Chadha, SR Choudhury

Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India.

E-mail: rohit.kapoor13081988@gmail.com

Aim: To evaluate results of primary pyeloplasty in patients with unilateral ureteropelvic junction obstruction (UPJO) with poorly functioning kidney (SRF of ≤ 20%).

Methods:- Data was collected prospectively for patients operated for unilateral UPJO with poorly function kidney between December 2017 to July 2019. Surgery performed was open AH pyeloplasty with a nephrostomy,,transanastomotic stent and perinephric drain placement. Parameter analysed was postoperative outcome. Success was defined on the basis of Symptomatic improvement.or stabilization in renal function and morphology or increase in SRF(>5%) and improvement in drainage on postoperative diuretic renogram done after 3 months.

Results: A total of 39 patients with mean age 5.47 years (2 months to 13 years) and male to female ratio 9:1 were included in the study. Left to right ratio was 2.25:1. Follow up diuretic renograms were available for 32 patients: 24 showed significant improvement in function and drainage while 8 patients showed very less or no improvement in renal function; of these 3 showed decrease in split renal function however no patient required redo pyeloplasty. 2 patients also developed asymptomatic culture positive UTI requiring no treatment.

Conclusion:- Primary Pyeloplasty gives good intermediate-term results in poorly functioning kidneys in the pediatric age group.


   Appendicular mucosal tube implant with dartos wrap operation for proximal hypospadias Top



   Category: Urology Short Oral Top


Sagar Jawale

Department of Pediatric Surgery, Jawale Institute of Pediatric Surgery, Jalgaon, Maharashtra, India.

E-mail: drsagarjawale@gmail.com

Aims and Objective: To develop a better operation for proximal hypospadias with poor and bad quality urethral plate and damaged urethral plate as in hypospadias cripples.

Materials and Methods: In past 5 years, I operated 21 cases with above technique (group A) and 27 cases were operated with conventional techniques such as extended Snodgross operation and Byar's two stage operation (group B), kept as control. Longest follow up was 5 years and shortst of 1 year.

Technique of operation: Appendicectomy performed without damaging the appendix. The serosa cut longitudinally and stripped off the mucosal tube without creating a breach in it. The mucosal tube scrapped with a blunt scalpel to strip of any remaining part of submucosa and muscularis to keep only mucosal tube. The tube kept in Metronidazole solution for 10 minutes to disinfect it. After degloving the penile skin, the proximal hypospadias opening mobilized for 1 cm and sutured with the appendicular mucosal tube with 6 sutures of 5-0 Vicryl. Dartos fascia is raised from the scrotum and through a hole at proximal opening level the tube is taken out forewards. The Dartos is wrapped over the tube and 8-10 interrupted stitches taken with 5-0 Vicryl. The distal end of the tube is passed through raised glans wings and glanuloplasty performed over it. Skin closed over the penis as usual. Suprapubic diversion done and kept for 3 weeks postoperatively.

Results: In group A, 3 patients developed fistula and only 1(4.76%) required repair at the end of 6 weeks. 2(9.52%) patients developed grade 3 infection and settled with conservative treatment. No patient developed stricture or stenosis. UFR was normal at the end of 6 weeks. In group B, 11 patients developed fistula and 9 (33.33%) required repaired. 9 (33.33%) patients developed strictures and all of them required multiple urethral dilatation under GA. 7 (25.92%) patients developed meatal stenosis.

Discussion: The operation of this kind is reported for first time in medical literature. The appendicular mucosal tube being of same patient does not have graft Vs host reaction. The tube acquires blood supply like a split skin graft. The tube has healthy mucosa, hence does not contract leading to stricture. The Dartos which is a tough tissue acts as Corpus Spongiosum which is absent in these patients. The vascular Dartos fascia neovascularizes the tube rapidly. Group A has results substantially superior to group B.

Conclusion: The operation proves to be a much better option compared to the conventional for the said group of patients. We need a series with longer follow up and larger number of patients.


   Learning curve assessment with pediatric robotic pyeloplasty Top



   Category: Urology Short Oral Top


Rishi Dwivedi, Ravi P Kanojia, Monika Bawa, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: rishi4702@gmail.com

Aim: Robotic pyeloplasty (RP) is a commonly done procedure known to have equitable results with open and laparoscopic pyeloplasty. We present our experience of first 43 cases of Robotic assisted pyeloplasty. Difficulties and handling of DaVinci system with pediatric work space are presented and discussed along with the medium-term outcomes for the operated patients.

Patients and Methods: All pediatric patients undergoing RP were studied. The data recorded were demographic profile, port time, docking time and console time. The end point of success was defined by unobstructed drainage on renal scan and clinical improvement. Dual console DaVinci Si system was used for these procedures.

Results: A total of 43 cases (15 females) were operated between 2017 and recent time. Mean age was 4.12 years (range 2 months to 11 years). One pt was done retroperitoneoscopically. Crossing vessel was present in 4 patients There were 2 conversions to open mainly due to difficulty in, renal pelvis access due to excessive bowel distention. The mean port time for transperitoneal pyeloplasty was 10 min with 9 min docking time. The mean console time for RP was 50 min. The mean hospital stay for RP was 36 hours. There was no mortality. Mean follow up duration was 5 month. All the patients under went EC scan at 3 months or more post-surgery. The scans showed improvement in drainage in 41 patients (95.3%) and no improvement in two who later underwent re-do pyeloplasty. All the patients are in long term follow up at present.

Conclusions: Smaller children pose a considerable challenge for port placement and docking. However once done correctly the DaVinci makes the reconstructive suturing better as compared to same procedure done laparoscopically. The docking time in the beginning was longer due to team learning and this reduced considerably in the latter half of patients.


   Efficacy and safety of supracostal access for percutaneous nephrolithotomy in pediatric patients Top



   Category: Urology Short Oral Top


Ravi Banthia, Priyank Yadav, Sarita Sayal, MS Ansari

Department of Pediatric Surgery, SGPGI, Lucknow, Uttar Pradesh, India.

E-mail: drravivbanthia@gmail.com

Aims: To evaluate the efficacy and safety of supracostal percutaneous nephrolithotomy (PCNL) through the 11th intercostal space and compare it with subcostal PCNL in children with renal calculi.

Methods: Patients younger than 18 years with renal calculi who underwent PCNL were between January 2010 and December 2017 were divided into two groups: supracostal PCNL (group 1) and subcostal PCNL (group 2). Patient characteristics, stone location, stone burden, location of the access points, operative time, postoperative visual pain score, success rate, hospital stay, and complications according to the modified Clavien classification were compared between group 1 and group 2. For statistical analysis, comparison of medians was done using the Mann Whitney U test and the means were compared using t test. Statistical analysis was done using SPSS (version 16.0).

Results: 110 patients underwent PCNL during this period. Group 1 had 50 patients while group 2 had 60 patients. The stone-free rate was 84.0% and 85.0% in groups 1 and 2 respectively after one session of PCNL (p=0.77). After auxiliary procedures, it increased to 96.0% and 96.6% respectively (p=0.98). The mean fall in hematocrit was 0.9% in group 1 and 1.5% in group 2 (p=0.26) whereas the median VAS score was 4 in group 1 and 3 in group 2 (p=0.37). In all, 54 complications were recorded the commonest among which were grade I (81.5%). 29 complications were observed in group 1 while 25 complications were observed in group 2 (p=0.79). One patient developed nephropleural fistula while another patient developed hydropneumothorax. Both belonged to group 1.

Conclusion: Supracostal access for PCNL is an effective and safe alternative to subcostal access for children with renal calculi in terms of stone free rate and complications.


   Complete primary repair for extrophy – An effective and satisfying solution to a complex surgical problem Top



   Category: Urology Short Oral Top


Rajendran, C Saravanan, Aniruthan, V Rohit Gopinath

Department of Pediatric Surgery, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India.

E-mail: velsurgeon@ymail.com

Introduction: Bladder exstrophy is a rare midline defect and exists as part of a larger spectrum of abdominal-pelvic fusion abnormalities, known collectively as the exstrophy-epispadias complex (EEC).

Cases Report: Here we are presenting 8 cases of EEC that we had operated on over a period of 2 years. These child presented to us in the newborn period (age ranging from D1 to D4 of life) and all of them underwent a Complete Primary Repair for Exstrophy within 72 hrs of admission. Preoperative X ray pelvis, USG Abdomen and renal function tests were done. Postoperative Renal function tests were done with a monitoring of the urine output. One child had elevated post op creatinine values which normalised after adequate hydration. One child had an urinary leak from the wound site which settled spontaneously. All 8 children are on follow up and doing well.

Conclusion: Complete primary reconstruction of the Exstrophy bladder is best done in the newborn period in our opinion. Neonatal closure employing this technique optimizes the chance for early bladder cycling and consequent normal bladder development. It may also obviate the need for a multistaged repair of the exstrophy bladder, including further BNR, bladder augmentation, and penile reconstructive surgery. All the 8 children are regular to follow up and have not required any secondary procedures.


   Outcome of initial endoscopic management of ureterocoeles in a tertiary care centre: An experience of 25 years Top



   Category: Urology Short Oral Top


Suramya Anand, Vishesh Jain, Sandeep Agarwala, Anjan Dhua, Aparajita Mitra, Divya Murali, Deepak Mittal, Devasenathipathy Kandasamy, Manisha Jana, Rakesh Kumar, Veereshwar Bhatnagar, CS Bal

Department of Pediatric Surgery, AIIMS, New Delhi, India.

E-mail: suramya.anand@gmail.com

Aim: To assess treatment outcomes in patients with ureterocoele treated at our centre.

Methods: Retrospective study design including patients with ureterocoele registered from 1992 to 2018.Demographic profile, presentation, renal function , type of ureterocoele and procedure performed were noted. Categorical data was analysed using Chi-square test.

Results: Of 47 patients with a median age at presentation of 21 months (range 0.1 to 135 months) 28(60%) were males and 38(81%) were symptomatic. Duplex system was present in 28(60%) children of whom 17(61%) were girls. Three of 28 (11%) patients with Duplex systems were bilateral resulting in a total of 31 renal units studied. Among these 31 renal units, 20(65%) underwent cystoscopic incisions ,of which 8 (40%) required a second procedure (4 reimplantation and 4 heminephrectomy). Out of 19 (40%) single system ureterocoeles,17 (90%) were males with 1 /19 (5%) having bilateral ureterocoele .Cystoscopic incision was performed in 14/20 (70%) and only 1/14(7%) required a second surgery (p=0.024).

Conclusions: Ureterocoeles are more commonly associated with Duplex systems. Duplex system ureterocoeles are more common in females (60% vs 40%) while single system ureterocoeles present primarily in males (90% vs 10%). Duplex systems are more likely to require a second procedure after endoscopic decompression as compared to single system(p=0.024).


   Technical nuances of nephron-sparing-surgery in bilateral Wilms' tumor and its outcome: Experience with five cases Top



   Category: Urology Short Oral Top


Akhilesh Kumar, SN Kureel, Archika Gupta, Anand Pandey, Ashish Wakhlu, JD Rawat

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India.

E-mail: akumarms781@gmail.com

Aims: To report technical nuances of nephron-sparing-surgery enabling maximum tumor-free renal-parenchyma preservation in five patients with synchronous-bilateral Wilms' tumor (BWT)and its outcome.

Methods: In last 10-years, five patients of synchronous-BWT underwent nephron-sparing-surgery after neoadjuvant chemotherapy. Relation of tumor to renal vasculature, collecting system and segmental vessels studied withCT angio. Via large transverse incision, Transperitoneal access gained to both kidney. to Increased safe renal ischemia time obtained via intraoperative cooling with sterile ringer-lactate ice-slursh.Selective renal segmental arteriessupplying tumorwere clamped and ligated without ligating veins near renal capsule leaving demarcation of tumor from normal renal-parenchyma. Nephron-sparing-surgery was performed alongthe line of demarcation leaving tumor-free normal renal-parenchyma. Collecting system and vein bleeders were repaired All patients received postoperative chemotherapy.Outcome measurement;complications, andtumor recurrence at followup.

Results: Nephron-sparing-surgery in nine kidneys and enucleation of tumor in one kidney were safely performedleaving tumor-free parenchyma. There was no urine-leak in postoperative period. None of patients had postoperative oliguria. Tumor recurrence occurred in one patient subsequently died due to chemotherapy-related-complications.

Conclusions: Nephron-sparing-surgery can be performed in BWT with use of intraoperative cooling along with ligation of segmental arteries without any complication.


   Bajpai single port-single instrument- lumboscopy assisted pyeloplasty – Technique and results Top



   Category: Urology Short Oral Top


Prabudh Goel, Minu Bajpai

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: prabudh.aiims@gmail.com

Aims: To present the the technique of Bajpai Single-Port-Single-Instrument Lumboscopy-Assisted-Pyeloplasty (BLAP) through a short video and short-to-mid-term outcomes of the procedure.

Materials and Methods: Prospective study reporting on the results of B.L.A.P. (n=89; M:F= 67:22; mean-age=5.8years, follow-up= 2-46mths). Observation parameters include short-term (surgical time, blood loss, conversion-rate, pain and scar-length) and long-term(relief of obstruction & scar-cosmesis).

Results: Indications for surgery included symptoms (n=63/89; 70.7%), palpable renal lump (n= 23/89; 25.8%) and related to function on renal dynamic scan (n=47/89; 52.8%). Intra-operative: Mean operating-time:69 minutes, average blood-loss:14 ml, no intra-operative complications or mortality; conversion rate:3.4%. Post-operative: Mean hospital stay 3 days (range 2-7 days) and mean scar-length @ 1mth: 16.8 mm. No surgical site infections. Long-term: 52 children completed >1-year follow-up. Redo pyeloplasty required in 1/52 (1.9%) for granulation around PDS suture stump at the neo-PUJ. Drainage in all other confirmed upon renal dynamic scan.

Conclusions: B.L.A.P. is a safe, reproducible and reliable procedure. It harvests the benefits of minimal-access but retains the gold-standard 'Hand-Sewn-Anastomosis-Advantage'. This is a tide-over- over the technical-complexities of laparoscopy with a shorter learning curve & less cost. The results are comparable to open surgery.


   Robotic pyeloplasty Top



   Category: Urology Short Oral Top


Rajat Piplani, Manish Kumar Gupta

Department of Pediatric Surgery, AIIMS, Rishikesh, Uttarakhand, India.

E-mail: rajatpiplani@yahoo.co.in

Robot assisted laparoscopic pyeloplasty is one of the primary robotic surgery that can be performed with ease in children. Use of robot in laparoscopic pyeloplasty has an added advantage of improved resolution and magnification of images, high level of dexterity and range of movements, better accessibility in addition to ergonomic advantage to the surgeon. We present our technique and approach in technically difficult cases of paediatric pelvi-ureteric junction obstruction.


   Glans substitution and frenuloplasty: Technical refinement in hypospadias surgery Top



   Category: Urology Short Oral Top


Satish K Aggarwal, Aparajita Mitra, Rashid Khan

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: dctrrupa@gmail.com

Aims: In hypospadias repair, a tight ventral glans closure often leads to ischemic complications like fistula and dehiscence. The concept of septum glandis and frenulum separating the ventral glans wings has recently been proposed. The conventional ventral glansplasty does not conform to this concept. We used a robust dartos flap with inner foreskin to recreate the glanulo-frenular complex (GFC) simulating normal anatomy.

Materials and Methods: Between January 2010 and May 2019, 340 new cases of hypospadias (age range 6 months to 11 years) were operated. Redo cases and proximal hypospadias were excluded. The degree of glans malformation was estimated by the distance between the glanular hillocks. Glans wings were raised. Urethroplasty was performed by standard TIP technique with a free inner preputial skin graft over the dorsal raw area on incised plate. The GFC was recreated using a pedicled flap of dartos on preputial skin tailored to the dimensions of the defect with dartos providing soft-tissue substitution to the glans and overlying inner prepucial skin replacing the frenulum.

Results: The procedure could be completed in all. Complication rate was 3 % [fistula formation in 5, partial skin necrosis in 2 (healed spontaneously), meatal stenosis in 2 (responded to dilatation)]. Out of five fitulae – two healed spontaneously and 3 required fistula closure. Cosmosis were satisfactory to the parents and the surgeon. Uroflowmetry data from 170 patients (>3 years) showed normal flow patterns in 70%. Follow up ranges from 3 months to 9 years. There has been no case of recurrent chordee or meatal retraction.

Conclusion: This is a useful technique to achieve tension free glansplasty, particularly where the glans anatomy does not allow tension free ventral closure.


   Penile reconstruction with abdominal and scrotal phalloplasty – Cosmesis is function in pediatric age-group Top



   Category: Urology Short Oral Top


Saket Davera, Minu Bajpai, Prabudh Goel

Department of Pediatric Surgery, AIMS, New Delhi, India.

E-mail: docsak.iaf@gmail.com

Aim: To describe techniques of phalloplasty that are devoid of donor site scarring and suitable for urethral inlay and penile prosthesis in subsequent stages in cases of aphallia.

Materials and Methods: Eight patients with various disorders of sex development with 46 XY and severe penile deficiency, including one with complete androgen insensitivity syndrome who was initially raised as female, have been operated using augmentation phalloplasty techniques. Five patients underwent “Bird Winged” lower abdominal skin crease incision phalloplasty and three patients underwent “scrotal” phalloplasty using anterior coronal approach.

Results: The patients' age ranged from 3 to 19 years with preoperative stretched penile lengths between 1 and 2.5 cm. The narrative of an adolescent with 'Locker Room Syndrome' will be presented and 'cosmesis is function' will be justified.With our techniques, phallic sizes between 7.5 and 12.5 cm was achieved leaving the donor site unremarkable with lower abdominal skin crease linear scar and excellent postoperative recovery.

Conclusions: These phalloplasty technique can be utilized as a definitive procedure in many situations of penile insufficiency. Subsequent stages of urethral repair and insertion of penile prosthesis can be easily added.


   Minimal access surgery in complicated diaphragmatic hernias Top



   Category: Video Top


Balamourougane Paramasamy, Balamourougane Paramasamy

Department of Pediatric Surgery, Mehta Children's Hospitals, Chennai, Tamil Nadu, India.

E-mail: bala_sowba@rediffmail.com

Introduction: Herniation of Intestinal contents into the chest occurs commonly through the Posterolateral defect- Bochdalek, but also through the anterior defect- Morgagni or paraesophageal/ Hiatal. Most are detected antenatally and managed in the immediate post natal period. However a small percentage may remain asymptomatic and present later in life. Thoracoscopic management is now the favoured approach for management of CDH in stable select children in the newborn period and for those presenting in later life. Presentation with Obstruction however is not common, We report 3 cases with obstruction/ complication managed by Minimal access Surgery.

Case Report: Case- 1 10 months old child presented with Intermittent colicky pain and on and off non bilious vomiting. Was initially managed conservatively and later an x-ray was done. Suspicious of lop herniating into chest with dilated loops. Diagnostic Laparoscopy done- Showed Left Postero lateral Hernia with Herniation of mid small bowel with obstruction. The hiatus was widened, contents reduced and repaired with Ethibond. Case 2 – 1 ½ year male child presented with irritable cry, desquamative rashes and constipation. USG done showed dilated bowel loops. Subsequent x-ray showed a knuckle of bowel herniating anteriorly into the chest. Laparoscopy done- Morgagni Hernia with obstruction, Loops reduced, sac excised and repair done. Case 3- Anternatally detected CDH with Unfavorable factors- on HFO ventilation, developed Gastric Perforation. Baby deescalated to Conventional ventilation and operated next day- Laparotomy. Closure of gastric perforation and CDH repair done. Baby recovered after a stormy course but found to have a recurrence till mid chest level at discharge. Baby was carefully followed up and underwent Thoracoscopic repair at 8 months age. All 3 babies made an uneventful recovery and doing well on follow up.

Conclusion: Minimal Access Surgery is useful not only in the initial management of Diaphragmatic hernias, but also in complicated ones. Smaller scars, less pain, lower morbidity and good outcome should make them the preferred modality of treatment.


   The long and short of “LUAA” technique for robotic assisted laparoscopic ureteral reimplantation- bilateral Top



   Category: Video Top


Kashish Khanna, Mohammad Mahmoud, Mohan S Gundeti

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: kash.modern@gmail.com

Aim: Robotic assisted laparoscopic ureteral reimplantation(RALUR) is being popularly performed at many pediatric surgical centres. Through this video, we share the step-by-step technical details of the “LUAA” technique for ureteric reimplantation.

Methods: A 4-years-old girl presented with recurrent urinary tract infections in spite of appropriate antibiotic chemoprophylaxis for one year. Her ultrasound showed bilateral hydronephrosis. Her voiding cystourethrogram was suggestive of bilateral vesico-ureteric reflux(VUR) with right grade4 and left grade3 reflux. The DMSA scan showed right side renal scars. For this, she underwent bilateral RALUR by the “LUAA” technique. In this technique, certain steps during detrusorrhaphy have been protocolised- ensuring adequate length(L), securing the ureter at the UVJ by the U stitch(U) taken at the inverted Y limb of the detrusor tunnel, placing the apical alignment stitch for the ureteric tunnel(A) and ensuring adequate ureteric adventitia(A) being taken in alternate bites during continuous suturing for detrusorrhaphy.

Results: The surgery was performed in 150minutes. Patient discharged on Day3.

Conclusion: The “LUAA” technique allows us to follow the critical steps in stepwise fashion. It ensures uniformity and reproducibility of RALUR, especially in bilateral cases of VUR. It will allow us to standardize the procedure of RALUR, especially in the pediatric cases and ensure satisfactory results.


   Endoscopic third ventriculostomy: Our experience in managing hydrocephalus Top



   Category: Video Top


Sarita Chowdhary, SP Sharma, Pranay, Shyamendra, Manoj, Imran

Department of Pediatric Surgery, Institute of Medical Sciences, B.H.U. Varanasi, Uttar Pradesh, India.

E-mail: saritaimsbhu@yahoo.com

Aim: To present the experience of ETV in children less than two years.

Materials and Methods: Paediatric patients present with Congenital Hydrocephalus were included in study.Patients with unfavourable anatomy and etiology were excluded from study.Follow up was done clinically. Dynamic MRI was planned in follow up after 6 months of Surgery.

Results: High ETVSS ( 70 – 90 ) : 4 patients,Moderate ETVSS ( 50-70 ) : 8 patients ,Low ETVSS ( <50 ) : 2 patients.In 2 pts procedure abandoned due non visualisation of mammillary body and septated lateral ventricle ( Low ETVSS Patients).3 patients had CSF leak which resolved on day 7.Only one death occur due to intractable seizures in follow up.

Conclusion: ETV can be used as alternative to MPVP shunt in treating obstructive hydrocephalus. Success with ETV is strongly dependent on surgical experience and preoperative evaluation. Detailed knowledge of third ventricle anatomy, ability to navigate the ventricle using surgical landmarks.However long term follow up need to see cognitive impairment , neurological deficit


   Laparoscopic pancreatectomy in congenital hyperinsulinism in infancy Top



   Category: Video Top


R Rajeswaran, R Velmurugan, C Saravanan, A Anirudhan, V Rohit Gopinath

Department of Pediatric Surgery, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India.

E-mail: dr.rajeswaran@gmail.com

Background: Congenital hyperinsulinism (HI) is a rare derangement of glucose metabolism, which carries an estimated incidence of 1 to 1.4 in 50,000 live births. It causes severe hypoglycaemia and may lead to permanent brain damage to neonates and children. We are presenting 3 cases of HI who failed medical management underwent laparoscopic pancreatectomy for the various types of HI.

Methods: From Jan 2019 to June 2019, we had 3 infants presented with symptoms of seizure and recurrent episodes of hypoglycaemia. Serial blood glucose level found to be < 50 mg/dl. Fasting serum insulin level and Sr C- Peptide level found to be elevated. These 3 children who failed medical management underwent PET- CT (68 Ga Dotanoc scan) found to have 1 focal HI and 2 of them had diffuse HI. Patient with Focal HI neonates were managed with laparoscopic partial pancreatectomy. Patients with diffuse HI managed with laparoscopic near-total pancreatectomy.

Results: All these 3 cases had uneventful postoperative period with average post op hospital stay 1 week. All of them are euglycemic.

Conclusions: CHI is an uncommon diagnosis in the new born period. We have learned that multidisciplinary approach can effectively diagnoses and treat cases of CHI. PET CT plays a vital role in preoperative localisation of CHI. Laparoscopic management is safe, feasible and has reduced morbidity.


   Rare cause of recurrent bloody stools – Diagnostic fallacies in a case of long tubular duplication of intestine Top



   Category: Video Top


Malla Aishwarya, Ashwitha Shenoy, S Kumaravel, J Sree Rekha, P Madhusudhanan

Department of Pediatric Surgery, JIPMER, Puducherry, India.

E-mail: aishwaryamalla61@gmail.com

Aim: To demonstrate video of Wrenn procedure in a case of long tubular duplication (84cms).

Introduction: Enteric duplication, a rare congenital malformation usually presents as Intestinal obstruction, Perforation or Gastrointestinal Bleed.

Methods (Case Report): A 10-month old male child presented with complaints of passing brown stools, Non-bilious Vomiting and fever of 1day. Child had similar complaints about 2months back for which he was treated as acute dysentery. Child was clinically dehydrated, febrile, and pale with Hb of 5.6g/dl with non-contributory Imaging findings. Meckel's scan revealed extensive uptake in left lower half of abdomen. Emergent Laparotomy revealed 84cms long tubular small bowel duplication with a sealed perforation at distal junction. A bowel preserving Wrenn procedure was carried out with resection of perforated site alone (<10cms) with an uneventful postoperative recovery within 5days. Biopsy revealed Ectopic gastric mucosa in the entire Mucosectomy specimen.

Conclusion: “High index of suspicion in bleeding per rectum leads to early diagnosis. Wrenn procedure though technically demanding can be performed safely and save patient from massive gut resections.” This Technically demanding procedure is demonstrated in the video.


   Laparoscopic/robotic handling and excision of large choledochal cyst overcoming the size scare Top



   Category: Video Top


Saalim Nazki, Ravi P Kanojia, Monika Bawa, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: saalim_nazki@yahoo.co.in

Aim: The presented video shows cases of large sized choledochal cyst being managed by laparoscopy and robotics, We aim to present the handling of oversized CDC which is difficult even while doing open excision. The video demonstrates the operative procedure and the technique.

Patients and Methods: A data audit was done for cases operated of CDC either by laparoscopy or robotics. Large CDC was defined by the maximum transverse diameter of CDC compared to the transverse span of liver. A value >40% was taken as large and the videos were included. These patients were operated by 4 ports in laparoscopic and 5 ports in robotic methods. The patients underwent excision and hepatico-duodenostomy.

Results: A total of 3 patients were included which met the above mentioned criteria. The age was 4,10 and 12 years. Complete excision of cyst was achieved in all the 3 patients. One patient was operated robotically.

Conclusion: Large sized CDC are technical difficult to be taken for minimal access surgery and most of the time the surgeon will have the clinical dilemma of inclining towards open surgery in view of bleeding and time taken for surgery. The presented video shows that excision of such large cysts can be done by laparoscopy and similar results to open can be achieved.


   Robot assisted resection and hand-sewn anastomosis for Meckel's diverticulum Top



   Category: Video Top


Kant J Shah, Hiren Doshi, Vivek Venkat

Department of Pediatric Surgery, Nanavati Hospital, Mumbai, Maharashtra, India.

E-mail: kantshah@gmail.com

Introduction: Less than 35% children undergo complete laparoscopic surgery for Meckel's as per large data sets such as NSQIP-Ped. In these cases, almost all being older children, use of staplers may cause artificial 'U' bend or 'S' shaped anastomosis or only diverticulectomy is done without segmental resection.

Aim: To study the outcomes of a child with Meckel's diverticulum and bleeding per rectum in whom a Robot assisted hand-sewn anastomosis was done.

Methods: Prospective data was kept for intraoperative duration, technique and time to discharge.

Results: A one year old child with profuse, painless rectal bleeding was diagnosed to have a Meckel's diverticulum on a Meckel's scan. The child underwent a robotic assisted resection of intestine about 2 cms each side of the Meckel's. A hand sewn anastomosis was made using 5-0 PDS in a single layer extra-mucosal interrupted fashion. The total operative time was 4 hours and the child was discharged on day 6 after surgery. The chld remains well 3 months after surgery.

Conslusion: Use of robot assistance enables us to preserve all the principles of open surgery by completing a segmental resection and a hand sewn anastomosis in a small child even at one year of age.


   Laparoscopic pyelo-ureteric anastomosis of retrocaval ureter Top



   Category: Video Top


Manasa Reddy, Prema Menon, Shailesh Solanki, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India.

E-mail: docmanasareddy@gmail.com

Background: Retrocaval ureter is a rare congenital anomaly of the urinary tract. We present the management of the same in an 8-year girl.

Case Report: An 8-year girl presented with history of vague dull-aching periumbilical pain for one year. There was no fever, vomiting, burning micturition or hematuria. Physical examination was unremarkable. Ultrasonography revealed right hydronephrosis and proximal hydroureter. Blood urea and serum creatinine were 31 mg/dl and 0.44 mg/dl respectively. On CT urography, the right ureter was seen looping behind inferior vena cava with a prominent proximal part and normal distal course. A diagnosis of symptomatic right retrocaval ureter with hydronephrosis was made. There were no other congenital anomalies. Laparoscopic repair was undertaken for the same. After adequate mobilization and precaval transposition of ureter, pyelo-ureteric anastomosis was performed over double J ureteric stent. Post-operative period was uneventful and the child was discharged after 2 days with stent in-situ. The stent was removed after 4 weeks. Currently, the patient is asymptomatic on follow-up.

Conclusion: Laparoscopy is a safe and feasible modality to repair retrocaval ureter.


   Mature extragastric teratoma of lesser curvature in an adolescence: A difficult surgical workout Top



   Category: GI Prime Poster Top


Sunita Singh, Sunita Singh, Debajyoti Mohanty, Niraj Kumar Srivastava, Hemlata Panwar

Department of Pediatric Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India.

E-mail: drsunitasingh28@gmail.com

Background: We discussed a mature extragastric teratoma of lesser sac with surgical difficulties.

Case Report: An eighteen-year-old male presented with early satiety, post parandial pain with occasional black stools. A nontender, immobile, ill defined, hard, lump (sixed 5x5 cm ) was palpable in epigatrium. There were no history of vomiting, hemoptesis, fever. Both testes were normal.

USG and Contrast enhanced CT abdomen revealed a 14x8x7 cm, heterogeneous mass with gross calcification extending on both sides of the midline and loss of plane between tumor and pancreas. Alfa feto protein and CA 19.9 were normal.

Exploratory laparotomy showed a lessor sac well-encapsulated glistening white wall, partially cystic, tumor, pushing gall bladder in right and lesser curvature of stomach in left. With best possible efforts clear plane of dissection between tumor, portal structures, celiac trunk and pancreas couldn't be found. The tumor was removed in pieces. After excision rent identified at lesser curvature at gastroesophageal junction, was closed. Post operatively patient had controlled enteric fistula. After 15 days fistula output become nill and patient discharged. Histopathology of specimen was suggestive of immature gastric teratoma.

Results: In three years of follow up (six monthly AFP and USG) no recurrence.

Conclusion: Gastric teratoma in a teenager male should kept in the differential diagnosis of a mass within the lesser sac. Piecemeal excision of mass can be an option if difficult asses.


   Use of single-photon emission computerized tomography scan with scintigraphy in child to diagnose a rare cause of severe gastrointestinal bleed (jejunal hemangioma) Top



   Category: GI Prime Poster Top


Sunita Singh, Sunita Singh, Nitin Borkar, Mudalsha Ravina, Karan Peepre, Abhimanyu Varshney, Rohit Meshram

Department of Pediatric Surgery, AIIMS, Raipur, Chhattisgarh, India.

E-mail: drsunitasingh28@gmail.com

Aim: To highlight the rare but important cause (jejunal hemangioma) of gastrointestinal bleeding in children. We diagnosed vascular lesion in jejunum via Tc-99m pertechnetate scan with single-photon emission computerized tomography-computed tomography (SPECT).

Methods: A 9-yrs- old boy presented with recurrent gastrointestinal bleeding, and severe anemia, needed repeated blood transfusion. On Tc-99m pertechnetate scintigraphy (Meckel's Scan) dynamic and static images depicted tracer accumulation in right hypochondrium changing position, suggestive of its small bowel origin. Technetium accumulates in areas of increased perfusion or hyperaemia. Added on scintigraphy was SPECT with low dose CT, which localized tracer focus in jejunal loops. These findings suggested a possible vascular lesion in proximal small bowel.

Results: The diagnostic laparoscopy showed jejunal hemangioma involving 15 cm of jejunum (about 5 cm distal to Duodeno-jejunal junction). Their was no Meckel's diverticula. Mini-laparotomy done. The feeder vessels was identified, ligated, and cut with resection anastomosis of involved jejunum. Patient improved and discharged on 7th day. One year of follow up is uneventful till date.

Conclusion: Visceral vascular anomalies have always posed a diagnostic challenge in the paediatric population. The diagnostic investigations of GI hemangioma are scintigraphy, computed tomography, magnetic resonance imaging, angiography, abdominal ultrasonography and esophago-gastroduodenoscopy /or colonoscopy. During suspicious results of scintigraphy, SPECT with low dose CT can identified these rare vascular anomalies.


   Morgagni – Larrey hernia: A rare case report Top



   Category: GI Prime Poster Top


Vivek Kumar Singh, V Shankar Raman, SK Dey, KK Arunjeet

Department of Pediatric Surgery, Command Hospital (SC), Pune, Maharashtra, India.

E-mail: singhvivec@yahoo.co.in

Introduction: Morgagni hernias(MH) comprises of only 3-5% of cases of diaphragm hernia(1). Morgagni Hernia is a defect in the retrosternal region of the diaphragm and is hypothesised to occur due to failure of fusion of the pleuroperitoneal membrane and developmental deficiency of muscularization. MH is more commonly observed in older children or adults with vague and nonspecific presentation of respiratory or gastrointestinal symptoms.. In this study we aim to share our experience with 2 cases of Morgagni hernia, its presentation and challenges faced.

Case Report: We are presenting 2 cases of Morgagni hernia aged 7 year and 6 months, with history of recurrent chest infections. Patients were evaluated with chest X ray followed by CECT chest which revealed right anterior diaphragmatic defect with liver, gall bladder and hepatic flexure as content in first child and transverse colon causing compression of Rt lower lobe and mediastinal shift to left side in second child. Both patients underwent open abdominal repair of Morgagni hernia with interrupted prolene sutures. They had uneventful post op recovery.

Discussion: Asymptomatic patients and late presentation of Morgagni-Larrey hernia makes it evade from diagnosis. Surgery is the treatment of choice with increasing trend towards laparoscopic and minimally invasive surgeries.


   Enteric cyst of the transverse colon in a 5-year-old child, a rare variant of mesenteric cyst: A case report Top



   Category: GI Prime Poster Top


Mishal S Patel, Sudhir Chandana

Department of Pediatric Surgery, SVPIMSR, Ahmedabad, Gujarat, India.

E-mail: contactmishal@gmail.com

A 5 year old male child with abdominal lump was admitted. Palpation revealed a tense cystic lump in the abdomen extending from the epigastrium upto the hypogastrium. USG was suggestive of a multiloculated heterogenous cystic collection. CT scan was suggestive of a fluid density lesion with peripherally enhancing wall with septations arising from the peritoneal lining most likely lymphangioma. At laparotomy, an approx 20x15x10 cms cyst was found adherent to gall bladder, duodenum, greater curvature of stomach and transverse colon arising from the transverse mesocolon.On incising it, brown gelatinous fluid was evacuated with multiple septations visible with a connection visible with the right transverse colon.Entire cyst with the involved colon was resected and an end to end ascending-left transverse anastomosis was done. Histological examination revealed infected mesenteric cyst lined by cuboidal cells with attached large intestine tissue with serositis. The lining wasn't mucosal hence ruling out duplicaton cysts. 60% mesenteric cysts are located in small bowel mesentery, 24% in large bowel mesentery, of which the sigmoid colon is most common. Enteric origin mesenteric cysts arising from transverse mesocolon are a rare.


   Giant chylolymphatic cyst presenting as midgut volvulus in a toddler Top



   Category: GI Prime Poster Top


R Narang, A Radhakrishnan, SS Panda, S Neogi, SK Ratan

Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: raghavnarang1601@yahoo.com

Aims: We present a case report of a 3 year old male with acute intestinal obstruction. Giant chylolymphatic cyst was noted intra operatively which was completely excised.

Methods: A 3 year old male child with complaints of multiple episodes of bilious vomiting and acute abdominal pain.On examination, the child had palpable bowel loops in the upper abdomen.An abdominal roentgenogram revealed dilated bowel loops with paucity of distal bowel gas. Ultrasound with colour doppler abdomen revealed grossly dilated bowel loops with a central whirlpool sign with echogenic ascites. Intra operatively, there was a large dumb bell shaped cyston either side of the jejunum around 60cm distal to DJ flexure.The entire cyst, along with the involved mesentery and segment of jejunum was resected and end-end jejuno-jejunal anastomosis was done.

Results: The entire specimen weighed 1950 grams. Histopathological examination revealed features of chylolymphatic cyst.

Conclusion: Chylolymphatic cysts, although rare, must be kept in mind when evaluating children with intestinal obstruction. Their clinical presentation may vary from chronic non-specific abdominal complaints to acute intestinal obstruction with or without clinically palpable lump per abdomen.


   Megacystis-microcolon-intestinal hypoperistalsis syndrome: A rare case Top



   Category: GI Prime Poster Top


Saurabh Tiwari, Pratik Raut, Paras Kothari, Shalika Jayaswal, Abhaya Gupta, Vishesh Dikshit, Geeta Kekre

Department of Pediatric Surgery, L.T.M.M.C and L.T.M.G Hospital, Mumbai, Maharashtra, India.

E-mail: 12saurabh@gmail.com

Aims: Megacystis Microcolon Intestinal Hypoperistalsis Syndrome (MMIHS) is a quite rare congenital and is often underdiagnosed and confused with other disorders. The clinicians priority is to be make a correct diagnosis.

Methods: 3 day old female child was brought with c/o not passed meconium since birth

with abdominal distension Antenatal scan at 29 weeks revealed 7.4 * 6.1 cm pelvic cystic lesion with over distended bladder with bilateral hydroureteronephrosis. Abdomen was moderately distended with lower abdomen fullness. Normal anal opening present.

Results: Xray abdomen erect revealed prominent stomach bubble with minimal gas distally. Postnatal ultrasound had distended bladder with bilateral hydroureteronephrosis. Barium enema was suggestive of microcolon. Child was catherized and on laparotomy small bowel from mid-jejunum upto colon & rectum was small in calibre huge size collapsed urinary bladder reaching upto epigastrium. Gastrostomy and vesicostomy was done for the patient. Histopathology of small bowel had thinned out muscle with ganglion cells

Conclusion: A rare congenital autosomal recessive alteration with usually fatal prognosis that predominantly affects females (4:1 ratio). Nutritional support is the mainstay of treatment. The earliest time to detect distended urinary bladder and hydronephrosis was at 16-20 weeks. In subsequent pregnancies and clinical genetic counselling is indicated.


   Clinical and management profile of children with acute appendicitis: An observational study from a tertiary care centre Top



   Category: GI Prime Poster Top


Simmi K Ratan, Shasanka Panda, Sujoy Neogi

Department of Pediatric Surgery, MAMC, New Delhi, India.

E-mail: drjohnsimmi@yahoo.com

Aims: 1. To study the clinical and management profile of children presenting with Acute Appendicitis (AA).

Methods: We reviewed the medical records of children admitted to our hospital between January 1, 2014 and Dec 31, 2018 with the diagnosis of AA.

Results: Out of 154 patients, 119 were male and 35 female. The average age was 8.65 ± 2.8 yrs. The most common symptom were RIF pain (137, 89%), vomiting (111, 72.08%) and fever (85, 55.19%). McBurney's point tenderness was elicited in 120 (77.92%) patients.

Surgeries done were abdominal exploration and appendicectomy (45), open appendicectomy (82), lap appendicectomy (18) and lap converted to open appendicectomy (3).

The most common complication was wound infection seen in 18 (12.16%) patients.

107 (73.79%) patients were diagnosed clinically whereas USG was used to aid the diagnose in 62 (75.61%) patients.

The average post-operative hospital stay was 6-8 days – 8.03 days in complicated and 4.47 days in uncomplicated AA.

Conclusion: Though a common emergency with good treatment outcomes, clinical signs may be masked at presentation due to prior treatment. Though in most cases, clinical diagnosis suffices, USG can be used as an additional aid to clinch the diagnosis.


   A jejunal trauma masquerading as a mass lesion? Top



   Category: GI Prime Poster Top


Ashitha K Unny, T Vidhya, S Namasivayam

Department of Pediatric Surgery, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India.

E-mail: ashitha.aku@gmail.com

Aim: To report a case of traumatic jejunal hematoma masquerading as a mass lesion.

Methods: A 5 year old hyperactive girl with intermittent vomiting and abdominal pain, loose stools for 6 months, symptoms aggravated for past 1 week. Her labs revealed elevated total counts with lymphopenia, coagulation profile were within normal limits, Abdominal X-ray was non-specific, USG revealed an intramural hemorrhagic mass in proximal jejunum and CECT confirmed a hemorrhagic intramural mass in the proximal jejunum with no luminal obstruction. Immunodeficiency with lymphoma was suspected, hence bone marrow aspiration was done, it was normal. During the hospital stay, she developed bradycardia, reduced urine output, fluctuations in blood pressure raising suspicion of paraneoplastic features. She was stabilized, planned for laparotomy. After induction she had fluctuations in BP, laparotomy revealed intramural hematoma extending from DJ flexure to about 10cm of proximal jejunum. Hematoma evacuated with intact mucosa. Her blood pressure stabilized and serosal closure done.

Results: Post-operative period was uneventful. Her vitals remained normal, oral feeds resumed on POD 5, she tolerated it well. She is doing well on follow up.

Conclusion: Traumatic injury involving DJ flexure is a known entity often masked due to unknown trauma in small children.


   Chilaiditi syndrome with congenital pericardial effusion: A case report Top



   Category: GI Prime Poster Top


Sugandh Chadha, T Heera, T Vidhya, Anis Akhtarkhavari, S Namasivayam

Department of Pediatric Surgery, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India.

E-mail: sugandhchadha@gmail.com

Aim: Chilaiditi syndrome is rare. Chilaiditi syndrome with Congenital pericardial effusion has not been reported. Presented for rarity and requirement of awareness.

Materials and Methods: 13 yrs old boy with a known congenital pericardial effusion presented with complaints of abdominal pain,distension, bilious vomitting,loose stools followed by obstipation for 4 days, fever for 1 day. On examination revealed tense and distended abdomen with absent bowel sounds.X-ray chest showed no pericardial effusion. X-Ray abdomen showed markedly dilated transverse colon. USG abdomen suggested colonic volvulus and interposition of ascending colon between liver and diaphragm. Contrast enema showed obstruction at the level of rectosigmoid and was reported as sigmoid volvulus. Emergency laparotomy revealed dilated colonic loop between chest wall and liver- clockwise volvulus of caecum, ascending colon and proximal transverse colon producing large eccenteric dilatation of colon with dusky discolouration. Distal to dilated colonic loop, the transverse colon and sigmoid colon is collpased.

Results: Derotation of volvulus done in anticlockwise direction.The partial ischaemia of hepatic flexure could not be ruled out. Ileotomy and decompression of proximal and distal bowel was carried out and ileotomy was converted in to formal ileosomy and abdomen was closed with a drain. Postoperatively child recovered well.

Conclusion: Although Chilaiditi syndrome is a rare entity overall, this challenging diagnosis should be considered when a patient presents with symptoms of intestinal obstruction with radiological evidence of colonic interposition between liver and right hemidiaphragm.


   Study of two cases of tubular small intestinal duplications Top



   Category: GI Prime Poster Top


Swetha Edamakanti, Sudhakar Jadhav, Santosh Patil



SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: eswethareddy22@gmail.com

Aim: To study 2 cases of Tubular duplications.

Methods: Case-1: A 8 years old boy presented to us with complaints of blood in stools and non bilious vomiting. On examination, general condition was good, pallor was present, systemic examination is normal. Usg abdomen revealed proximal dilated colon with edematous changes.Colonoscopy was normal.On exploratory laparotomy there was a tubular duplication in the ileum about 4cm in lenth.Resection and anastomosis done. Histopathology confirmed ileal duplication cyst.

Case 2: A 12 year old girl presented with complaints of abdominal pain and non bilious vomiting .on general examination she is cachexic , severe pallor present. X ray abdomen is normal . USG abdomen dilated bowel loops. CT abdomen shows thickened bowel wall with collapsed distal bowel loops. Diagostic laparoscopy done outside was normal . Exploratory laparotomy revealed long tubular small intestinal duplication extending from distal jejunum to proximal ileum. About 80 cm bowel resection and anastomosis was done. Histopathology confirmed ileo jejunal duplication.

Results: The patient did well post operatively.

Conclusion: Tubular duplications are rare duplications and resection anastomosis is treatment of choice.


   Infected omental cyst: A rare case Top



   Category: GI Prime Poster Top


Nitin Vyas, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: nitintg@gmail.com

Aim: To study a case of infected omental cyst.

Methods: A 2 years old male presented with abdominal distension, one episode of non bilious vomiting, constipation since 2 days. On exam there was abdominal distension, and flatus with faeces on PR exam. X -ray showed gaseous distension of bowel loops on left side. USG revealed large hypoechoic collection (13.5x 9 cm) in abdomen and pelvis with internal echoes. Exploratory laparotomy revealed Infected omental cyst with dense adhesions. Excision of omental cyst done. Patient had uneventful recovery.

Results: Patient did well post- operatively, and is on regular follow ups.

Conclusion: The case presented for its rarity as infection in omental cyst is rare.


   Hiatus hernia- paraesophageal type: A rare entity in children Top



   Category: GI Prime Poster Top


Nitin Vyas, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: nitintg@gmail.com

Aim: To study a case of hiatus hernia- paraesophageal.

Methods: This is a study of a case of 1 year old female child who presented with respiratory distress since 1 month. On examination, decreased breath sounds heard in right mid and lower zones. X-Ray chest revealed air fluid level in right retro-cardiac region, and fundic bubble not visualised in upper abdomen. CT chest was suggestive of hiatus hernia with herniation of stomach. On abdominal exploration, right paraesophageal hiatus hernia with sac was revealed. Herniated stomach was reduced back to peritoneal cavity and sac was excised and defect was closed. Fundoplication was done. Patient had uneventful recovery.

Results: Patient did well post- operatively, and is on regular follow ups.

Conclusion: Hiatus hernia- paraesophageal type is a rare entity in children.


   Intussusception in older children look for lead point Top



   Category: GI Prime Poster Top


Abhishek Anand, Krishnendu Moitra, Kuntal Bhaumik, TJ Banerjee, AK Basu

Department of Pediatric Surgery, Institute of Child Health, Kolkata, West Bengal, India.

E-mail: pandeyabhi16@gmail.com

Aim: To draw attention towards intussusceptions in older children which often have a pathology at lead point which if not carefully looked will come with recurrence.

Materials and Methods: Out of 34 cases of intussusceptions in last 1 year 8 patients were older than 2 years and 26 patients were less than 2 year. Out of 8 older children we found polyp in 1 case, lymphoma in 2 cases and inverted meckels diverticulum in 5 cases. Out of 26 cases of less than 2 year 3 patients had inverted meckels diverticulum as lead point.

Results: All patient had uneventful recovery in the post operative period . Biopsy showed lymphoma in 2 case, peutz jegher syndrome in 1 case. Inverted meckels was found in 5 cases.

Conclusion: We should keep in mind of underlying pathology in intussusceptions in children over two years.


   Rare cause of acute abdomen in 2-year-old child Top



   Category: GI Prime Poster Top


Abhishek Anand, Kuntal Bhaumik, AK Basu, TJ Banerjee

Department of Paediatric Surgery, Institute of Child Health, Kolkata, West Bengal, India.

E-mail: pandeyabhi16@gmail.com

Aim: To report a case of duodenal perforation which is a very rare cause of acute abdomen in infant.

Methods: After proper resuscitation exploratory laparotomy performed. Perforation seen at 1st part of duodenum. Perforation closed and omental patch applied.

Results: Severe sepsis and hypoalbuminemia treated with Inj Colistin and Tigecycline and infusion albumin and total parenteral nutrition. Burst abdomen occurred on 7th post operative day which was repaired. Patient got discharged after 21 days of treatment with iv antibiotics and currently doing well.

Conclusion: Peptic ulcer disease is not uncommon in children now a days but perforation is very rare.


   Congenital duodenal stenosis: A case report Top



   Category: GI Prime Poster Top


Vibhu Sharma, SudhakarJadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: vibhusharma7191@gmail.com

Aim: To study a case of Intestinal Obstruction – Late Presentation

Methods: Two month old male infant presented with non-billious vomiting since 1.5 month. Vomitus was curdled milk. P/A Examination there was epigastric fullness on palpation no lump. X-ray erect abdomen – normal. USG abdomen was normal, no evidence of IHPS, overdistended stomach, normal gas shadow in large and small intestine. Barium meal revealed hugely dilated stomach and 1st part of duodenum with stasis of dye in duodenal loop s/o obstructive lesion In duodenum. On exploration duodenal stenosis was revealed and a kimuraduodeno-duodenostomy with duodenal tapering was performed.

Results: The patient did well post operatively.

Conclusion: Duodenal stenosis is rarer than duodenal atresia and a separate entity but presents with symptoms similar to duodenal atresia.


   Management of a case of stricture of lower 1/3rd of esophagus Top



   Category: GI Prime Poster Top


Vibhu Sharma, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: vibhusharma7191@gmail.com

Aim: To study a case of stricture of lower 1/3rd of oesophagus.

Methods: Seven year female patient with difficulty in swallowing solids more than liquids since 3 years. Barium swallow revealed holdup at the lower end of esophagus with ?stricture ?Gastroesophageal reflux ?Hiatus Hernia.Oesophagoscopyshowed a foreign body above the stricture in lower 1/3rd of esophagus, foreign body removed and dilatation done. Patient improved but again came with intractable vomiting so decided for excision of stricture. Combined approach of Exploratory laparotomy and right thoracotomy with resection of stricture esophagus with gastric pull up done.

Results: Patient recovered well and is on regular follow up.

Conclusion: Management of stricture of lower 1/3rd of esophagus not responding to dilatation is difficult and requires a combined approach of Right Thoracotomy and exploratory laparotomy.


   Mesenteric chyloma in a neonate: Rare clinical entity Top



   Category: GI Prime Poster Top


Sujoy Neogi, Aravindh Radhakrishnan, Ravinder Naik Noonavath, Ashish Kumar, Shasanka Shekar Panda, Simmi K Ratan

Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: dr.sujoyneogi@gmail.com

Background and Aims: Abdominal cystic lymphangiomas (ACLs) are rare congenital benign malformations of the lymphatic system, mostly presenting with head & neck distribution. Intraabdominal locations are very unusual. We report a case of extensive chyloma mesentery with retroperitoneal extension in a neonate managed by a novel technique.

Case Report: A 25-day-old boy was brought to the emergency with a history of progressive abdominal distension since birth associated with occasional non-billous vomiting. There was no history of fever, bowel or bladder complaints. The child was hemodynamically stable. Abdomen was tensely distended with a lump involving entire abdomen sparing right lumbar and iliac regions. The lump was not moving with respiration and had a dull percussion note. Ultrasound and CT scan reported a provisional diagnosis of retroperitoneal cystic lesion with mesenteric vessels traversing through it. Laparotomy revealed multiple cysts containing white milk like fluid in the mesentery corresponding to ileum and jejunum. In addition, there was large solid lump at the base of the mesentery which was fixed to the retroperitoneum. A sample from both mesenteric and retroperitoneal mass was sent for frozen section which was reported as benign lympho-vascular lesion. In view of extensive distribution of lesions, de-roofing of the cysts with intra-operative bleomycin injection was done to relieve the distension. Final histopathology report suggested a cystic lymphangioma. Post-operative period was uneventful. The child is being closely followed up monthly. Follow up abdominal sonography still reveals small multi-cystic lesions in the mesentery. However, at one year follow up, the child is asymptomatic without any further distension.

Conclusion: Abdominal cystic lymphangiomas in a neonate are rare clinical entity. Due to their wide spread distribution, attempts to surgical excision can lead to extensive loss of associated bowel. De-roofing of smaller cysts and intra-op bleomycin injection is a promising alternative in surgical management.


   A rare case of duodenal duplication cyst Top



   Category: GI Prime Poster Top


D Swetha, P Sreenivas Reddy

Department of Paediatric Surgery, Osmania Medical College, Niloufer Hospital, Hyderabad, Telangana, India.

E-mail: d.swethavarma@gmail.com

Aim: To evaluate and manage a case of duodenal duplication cyst.

Methods: A 30 month old female with complaints of pain abdomen since 1 month was admitted in hospital.0n further evaluation a duodenal duplication cyst in 3 rd part of duodenum was present.child was taken up for surgery,laparotomy with marsupialization of cyst was done. post operative period was uneventful.

Results: Case of duodenal duplication cyst was managed successfully.

Conclusion: Of all the alimentary tract duplication cysts, duodenal duplication cysts are 4-6%.They may have varied clinical presentations and difficult diagnosis.Hence correct diagnosis and proper management is necessary.


   Huge omental cyst masquerading as ascites in pediatric age group- two case reports Top



   Category: GI Prime Poster Top


Piyush Kumar, Ashutosh Pandey

Department of Paediatric Surgery, Vivekanand Polyclinic and Institute of Medical Science, Lucknow, Uttar Pradesh, India.

E-mail: drpiyushkashyapms@gmail.com

Aim: To report clinical course and management of huge omental cyst in pediatric age group – a rare intra abdominal pathology.

Methods: We encountererd two male patients aged 4 years and 6 years who presented with significant abdominal distention without any obvious palpable mass . One patient was diagnosed elsewhere as a case of ascitis and had even received full course of antitubercular treatment. Ultrasonography reported mearly ascitis , however owing to a high index of suspicion CECT abdomen was done which reported suspicion of mesenteric cyst in one patient and lymphangioma in second patient. Both patients were taken for laparotomy electively.

Results: In both the patients huge omental cyst was found intraoperatively which was attached to the omentum. Cyst was completely excised .Post operative period was uneventful.

Conclusion: Huge omental cyst should be considered as a differential diagnosis in case of ascites in pediatric age group.


   Unusual variant of perineal canal associated with urogenital sinus Top



   Category: GI Prime Poster Top


Piyush Kumar, Ashutosh Pandey

Department of Paediatric Surgery, Vivekanand Polyclinic and Institute of Medical Science, Lucknow, Uttar Pradesh, India.

E-mail: drpiyushkashyapms@gmail.com

Aim: Reporting unusual variant of perineal canal associated with Urogenital sinus(UGS).

Methods: A 3 year old female child presented with complain of passing stool through urinary opening and abdominal distention. On examination, normal appearing native anal opening was present with both labial folds fused and small single opening was present through which patient used to pass both urine and stool along with passage of stool from native anus as well. X ray abdomen revealed fecal impaction and dilated gut loops.

Results: Examination under anesthesia revealed subcuticular track between native anus and opening in fused labia. Divided colostomy was done . Three months later distal loopogram was done and definitive surgery planned.

Anterior sagittal anorectoplasty was performed. Mucosal lining was present in subcuticular tract. Muscle complex was present anterior to native anus. UGS and anorectum were mobilized and anoplasty was done between the muscle complexes. UGS was placed anteriorly along with labioplasty and perineal reconstruction. Redoanoplasty was done later for postoperative fistula formation. Patient now awaits colostomy closure.

Conclusion: This type of unusual variant of perineal canal associated with UGS with posteriorly placed genitourinary and anorectal complex has never been reported before.


   Hepatic entomophthoromycosis in a child: Management options and outcomes Top



   Category: Hepatobiliary Prime Poster Top


G Vidhya, Nitin J Peters, Muneer A Malik, Ram Samujh

Department of Paediatric Surgery, PGIMER, Chandigarh, India.

E-mail: aanoor90@gmail.com

Introduction: Fungal infection of the liver is usually a manifestation of systemic fungal infection in immunocompromised adults post transplantation or after chemotherapy for malignancies. In this population it has an incidence of 5% -25%. Invasive fungal infection in a immunocompetent child is rare and is often missed when they present as visceral lesions. They are commonly associated with non-specific signs and symptoms like fever and malaise. We present one case and review management options.

Case Report: 3 year male child presented with high grade fever, associated with abdominal pain and distension for 5 months. On Examination there was a palpable upper abdominal lump. Imaging was suggestive of focal lesion in the left lobe of liver of 8x 7cm with cystic component. Se AFP levels were normal. FNAC showed fungal elements of Entomophthoromycosis. Complete medical work up for systemic fungemia and immune system were essentially normal. Due to the large size of lesion and exploration with excision of mass with left hepatectomy done. The final HPE showed fungal mass with clear margins. The child received anti-fungal therapy for 6 months post operatively. He is doing well on a 1 year follow up.

Conclusion: Early diagnosis is the key to survival. Hepatic fungal masses respond well to liver resections and post-operative anti-fungal therapy. An extensive workup for immune response is warranted in such patients.


   Empyema of gall bladder: A case report Top



   Category: Hepatobiliary Prime Poster Top


Vibhu Sharma, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: vibhusharma7191@gmail.com

Aim: To study a case of Empyema of Gall Bladder.

Methods: A 4 year old male child presented with c/c of fever and pain in abdomen since 15 days. Pain was dull in nature, intermittent, non-radiating, associated with non- billious vomiting. Fever was high grade continuous. On examination baby was pale but no jaundice. P/A – tenderness with guarding present in right hypochondriac region, lump in the right hypochondrium.WIDAL test was negative. USG abdomen revealed distended gall bladder filled with debris with thick and edematous wall S/O Empyema of gall bladder. Baby was planned for Cholecystostomy on Exploration – Gall Bladder was aspirated and 20 cc of pus was drained. cholecystectomy was possible and was performed. Histopathology report confirmed it as acute cholecystitis.

Results: The patient recovered well and is on regular follow up.

Conclusion: Empyema of gall bladder is rare in paediatric population.


   Unusual complication after lap orchiopexy Top



   Category: Laparoscopy Prime Poster Top


Abirami Krithiga, Harish Jayaram

Department of Paediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India.

E-mail: drabiramikrithiga@gmail.com

Aim: To highlight a rare complication of laparoscopic orchiopexy.

Methods: An 8 years old boy underwent laparoscopic left orchiopexy by mobilizing the testis medial to the inferior epigastric artery after dividing the gubernaculum and closing the internal ring. He developed ipsilateral inguinal hernia 6 months later.

Results: Laparoscopy revealed a direct hernia sac adjacent to the mobilized cord structures. The previously sutured internal ring was found closed at the time of second surgery. The peritoneum was divided around the hernia sac opening and purse string vicryl suture was used to close the defect. At 6 months follow up, the child is asymptomatic and the testis was in orthotopic position.

Conclusion: The surgically dissected path for mobilizing the testis during orchiopexy through muscular layers can be potential sites for herniation especially in older children and the peritoneum should be closed at the time of initial surgery.


   A rare case of hydatid cyst of lung and liver in 2-year-old boy: Thoracoscopy and laparoscopy for management Top



   Category: Laparoscopy Prime Poster Top


Inugala Anusiri, Anusiri Inugala

Department of Paediatric Surgery, Krishna Institute of Medical Sciences, Hyderabad, Telangana, India.

E-mail: anusirireddy@gmail.com

Aim: To present a rare case of a two year old boy with hydatid cysts of left lung and left lobe of liver treated with minimal access surgery.

Methods: A two year old boy was brought with the complaints of fever, abdominal pain and decreased appetite of 4 days duration. There was history of contact with a pet dog since 6 months. Investigations showed leukocytosis with eosinophilia. Ultrasound of abdomen showed a cystic lesion in the left lobe of liver. CECT showed hepatic and left lung hydatid cysts.

Thoracoscopy was done, the cyst was punctured with veress needle, fluid aspirated, scolicidal agent instilled and reaspirated. The cyst was opened and the germinal layer was removed and extracted by placing in an endobag. There was no air leak. ICD was placed.

Laparoscopy was done and similar procedure as above was done for liver hydatid. Liver cyst was checked for bile leak, which was absent.

Results: Post operatively the fever spikes and leukocyte count decreased. Drains were removed on 4th post-operative day.

Conclusion: Concomitant lung and liver hydatid is rare in children. Minimal access surgery for the management of hydatid disease is feasible and safe in well selected cases.


   Ingested and aspirated foreign bodies in paediatric population Top



   Category: Miscellaneous Prime Poster Top


Shyamendra Pratap Sharma, Sarita Chowdhary, SP Sharma, Pranaya Panigrahi, Rakesh Kumar, Arjdeo Upadhyay

Department of Paediatric Surgery, Institute of Medical Sciences, B.H.U., Varanasi, Uttar Pradesh, India.

E-mail: shyambrd07@gmail.com

Aim: Awareness about various types of ingested and aspirated foreign bodies in paediatric population.

Methods: This study was done in department of Paediatric Surgery, Institute of Medical Sciences, BHU. 1100 patients with ingested or aspirated foreign bodies from 2014 to 2019 were included. Data was retrieved from OT records. Study population: 6 months to 15 years old children.

Results: Out of 1100 cases, 800 were of foreign body ingestion and 300 were of foreign body aspiration. The ingested foreign bodies included coins, button batteries, meat bones, seeds, hair clips, magnets, pins, LED bulb. Most of foreign bodies were impacted in upper oesophagus and were removed through Magill forceps. Oesophagoscopic removal was done in 175 cases and in 25 cases laparotomy with enterotomy was required. The aspirated foreign bodies required rigid bronchoscopy.

Conclusion: Children between 1- 5 years are more susceptible to foreign body ingestion or aspiration. Batteries are most feared may lead to many serious complications. Suspicion of foreign body aspiration should be kept in mind in situations like refractory asthma, bronchiectasis, or haemoptysis without any underlying cause. Radiography is the most im¬portant modality in the evaluation. Computed tomography, virtual bronchogram play an important role in complicated cases.


   Pediatric tamarind seed aspiration: A predictor of difficult bronchoscopy Top



   Category: Miscellaneous Prime Poster Top


Sunita Singh, Sunita Singh, Nitin M Nagarkar, Nand Kishor Agrawal, Abhimanyu Varshney, Chinmaya Panda, Atul Jindal, Nitin Borkar

Department of Paediatric Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India.

E-mail: drsunitasingh28@gmail.com

Aim: Vegetative foreign body in bronchus is more dangerous, as they swell up with bronchial secretions added on is the chemical bronchitis due to seeds oil.

Methods: 13 yr female presented with history of tamarind seed aspiration two days back. X-ray chest showed white out right lung field. The girl had cardiopulmonary arrest (probably dislodgment of seed to main bronchus) while arranging for OT. After successful resuscitation and ventilator support, patient taken for OT. Under spontaneous ventilation, Flexible bronchoscopy confirmed tamarind seed in right main bronchus. On rigid bronchoscopy we couldn't catch the seed, as it was so slippery. Their was frequent desaturation because seed significantly occluding main bronchus. With Fogarthy embolectomy catheter, seed was dragged upto glottis, and attempted to deliver through glottis. But, was large enough to deliver through glottis. Further, seed was too hard to crush. Team decided to retrieve seed through tracheostomy. The ENT colleague exposed trachea under Local anesthesia. Seed dragged upto glottis, than below cricoids tracheostomy done and ventilation performed through tracheostomy tube. After achieving appropriate saturation, tracheostomy tube removed, seed push back to tracheostomy and delivered through thacheostomy site. The tracheostomy tube was repositioned. The patient was of the ventilators in one day and discharged with tracheostomy in situ.

Results: In 10 years, out of 25 cases of vegetative foreign body in children, two were tamarind seed. In both cases, sequence of events were same. I.e. tracheostomy is required for tamarind seed retrieval.

Conclusion: Suspected Tamarind seed aspiration often invites tracheostomy for removal.


   Double meningomyelocele – Changing concepts in neural tube defects Top



   Category: Miscellaneous Prime Poster Top


Santosh Dey, VS Raman, Kamal Kishore

Department of Paediatric Surgery, Army Hospital, Pune, Maharashtra, India.

E-mail: santodey@gmail.com

Introduction: The presence of a myelomeningocele (MMC) at multiple levels is very rare . Only a few cases of double myelomeningocele reported in the world's literature. We present a case of double MMC at thoracic and lumbar levels. It supports the multiple level zipper closure theory of neural tube defects.

Materials and Methods: A 7 month old female child presented with meningomyelocele at thoracic and lumbar levels without any associated anomaly. She was successfully managed by surgical excision and repair of both MMC at the same time. Postop recovery was uneventful and there was no neurological deficit.

Discussion: Only 09 cases of double NTD and single case of triple NTD has been described in world literature. The conventional theory on etiogenesis of MMC is that it results from defective closure of neural tube between 26 and 28 days of gestation. 'The single site' closure theory postulates that closure starts like a 'zipper' from single site and moves bidirectionally. Multisite closure theory states that there are five sites of closure and NTD can result from defective closure at any of these sites. The multisite theory though having few drawbacks better explains the embryogenesis of NTD and presence of such multiple neural tube defects supports the theory of multi level zipper closure which are controlled by various genes.


   Topical 0.5% timolol maleate in the treatment of disfiguring superficial capillary hemangioma: Preliminary results Top



   Category: Miscellaneous Prime Poster Top


Sunita Singh, Sunita Singh, Nitin Borkar, Atul Jindal

Department of Pediatric Surgery, AIIMS, Raipur, Chhattisgarh, India.

E-mail: drsunitasingh28@gmail.com

Aim: To report effectiveness of topical Timolol Maleate solution (nonselective β-blocker) in severely disfiguring superficial capillary hemangima(CH).

Methods: A 1.5 month- old- male presented with a bright red, intact CH (sized 8×6cm 2) involving right peri-ocular area with facial disfigurement and risk of vision (baby not able to open affected eye). Colour-Doppler suggested superficial CH. Under supervision 1 drop (0.05 ml) of 0.5% of timolol eye drop solution (25 mg)/ day was applied over skin lesion. Simultaneously 1 drop/day instilled in affected eye. Close monitoring of adverse effects (hypotension, bradycardia, bronchospasm and hypoglycemia) was done. The dose is gradually increased over 1 week to application twice in a day. After 2 days baby was able to open eye, so intraocciular instillation stopped. In 2013-2019, 25 cases of superficial CH (mean sized 6×4 cm 2) at different sites was treated, excluding ulcerated CH (unpredictable systematic absorption), patients <4weeks corrected gestational age, history of apnea/and bradycardia, progressive aggressive CH (needed add on systematic therapy).

Results: Duration of therapy was 180 ±15days. In 9±2months lesion effectively reduced in size. visual analog scales for color, size, extent, and volume, at 1 month of follow- up with serial digital pictures, showing 80% success rate.

Conclusion: Early proliferative phase in CH lasts upto 4 months of age. Involution is anticipated after 1 year of age and completed by 3.5 to 4 years of age. Our results showing improvements at a much younger age diverge from this known natural history, strongly supporting efficacy of timolol.


   The wandering ventriculo-peritoneal shunt Top



   Category: Miscellaneous Prime Poster Top


Nitin Pant, Nitin Pant, Sudhir Singh, Gurmeet Singh, Rahul Kumar Rai, Ashish Wakhlu

Department of Paediatric Surgery, King George Medical University, Lucknow, Uttar Pradesh, India.

E-mail: drnitinpant@gmail.com

Aims: To highlight rare complications following ventriculo-peritoneal (VP)shunt placement.

Methods: Retrospective collection of data from January 2013 to June 2019 of children treated for complication following V.P. shunt placement was done. Data was analyzed for clinico-radiological presentation, intraoperative finding, operative intervention, post-operative complications, and outcome. Last out-patient follow up was between three-eight months.

Results: There were seven boys and five girls. Mean age of presentation was 11.25 months. Complication rate following VP shunt placement was 10.1%. Spectrum of presentation included cervical skin necrosis with shunt herniation (n=3), adhesive intestinal obstruction following bowel perforation (n=2), right inguinal hernia (n=2), umbilical hernia (n=2), urinary bladder perforation (n=1), extrusion of distal catheter from scalp incision (n=1), and abdominal pseudocyst (n=1). No patient presented with peritonitis, meningitis, sepsis. Nine were initially managed by shunt removal and antibiotics. Replacement of VP shunt was done after 3-6 weeks. In two, the tube was put back in peritoneum at herniotomy. Marsupialization of pseudocyst was done and tube replaced in peritoneum. Post-operative period was uneventful.

Conclusions: Intra-abdominal complications of VP shunt are not uncommon. Despite visceral perforation, peritoneal and meningeal signs are infrequent. Shunt removal, antibiotics and subsequent shunt replacement yield good results.


   Retrospective analysis of foreign body impaction in the upper aerodigestive tract at a tertiary care centre in paediatric age group Top



   Category: Miscellaneous Prime Poster Top


Varun Sabari, Shinaz Sadiq

Department of Paediatric Surgery, Trivandrum Medical College, Trivandrum, India.

E-mail: varunsabari1985@gmail.com

Aim: Retrospective analysis of foreign body impaction in the upper aerodigestive tract at a tertiary care centre in paediatric age group.

Materials and Methods: retrospective study which includes 422 cases of foreign body impaction admitted in department of paediatric surgery in Trivandrum medical college from the year 2010 to 2018.

Results: 300 cases underwent scopy within 4 hours of diagnosis.

Total of 252 patients underwent bronchoscopy, of which 198 cases were of < 3 years , 120 of them was impacted in right bronchus , peanut was the commonest of all, others were jackfruit seed, ear ring stud, coconut piece

Total of 92 patients underwent esophagoscopy , of which 37 cases were of < 3 years, 62 of them were coins, others were button cell, metal washer, fish bone / chicken bone

Total of 79 patients underwent direct laryngoscopy, of which 33 cases were of < 3 years , 67 of them were coins, others were button cell, fish bone, safety pin. Mortality of only 1 patient with button battery impacted in esophagus who developed perforation.

Conclusion: Early intervention will help to reduce complication Parental counselling will help to reduce the incidence.


   Rare associated congenital structural anomalies of infantile haemangioma Top



   Category: Miscellaneous Prime Poster Top


Uday Bhaskar, Ashitha, Suganth, S Namasivayam

Department of Paediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India.

E-mail: naga0910.ub@gmail.com

Aim: Infantile Haemangioma are associated with rare congenital structural anomalies. The awareness of these conditions are important to not to miss these anomalies hidden under cover of innocuous looking haemangiomas. Three cases presented illustrate this factor.

Methods: Case 1:Five year-old boy with Infantile Haemangioma of Rt Medial canthus of Eye showed associated PHACES syndrome.

Case 2: Five months female infant presented with perineal infantile Haemangioma and further examination and investigations revealed PELVIS syndrome.

Case 3: Two year-old boy with a perineal Infantile Haemangioma on further investigations showed Spinal lipoma and tethered cord.

Results: All the three cases required management of Haemangioma and the underlying structural anomalies and are on follow up for sequlae.

Conclusion: Significantly large midline infantile Haemangioma of face, perineum and lumbosacral region should be investigated for these associated congenital structural anomalies and managed early. Awareness is important.


   Complications in hydrocephalus VP shunt surgery Top



   Category: Miscellaneous Prime Poster Top


Usha Gajbhiye, Usha Gajbhiye

Department of Paediatric Surgery, Matruchhaya Hospital and RRSH, Amravati, Maharashtra, India.

E-mail: ushagajbhiye@gmail.com

Aim: Complications in Hydrocephalus VP shunt Surgery

Materials and Methods: It is a clinical retrospective observational study that was conducted on 94 patients of both genders with different ages who presented with signs and symptoms of shunt malfunction between 2010 and 2019. After Assessment and diagnosis, the treatment of individual patients was planned accordingly.

Results: VP shunt was inserted for 94 patients out of whom 11 children needed Revision of the shunt, one had Ventriculopleural shunt. Shunt needed to be removed in 8 of the cases. Complications observed were leak from scalp incision 4, leak from abdominal incision site one, abscess along the shunt 3, Shunt exposure 2, Blockage of shunt at various sites 3, Extrusion of shunt 2 cases, Pleural effusion in one child, meningitis in two, and raised ICT needing tapping of shunt in two. Most of the children managed surgically except two. There were three deaths. (85%) patients of them showed marked improvement at the end of the first month postoperatively, while (15%) patients needed more than one surgical intervention.

Conclusion: A great care should be taken during insertion of the shunt system. Despite complications, the VP shunt remains the main surgical procedure used for hydrocephalus management.


   Statistical assessment of eFAST as a screening tool in pediatric blunt abdominal trauma patients Top



   Category: Miscellaneous Prime Poster Top


Mehak Sehgal, Mehak Sehgal, Prabudh Goel, Ajay Verma, Minu Bajpai

Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: mehak.sehgal91@gmail.com

Aim: To statistical evaluate the utility of eFAST as a screening modality in Pediatric Blunt Abdominal Trauma patients.

Materials and Methods: Prospective study conducted over a period of nine months based on consecutive children presenting to our Trauma Centre following blunt abdominal injuries.

Results: Study cohort comprised of n=5551 children of which 5450 were managed and discharged while 101 required in-patient care. Mean age: 7.2 years (5months-14 years); Male to female: 1.8:1. Most common mechanisms of injury (data limited to in-patients) was Road-Traffic-Accidents (n=48) followed by fall-from-height (n=41). FAST and eFast were positive in 53 and 62 patients respectively. CT findings were suggestive of liver injury(n=36), splenic injury (n=21), renal injury(n=11) and others organ injury (n=11). Thoracic findings included lung contusion(n=27) and pneumothorax(n=21).

The sensitivity of FAST and eFAST was 63.9 and 75.3% respectively. The specificity and negative predictive value of eFAST were 99.9% and 99.6% respectively.

Conclusion: Without clinical examination and CT scan, eFAST has a poor sensitivity and cannot be used independently as a screening modality for children with blunt abdominal trauma in its current form.


   Lingual thyroglossal cyst: A rare case Top



   Category: Miscellaneous Prime Poster Top


Swetha Edamakanti, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: eswethareddy22@gmail.com

Aim: To study a case of Lingual Thyroglossal Duct.

Methods: One year old male child presented with incidentally diagnosed swelling at base of tongue . On exam there was single swelling at the base of tongue. Surface was moist with dilated veins seen.USG of neck shows thyroid gland normal site. CT scan shows 1.5 *1.5 cm cystic swelling at the base of tongue at foramen cecum. Thyroid scan revealed normal thyroid in neck without ectopic tissue any whereelse. Complete excision of cyst was done .histopathology revealed retension mucocoele – Lingual thyroglossal cyst.

Results: Patient recovered well and is on regular follow up.

Conclusion: Lingual thyroglossal cyst is a rare type of Thyroglossal cyst.


   Bronchoscopic removal of foreigh body bronchus -LED Bulb: A rare case Top



   Category: Miscellaneous Prime Poster Top


Swetha Edamakanti, Sudhakar Jadhav, Satosh Patil

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: eswethareddy22@gmail.com

Aim: To report a case of foreign body- LED bulb and its bronchoscopic removal.

Methods: A 8 month old male infant referred to us with complaints of cough and fever since 8 days. On examination, general condition was good, pallor was present, wheeze present , respiratory sounds were decreased on right side. X- ray chest PA view revealed a linear radio-opaque structure in right main bronchus probably paper clip. Bronchoscopy was done and foreign body- LED BULB removal done.

Results: The patient did well post operatively.

Conclusion: LED bulb is a rare foreign body.


   Congenital epulis of the new born: Surgical excision versus conservative management!! Top



   Category: Miscellaneous Prime Poster Top


Md Mokarram Ali, Nitin J Peters, Ram Samujh

Department of Paediatric Surgery, PGIMER, Chandigarh, India.

E-mail: mohdmokarramali1990@gmail.com

Introduction: Congenital epulis of newborn (CEN) is a rare lesion found in the alveolar process, of neonates detected soon after birth. The commonest site is the maxillary alveolar ridge. It usually occurs as single mass and may interfere with feeding and breathing. Conventional management warrants surgical resection, however spontaneous resolution has occasionally been documented in literature.

Methods: Retrospective analysis of two cases of CEN. Clinical data and photographs were collected from the medical records and analyzed.

Case Report: Two neonates presented in the OPD with a swelling from the maxillary alveolar ridge. They were diagnosed to be Epulis. The swelling were 3x2 cms and 2.5x3 cm in both patients. The Epulis was not interfering with feeding or causing any respiratory embarrassment. The patients were managed with watchful waiting and both lesions were gradually regressed. Neither patient required surgical intervention and were subsequently discharged from follow up.

Conclusion: Even though, surgical excision is recommended, congenital epulis can be managed expectantly in a subset of patients of CEN, thereby avoiding unnecessary surgery and anesthesia exposure in newborns.


   Status of pediatric surgery under the Ayushman Bharat Yojana – Pradhan Mantri Jan Arogya Yojana (or the national health protection mission) Top



   Category: Miscellaneous Prime Poster Top


Prabudh Goel, Minu Bajpai, Anjan Kumar Dhua, Ajay Verma, Vishesh Jain, Devendra Kumar Yadav

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: prabudh.aiims@gmail.com

Aim: To evaluate the Ayushman Bharat Yojana from the perspective of Pediatric Surgeons and Pediatric Surgery.

Materials and Methods: Prospective study based on data mining from the official web-address to decipher 1) criteria for empanelment of a hospital for pediatric surgery as a specialty, 2) number and distribution of empaneled hospitals providing pediatric surgical services across the country, 3) number of packages designed for pediatric surgery and the diseases covered therein, 4) diseases related to the specialty of pediatric surgery but enlisted within other specialties and its implications.

Results: The results related to each of the point as outlined above and its implications to pediatric surgery will be discussed in detail during the presentation.

Conclusions: Ayushman Bharat is a laudable national initiative targeting 10 crore poor and vulnerable families and is the future of our country. However, a critical appraisal of several aspects of the scheme in relation to our specialty and its ambassadors need to be taken up by the Indian Association of Pediatric Surgeons of the country.


   Conjoined twins – Experience and insights gained during management of seven pairs from an apex institute Top



   Category: Miscellaneous Prime Poster Top


Shreya Tomar, Prabudh Goel, Kashish Khanna, Minu Bajpai

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: shreya305@gmail.com

Aim: To share our experience and insights gained during the management of seven pairs of conjoint twins at our centre.

Materials and Methods: We discuss the anatomy, work-up &; management and outcomes of conjoined twins: epigastric heteropagus (n=1), omphalopagus-with liver fused (n=1), pygopagus (n=2) and thoraco with omphalopagus (n=2), parapagus (n=1).

Results: The anatomy, work-up &; management, problems encountered in planning separation and outcomes of each pair of conjoined twins will be discussed individually in detail. A broad management protocol will be outlined.

Conclusions: The complex anatomy and limitations imposed by availability of tissues requires multidisciplinary approach in an integrated fashion towards successful outcomes.


   Omphalocele with patent vitellointestinal duct- a rare entity with rarer association Top



   Category: Neonatal Prime Poster Top


Akshay Prasad, Kaushik Saha, Dipak Ghosh, Subhankar Chakravorty

Department of Paediatric Surgery, Nilratan Sircar Medical College, Kolkata, West Bengal, India.

E-mail: akshay.prasad@yahoo.co.in

Aim: Abnormalities in abdominal wall closure leads to a defect popularly known as omphalocele .Its rare with incidence of 1 in 15000 live birth .The incidence of patent VID is reported as 0.0053% in world literature. In period of 2 years 4 cases of omphalocele has been encountered with patent VID.

Methods: CASE 1-2 day old male weighs -2.2kgs born to 19 yrs old mother ftnd c/o –opening at tip of umbilical swelling since birth o/e-omphalocele with opening at the fundus with meconium discharge. Emergency surgery with resection was done with uneventful follow up.CASE 2- 3day old male weighs -2kgs born to 17 yrs old mother ftvd c/o –umbilical swelling smeared with meconium o/e-sac with perforation emergency surgery with resection was done .CASE 3-1 day old male weighs -2.4kgs born to 25yrs old mother c/o –omphalocele with meconium in umbilical cord.Emergency laparotomy was done.

Results: Omphalocele is opened up and excision of tract with resection and anastomosis is done in all cases and post operative results were uneventful.

Conclusions: Omphalocele with fistula is rare entity.At birth it can be diagnosed easily by meconium staining of omphalocele.Early intervention is required to reduce mortality and morbidity.


   Symmetrical pyopagus twins surgical separation in a tertiary centre Top



   Category: Neonatal Prime Poster Top


Chiranjiv Kumar, Simmi K Ratan

Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: chiranjiv123@rediffmail.com

We are reporting a rare case of symmetrical female conjoined twins, FTNVD joined at lower back (pyopagus) and presented to us on day 3 of life. Each baby was passing urine and meconium through there own separate urinary and anal openings and normal movements in all limbs and had stable vitals. Both babies weighed 4.8 kg together. There was fusion of lower back at sacral area with bridge size of 3.5cm x 1.5 cm, firm in consistency. Perineal examination was within normal limits and no other congenital anomaly was obvious or detected on screening sonography. X-ray spine, neurosonogram and MRI spine of babies suggested fused coccygeal vertebrae, divergence of posterior elements of lower lumbar and sacral spine with no hydrocephalus. The babies were placed side to side on operation table and induced for surgery. Cruciate incision over common skin bridge adjusting for enough skin to cover raw area after separation of twins was made and deepened. The fused area was divided with resection of lower most part of coccyx. Communicating spinal canal with neural tissue (?filum terminale) identified. Spinal canal dural closure done and buttressing of the repair done. The babies put in prone position and muscles were sutured to coccyx. Skin flaps mobilised to cover the raw area. Both babies was started on breast feeds orally from post-operative day1 which they tolerated well. Both babies discharged after 1 week in stable conditions. Both babies are now about 3 years old and are doing well.


   Respiratory distress with pneumothorax-A rare presentation of TEF with EA Top



   Category: Neonatal Prime Poster Top


PS Madhulika, A Narendra Kumar, S Srinivas

Department of Paediatric Surgery, Osmania Medical College, Niloufer Hospital, Hyderabad, Telangana, India.

E-mail: drpsm.mch@gmail.com

Aim: To discuss a rare presentation of Tracheo esophageal fistula with esophageal atresia.

Introduction: TEF with or without EA is a common neonatal emergency, usually referred with excessive oral secretions or choking spells after feeds.

Methods and Results: We came across a four day old Baby with respiratory distress and left pneumothorax ,Inter costal drain placed by neonatologist and referred to us on day 4 of life with excessive oral secretions. Baby was examined and diagnosed with Tracheoesophageal fistula with esophageal atresia .Through Right postero lateral thoracotomy,fistula ligation and primary anastomosis of esophageal atresia procedure was done. Post operative period baby had bilateral crepts and respiratory distress, deteriorated on day four and expired.

Conclusion: EA with TEF is a real challenge to pediatric surgeon. Success in survival of such neonate with TEF is attributed to improved clinical examination, neonatal resuscitation and care,most importantly time of presentation to a pediatric surgeon.Late presentation or Delay in diagnosis leads to poor outcome.


   Phytobezoar in a 2 day old newborn: A mysterious cause of intestinal obstruction Top



   Category: Neonatal Prime Poster Top


Ravi Patcharu, Karunesh Chand

Department of Paediatric Surgery, Army Hospital (Research and Referral), New Delhi, India.

E-mail: ravipatcharu@gmail.com

Aim of the Study: Phytobezoars, though are the most common types of bezoars associated with small bowel obstruction in children, however it is extremely unusual in newborns. We present a case of intestinal obstruction in a 2-day-old neonate, who on exploratory laparotomy was found to have a raisin impacted in the distal ileum.

Case Report: Full term male baby, passed meconeum on day 1 of life, accepted breast feeds normally till about 30 hours of life when he developed vomiting which was initially non bilious, then bilious. On admission, nasogastric output was bilious, abdomen was soft, and anal opening was normally located. X ray abdomen showed dilated small bowel loops and no air shadow in the pelvis. Child was taken up for exploratory laparotomy. Intraoperatively, a foreign body was found impacted in the distal ileum and enterotomy revealed a raisin. Interrogation in the post op period revealed that the elder sibling had playfully put a raisin into the mouth of the newborn, which he swallowed.

Conclusions: Bezoars, though rare, should be considered as a cause of neonatal intestinal obstruction in a child who otherwise had normal passage of meconeum and was feeding normally. A careful history needs to be taken and an early exploration is recommended in all neonates with bilious vomiting.


   Massive cervical rhabdomyosarcoma: A surgical and anaesthetic challenge Top



   Category: Surgical Oncology Prime Poster Top


Rishi Dwivedi, Ravi P Kanojia, B Neerja, Ram Samujh

Department of Paediatric Surgery, PGIMER, Chandigarh, India.

E-mail: rishi4702@gmail.com

Aim: we present a case scenario of massive sized cervical soft tissue mass which was occupying the entire cervical region. The size of the lesion posed significant challenge to both anaesthesia team and the surgeon. We aim to discuss the management and rarity of the situation.

Methodology: 2.5 yrs. old boy presented to us with a large cervical mass. The mass was more towards the left and was firm and nontender. There was no respiratory and deglutition problems. He underwent evaluation with CECT and MRI which showed Solid cystic lesion involving the entire neck region with areas of calcification likely malignant with Internal vascularity. AFP was 2.61ng/ml.The initial clinical impression was of cervical mature teratoma. FNAC was done which showed Cyst NOS, no malignant cells. He was subsequently evaluated for anaesthesia point of view for operative planning.

Results: The patient was operated with intubation using video laryngoscope. Back up for tracheostomy was in place in case of difficulty. However the anaesthesia team was able to intubate him uneventfully in supine position. The presentation includes operative demonstration of the incision and other intra op pictures. The lesion was excised completely. There was no major vessel involvement. Post op recovery was uneventful. HPE suggested embryonal variety of RMS with anaplasia. The follow up durations is 6 months now.

Conclusion: Large cervical lesion of the presented variety pose a significant challenge. Intubation planning is critical before the surgeon can start. RMS in cervical region are known but presentation of this size is unusual.


   Pulmonary Blastoma in a 5 day old newborn Top



   Category: Surgical Oncology Prime Poster Top


Pradeep KumarvJena, Pradeep Kumar Jena, Prasanta K Tripathy, Asarantee Kar, Mita Nayak

Department of Paediatric Surgery, S.C.B. Medical College, Cuttack, Odisha, India.

E-mail: drpkjena@gmail.com

Aim: (1) To highlight the extreme rarity of the disease in newborn period. (2) Our experience in the diagnosis and treatment of this unusual tumor in a 5-day female neonate.

Methodology: The newborn was managed in the dept. of Pediatric surgery, SVP PG Institute of Pediatrics, SCB Medical College, Cuttack, Odisha. After initial resuscitation and care of respiratory distress, haematological, biochemical and radiological investigations were performed. Patient was operated and excised specimen send for histopathological study.

Results: The ultrasonographic finding of a hypoechoic lesion without internal vascularity in right thorax prompted us to perform CT scan, which revealed 45X50 mm soft tissue lesion in right lower lobe, suggestive of bronchogenic cyst/mass. During surgery, the lesion was found to be involving whole of the lobe and right lower lobe lobectomy was done. Histopathological and immunohistochemical examinations suggested classical biphasic pulmonary blastoma (CBPB).

Conclusion: Primary pulmonary malignancies are rare in newborn period. This biphasic pulmonary blastoma (CBPB) are seen in adults and are different from pediatric onset pleuro-pulmonary blastoma (PPB). PPB are monophasic and contain mesenchymal components only, whereas CBPB are biphasic containing both epithelial and mesenchymal components. On extensive search of English literature, such adult onset CBPB is not reported in this extreme newborn period.


   Congenital stage IV cervical neuroblastoma : A rare scenario Top



   Category: Surgical Oncology Prime Poster Top


Geetika Mathur, Parveen Mann, Niyaz Khan, Chhabi R Gupta

Department of Paediatric Surgery, Chacha Nehru Bal Chikitsalya, New Delhi, India.

E-mail: drgeetikamathur02@gmail.com

Aim: To highlight a rare case of stage 4 congenital neuroblastoma in 2 months old baby.

Methods: A 2 months old male baby presented with large left cervical neck mass with multiple subcutaneous swellings on scalp and trunk since birth. FNAC and trucut biopsy from masses revealed round blue cell tumor with high N:C ratio with rosette formation and high mitosis. Tumor cells had synaptophysin positivity and focal aberrant expression of CD 99, features suggestive of differentiating type neuroblastoma. The radiological assessment showed multiple lytic lesions of D12, L3 vertebrae, bilateral ischium and left femur. Also seen were well defined lesions in bilateral adrenals , left kidney, liver and lung suggesting multiple metastasis. Bone marrow aspiration and bone biopsy were negative for any tumor deposits.

He was started on neo-adjuvant chemotherapy(Cyclophosphamide and Adriamycin based) for 2 cycles and subcutaneous tumor deposits disappeared, with reduction in size of cervical mass.

Results and Conclusion: The presence of metastatic congenital cervical neuroblastoma in 2 months old baby is noteworthy and highlight the need for early detection and management.


   To highlight diagnostic pitfall for angiosarcoma in one year old child with extremity tumour Top



   Category: Surgical Oncology Prime Poster Top


Geetika Mathur, Parveen Mann, Niyaz Khan, Mamta Sengar

Department of Paediatric Surgery, Chacha Nehru Bal Chikitsalya, New Delhi, India.

E-mail: drgeetikamathur02@gmail.com

Aim: To highlight diagnostic pitfall for angiosarcoma in one year old child with extremity tumor.

Methods: A 1-year-old male child presented with right forearm mass since 6 months. The incisional biopsy had more of necrotic tumor, causing interpretation of IHC difficult. The tissue had spindle cells and desmin positivity and was reported embryonal RMS. It had metastasis to right axillary lymph nodes, occipital and sphenoid bones on presentation.

He received 12 weeks of VAC (Vincristine, Actinomycin D and Cyclophosphamide) neo-adjuvant chemotherapy and had partial response(> 50 % size reduction). He underwent above elbow amputation for mass and histo-pathological examination showed presence of vague vessel formation, giving an impression of vaso-formative tumor on histology. IHC was supportive with positivity of CD31, CD34 and D2 40 and final reporting was angiosarcoma. Post-operatively he developed edema of amputated stump and was given VAC for 4 weeks but later child succumbed to neutropenia.

Result and Conclusion: Angiosarcomas are aggressive malignant vascular tumor extremely rare in childhood. The role of chemotherapy is uncertain, with complete surgical excision as mainstay of treatment albeit possible in only few cases. Post-operative radiotherapy may have a role in local control only.


   Second primary tumor in the same location in abdomen Top



   Category: Surgical Oncology Prime Poster Top


Abhishek Anand, AK Basu, TJ Banerjee, Kuntal Bhaumik

Department of Paediatric Surgery, Institute of Child Health, Kolkata, West Bengal, India.

E-mail: pandeyabhi16@gmail.com

Aim: To report a case of second primary tumor in abdomen within 6 months which was managed successfully.

Methods: Patient presented at 2 months of age with retro peritoneal tumor which was excised completely and sent for biopsy.At the age of 8 months tumor reappeared in the same location which was again resected and sent for biopsy.AFP before 1st operation was 323 and before 2nd.

Results: First resected tumor revealed teratoma and the second one revealed neuroblastoma with poor MKI .4 cycles of chemotherapy administered after 2nd operation. 1 year after chemotherapy PET scan was performed.patient is tumor free at present.

Conclusion: Appearance of tumor on same side may not be recurrent but may rarely be 2nd Primary tumor.


   Bronchocavitary communication in lung hydatid: Challenges in the management and outcome Top



   Category: Thoracic Prime Poster Top


Nitin Sharma, M Amin Memon, Shipra Sharma, JL Patel

Department of Paediatric Surgery, DKSPGI and Associated Pt JNM Medical College, Raipur, Chhattishgarh, India.

E-mail: nitinsharma4you@gmail.com

Aims: To analyze the presence of bronchocavitary communications and their outcomes.

Materials and Methods: The data between June 2017- May 2019 was obtained. The number of bronchocavitary communications was recorded and they were suture repaired using Polypropylene. The duration required for repair and the average fall in the SPO2 was recorded. Those with incomplete data or follow-up were excluded. The outcome parameters considered were number of bronchocavitary communications, duration of stay, duration of intercostal tube, duration of air leak, requirement of ventilator support.

Results: 36 cases were operated during the study duration. Mean age at presentation and surgery was 6 years (Range 2-14 years). There were 25 right, 8 left and 3 bilateral cysts. The average hospital stay was 14 days (Range:12-34 days). Mean duration of surgery was 2.15 hours (Range:1.45-3.15 hours). Bonchopleural fistulas were present in 34. The average number of communication was 3 (Range: 0-8). The average duration required for suture closure was 30 seconds(Range 20-180seconds). The average fall in the SPO2 was 40% (Range 20-74%). Ventilator support was required in 4 cases. Average duration of intercostals tube drainage was 7 days(Range:6-14 days).

Conclusion: Hydatid cyst lung is generally associated with bronchocavitary communication which requires judicious management.


   Outcomes of management of empyema thoracis in tertiary care children hospital Top



   Category: Thoracic Prime Poster Top


MNS Uday Bhaskar, Lakshmi Sundararajan

Department of Paediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India.

E-mail: naga0910.ub@gmail.com

Aim: To analyze outcomes of management of Stage 2 Empyema thoracis (ET) in a tertiary care children's hospital.

Methods: Cases of Stage 2 ET managed at our institute between May 2014 to Apr 2019 were retrospectively analyzed. The modality of interventions were Intercostal drainage (ICD) tube only (Gr A), ICD with fibrinolytics (Gr B), Video assisted thoracoscopic surgery (VATS) /Debridement (Gr C). Outcomes analyzed are success rate, duration of ICD, length of hospital stay and complications. Cases were divided into necrotising (NP) and non-necrotising pneumonia (NNP). Different modalities within each division were compared and analyzed statistically.

Results: 50 children were included in our study of which 41 were NNP and 9 were NP. Out of 41 in NNP, 6 were in Gr A, 7 in Gr B, 28 in Gr C. In 9 cases of NP, 2 were in Gr A, 1 in Gr B and 6 in Gr C. Outcome analysis showed there is difference between Gr A and Gr C regarding ICD duration. Children with NP (4/9) had higher failure rate with treatment than NNP (5/41, 3 in Gr A). 3 children with NP had air leaks compared to 1 in NNP. There was no mortality in our series.

Conclusion: ICD with fibrinolytics and primary VATS are both modalities of choice in Stage 2 empyema. Failure rates and complications in NP are higher when compared to NNP.


   Mediastinal teratoma in paediatric age group Top



   Category: Thoracic Prime Poster Top


VK Singh, V Shankar Raman, SK Dey, Ikroop Kaur Sahota

Department of Paediatric Surgery, Command Hospital (SC), Pune, Maharashtra, India.

E-mail: singhvivec@yahoo.co.in

Abstract: Introduction: Teratoma is a neoplasm with tissue components derived from ectoderm, mesoderm and endoderm. These are commonly found in ovaries, testes, retroperitoneum, and sacrococcygeal region. Mediastinal teratomas are rare tumours.

Case Report: We are presenting a case of a 15 months old female who presented with a history of frequent cough of 6 months duration. Chest X Ray showed a homogenous opacity in antero-superior mediastinum with calcifications. CT Chest revealed a 7.7x5.6x5.8cm fairly large well defined heterogenous lesion involving the left hemithorax with multiple pockets of fatty component and large calcifications. Tumour markers (β hCG, LDH and AFP) were normal. The teratoma was excised via an anterior thoracotomy. Intra-operatively, 8x8cm solid cystic teratoma arising from the anterior mediastinum was excised leaving a sliver of adherent pseudo-capsule on the pericardium.

Discussion: The case is being presented here because mediastinum is a rare site (1-3 % of all germ cell tumours) for teratoma and children are less commonly affected. The imaging modality of choice is CECT. Most of the times, benign teratomas are asymptomatic and discovered incidentally on Chest X-ray. Complete resection of benign teratoma is curative and there is no role for adjuvant chemotherapy or radiotherapy.


   Congenital diaphragmatic hernia with associated conditions- A challenging case managed successfully Top



   Category: Thoracic Prime Poster Top


Saurabh Tiwari, Pratik Raut, Paras Kothari, Shalika Jayaswal, Abhaya Gupta, Vishesh Dikshit, Geeta Kekre

Department of Paediatric Surgery, L.T.M.M.C and L.T.M.G Hospital, Mumbai, Maharashtra, India.

E-mail: 12saurabh@gmail.com

Aim: To describe a case of congenital diaphragmatic hernia (CDH) with challenging associated conditions like persistent pulmonary hypertension (PPHN) and persistent gastroesophageal reflux (GER) managed successfully.

Methods: A term baby weighing 2.3kg, with antenatally detected left-sided CDH, cried immediately after birth and was given oxygen by hood. He was vitally stable with decreased air entry on left side of chest. CDH repair was done on Day 1 of life and baby was on ventilatory support. After developing PPHN, he was shifted to high frequency oscillatory ventilator (HFOV) on Day 8 and put on multiple vasodilators. Feeds were started on Day 13 after which he developed ventilator-associated pneumonia and GER.

Results: After failing all medical management, feeding gastrotomy was done in the NICU BEDSIDE but GER persisted. After 6 weeks of HFOV support baby was weaned off and put on conventional ventilator. Nissen's fundoplication was then done after which GER episodes reduced. Baby started tolerating feeds and was discharged on Day 73 on gastrostomy tube feeds after suture removal with no surgical side infection.

Conclusion: GER is a known association of CDH but is usually well managed medically. In rare scenarios, repeated surgical intervention may be required.


   Empyema- A rare sequelae of diesel ingestion in a child: A case report Top



   Category: Thoracic Prime Poster Top


PS Madhulika, A Narendra Kumar, S Srinivas

Department of Paediatric Surgery, Osmania Medical College, Niloufer Hospital, Hyderabad, Telangana, India.

E-mail: drpsm.mch@gmail.com

Aim: To present a Rare case of chemical pneumonitis with Empyema and it's management.

Introduction: Chemical pneumonitis refers to the aspiration of any compound that is an irritant to the lungs. The more soluble agents tend to involve the upper respiratory tract, whereas less soluble agents reach the distal airways.

Methods and Results: We are reporting a case of 10years old girl who developed empyema secondary to accidentally ingestion of Diesel and presented to us with respiratory distress and lower respiratory tract infection. The child was stabilized, evaluated and diagnosed with chemical pneumonitis with Empyema of left lung. Through Right Posterolateral Thoracotomy approach thoracic cavity entered and intraoperatively right middle lobe was noticed to be densely adherent to lower lobe along with thick pus filled cavity, Right middle Lobectomy was done. Post operatively child recovered well and discharged with monthly follow up.

Conclusion: Diesel ingestion and aspiration is an uncommon cause of chemical pneumonitis, and aspiration leading to empyema is an even rarer occurrence. Importance should be given to history taking when evaluating a case of acute respiratory distress and should be admitted and evaluated for respiratory system and gastrointestinal tract sequelae.


   Rib osteomyelitis with empyema chest: A case report Top



   Category: Thoracic Prime Poster Top


Nitin Vyas, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: nitintg@gmail.com

Aim: To study a case of empyema chest with rib osteomyelitis.

Methods: This is a study of a case of 1 month male neonate who presented with high grade fever with cough and breathlessness since 4 days. On exam, baby had right chest wall abscess with absent breath sounds in right middle and lower zones. Chest X ray was suggestive of right sided pleural effusion. CT chest revealed consolidation of right lower lobe, loculated right pleural effusion, soft tissue swelling overlapping anterior end of right 6th rib with air within; suggestive of abscess and early erosion of anterior end of rib. Right thoracotomy with drainage of chest wall abscess with subperiosteal excision of right 6th rib with debridement of right necrotising lower lobe pneumonia with decortication of lung was done.

Results: Patient had prolonged hospital course but eventually recovered well.

Conclusion: Osteomyelitis of rib is a rare entity. Osteomyelitis of rib with Empyema chest is very rare.


   Recurrent congenital diaphragmatic hernia repair with meshplasty Top



   Category: Thoracic Prime Poster Top


S Soundharya, Sandesh V Parelkar, Beejal V Sanghvi, Rahul K Gupta, Kedar Mudkhedkar, Rujuta Shah, Deepa Makhija

Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India.

E-mail: soundharya.s@gmail.com

Introduction: Recurrence remains one of the most feared complications after congenital diaphragmatic hernia (CDH) repair. Incidence of recurrence in CDH can vary from 3-22% based on multiple factors. We present a case series of 3 cases of recurrent CDH operated either by open or by thoracoscopic method by using a mesh.

Description: Over the last 10 years, 115 patients of CDH have been operated thoracoscopically. Three patients who were initially operated in the neonatal period for CDH, presented during infancy with a recurrence. One patient was reoperated by a thoracotomy while the other two underwent thoracoscopic repair. All three patients were provided meshplasty for additional reinforcement, and all three patients are doing well on follow up till date. A literature review shows only 2 reports where mesh and mesh fixation devices have been used in pediatric cases of CDH. Hence we present this series for highlighting the advantages of mesh repair in a recurrent CDH.


   Diagnostic difficulty and thoracoscopic approach of bronchogenic cyst: A series of four cases Top



   Category: Thoracic Prime Poster Top


Swetha Edamakanti, Sudhakar Jadhav, Santosh Patil

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: eswethareddy22@gmail.com

Aim: To study diagnostic difficulties and Thoracoscopic approach of bronchogenic cyst.

Methods: In our study 4 patients, 3 males and one female .Youngest being 8 months and oldest being 9 years. These patients presented with recurrent episodes of lower respiratory tract infection. symptoms were present since birth in 2 patients and for duration of 3 months in 2 patients. Considering empyema and pneumothorax intercoastal drainage was put in 3 patients without improvement before they reached us . One patient was diagnosed with pneumonia.Diagnostic bronchoscopy was normal. CECT chest revealed bronchogenic cyst . In 3 cases thoracoscopic excision was done and one case thoracotomy with excision was done . Histopathogy confirmed brochogenic cyst.

Results: The patient did well post operatively.

Conclusion: In patients presenting with recurrent urti-hrct chest evaluation is mandatory. thoracoscopic approach for bronchogenic cyst.


   Post button battery ingestion tracheoesophageal fistula in children: A case for conservative management Top



   Category: Thoracic Prime Poster Top


Garvita Singh, Satish Kumar Aggarwal, Rupa Banerjee, Muni Varma, Nishant Wadhwa, Anil Sachdev

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: garvitasingh429@gmail.com

Aims and Objectives: Accidental ingestion of button batteries may cause tracheoesophageal fistula due to chemical burn of oesophagus and adjacent tracheal wall. We report 4 cases of post button battery ingestion induced TEF and their management.

Case Reports:

  1. A 21 months old boy presented with respiratory distress and cyanosis following endoscopic removal of an ingested button battery lodged in his oesophagus. He required ventilatory support- ET tube was placed beyond the TEF discovered on endoscopy. CECT and bronchoscopy defined the fistula at D1 level. He underwent decompressive gastrostomy and feeding jejunostomy and 12 days later, left lateral cervical oesophagostomy had to be done. 6 months later, a delayed repair of TEF was done and child recovered well post operatively.
  2. A 20 months old boy presented with cough, swallowing difficulty and hoarseness post button battery ingestion which had been removed endoscopically within few hours of ingestion. Bronchoscopy revealed TEF. Upper GI endoscopy showed fistulous opening on left lateral wall of oesophagus. He underwent feeding jejunostomy and managed conservatively. He became asymptomatic and bronchoscopy after 2 months revealed a healed TEF. He was allowed oral feeds and a contrast swallow revealed normal oesophagus.
  3. A 20 months old girl presented with cough and swallowing difficulty 15 days post button battery ingestion, which had been removed on the day of ingestion itself. Upper GI dye study showed TEF at T1 level. She underwent decompressive gastrostomy and feeding jejunostomy and was discharged on jejunostomy feeds. Bronchoscopy done 3 months later revealed a healed TEF. She tolerated oral feeds and there was no oesophageal stricture. Jejunostomy and gastrostomy were removed.
  4. A 16 months old girl presented with respiratory distress after button battery ingestion, which had been removed on day1. She had undergone a tracheostomy and was on NG feeds. Bronchoscopy after 1 month revealed a large TEF at posterolateral wall of trachea. A decompressive gastrostomy and feeding jejunostomy was done. She is awaiting repair.


Conclusion: TEF can occur in post button battery ingestion even when endoscopically removed as soon as within 6 hours of ingestion. Staged management should be preferred as there can be spontaneous healing of the fistula and also in acute phase the tissues are friable and necrotic. In some cases repair of TEF is needed and further oesophageal dilatation may be required. Has good prognosis if identified early and managed vigilantly.


   To study the outcomes of preputioplasty in patients undergoing tip urethroplasty (tubularization of incised urethral plate) for hypospadias repair Top



   Category: Urolgy Prime Poster Top


Gunjan Shoor, Deppak Bagga, Samir Kant Acharya, Nidhi Sugandhi, Amitkumar Jadhav, Narinder Teckchandani, C Goutam, Anand Dixit, B Amit, Himanshu, Anjana Sreedharan, Saurav Srivatsav

Department of Pediatric Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

E-mail: amit5249@yahoo.co.in

Aim: To study foreskin outcomes in patients undergoing TIPS procedure for hypospadias repair with preputial reconstruction in terms of preputial tightness and cosmetic acceptability.

Methods: An observational prospective Study carried out in Department of Pediatric surgery, from March 2017 to December 2018. 50 consecutive patients attending OPD for intended hypospadias repair, were enrolled in our study. Outcomes were assessed in terms of preputial tightness, need for circumcision, over all look and acceptability to the Parents and surgeon. Only percentages were used for statistical purpose.

Results: Out of 50 consecutive cases of hypospadias fitting into the inclusion criteria, 2 were excluded. 3 of 48 patients who underwent preputial reconstruction had preputial dehiscence. 2 of 48 patients had tight prepuces at 3 months and tightness persisted in 1 patient at 6 months who was offered circumcision. 36/48 (75%) had normal looking prepuces, 3/48 (6.25%) had ventral tethering, 3/48 (6.25%) had irregular preputial hood, 2/48 (4.16%) had redundant prepuce, In 2/48 (4.16%) there were persistent whorls on the dorsum.

Conclusion: Preputial reconstruction is feasible with good cosmetic outcome and with minimal complications in most patients of hypospadias without chordee which is acceptable both to the parents and to the surgeon.


   To study the relationship between Glans width and surgical outcome in distal penile hypospadias Top



   Category: Urology Prime Poster Top


Anand Dixit, Samir Kant Acharya, Deppak Bagga, Nidhi Sugandhi, Amitkumar Jadhav, Narinder Teckchandani, C Goutam, Gunjan Shoor, B Amit, Himanshu, Anjana Sreedharan, Saurav Srivatsav

Department of Pediatric Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

E-mail: drsamir293@gmail.com

Aim: To compare rate of various post-TIP complications in distal penile hypospadias with small width versus normal width glans.

Materials and Methods: This prospective observational study comprises of 30 cases of distal penile hypospadias in the department of Paediatric surgery, Safdarjung Hospital, New Delhi from June 2017 to December 2018. All the 30 boys of distal penile hypospadias underwent primary TIP urethroplasty repair with strict adherence to procedure described by W Snodgrass. The age group ranges from 18 months to 120 months with mean age of 59.6 months.

Results: Meatal stenosis in relation to glans width was found in 5 of patient with gw <12mm, 4 patients with gw >12 mm. Total of 9 out of 30 patients at the end of two weeks. 02/09 patients having poor stream improved at 3 month. 04/07 patients were subjected to regular calibration with 08 Fr Feeding tube after 3 months, after which the flow of urine significantly improved. Only 2 patients 2 year and 9 year of age respectively, required weekly regular calibration beyond 6 months and intermittent calibration is still needed, confirmed by the telephonic survey.

Conclusion: Glans width does not have significant effect on surgical outcome in cases done by experienced surgeon.


   Testicular prosthesis in children following orchidectomy Top



   Category: Urology Prime Poster Top


K Prabhu, Vinay, Ramesh S

Department of Paediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India.

E-mail: k.prabhucr@gmail.com

Aim: To Assess the feasibility of the Testicular Prosthesis in children post orchiectomy status.

Methodology: All children post orchiectomy for non-palpable testis, testicular torsion, testicular tumour, various disorders of sexual development undergoing masculinizing genitoplasty from 2014-2018 were involved. Size of the inserted prosthesis was based on the age. Prosthesis was made of medical grade silicone elastomer. Children were followed up to look for signs of prosthesis rejection and wound infection. In case of wound infection, skin necrosis and foreign body rejection, prosthesis was removed. Children with scrotal abscess post orchiectomy were excluded.

Results: Total numbers of children were 25. Among them 15 were for absent testis, 2 for testicular tumors, 4 for testicular torsion,4 for 46 xx DSD reared as male,. 15 Children are well, 7 lost for follow up, 3 children had complications. Two children had skin necrosis, one had foreign body reaction and they underwent prosthesis removal.

Conclusion: Contemporary placement of testicular prosthesis in children following orchiectomy is a feasible option. It provides psychological and cosmetic benefit and confidence for children with testicular disorders, which was enforced by the feedback form the parents and patients themselves.


   A retrospective study on the outcome of pyeloplasty in poorly functioning kidneys Top



   Category: Urology Prime Poster Top


KT Sreekanth, Ravi Kishore, Sundeep Kisku, L Arun Kumar

Department of Paediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India.

E-mail: ktsreekanth06@gmail.com

Aim: To study the outcomes of pyeloplasty done in kidneys with less than 15% split renal function secondary to pelviureteric junction obstruction.

Methods: All children who underwent pyeloplasty in Christian Medical College between 2008 to 2018 were screened. 50 children who underwent pyeloplasty for pelviureteric junction obstruction with split renal function less than 15% were selected for study. Those secondary to VUR and cases of redo-pyeloplasties were excluded. Preoperative split function was assessed with DTPA/ EC scan. The preoperative antero-posterior pelvic diameter was also recorded. The post-operative outcome was assessed at 1 year in terms of split renal function with DTPA/ EC scan and reduction in antero-posterior diameter of renal pelvis.

Results: The mean age was 5.36 years and ranged from 2 months to 13 years. There was a 2:1 predominance of left to right side. The preoperative split function ranged from non-functioning kidneys to 15% with a mean function of 9.2%.The mean post-operative split renal function was 17.9 % with 2 cases requiring nephrectomy at follow up. The mean antero-posterior diameter pre-operatively was 51.09mm and post operatively was 27.8mm.

Conclusion: Pyeloplasty preserves the function, even in poorly functioning kidneys and should be considered before nephrectomy.


   Outcomes following ureteric re-implantation in children; a single center observational study Top



   Category: Urology Prime Poster Top


Palreddy Avinash Reddy, N Bhuvaneshwar Rao, KVS Narayana, KT Mandakini

Department of Paediatric Surgery, Niloufer Hospital for Women and Children, Osmania Medical College, Hyderabad, Telangana, India.

E-mail: palreddyavinash@gmail.com

Aims and Objectives: The purpose of this study was to perform a retrospective review and prospective analysis of outcomes after ureteric re-implantation with respect to incidence of UTI, persistance of reflux and new renal scaring.

Methodology: All consecutive patients 1month to 12 years of age since August 2017 ,who underwent ureteric re-implantation for primary VUR ,Obstructed megaureters, duplication anomalies were included in the study.

Results: Total number of patients studied were 28 with 41 case units(Each ureter re-implanted was taken as single case unit).Mean age of presentation was 3.5yrs with male to female ratio of 6:1.Of the 41 case units 26 were diagnosed as primary VUR,9 units had obstructed megaureters,3 were duplex moieties,2 with ureteroceles and 1 with para ureteral diverticulum.38 cases underwent Cohens cross-trigonal ureteric re-implantation and Politano-Leadbetter's in 3 cases .5 patients(18%) had breakthrough UTI s following ureteric re-implantation within one year of surgery. 14.6% had persistence of reflux at six months following surgery. Differential function decrease of more than 10% was seen in 12% .New scars were seen in 4.8% at end of one year.Six patients(21.4%) had to undergo redo surgeries.(2 wound dehiscence, 2 persistent high grade reflux, 1 opposite side reflux, 1 exploration).

Conclusions: The present results show ureteral re-implantation to be a safe and effective way of preventing UTI's.Ureteral re-implantation has been successful in preventing further deterioration.


   Role of Double-J stenting in primary obstructive megaureters Top



   Category: Urology Prime Poster Top


Anupam Lall

Department of Paediatric Urology, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom.

E-mail: anupamlall@doctors.org.uk

Aims: Double-J (DJ) stenting has been described as temporising treatment for persistent orprogressive primary obstructive megaureter in pediatric patients. To determine the efficacy and potential complications of DJ stenting a retrospective casenote review was done at our institution.

Methods: During 2009 - 2017, 22 obstructive megaureters in 15 patients were stented. Complications both intra and postoperative were recorded. The main indications for stenting were recurrent urinary tract infections despite being on prophylaxis, reduction in functions and increasing hydro-ureteronephrosis. Patients were followed up (9-65 months) and need for definitive surgery was endpoint.

Results: The age at stenting varied from 3 to 20 months. M:F ratio was 1:1. All stents were inserted endoscopically under fluoroscopic guidance. Ureteric size varied from 10-28 mm and function on DMSA varied from 24 - 47%. Complications included two cases of stent migration into ureter, 4 cases of haematuria (microscopic to gross) and four cases with recurrent urine infections. All had some degree of discomfort due to bladder spasms and were on oxybutynin. There were 14 stent related hospital admissions (mean of 1.2, one requiring up to 4 admissions). Post stenting ultrasound showed partial resolution in 10 and no resolution in 12 units. Repeat DMSA scans on three patients showed further deterioration in renal functions. Nine patients (60%) have had ureteric reimplantation with or without tapering at age ranging from 9-26 months and have no complications. Remaining six patients are on close follow up to look for deterioration in functions or resolution of dilatation.

Conclusions: DJ stenting is not without complications. Stent migration and inadequate decompression meant the benefits are temporary and majority will need ureteric reimplantation. The only benefit of stenting was delaying reimplantation to a later date in very young children. However consideration should be given to do reimplantation as primary procedure at the outset in these cases as its safe.


   Coverings of hernial sac for anterior bladder cover in exstrophy repair: Safe and effective technique Top



   Category: Urology Prime Poster Top


Nidhi Sugandhi, Deepak Bagga, Goutam Chakraborty, Sameer Acharya, Amit Jadhav, Narinder Teckchandani

Department of Paediatric Surgery, VMMC and Safdarjung Hospital, New Delhi, India.

E-mail: drnidhisugandhi@gmail.com

Aim: To describe the technique and outcome of using the coverings of hernial sac as an anterior layer for the cover of turned-in bladder in exstrophy repair.

Materials and Methods: Children with exstrophy and large inguinal hernia were offered repair by this technique. After the bladder closure, the lateral margins of the incision were retracted and inguinal hernia approached from inside the incision. After herniotomy, the coverings of the sac( cremaster muscle , tunica vaginalis)were meticulously preserved on its broad based pedicle and rotated medially . This was then anchored to, symphysis pubis, contralateral superior pubic rami and posterior rectus sheath. Further incision was closed in the usual manner. The rate of fistula formation and wound breakdown were noted.

Results: 5 children with exstrophy and large inguinal hernia underwent above procedure to buttress the bladder repair site. None of them developed a fistula or breakdown of repair, though 1/5 (20%) had superficial wound infection.

Conclusion: In children with exstrophy and large inguinal hernia , it's coverings lends itself for a reasonably robust buttressing barrier layer to effectively reduce the breakdown rates.


   Long-term outcomes of cohen's cross trigonal reimplantation for primary vur in poorly functioning kidney Top



   Category: Urology Prime Poster Top


Ravi Banthia, Priyank Yadav, Sarita Sayal, MS Ansari

Department of Paediatric Surgery, SGPGI, Lucknow, Uttar Pradesh, India.

E-mail: drravivbanthia@gmail.com

Aims: Open ureteric reimplantation by cross trigonal technique described by Cohen is amongst the commonest options for surgical correction of vesicoureteric reflux (VUR). The aim of this study was to assess the long-term outcomes of ureteric reimplantation in poorly functioning kidneys in children with unilateral primary VUR.

Methods: Children with unilateral primary VUR and a relative renal function less than 30% who underwent open or laparoscopic ureteric reimplantation between January 2003 and December 2013 were included in the study. Patients who had a follow up of less than one year were excluded. Preoperative evaluation consisted of a voiding cystourethrogram (VCUG) and dimercaptosuccinic acid (DMSA) scan. In the follow up period, patients underwent diuretic scan at 6 weeks and at 6 months. For assessment of cortical function DMSA was repeated annually for 5 years after surgery. Paired samples t test was used to test the mean difference of DMSA between pre-post observations.

Results: During this period, 32 children underwent ureteric reimplantation for unilateral primary VUR. The grades of VUR were II (1 patient), III (6 patients), IV (9 patients) and V (12 patients). The pre and post operative DMSA was 21.07±8.03 and 21.57±8.77, which was almost same (statistically equal, paired samples t test: p=0.632). One patient had persistent reflux after surgery (preoperative: grade IV, postoperative: grade III). The difference in the preoperative and postoperative DRF was less than 5% in 26 patients. In one patient, the DRF decreased by 10% (22% to 12%) while in another patient, the DRF increased by 7% (34% to 41%) after surgery. 15% patients were hypertensive before surgery and all of them continued to be hypertensive after surgery while no patient developed hypertension after surgery. No patient had significant proteinuria (>150 mg/ day) during follow up period.

Conclusion: Children with unilateral primary VUR and poorly functioning kidney maintain the renal function over long term in most cases. Hypertension and proteinuria does not progress over time in these patients.


   Early warning parameters for the development of chronic kidney disease in children with posterior urethral valves Top



   Category: Urology Prime Poster Top


Ravi Banthia, Priyank Yadav, Sarita Sayal, MS Ansari

Department of Paediatric Surgery, SGPGI, Lucknow, Uttar Pradesh, India.

E-mail: drravivbanthia@gmail.com

Aims: Serum creatinine levels and the presence of dysplasia have been traditionally used as prognostic markers for the progression of Chronic Kidney Disease(CKD) in children with Posterior Urethral Valve(PUV). We evaluated the role of urinary indices as prognostic factors to predict the progression to CKD3 and above in children undergoing Trans Urethral Valve Fulguration(TUVF) for PUV.

Methods: We conducted a prospective study from January 2014 to January 2019. The baseline demographics, laboratory and imaging parameters were observed. Children with eGFR<60ml/min at presentation were excluded. We evaluated 24-hour urine protein, creatinine and volume (24P, 24C and 24V), urine protein creatinine ratio (P:C), urine microalbumin, urine pH and osmolality on post op day 2(POD2) following TUVF. On follow up, the children were grouped into CKD grades 3 and above (group A) and CKD1-2 (group B) on the basis of their nadir creatinine and eGFR in the first year after TUVF.

Results: A total of 92 children were included. Median follow up was 22.4 months. Median age was 30 months(2-140). On follow up the number of patients in group A was 67 and group B was 25. Median 24P was 0.379 g/day, 24C was 0.135g/day and P:C was 2.64. On logistic regression, 24P (β-0.412,95%CI-0.263 – 0.56) and P:C ratio (β-0.044,95% CI 0.024- 0.064) were found to significantly predict the progression to CKD3 and above in these children. ROC curve for 24P and P:C was drawn and area under curve was 0.7719. A cut off of 1.73 for P:C yielded a specificity of 82% and sensitivity of 80.5%. Additionally predictors, which were statistically significant, were serum creatinine at presentation and age at TUVF.

Conclusion: POD2 24 hour urine protein and protein creatinine ratio (cut-off 1.73) can be used to predict the development of CKD3 and above in children with Posterior Urethral Valves undergoing Trans Urethral Valve Fulguration.


   Ureteric reimplantation in infants with vesicoureteric reflux – Our experience Top



   Category: Urology Prime Poster Top


Rohit Gopinath, Velmurugan, C Saravanan, Aniruthan

Department of Paediatric Surgery, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India.

E-mail: rogopaedsurg@gmail.com

Aim: To assess our results of reimplantation in infancy. To assess bladder function post reimplantation in infancy.

Materials and Methods: This is a retrospective study conducted between December 2015 to May 2019 including 30 children between the age group of 6 months to 1 year who presented to the 2nd surgical unit , Department of Paediatric surgery , Institute of Child Health .Materials collected included age , sex , USG abdomen, MCU , DMSA ,surgical technique ,Post op USG abdomen Post op MCU and UDS.

Results: Average follow up period was 13 months. 70% of the children operated were male.65% of the children were operated beyond 9 months of age. Antenatal diagnosis of a Ureterohydronephrosis was seen in 80% of children. Most of them had grade 4 VUR. 25% of children had scars in a DMSA at 3 months of age while the number increased to 70% at 6 months of age. Post operatively none of the children had a reflux in MCU or significant post void residual urine. Post op DMSA showed no new scars and preserved renal function.

Conclusion: Ureteric reimplantation is a safe option with guaranteed success in infants with high grade reflux.


   Single stage double faced transverse prepucial island flap urethroplasty for proximal penile hypospadias – Our experience Top



   Category: Urology Prime Poster Top


Rohit Gopinath, Velmurugan, C Saravanan, Aniruthan

Department of Paediatric Surgery, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai,

Tamil Nadu, India.

E-mail: rogopaedsurg@gmail.com

Aim: To compare single stage transverse double faced prepucial island flap urethroplasty with staged urethroplasty in the repair of posterior hypospadias.

Materials and Methods: This is a retrospective study conducted between Jan 2015 to may 2019 including 30 children of age ranging from1.5 years to 8 years who had undergone single stage transverse prepucial island flap urethroplasty for posterior hypospadias. Details collected included age, associated anomalies, operating time, blood loss , hospital stay, post op cosmesis, functional outcome.

Results: Average follow up period was 18 months. 80% of the children operated were less than 5 years of age. Average duration of the single stage procedure was 189 mins. Average duration of hospital stay was 7 days which was significantly shorter than in children who underwent staged urethroplasty. Complications in both groups were recorded and was significantly less in the group undergoing the single stage procedure. Only 3 children developed a urethrocutaneous fistula in the group which underwent single stage procedure.

Conclusion: Use of a double faced transverse prepucial island flap for repair of posterior hypospadias is associated with good functional outcome and cosmesis.


   Neurogenic bladder Top



   Category: Urology Prime Poster Top


Saikrishna Vuppala, Narendra Kumar, Sasidhar T

Department of Paediatric Surgery, Niloufer Hospital for Women and Children, Hyderabad, Telangana, India.

E-mail: drsaikrishna88@gmail.com

Aims: To evaluate the effectiveness of non surgical management and follow up in the neurogenic bladder children.

Materials and Methods: This is an observational study in children <12 yrs age presented with neurogenic bladder to the department of pediatric surgery, Niloufer hospital during 2016-2018. Children are evaluated using estimation of serum creatinine, ultrasound, MCUG, DMSA, and urodynamic studies at regular interval. Patients are managed using clean intermittent catheterization and anticholenergic medication.

Results: 59 cases presented with lower urinary tract symptoms among which 31 cases were included into the present study and the remaining were excluded in view of anatomical abnormalities. 93.5% cases presented with abnormal urodynamic studies at presentation. There was a 50% reduction of cases with unsafe end filling pressures of the bladder (>40 cm of H2O) over a period of 2 yrs of follow up.there was 41.9% improvement in bladder complicance and 23% improvement in vesicoureteric reflux.

Conclusion: Non surgical management using CIC and anti cholenergics has positive impact in terms of improvement of symptoms, renal function, reduction of VUR and urodynamics.


   Expect the unexpected! Top



   Category: Urology Prime Poster Top


Ashitha K Unny, T Vidhya, Senthil Ganesh Kamaraj, VK Sairam

Department of Paediatric Surgery, Kanchi Kanchi Childs Trust Hospital, Chennai, Tamil Nadu, India.

E-mail: ashitha.aku@gmail.com

Aim: Series of most common congenital uropathy, pelviureteric junction obstruction(PUJO), presenting with uncommon or life-threatening complications from the PUJO itself or from a pyeloplasty.

Methods: Case-1, 5yr old PUJO with malignant hypertension and PRES (posterior reversible encephalopathy syndrome), Page-kidney type phenomenon, ruptured renal calyx and large sub capsular urinoma. Underwent emergency drain and jj stenting.

Case-2 Infant presented in acute renal failure with bilateral PUJO. Necessitated emergency jj stenting.

Case-3 Infant underwent Redo Pyeloplasty- developed VUJ obstruction secondary to coiled stent and perinephric leak, underwent cysto-ureteroscopic stent repositioning under image guidance.

Case-4, 11 Year old presented with PUJO, underwent a Laparoscopic Pyeloplasty and stent removal two months later, warranted emergency restenting secondary to acute obstruction and repeat stent removal after 3months.

Case-5, 12 Year old had undergone a pyeloplasty with a stent tube cum nephrostomy .Developed gross urinary leak after removal of the stent tube. Underwent guided nephrostomy tube placement with cystoscopic JJ stent placement

Results:

Case1- hypertension resolved and pyeloplasty done.

Case2- Underwent pyeloplasty later.

Case 3-Perinephric leak settled, JJ stent removed after 8 weeks

Case 4- Asymptomatic after the second stent removal

Case 5-Leak settled. Nephrostomy removed on day 5, stent after 8 weeks.

Conclusion: This common uropathy can be associated with uncommon and severe complications: requiring awareness, prompt diagnosis and timely management.


   Comparison of reinforcing tunica vaginalis flap and dartos flap to tubularized incised plate urethroplasty in distal penile hypospadias Top



   Category: Urology Prime Poster Top


Anju Verma, Shashanka Shekhar Panda, Simmi K Ratan, Sujoy Neogi

Department of Paediatric Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India.

E-mail: anju_v2006@rediffmail.com

Aim/Purpose: To present our experience of comparison of reinforcing tunica vaginalis flap (TVF) and dartos flap (DF) to tubularized incised plate (TIP) urethroplasty in distal penile hypospadias.

Methods: A total of 40 patients of distal penile hypospadias were repaired using TIP urethroplasty with TVF or DF as second layer from December 2017 to January 2019. Post-operative complications namely wound infection, urethral fistula, meatal stenosis were recorded and analysed. Re-do surgery was considered as failure of the operative procedure. Out of 40 patients, in 22 patients TIP with DF was used (Group A) and in 18 patients TIP with TVF was used (Group B). Mean post-operative follow-up was 6 months.

Results: During the follow-up complications noticed included wound infection (Gp A-3, Gp B-2), urethrocutaneous fistula (GP A-7, Gp B- 4), flap necrosis (Gp A- 2, Gp B -0), scrotal hematoma (Gp A- 0, Gp B- 2) and meatal stenosis (Gp A-1, Gp B- 0).

Conclusion: To conclude, TVF as an additional cover is associated with an acceptable complication rate and good cosmetic results as compared to DF and is technically easy to learn.


   An unusual ureterocele: A pointer to embryology? Top



   Category: Urology Prime Poster Top


Sugandh Chadha, T Vidhya, T Heera, Anis Akhtarkhavari, Thulasiraman, S Balasubramanian, S Namasivayam

Department of Paediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India.

E-mail: sugandhchadha@gmail.com

Aim:- In this case report, cystoscopy of a child with Ureterocele showed an unusual appearance. This case is presented as it may lead on to unravel the embryology of Ureterocele.

Materials and Methods:- A 20 month-old male child with history of recurrent UTI, on evaluation found to have duplex system on right with lower moiety high grade reflux, upper moiety ureterocele and high grade reflux on left side. Cystoscopic examination revealed a very unusual appearance of the upper moiety orifice with ureterocele. Bilateral ureteric reimplantation was carried out. The excised right distal end of ureter with Ureterocele was subjected to histopathological examination to find out more about the relationship of this case with embryology of Ureterocele.

Results:-HPE of ureter at the level of membrane, proximal to the membrane and distal to the membrane showed histopathological changes suggestive of Chwalla membrane theory.

Conclusion: Histopathological examination of the excised specimen of an unusual ureterocele showed pointers for Chwalla membrane theory of embryology.


   Outcome and prognosis of antenatally detected hydronephrosis Top



   Category: Urology Prime Poster Top


G Vidhya, Monika Bawa, Ravi P Kanojia, Ram Samujh

Department of Paediatric Surgery, PGIMER, Chandigarh, India.

E-mail: aanoor90@gmail.com

Objective: To analyze prevalence, associations, significance and prognosis of antenatally diagnosed hydronephrosis.

Methods: Prospective observational study involving 108 consecutive pregnancies diagnosed with fetal hydronephrosis (HN) and their postnatal follow up over a period of 2.5years. All the patients were evaluated with antenatal and post natal ultrasonography of KUB, renal function tests and urine culture. Follow up investigations and management was individualized for all patients.

Results: In 60% patients HN was detected in the second trimester scan around 20 weeks. Hydroureteronephrosis(HUN) was detected in 9%. Bilateral HN was seen in 50%. Amongst unilateral HN, left sided HN was seen in 56%. Male to female ratio was 2.5:1. Postnatal investigations revealed obstruction in only 3 patients, non-functioning kidney in 2, and MCDK in 5. Average antero-posterior diameter of pelvis was 8mm. Except for 6 patients who had oligohydramnios rest all had adequate liquor. Only 3 patients presented with urosepsis. Most of the lesions were isolated (85%). 5% patients needed intervention for obstruction and rest of HN with unobstructed drainage on imaging are managed conservatively with spontaneous resolution in 60% of them by 2 years.

Conclusion: Most of the unilateral hydronephrosis diagnosed antenatally needed no intervention postnatally and resolved spontaneously. Prognostication of HN accurately is a must to relieve the anxiety of the parents.


   Testicular remnant “nubbin” and their histopathology correlation: Is excision absolutely necessary? Top



   Category: Urology Prime Poster Top


Biangchwadaka Suchiang, Manish Pathak

Department of Paediatric Surgery, AIIMS, Jodhpur, Rajasthan, India.

E-mail: dbbcc17@gmail.com

Aim: To determine whether excising a testicular remnant or nubbin is necessary based on their histology.

Materials and Methods: The retrospective study was done between may 2016 and June 2019 in the Department of Pediatric Surgery in our institution, where demographic data, intra-operative findings and histopathological reports were analysed.

Results: 43 cases of impalpable undescended testis, out of which nubbins were identified in 9 cases. These nubbins were excised and sent for histopathological examination. Out of the 9 cases, 4 had tissues of vas deferens, 1 had vas deferens and calcified seminiferous tubule, 2 had only fibro-collagenous and fibro adipose tissue, while 2 had ectopic adrenal cortical rest, none of which had any testicular tissue nor germ cells.

Conclusion: A testicular nubbin is a condition whereby no testicular tissue can be identified in a case of impalpable testis, either in the form of a testicular remnant, nodule or a strand of testicular tissue. The presence of a potential germ cell increases the risk of malignancy; hence excision has been advised.

Since none of the cases demonstrated any testicular tissue or germ cells, we may conclude to a certain extent that excision of nubbins may not be necessary, although more studies are required to confirm the same.


   Congenital urethral stricture: A case report Top



   Category: Urology Prime Poster Top


Nitin Vyas, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Pediatric Surgery Centre and P.G. Institute, Sangli, Maharashtra, India.

E-mail: nitintg@gmail.com

Aim: To study a case of congenital urethral stricture.

Methods: This is a study of a case 3 days male neonate who presented with poor stream of urine since birth. Initially catheterisation was attempted but was not possible. USG revealed bilateral hydro-uretero-nephrosis. Ascending urethrogram revealed dilated posterior urethra.After stabilization vesicostomy was done. Baby was thriving well. Six months later, repeat USG revealed bilateral hydro-uretero-nephrosis. MCU revealed gross left Vesico-ureteric reflux with dilated posterior urethra. Cystoscopy using ureteroscope showed stricture posterior urethra, trabeculared bladder wall with no evidence of posterior urethral valves. Dilatation of urethral stricture was done. Following this, serial urethral dilatation was done once a month for next 4 months. At 1 year of age, vesicostomy was closed after adequate calibre of urethra was confirmed on cystoscopy.

Results: Baby is passing good stream of urine with no complains.

Conclusion: Urinary Diversion with urethral dilatation is a treatment option for congenital stricture urethra.


   Obstructed hemivagina and ipsilateral renal anomaly syndrome associated with pouch colon Top



   Category: Urology Prime Poster Top


Priyanka Garg, Nitin J Peters, Muneer A Malik, Ram Samujh, Anmol Bhatia

Department of Paediatric Surgery, PGIMER, Chandigarh, India.

E-mail: priyanka1986mittal@gmail.com

Background: Werner-Wunderlich Syndrome, otherwise known as obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), is a rare Mullerian anomaly consisting of uterine didelphys, hemi vaginal septum, and ipsilateral renal agenesis. Association of OHVIRA with anorectal malformations is extremely rare. We report a case of OHVIRA associated with pouch colon.

Case Report: We report a case of 13 years old girl; presenting with right lower abdominal pain since, 3 months. She had not attained menarche. On palpation, 6*6cm tender, soft to firm mass was present in suprapubic region. Child was an operated case of high anorectal malformation with type 4 pouch colon; all stages complete by 3 years. On evaluation, USG KUB was suggestive of non-visualized right kidney and right uterine and tubal collection. MRI pelvis was suggestive of uterine didelphys, hematometrocolpos, hematosalpinx and absent right kidney and ectopic left kidney. On cystoscopy and genitoscopy, urinary bladder was normal with bulge in posterior wall with a septate vagina. Initial management was done by a tube a vaginostomy. Suprapubic exploration and a vaginoplasty was carried out. The patient was kept on routine vaginal dilatations for the initial 3 months. Presently patient is having regular menstrual cycles and is asymptomatic over a close follow up of 2 years.

Conclusion: While OHVIRA cases usually present at an older age, it is important to keep this in the differential diagnosis in female patients with renal agenesis with or without association with other, anomaly. Management entails vaginoplasty and close follow up.


   Squamous metaplasia in cutaneous ureterostomies Top



   Category: Urology Prime Poster Top


Suramya Anand, Minu Bajpai, Prabudh Goel

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: suramya.anand@gmail.com

Aim: Ureterostomy is an uncommon form of urinary diversion and often performed as a salvage procedure while dealing with urinary tract anomalies. Infrequently though, use of ureterostomy for permanent diversion has been reported.

To assess the histopathological alterations and look for any metaplastic changes at the site of ureterostomy at the time of ureterostomy closure.

Materials and Methods: Prospective study on eight specimens collected from 8 children (all male) who underwent ureterostomy closure over the past two years (January 2017 onwards). Full-thickness biopsies were taken for histopathological assessment at the time of ureterostomy closure and evaluated for presence of metaplasia and other histopathological alterations.

Results: The histopathology was unremarkable with urothelium-lined tissue and fibro-muscular tissue in the sub-epithelium in 2 of 8 (25%) specimens. Mild to moderate chronic inflammation was seen in 6 of 8 (75%) and fibrosis was seen in 5 of 8 (62.5%) of cases with no evidence of dyplasia/metaplasia. Squamous metaplasia was found in 2 of the 8 (25%) biopsy specimens.

Conclusions: Very few reports of development of carcinoma in the ureterostomized ureter have been described in literature and mostly in the adult population. Yet, as shown in this study, due to the presence of metaplasia this remains a very real risk and calls for long-term follow-up and surveillance in children who undergo a cutaneous ureterostomy , even after ureterostomy closure.


   A retrospective review of management of urethral prolapse in young girls Top



   Category: Urology Prime Poster Top


Subash Chandra Subudhi, Harshjeet Singh Bal, Tarun John K Jacob

Department of Paediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India.

E-mail: subashsubu@gmail.com

Aim of the Study: Urethral prolapse is a rare condition , evidenced by circular protrusion of the distal urethra through the external meatus. It has to be distinguished from other differentials by examination such as ureterocele, tumours, sexual abuse. The aim of the study was to know the benefits of surgical treatment in urethral prolapse.

Methods: A retrospective review of two young girls who had presented to us with mass per vulva associated with mild vaginal bleeding and dysuria. Both of them underwent surgical excision of circular strangulated urethral prolapse followed by urethral repair.

Results: The most common symptoms were mass per vulva ,vaginal spotting and bleeding. No predisposing factor was found, but both patients had a mean weight, height and BMI greater than the 50th percentile. Both of the patients underwent surgery successfully. They voided freely after removal of foley's catheter. There was no case of recurrence after 12 months of follow-up.

Conclusion: Urethral Prolapse is a rare condition occurring in prepubertal girls, which results in a discernible mass and bleeding. UP treatment should begin with conservative therapy therapy. Any complication or recurrence of UP would indicate surgical intervention. The best results were obtained by complete excision of the UP.


   Pediatric penile length anthropometry nomogram from India Top



   Category: Urology Prime Poster Top


D Harikrishna, Hari Krishna Devadasan, Prabudh Goel, Minu Bajpai, Mani Kalaivani

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: krishna.aiims@gmail.com

Aims: To standardize the technique of measurement of stretched penile length and develop a penile length nomogram specific to children of Indian origin.

Patients and Methods: Prospective study on 1276 boys (1-14 years). Technique was standardized, inter-observer/ intra-observer variations were calculated. Observation parameters included age(years), weight(kg) and stretched penile length(SPL).

Results: Standardization of the technique was done on 177 participants enrolled for this study (mean age of 73.06 + 44.08 months). Mean SPL was 5.5 + 1.5 cm (2.8-12.4 cm). Inter-observer variation was 0.02 cm (95% Confidence Interval: -0.02 –0.06) which was ignorable (pvalue= 0.372). The Bland-Altman plot of inter-observer variation has shown that only 4.5% of the observations were out of the 95% limits of agreement.

Centile curves (3,5, 10, 25, 50,75, 90, 97) were generated. SPL increases with age and weight of the child in a non-linear fashion. A spurt in penile length has been observed in the age-group 12-14 years.

Conclusions: This is the largest cross-sectional study on pediatric SPL. The statistical analysis complies with the WHO Child Growth Standards. This will serve as a useful resource for parents and physicians in diverse clinical practices.


   Squamous metaplasia in cutaneous ureterostomies Top



   Category: Urology Prime Poster Top


Suramya Anand, Minu Bajpai, Prabudh Goel

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: suramya.anand@gmail.com

Aim: Ureterostomy is an uncommon form of urinary diversion and often performed as a salvage procedure while dealing with urinary tract anomalies. Infrequently though, use of ureterostomy for permanent diversion has been reported.

To assess the histopathological alterations and look for any metaplastic changes at the site of ureterostomy at the time of ureterostomy closure.

Materials and Methods: Prospective study on eight specimens collected from 8 children (all male) who underwent ureterostomy closure over the past two years (January 2017 onwards). Full-thickness biopsies were taken for histopathological assessment at the time of ureterostomy closure and evaluated for presence of metaplasia and other histopathological alterations.

Results: The histopathology was unremarkable with urothelium-lined tissue and fibro-muscular tissue in the sub-epithelium in 2 of 8 (25%) specimens. Mild to moderate chronic inflammation was seen in 6 of 8 (75%) and fibrosis was seen in 5 of 8 (62.5%) of cases with no evidence of dyplasia/metaplasia. Squamous metaplasia was found in 2 of the 8 (25%) biopsy specimens.

Conclusions: Very few reports of development of carcinoma in the ureterostomized ureter have been described in literature and mostly in the adult population. Yet, as shown in this study, due to the presence of metaplasia this remains a very real risk and calls for long-term follow-up and surveillance in children who undergo a cutaneous ureterostomy , even after ureterostomy closure.


   Supernumerary kidney associated with horseshoe malformation with pelvi-uretric junction obstruction: An unusual case report Top



   Category: Urology Prime Poster Top


Rahul Kumar Rai, SN Kureel, Archika Gupta, Anand Pandey, Survesh Kumar Gupta

Department of Paediatric Surgery, KGMU, Lucknow, Uttar Pradesh, India.

E-mail: drrahul2004@gmail.com

Aim: To report an unusual case of supernumerary kidney associated with horseshoe malformation with pelviuretric junction obstruction (PUJO).

Case Report: 20-months-old female was admitted with complain of lump over left side of abdomen and off and on mild abdominal pain for two months. Physical examination revealed cystic, globular and partially mobile swelling (14x12cm) occupying left lumbar and umbilical region. Ultrasound abdomen and CT pyelography showed horseshoe kidney with left-sided severe hydronephrosis due to PUJO. 99mTc-DTPA diuretic-renography confirmed left-sided PUJO with 12% differential-function. In view of horseshoe kidney, access gained via large transverse incision. Laparotomy revealed horseshoe kidney with left-moiety grossly dilated pelvicalyceal sytem with PUJO and noncanalised ureter and right-moeity dilated pelvis fused to left-sided pelvis. Cephalad to and fused with right-moiety of horseshoe kidney, another malrotated right kidney with anterior pelvis and lateral displaced right ureter was seen. Left noncanalised ureter excised and left-moiety pelvis was directly anastomosed to bladder dome with placement of nephrostomy and perinephric drain. Patient was discharged in satisfactory condition.

Neprostogram after 6-weeks reveals decompression and free drainage of pelvicalyceal system.

Conclusion: Exact knowledge of surgical anatomy of Supernumerary kidney associated with horseshoe malformation with PUJO is must for successful and optimum outcome of pyeloplasty.


   Triplication of ureter: A rare case report Top



   Category: Urology Prime Poster Top


Teg Rabab Singh, Anjan Dhua, Sandeep Agarwala

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: tegrababsingh123@gmail.com

Aim: To describe a rare congenital anomaly with triplication of the left ureter with its attendant diagnostic and management challenges.

Case Report: A 2-year-old male child was antenatally diagnosed with left hydronephrosis. The urinary stream was reported normal, with no history of dribbling of urine. The child had one episode of pyuria at six months of age. General physical examination was unremarkable. USG suggested the possibility of duplex kidneys on the left side. MR urography revealed left gross hydroureteronephrosis with thinning of renal parenchyma and dilated ureters, possibly three, fusing to form a single megaureter, inserting ectopically into the bladder neck or urethra. Renal dynamic scan reported a duplex left system with hydronephrotic, functioning moieties with no obstruction.Left ureteric reimplantation was planned. Excisional tapering ureteroplasty was required after ligating the ureter just proximal to the insertion of the ureter at the bladder neck.Three openings of the trifurcated ureter was confirmed. A modified Leadbetter-Politano reimplantation was then performed. Post-op course was uneventful.

Conclusion: Diagnosis of ureteric triplication can easily be missed and multiple investigative modalities may be required to confirm triplication of the ureter. Management depends on the exact anatomy, presence of reflux and functional status of each moiety.


   Pelvic fracture urethral injury in children: Surgical options and outcomes Top



   Category: Urology Prime Poster Top


Sarita Syal, Shrey Jain, Ravi Banthia, Priyank Yadav, MS Ansari

Department of Paediatric Surgery, SGPGI, Lucknow, Uttar Pradesh, India.

E-mail: drsaritasyal@gmail.com

Introduction: Management of pelvic fracture urethral injury (PFUI) pediatric patients remains a challenging task. In this study, we reviewed our experience of pediatric PFUIs and discussed the current spectrum of potential management options.

Materials and Methods: We retrospectively reviewed the records of 70 boys with PFUI managed at our institute between 1992 and 2017. The etiology, radiologic findings, previous treatment, current treatment complications and failure were evaluated. Preoperative evaluation included clinical & radiological evaluation with RGU/MCU to ascertain the site, length of stricture and state of the bladder neck. Success was defined as presence of initiation, flow, and completion of voiding with radiological evidence of reestablishment of urethral continuity.

Results: The mean age was 12.43 ± 5.17 years (Range 1-18 years). Suprapubic cystostomy was performed in all cases. Mean length of distraction defect was 3.41 cm (range 2-6cm). Urethral manipulation before anastomotic urethroplasty was present in 39 children. They had a satisfactory result similar to those without previous surgical intervention (p>0.05). Reconstruction route was perineal in 69 children (98.5%) and abdominoperineal in one child (1.5%).7 children required total pubectomy while 27 required only inferior pubectomy. Overall success rate was 80%. Recurrent strictures were present in 11 children and incontinence was present in 3 children. Recurrent strictures were managed with DVIU (n=8) and redo anastomotic urethroplasty (n=3).

Conclusion: Most PFUI in children can be managed through the perineal route with high success rate after primary repair. The transpubic approach should be reserved for more complex cases.


   Testicular teratoma: A case report Top



   Category: Urology Prime Poster Top


Vibhu Sharma, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: vibhusharma7191@gmail.com

Aim: To study a case of testicular swelling.

Methods: Three months old male infant presented with c/c of swelling of left testis since 4 days. On local examination left testis larger in size with normal scrotal skin over it, left testis nontender, normal temperature, 4cm *2.5cm * 2 cm size, oval, firm consistency, smooth surface, free scrotal skin all around it, non-transilluminant, cord structures B/L normal, no palpable inguinal lymphadenopathy, right testis normal. USG scrotum and pelvis –heterogenous mass of size 2.8cm * 2cm with mild hyperemia of left testis with small cystic areas 2-4mm size, with moderated internal vascularity ?testicular neoplasm (Germinoma). No inguinal or pelvic lymphadenopathy noted.

Treatment – high inguinal orchidectomy.

Histopathology – Immature teratoma left testis.

Results: The patient recovered well and is on regular follow up.

Conclusion: Testicular Teratoma is a rare entity.


   Pyeloplasty - Perinephric drain – is it mandatory? Top



   Category: Urology Prime Poster Top


Vibhu Sharma, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKC Trust's Paediatric Surgery Centre and P.G. Institute, Sangli, Maharashtra, India.

E-mail: vibhusharma7191@gmail.com

Aim: To Study that Is it mandatory to place perinephric drain after stented Pyeloplasty.

Methods: We retrospectively reviewed 146 cases of primary PUJ Obstruction who underwent dismembered A.H. Pyeloplasty at our institute, operated by a single surgeon, over a period of 2 years. Exclusion criteria included patients previously operated for puj obstruction, patients with concomitant urinary problems like VUJ obstruction or DJ stent not passing through VU junction into the bladder. Preoperative workup included renal function test, Urine examination, USG and DTPA / EC renogram. All pyeloplasties were performed through anterior subcostal incision and retroperitoneal approach. Principles of pyeloplasty was same as Anderson hynes method and keeping a DJ stent across the peviureteric anastomosis and without placing a perinephric drain with self retaining bladder catheter. Post operatively patients were sent home on 5th post-operative day. Patients were followed up on 10th post –operative day and 1 month and assessed for any late complications especially urinoma formation by clinical examination and if required by USG. Except one none of the patients developed perinephricurinoma. One patient had urinoma formation with discharging sinus from incision site on 3rd post-postoperative day which was confirmed by USG and was managed conservatively.

Results: All patients recovered well and are on regular follow up.

Conclusion: Perinephric drain with stented pyeloplasty is not necessary and it unnecessarily adds to post-operative morbidity.


   Extraperitoneal approach for surgery on horseshoe kidney Top



   Category: Urology Prime Poster Top


Vibhu Sharma, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKC Trust's Paediatric Surgery Centre and P.G. Institute, Sangli, Maharashtra, India.

E-mail: vibhusharma7191@gmail.com

Aim: To present our experience of surgical approach for horseshoe kidney with various associated anomalies.

Methods: We retrospectively reviewed 21 cases of horseshoe kidney. Inclusion criteria included patients with horseshoe kidney with associated anomalies which require surgical intervention. Out of 21 cases, 10 cases of HSK were symptomatic and required surgical intervention. Out of these 10 cases 7 had upper urinary tract anomaly requiring exploration of kidney. Out of these 7 cases, 4 were associated with PUJO. For all 4 cases, A.H. Pyeloplasty through anterior subcostal incision with extraperitoneal approach was done. 2 cases underwent Extraperitoneal U/L Nephroureterectomy for non-functioning U/L kidneys respectively. One case associated with B/L renal stone underwent transperitoneal B/L pyelolithotomy. Out of remaining 3 cases which didn't required kidney exploration, 2 cases with B/L VUR underwent B/L ureteric reimplantation and one case with PUV underwent PUV fulguration.

Results: All patients recovered well and are on regular follow up.

Conclusion: Our experience concur with literature thatU/L anomaly in HSK can be treated surgically through Extraperitoneal approach while B/L anomaly needs transperitoneal route.


   DJ stent or nephrostent in pyeloplasty: What to choose? Top



   Category: Urology Prime Poster Top


Gaurav Singh, Satish Kumar Aggarwal, Alpana Prasad, Rajeev Kulshrestha

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: gauravpsurg86@gmail.com

Aim: Comparison of outcomes related to DJ stent and Nephrostent, used for transanastomotic drainage following open pyeloplasty for Pelvic-ureteric junction obstruction.

Methods: Case records of patients who underwent pyeloplasty between February 2016 and July 2019 were reviewed for DJ stent/nephrostent placement, and their outcomes.

Results: 139 patients (104 male and 23 female ) underwent pyeloplasty for PUJO (Age 12 days-7 years). In 101 patients DJ stent was placed while in 38 cases nephrostent was required. DJ stent was removed after ~ 6 weeks of surgery while those with nephrostent underwent nephrostogram on 7th post operative day before removal. In 4 cases nephrostogram revealed VUJ obstruction.

The most common complication with DJ stent was bladder spasm (35 cases) and stent migration in 10 cases. Due to UTI early stent removal was done in 6 cases. Total VUJO was found in 4 cases, for which 3 underwent ureteric reimplant later and 1 required nephrectomy. Peritubal leak was seen in 3 children with nephrostent.

The mean hospital stay in cases with DJ stent was 4 days and 9 days in those whom nephrostent was used. The average cost of stay and treatment in those with DJ stent was lesser as compared to those with nephrostent.

Conclusion: Both DJ stent and nephrostent serve the purpose of stenting the anastomosis and provide drainage to the kidney. Hospital stay is shorter with DJ stent. Concomitant VUJO is likely to be picked up at nephrostogram through nephrostent. DJ stent placement will not be possible with VUJO. While DJ stent is preferred, nephrostent kept as an alternative if DJ does not go. Incidental VUJ obstruction can be found in about 3 % cases.


   Significance of urethral ratio in children with posterior urethral valves having recurrent urinary tract infection Top



   Category: Urology Prime Poster Top


Arun Chauhan, Archana Puri

Department of Paediatric Surgery, Lady Hardinge Medical College, New Delhi, India.

E-mail: puriarchana@hotmail.com

Aim: Recurrent urinary tract infection (UTI) in children with posterior urethral valves (PUV) has varied etiology and is a significant predictor of end stage renal disease. This study aims to explore the significance of urethral ratio in management of recurrent UTI in children with PUV.

Methods: Follow-up records of survivors of PUV were scrutinized to identify those with recurrent UTI (n: 13, defined as ≥ 3 episodes of culture positive UTI in a year). Postoperative micturating cystourethrogram at last follow-up were analyzed to record posterior urethra to anterior urethral ratio by measuring the maximum diameters of posterior and anterior urethra in oblique voiding films. Based on urethral ratio, patients were divided in 2 groups: Group 1: Urethral ratio < 2 (n:6) and Group II: Urethral ratio ≥ 2 (n:7). Age at surgery, initial procedure performed, blood urea and serum creatinine at presentation and at last follow-up, grade of hydronephrosis, post void residue, polyuria, voiding dysfunction and persistent vesicoureteric reflux (VUR) were compared in the 2 groups. Check cystoscopy was performed in presence of voiding dysfunction Data was analyzed using Chi-square test and student-t test with p<0.05 taken as statistically significance.

Results: Mean follow-up was 6.2 ± 1.5 years. Age at surgery, grade of hydronephrosis and mean serum urea were comparable in the two groups. All of them presented with dribbling of urine. Five patients had vesicostomy (GroupI: 3, Group II: 2) and were undiverted and fulgurated at least one year before this study. Mean serum creatinine at last follow-up was significantly higher in Group I (3.7 ± 2.2) as compared to 1.7 ± 1.5 in Group II. Nadir serum creatinine in Group I (0.87± 0.3) was much higher than that in group II (0.6 ± 0.4, p: 0.01). Mean urethral ratio in Group I was 1.3 ± 0.3 as compared to 2.6 ± 0.9 in group II. Persistent VUR was seen in both the groups (Group I: 31%, Group II: 42%). Significant post void residue, polyuria and other features of tubular dysfunction (anemia, acidosis) were present in all patients in Group I and in one patient in group II. On check cystoscopy residual valve were present in 4 patients (57%) in group II and none in group 1.

Conclusion: Children with PUV presenting with recurrent UTI and PU/AU ≥ 2 often have residual valves and check cystoscopy is warranted in them, while significant post void residue contributes to UTI in those with PU/AU <2.


   Impact of urethral ratio on final renal outcome in children with posterior urethral valves Top



   Category: Urology Prime Poster Top


Arun Chauhan, Archana Puri

Department of Paediatric Surgery, Lady Hardinge Medical College, New Delhi, India.

E-mail: puriarchana@hotmail.com

Aim: To study the impact of urethral ratio on final renal functional outcome in children with posterior urethral valves (PUV).

Methods: All boys with endoscopically proven PUV with at least one year follow-up were included in the study. Urethral ratio was calculated by measuring the maximum diameter of posterior and anterior urethra on Micturating cystourethrogram on an oblique voiding film at presentation and postoperatively (at one year after fulguration of valves). Renal functional outcome was evaluated by nadir serum creatinine, serum creatinine at presentation and at the last follow-up, severity of hydronephrosis on ultrasonography and glomerular filtration rate (GFR). Deranged renal function was defined as serum creatinine of more than 1 mg/dl with sub-normal GFR for age. Based on renal outcome patients were divided in 3 groups: Group I (n: 14): Those who had normal renal function at presentation and remained so at last follow-up; Group II (n: 6): Those who had abnormal renal function at presentation but normalized at last follow-up; Group III (n: 12): Those who had abnormal renal function at presentation and remained so at last follow-up. Age at surgery, initial procedure performed, nadir serum creatinine, severity of hydronephrosis, detrusor wall thickness, urethral ratio, post void residue (PVR), recurrent urinary tract infection and voiding dysfunction were compared in the three groups. Data was analyzed by using chi-square test and student-t test with p < 0.05 taken as statistically significance. Receiver operating characteristic (ROC) curve was generated for urethral ratio to assess the predictive value for deranged renal function.

Results: Thirty patients were included in the study with a mean follow-up of 4.8 ± 3.7 years. The groups were comparable as regard age at presentation and initial procedure performed, Nadir serum creatinine was comparable in group I and II (0.35 ± 0.1) while in group III it was 0.7 ± 0.4 (p:0.002). Similarly, severity of hydronephrosis at last follow-up was comparable in Group I and II (grade I-II) while in group III, it was predominately grade III-IV (p: 0.022). Detrusor wall thickness varied significantly in the three groups (Group I: 2.96 ± 0.1, Group II: 3.1 ± 1.2 and Group III: 4.76 ± 2.8 mm). There was no significant difference in urethral ratio in the three groups at presentation while at last follow-up it was 2.3 ± 0.98, 1.5 ± 0.9 and 1.9 ± 0.9 respectively in Group I, II and III (p:0.13). Area under the ROC curve of urethral ratio was 0.633 suggesting a poor correlation with functional renal outcome. Significant PVR was noted in 83.3% in group III and in 15% in the other two groups. Similarly, recurrent UTI and voiding dysfunction were noted in 91.7% and 75% patients in Group III and 15% in the other two groups (p<0.001).

Conclusion: Urethral ratio has poor predictive value for functional renal outcome. Increased detrusor wall thickness, significant PVR, recurrent UTI and voiding dysfunction show positive correlation with the renal outcome in children with PUV.


   Orchidopexy – Technical refinements to improve survival of the testis Top



   Category: Urology Prime Poster Top


Muni Varma, Satish Aggarwal, Gaurav Singh, Rupa Banerjee, Garvita Singh, Chandrika Kalagotla

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: drmunivarma@gmail.com

Aim: Orchidopexy for testicular maldescent is a common operation, aiming to bring the testis in the scrotum without tension on the vas/vessels. Open inguinal approach is the standard technique for palpable undescended testis (UDT) – the spectrum including peeping testis to the testis in superficial inguinal pouch. We present technical refinements in orchidopexy for better survival.

Methods: The records of 96 patients who underwent orchidopexy between February, 2016 to June,2019 were retrieved. Six of them were staged Fowler-Stephen's (FS) and hence have been excluded from this analysis. Of the remaining 90 cases, 79 cases (testicular units) underwent open orchidopexy for palpable UDT and 11 cases underwent Laparoscopic assisted single stage orchidopexy. Demographics – Age at orchidopexy/site of testis were recorded. The following steps were concluded to be of benefit while doing orchidopexy : (1) Retroperitoneal dissection – division of the conjoint muscle (2) Prentiss maneuver (3) Gubernaculum preservation (4) Gubernaculum preservation with Modified Prentiss maneuver.

Results: 90 patients ( aged between 9 months to 12yrs), 79-open orchidopexy and 11-Laparoscopic assisted single stage orchidopexy had satisfactory results with 100% testicular survival at minimum follow up of 6 months.

Conclusion: Optimum tension free mobilisation of testicular vessels and vas, and shortening of it's route to the scrotum are key factors. The described modifications in technique achieve this goal in most patients.


   Rare surgical cause of progressive jaundice Top



   Category: Hepatobiliary E Poster Top


Abhishek Anand, Manish Kumar Gupta, Kuntal Bhaumik, TJ Banerjee, AK Basu

Department of Paediatric Surgery, Institute of Child Health, Kolkata, West Bengal, India.

E-mail: pandeyabhi16@gmail.com

Aims: To make surgeons aware of the uncommon condition which leads to progressive jaundice.

Methods: 1)Exploratory laparotomy 2)Alternative to laparotomy is endoscopic exploration and removal of cause.

Results: Both the patient became asymptomatic after successful treatment of surgical jaundice cause for which is Fasciola hepatica.

Conclusion: Fasciola hepatica is a rare cause of surgical jaundice in pediatric age group.The differential diagnosis should be kept in mind while treating the cause of jaundice.


   Giant choledochal cyst of infancy: A case report Top



   Category: Hepatobiliary E Poster Top


Aravindh Radhakrishnan, Shishir Kumar, Yogesh Kumar Sarin

Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: dr.aravindhradhakrishnan@gmail.com

Aim/Purpose: Giant choledochal cyst (GCDC) defined as a cyst larger than 10cm in diameter, is a rare entity. We report an infant with GCDC who required a pre-surgical tube-drainage to improve liver functions.

Case Report: A 10-month-old boy presented to us with progressive abdominal distension associated with on and off low-grade fever. Examination revealed icteric child with a large cystic mass occupying most of the abdomen only sparing the left iliac and lumbar regions. Investigations at admission revealed leukocytosis (TLC-16,600/cu.mm) and altered liver function tests (Total bilirubin-6.8 mg/dL, Direct bili-3.3mg/dL, SGPT-380 IU/L, SGOT-399IU/L and serum ALP -1038 IU/L). Ultrasonogram revealed a large cystic intra-abdominal space occupying lesion adjacent to the liver with internal echoes with intra hepatic biliary radical dilatation. MRCP confirmed GCDC measuring 12x9x8cm with mass effect on pancreatic head and bowel loops. An US-guided pigtail catheter was inserted in GCDC that drained 250-300ml of bile daily. Six days later, complete excision of the GCDC with hepatico-duodenostomy was done. Post-operative period was uneventful. HPE revealed inflamed CDC.

Conclusion: GCDC must be kept in mind as one of the differentials for cystic SOL in children presenting with icterus/poor feeding. As internal stenting is technically difficult in such a small infant, external tube drainage is suggested as a modality to optimize the child before definitive surgery.


   A rare case of liver cyst Top



   Category: Hepatobiliary E Poster Top


Vibhu Sharma, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Ravindra Vora

SJKCT Paediatric Surgery Centre and PG Institute, Sangli, Maharashtra, India.

E-mail: vibhusharma7191@gmail.com

Aim: To study a case of huge liver cyst.

Methods: A 10 months old male child, presented with lump in right upper quadrant of abdomen since 15 days. On examination a lump in right hypochondriac region in continuation with liver dullness, lower margin convexity extending about 6cm below right costal margin in midclavicular line, smooth surface,well defined margins, moving with respiration, LFT and tumor markers were within normal limits. USG revealed gross hepatomegaly, with large well defined about 11*10.4*9 cm multiseptated cystic lesion in right lobe of liver.CECT revealed 12*10.5*8cm large cystic lesion in right lobe of liver with internal septation showing enhancement in post portal and venous phase suggestive of neoplastic lesion D/D ?Undifferentiated Embryonic Sarcoma, ?Biliary cystadenoma. On exploration, thick walled cyst in right lobe of liver with clear fluid on aspiration. Total excision of the cyst wall was done, haemostasis achieved and residual cyst cavity in liver parenchyma packed with gelfoam and edges of the liver sutured with continuous interlocking catgut sutures. Histopathology showed benign liver cyst. But true nature of cyst not commented on as there was no epithelial lining.

Results: Patients did well post operatively and are on regular follow up.

Conclusion: Huge benign liver cyst without epithelium lining is a rare entity.


   Thoracoabdominal pseudocyst of pancreas communicating across oesophageal hiatus- a rare manifestation masquerading as empyema Top



   Category: Hepatobiliary E Poster Top


Garvita Singh, Satish Kumar Aggarwal, Rupa Banerjee, Dipesh Goyal

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: garvitasingh429@gmail.com

Aims and Objective: Thoracoabdominal pseudocyst of pancreas is rare. We report such a case which was being managed as empyema.

Case Report: A 10 years old girl presented with cough, vomiting, fever and tachypnoea. A chest X ray revealed large empyema on both sides. She was managed as empyema with antibiotics. Past history revealed chronic abdominal pain. CT chest revealed the empyema cavity reaching intraabdominally through oesophageal hitus. Further imaging with MRCP revealed chronic pancreatitis with dilated pancreatic duct and PD stones. A revised diagnosis of chronic pancreatitis and large pseudocyst was made. ICD was placed first to drain the chest components and relieve respiratory symptoms. 1.5 litres of dirty fluid (high Amylase content) was drained. She then underwent LPJ (lateral pancreatico-jejunostomy). Post operatively she developed re-accumulation of fluid in the chest and persistent vomiting. Contrast swallow showed obstruction at lower oesophagus. A thoracotomy was done to excise the pseudocyst which was retrocardiac and encompassing the oesophagus. She recovered completely.

Discussion: Pseudocyst extending in the chest is a rare complication of pancreatitis. It may be misdiagnosed as empyema but the chest symptoms are not usually commensurate with a large fluid collection which is essentially retropleural and retrocardiac. A high degree of suspicion is needed to diagnose it correctly. Treatment should be individualised. Our case represents stagewise successful management.


   Atypical malrotion of gut – Whether to explore or not Top



   Category: GI E Poster Top


Shyamendra Pratap Sharma, Sarita Chowdhary, SP Sharma, Pranaya Panigrahi

Department of Paediatric Surgery, Institute of Medical Sciences, B.H.U, Varanasi, Uttar Pradesh, India.

E-mail: shyambrd07@gmail.com

Objective/Aim of Study: Whether to explore or not in cases of Malrotation gut in our developing country scenario.

Materials and Methods: Three cases were introspect in retrospective manner.This case study was done from 2016-2018 in department of Paediatric Surgery ,Institute of Medical Sciences, B.H.U.

Result and Observation: All three cases are present as bilious vomiting.But barium study was not of typical Malrotation gut.But conservative management result in complication in all three cases in follow up.As conventional mode is to do follow up which result in vain in 100 percentage cases.

Discussion and Conclusion: Malrotation gut is one of common cause of upper bowel obstruction in neonate as well as children.Typical Malrotation present with bilious vomiting .Atypical presentation is dubious for management .Previous articles support for regular follow up and conservative management.Our study support for operative intervention even at first symptoms despite having atypical type of barium study.


   Congenital chylous ascites: Managed with fibrin glue after failure of conservative management Top



   Category: GI E Poster Top


Biangchwadaka Suchiang, Rahul Saxena, Manish Pathak, Arvind Sinha

Department of Paediatric Surgery, All India Institue of Medical Sciences, Jodhpur, Rajasthan, India.

E-mail: drrahulsaxena@gmail.com

Aim: To report a rare case of congenital chylous ascites and discuss its management.

Methods: We describe a case of congenital chylous ascites which presented to us at age of 2 months with respiratory distress and increasing abdominal distension since day 5 of life. Result- On examination of peritoneal fluid the diagnosis of chylous ascites was confirmed but there was no evidence of source of chyle leakage on imaging. Trial of conservative management started by keeping patient on MCT based diet and then on total parenteral nutrition with octreotide for total of 6 weeks. However, the failure of both, lead us to operate the child during which we incorporated the use of fibrin glue over the leaking mesenteric lymphatic vesicles, which ultimately led to resolution of the chylous ascites.

Conclusion: Although the diagnosis of CCA is straight forward, but the management is very demanding and bears an unprecedented course. Although most of the cases are managed conservatively, surgery may be required for refractory cases. The prolonged course of TPN and octreotide, make it difficult to dispense in resource limited settings and enduring to patient, parents and treating team. The localisation and ligation of leakage site is difficult especially in new-borns and young infants due to small size lymphatics. Use of fibrin glue to seal the lymphatics is quite promising especially in cases where one cannot identify any specific site of leakage.


   A case of infantile abdominal mass- first Indian report of pediatric gastrointestinal basidiobolomycosis Top



   Category: GI E Poster Top


Rahul Saxena, Manish Pathak, Shreyas Krishnamurty, Arvind Sinha

Department of Paediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

E-mail: drrahulsaxena@gmail.com

Aim: To report the first case of Pediatric Gastrointestinal Basidiobolomycosis (GIB) from India and the youngest child ever reported with GIB across the globe.

Case Report: A 2month old presented to us with constipation, vomiting, lethargy and abdominal distension. On examination there was a large mass occupying the pelvis, and right side of abdomen. The mass was palpable on per rectal examination and found to be obstructing the lumen of rectum. Findings were confirmed on CT scan and guided biopsy was done which suggested it to be chronic granulomatous inflammation (? Fungal mass). Patient underwent ileostomy and nephrostomy during the course in hospital and basidiobolomycosis was grown in urine culture. Finally tissue from mass sent for culture which also grew basidiobolomycosis. Itraconazole started accordingly. After three months of treatment hydronephrosis subsided and nephrostogram showed flow of contrast through right ureter, which allowed removal of PCN. After 6 months of therapy, size of mass is reduced significantly on repeat imaging.

Conclusion: Basidiobolomycosis is a rare fungal infection caused by B. ranarum. was first isolated in 1955 from decaying plants in the United States. Patients are usually immunocompetent and males. Approximately 28 case reports of pediatric GIB, with the majority being from Saudi Arabia (19 cases). Others have been reported from Iran, Iraq, Brazil, Nigeria and Oman. It is an emerging disease and among patients with GIB, 84% are diagnosed after 1995 and should now be considered in differentials of abdominal swelling.


   A rare case of malrotation of gut with congenital internal hernia presented with life threatening extensive small bowel strangulation Top



   Category: GI E Poster Top


Devendra Soni, Devendra Soni

Choithram Hospital and Research Centre, Indore, Madhya Pradesh, India.

E-mail: devendrasoni83@gmail.com

Internal hernia (IH) is a rare cause of small bowel obstruction occurs when there is protrusion of an internal organ into a retroperitoneal fossa or a foramen in the abdominal cavity. IH can present with acute or chronic abdominal symptoms and usually detected during surgical exploration. Although different types of imaging modalities often do not provide the assistance to diagnose IH preoperatively, but computed tomography (CT) scan has a high diagnostic accuracy.

We report a case of malrotation of gut with congenital IH in a 7-year-old boy who presented with acute abdomen with life threatening shock. Abdomen skiagram showed dilated bowel gas shadow in upper abdomen and ultrasound abdomen revealed small bowel dilatation with sluggish peristalsis. CT abdomen showed malrotation of gut with moderate ascites, small bowel wall thickening with poor enhancement of the strangulated bowel segment with internal herniation. Surgical exploration was performed immediately, with reduction of internal hernia (inferior ileo-cecal recess) and Ladd's procedure with resection of gangrenous bowel (~90cm) and end to end anastomosis of bowel. In cases of acute abdomen, it is imperative to perform CT abdomen in order to prevent the delay in the diagnosis of IH.


   Laparoscopic heller's cardiomyotomy for achalasia: A follow-up study Top



   Category: GI E Poster Top


Rajeswaran, R Velmurugan, C Saravanan, A Anirudhan, V Rohit Gopinath

Department of Paediatric Surgery, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai,

Tamil Nadu, India.

E-mail: dr.rajeswaran@gmail.com

Background: Achalasia cardia is an incurable neuromuscular disorder of the lower end of esophagus resulting in dysphagia and failure to thrive. It usually presents in the 3rd decade of life and rarely manifests in childhood.

Methods: 15 patients with manometric features of achalasia cardia underwent Laparoscopic Heller's Cardiomyotomy with fundoplication between 2017 and 2019.

Results: The average hospital stay was 6 days and operating time 52 minutes.One had mucosal perforation occurred which was repaired intraoperatively. No patients required secondary operative intervention.At mean follow up of 10 months there is significant improvement in dysphagia and weight gain.

Conclusions: Laparoscopic Heller's Cardiomyotomy is a safe, highly effective and minimally invasive treatment for achalasia.


   Early postoperative recurrent intussusception proximal to ileostomy in an infant: A rare case report Top



   Category: GI E Poster Top


Gaurav Shandilya, Gurmeet Singh, Akhilesh Kumar, Survesh Kumar Gupta, Rahul Kumar Rai, Archika Gupta, Anand Pandey, SN Kureel

Department of Paediatric Surgery, King George Medical University, Lucknow, Uttar Pradesh, India.

E-mail: megauravshandilya@gmail.com

Aims: Postoperative recurrent intussusceptions are very unusual after resection and anastomosis/enterostomy with reporting of only few cases in literature. We report an unusual case of recurrent ileoileal intussusception proximal to ileostomy in early postoperative period.

Methods (Case-Report): A 4-months-old female baby was admitted with abdominal distension, unable to pass stool for five days and palpable abdominal mass. Digital-rectal-examination revealed blood-staining on examining finger. Clinical diagnosis of intussusception was made and confirmed on ultrasound abdomen. After resuscitation, laparotomy was done. Laparotomy revealed ileocolic intussusception that was manually reduced successfully. However in view of dusky patches in cecum, proximal terminal loop-ileostomy was performed. Patient was improving till postoperative day-2, when patient started developing abdominal distension and increasing bilious nasogastric drainage. Plain abdominal radiograph revealed distended bowel loops with multiple, air-fluid levels consistent with an intestinal obstruction Ultrasound abdomen revealed intussusception. Relaparatomy revealed a new ileoileal intussusception proximal to ileostomy that was reduced manually. Patient was discharged satisfactorily at 8th postoperative day of relaparotomy. At 6-months follow-up, patient was doing well with no episode of recurrence.

Conclusion: Clinician should always suspect possibility of postoperative intussusception, though rare, in early postoperative obstruction. Early ultrasound diagnosis and prompt surgical intervention are crucial for improving outcome.


   Rectal atresia – Rare cause of neonatal intestinal obstruction Top



   Category: GI E Poster Top


Saurabh Tiwari, Pratik Raut, Paras Kothari, Shalika Jayaswal, Abhaya Gupta, Vishesh Dikshit, Geeta Kekre

Department of Paediatric Surgery, L.T.M.M.C and L.T.M.G Hospital, Mumbai, Maharashtra, India.

E-mail: 12saurabh@gmail.com

Aim: To highlight an uncommon cause of bowel obstruction in neonate and outline its management and outcome.

Methods: 2 patients of rectal atresia have been presented here

i) 3 day old 28 weeks 1kg male child was referred with abdominal distension and not passed meconium since birth. Baby had a normal appearing anal opening but red rubber or infant feeding could not be passed beyond 1.5 cm from anus

ii) 1.8 kg IUGR male child presented on DOL2 with abdominal distension fever, breathlessness and not passed meconium since birth. Normal looking anal opening but IFT could not be passed beyond 1 cm.

Results: i) Right transverse colostomy done and baby discharged after weight gain upto 1.5 kgs after 2 months

ii) High sigmoid colostomy done.

Both patients had an uneventful postoperative recovery.

Conclusions: Rectal atresia; is an extremely rare anorectal malformation, is predominant in male with an incidence of 1%-2%. X-ray (Invertogram), perineal ultrasonography and MRI have been used to verify the exact anatomy preoperatively. Clinician should be aware of different clinical presentations and the subsequent management so as to avoid undue morbidity and mortality associated with delayed diagnosis and treatment.


   Study of liver histology in cases of choledochal cyst and its correlation Top



   Category: GI E Poster Top


D Swetha, P Sreenivas Reddy

Department of Paediatric Surgery, Osmania Medical College, Niloufer Hospital, Hyderabad, Telangana, India.

E-mail: d.swethavarma@gmail.com

Aim: To study the histology of liver in cases of choledochal cyst and to correlate with age.duration of symptoms and severity of disease.

Methods: All cases of choledochal cyst admitted from January 2018 to January 2019 in Niloufer hospital are evaluated clinically,radiologically and biochemically .Intra-operatively cyst excision and hepatico-duodenostomy or roux-en-y-hepatico-jejunostomy was done. Liver biopsy is taken in all cases.Postoperatively patients are managed and discharged.Grading of liver biopsy was done by Ohkuma classification as grade 0 to 5.Grade of liver was correlated with age,duration of symptoms,bilirubin levels pre-operatively and postoperative period.

Results: Higher the grade of liver histology ,more is the age of the patient,duration of symptoms and bilirubin levels.

Conclusion: All cases of choledochal cyst should have liver biopsy done routinely to document the severity of disease, disease progression and follow up of cases.


   Amyand hernia in bladder exstrophy: A rare presentation Top



   Category: GI E Poster Top


Rahul Kumar Rai, Archika Gupta, SN Kureel, Anand Pandey, Gaurav Shandilya, Akhilesh Kumar

Department of Paediatric Surgery, King George Medical University, Lucknow, Uttar Pradesh, India.

E-mail: drrahul2004@gmail.com

Aim: To report an unusual case of Amyand hernia in exstrophy bladder being first in literature.

Methods: 4.5-year male, a follow-up case of operated Classic Exstrophy Bladder (CBE), presented in paediatric surgery emergency with complain of pain and irreducible swelling in right inguinal region for two days. There was history of recurrent but reducible swelling in right inguinal region. Physical examination confirmed the diagnosis of right obstructed inguinal hernia. The contralateral inguinal region was normal. Patient was initially resuscitated and conservatively managed with sedation and hip elevation resulting in reduction of hernia content. Surgical management was planned.

Results: Through standard inguinal incision, the hernia sac was approached. After opening the hernia sac, the vermiform appendix with no signs of inflammation was encountered as content. Appendix was reduced back to the peritoneal cavity. Hernia sac was ligated and posterior wall darning performed. Postoperative period was uneventful and the patient was discharged after two days. Follow-up at ten-days and 6-months after surgery revealed no recurrence or signs of appendicitis.

Conclusion: Amyand hernia is itself a rare entity and not yet has been reported in CBE. This is a unique case and one must suspect it if appendix is present as a content.


   A rare case of vascular malformation of small intestine presenting as acute gastro intestinal bleeding Top



   Category: GI E Poster Top


Venkatesh Kolla, Narendra Babu

Department of Pediatric Surgery, IGICH, Bangalore, Karnataka, India.

E-mail: kolla.venkatesh@gmail.com

Introduction: Vascular malformation involving abdominal viscera is a rare entity compared to other parts of the body. It is a rare cause for acute gastrointestinal bleeding in children.

Case Report: a 10 month old baby girl presented to our institute with history of malena and hematochezia on evaluation with CECT whole abdomen found to have mesenteric vascular malformation underwent selective angiogram which is negative for vascular malformation.child underwent laparotomy in view of continous bleed which showed a vascular malformation involving duodenum and jejunum underwent resection and anastamosis.

Conclusion: Vascular malformation of small intestine, a rare clinical entity in pediatric patients but are among the important causes of acute massive or chronic obscure lower gastro intestinal bleeding.


   Paediatric gastric perforation secondary to fungal infection: Rare case reports Top



   Category: GI E Poster Top


AB Jagadeesh, Narendra Babu, S Ramesh, Gowri Shankar

Department of Pediatric Surgery, IGICH, Bangalore, Karnataka, India.

E-mail: abjagadeesh44@gmail.com

Introduction: Bowel perforation secondary to fungal infection is a rare entity in paediatric age group .It is most commonly associated with immunocompromised conditions in adults and rarely in paediatric age group.

Case Presentation: We present here two cases of age group five and fifteen years otherwise healthy children presented with symptoms and signs of perforation peritionitis, confirmed with X ray. child was taken for exploration and on table the findings in one child is curdly white and bluish black slimy layer for other child. Histopathology showed candidal infection in one case and mucormycosis in another child .post operatively child managed with antifungal drugs.

Conclusion: Fungal perforation in paediatric age group is a rare entity in otherwise healthy child. Surgeon should have a high index of suspicion in case of unusual findings even in a immunocompetent child and requires appropriate management.


   Sigmoid volvulus due to Hirschsprung disease: An uncommon presentation Top



   Category: GI E Poster Top


Akhilesh Kumar, Gaurav Shandilya, Gurmeet Singh, Anand Pandey, Archika Gupta, SN Kureel

Department of Paediatric Surgery, King George Medical University, Lucknow, Uttar Pradesh, India.

E-mail: akumarms781@gmail.com

Aim: Sigmoid volvulus (SV) is rare cause of intestinal obstruction in childhood. Hirschsprung disease (HD) is a developmental disorder of enteric nervous system. Rarely, HD may be complicated by SV. We treated one such patient.

Methods: A 3-year-old male child was admitted with complaints of intestinal obstruction for last 5 days. On examination, his abdomen was distended and visible bowel loop present. Digital rectal examination had no significant finding. X-ray abdomen and pelvis AP erect view was obtained, which showed multiple air and fluid levels. The patient was planned for emergency laparotomy.

Results: Exploratory laparotomy revealed sigmoid volvulus with 270° anti-clock wise rotation. On clockwise de-rotation of volvulus, a transition zone was noticed with collapsed distal segment. Divided sigmoid colostomy was made, along with serial biopsy Post-operative period was uneventful. Histopathology confirmed diagnosis of HD.

Conclusion: SV with HD is an extremely uncommon clinical association. It may have varied presentation. Any case of SV in pediatric age must have histological confirmation of adequate ganglion cells in colon before proceeding with definitive management.


   Posttraumatic pyloroduodenal transection: A surgical challenge Top



   Category: GI E Poster Top


Shasanka Shekhar Panda, Shishir Kumar, Ashish Tiwari

Department of Paediatric Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India.

E-mail: drshasank_aiims@yahoo.co.in

Aim/Purpose: To report a case of double transection of duodenum following blunt trauma abdomen managed successfully by primary repair and triple tube decompression.

Methods: A 10-year-old boy was brought with features of bowel perforation after road traffic accident and underwent emergency laparotomy, which revealed complete transaction of duodenum at D1 and D2 and pyloroduodenal junction extending towards lesser curvature. Primary closure of pyloroduodenal junction and D1 –D2 were done with omental patch along with triple tube decompression (cholecystostomy, gastrostomy and jejunostomy).

Results: The patient had an uneventful recovery and has been doing well till last follow up.

Conclusion: Primary closure of disturbed ends with triple diversion is a safe approach in young children in absence of gross peritoneal contamination and early presentation.


   Intestinal ascariasis – what's the end point of conservative management? Top



   Category: GI E Poster Top


Aravindh Radhakrishnan, Sujoy Neogi, Shashanka Shekhar Panda, Simmi K Ratan

Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: dr.aravindhradhakrishnan@gmail.com

Aim/Purpose: Intestinal ascariasis is a common problem in developing countries. Intestinal obstruction has been reported to occur in 2 out of 1000 ascaris infected children per year. Not all intestinal obstruction due to worm bolus needs surgical intervention. We present our experience of managing worm obstructions in the last 2 years period and document the efficacy of conservative management in children with worm intestinal obstruction without signs of peritonitis or sepsis.

Methods: A retrospective review of all children with features of worm intestinal obstruction without signs of peritonitis/septic shock during the period of Sept 2017- July 2019 were studied. Those children with frank peritonitis or pneumoperitoneum at the time of presentation were excluded. As per the department protocol, others were given a trial of conservative management for 48 hours with bowel rest, nasogastric tube decompression and instillation of hypertonic saline or mannitol via nasogastric tube. Passage of worm bolus per rectum along with flatus and stools with decrease in Ryle's tube (RT) aspirates was considered end point of treatment. Those children who had persistently elevated RT aspirates, persisting or increasing abdominal girth, onset of signs of peritonitis or septic shock or acidosis in blood gas analysis despite the trial of conservative treatment for 48 hours were taken up for surgical exploration.

Results: A total of 12 children were treated as worm obstruction during this period. Out of these, 5 children required surgical exploration (41.6%). Among the operated ones, one (8.3%) had non-rotation of the gut, one (8.3%) had patent vitello-intestinal duct (PVID), one (8.3%) had band obstruction and the remaining two (16.6%) had impending perforation. Pre gangrenous changes of the intestines were found in almost all cases who underwent exploration (41.6%). Ileostomy was made in 4 out of 5 cases. Ileal resection & anastomosis was done in 1 child. 1 of the 5 cases developed extensive gangrenous colitis post ileostomy for which a revision right hemicolectomy was done.

Conclusion: In those children failing conservative management, some anatomical abnormality must be strongly suspected. Early recognition of failure of conservative management and intervention decreases the morbidity significantly.


   Presentation and outcome of management of achalasia cardia in children Top



   Category: GI E Poster Top


Harikrishna Devadasan, Hari Krishna Devadasan, S Agarwala, V Jain, A Dhua, P Goel, DK Yadav, M Jana, D Parthasarthy, M Srinivas, V Bhatnagar, DK Gupta, M Bajpai

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: krishna.aiims@gmail.com

Aim: To review a single institution's experience with surgical management in children with achalasia.

Materials and Methods: Retrospective study of cases of achalasia cardia from January 2010 to December 2017 was performed in terms of symptoms, investigations, management, complications and post-operative recovery.

Results: Of the 15 patients managed, records were available for 12. Median age at surgery was 3.5 years (1-14). Median period from onset of symptoms to surgery was 16 months (6-30). Vomiting was the predominant symptom in 91% (11), followed by dysphagia 50% (6), repeated respiratory tract infections 42% (5). Two (17%) had associated Allgrove syndrome. Six (50%) had undergone an initial trial of oesophageal balloon dilation. While one was managed with repeated dilatations, 12 underwent Heller's myotomy with Thal's fundoplication. All operated patients had immediate improvement of symptoms and no immediate post-operative complications though mild dysphagia persisted in most for a short period. Weight gain was adequate in all patients. One patient, who had undergone surgery elsewhere initially had severe dysphagia requiring redo- surgery.

Conclusions: Heller's myotomy with an anti-reflux procedure is an effective treatment for achalasia in children. There are minimal complications and most become symptom free.


   Posterior cloaca: A rare problem Top



   Category: GI E Poster Top


Abhishek Anand, Manish Gupta, Krishnendu Moitra, AK Basu, TJ Banerjee, Kuntal Bhaumik

Department of Paediatric Surgery, Institute of Child Health, Kolkata, West Bengal, India.

E-mail: pandeyabhi16@gmail.com

Aims: To present the management of an unique anamoly in which urethra and vagina are fused together forming a urogenital sinus that deviated posteriorly and open in anterior rectal wall at the anus.

Methods: Female baby presented on day 1 with single orifice in the perineum at the location of anus, A lump in the abdomen and severe oliguria. USG on day 1 showed distended urinary bladder and solitary right kidney . Vesicostomy was done. It failed to drain urine and a vaginostomy was performed on day 3. Vaginostomy drained urine and the renal biochemistry improved. A colostomy was performed prior to perineal operation .Perineal operation was performed at age of 1 year 2 month.

Results: Total mobilization of anorectum and urogenital sinus was done. The anus was placed at the striated muscle complex and urogenital sinus was shortened and placed at the introitus. Patient is now waiting for closure of ostomies.

Conclusion: Such complicated anomaly requires well planned staged repair. Total urogenital mobilisation should be performed preserving the anorectum in its normal location.


   Role of diffusion weighted MRI (DW-MR) in detection of satellite lesions in hepatoblastoma Top



   Category: GI E Poster Top


Kanika Sharma, Sandeep Agarwala, Sameer Bakshi, Anjan Dhua, Vishesh Jain, Manisha Jana , Devasenathipathy Kandasamy, Veereshwar Bhatnagar

Department of Paediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

E-mail: kanika_medico@yahoo.com

Aim: To evaluate the role of DW- MRI (a contrast-free phase) in new cases of hepatoblastoma in comparison with CT scan to detect satellite lesion.

Methods and Results: In a prospective study of 10 new cases of hepatoblastoma, before initiation of treatment, multiphase CECT and MRI was conducted. Of 10 cases, 9 males and 1 female child- with mean age of 20.3 months, all patients were stratified under high risk group with two patients in PRETEXT II and eight in PRETEXT III. Two patients showed multifocal hepatoblastoma with multiple satellite lesions on DW-MR while triple phase CECT detected had detected only one satellite lesion in one of these patients. One of the two patients, had one satellite lesion identified on CECT, while additional seven satellite lesions were identified on DW- MR imaging. For the other patient, CECT did not identified any satellite lesion while DWI picked up six satellite lesions.

Conclusion: MRI has become the gold standard investigation for the evaluation of hepatoblastoma. DW- MRI is a better tool for assessment of satellite lesions which are usually missed on CT-scan and thus will help in proper staging and planning.


   Complete transaction of duodenum after blunt abdominal trauma: A report of experience in two cases Top



   Category: GI E Poster Top


M Varunkumar, Prabudh Goel, Minu Bajpai, Anjan Dhua, Aparajita Mitra, Richa Aggarwal, Rajesh Malhotra

Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: drvarunkumar999@gmail.com

Aim: To present our experience in two cases of transection of complete duodenal transection following blunt abdominal trauma one of which sustained rarely encountered isolated duodenal injury.

Materials and Methods: Case 1: Nine-year boy with blunt trauma abdomen leading to duodenal transection (D3-D4 junction) along with gastric perforation and injuries to the liver and kidney.

Case 2: Ten-year boy with blunt trauma abdomen leading to isolated duodenal transection (D1-D2 junction).

Results: Modes of injury, clinical presentation, management protocol, principles of surgery and final outcomes will be discussed in detail. A review of treatment options as outlined in literature will also be presented.

Both kids were discharged in stable condition on full oral feeds.

Conclusions: Duodenal injuries in Pediatric population are rare; isolated duodenal injuries are even rarer.

Early diagnosis, prompt intervention and a thorough knowledge of surgical principles are very important in the management of such cases so as to minimize morbidity and avoid mortality.


   Robotic assisted Laparoscopic Gastro-Jejunostomy in a child with gastric outlet obstruction Top



   Category: GI E Poster Top


Rajat Piplani, Manish Kumar Gupta, Sunil Kumar Singh Gaur

Department of Paediatric Surgery, AIIMS, Rishikesh, Uttarakhand, India.

E-mail: rajatpiplani@yahoo.co.in

A 15-year-old girl referred form a private hospital with complains of recurrent episodes of non bilious vomiting and loss of weight for one month. No history of corrosive ingestion. On examination visible gastric peristalsis was noted in the epigastrium. On investigations a diagnosis of pyloric canal stricture (non-negotiable on endoscopy) was made. Child underwent Robot assisted Gastro-Jejunostomy (stapled). Postoperative period was uneventful. Child has gained weight and is asymptomatic on three months follow up.


   Pharyngo-cutaneous fistula following accidental foreign body ingestion – How we managed it? Top



   Category: GI E Poster Top


Aravindh Radhakrishnan, Shasanka Shekar Panda, Shishir Kumar, Sujoy Neogi, Yogesh Kumar Sarin

Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: dr.aravindhradhakrishnan@gmail.com

Background and Aim: Post traumatic pharyngo-cutaneous fistula (PCF) is a unusual and problematic disease in children. We report a rare case of a child with benign pharyngo-cutaneous fistula post foreign body ingestion who was managed successfully. To the best of our knowledge, this is the first such case of acquired benign PCF reported in pediatric age group.

Case Report: 7 year old male child who came with alleged history of accidental ingestion of glass piece mixed with his food. The child was brought with complaints of pain in the throat associated with dysphagia and drooling of saliva for 2 days duration. Child was hemodynamically stable but febrile. There was a boggy swelling in the left side of the neck with erythema. X ray and ultrasound neck revealed left parapharyngeal abscess. Laryngo and pharyngoscopy revsealed erythema with granulation tissue in the post cricoid region without any evidence of intraluminal foreign body. Neck exploration was done and the parapharyngeal abscess was drained along with removal of the ingested foreign body. 2 weeks later, the child had persistent leak of saliva from the neck exploration site. CECT neck, oral contrast study and a fistulogram revealed leak from laryngopharynx/upper esophagus. Child was kept on nasogastric (NG) feeds but the leak persisted. In view of frequent self-removal of NG tube, open feeding jejunostomy (FJ) was done. 3 months post FJ follow up, child is currently on full oral feeds with a completely dry fistula site.

Conclusion: Adequate nutrition by feeding jejunostomy reduces morbidity and enhances early closure of small, benign pharyngo-cutaneous fistula tracts, probably due to better healing nature of tissues, in children.


   Intraduodenal duplication cyst causing gastric outlet obstruction Top



   Category: GI E Poster Top


Garvita Singh, Satish Kumar Aggarwal, Rupa Banerjee

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: garvitasingh429@gmail.com

Aims and Objective: Intraduodenal duplications of the alimentary tract are rare. We report a case of duodenal duplication cyst which presented as gastric outlet obstruction.

Case Report: A 7 years old girl presented with long standing abdominal pain and non-bilious vomitings. She was evaluated outside and on suspicion of a choledochal cyst on ultrasound, an MRCP was done. It was reported as choledochocoele. Review of imaging at our center showed a possibility of duodenal duplication as the common bile duct and pancreas were normal. On laparotomy, a cystic mass was felt within the lumen of second part of duodenum. On duodenotomy through D2, there was a tense cyst with stretched mucosa within the lumen very close to the ampulla of Vater. The cyst was excised retaining part of wall at the ampulla. She recovered well. Histopathology revealed foregut duplication.

Discussion: Duodenal duplication within the lumen is rare. Diagnosis may be confusing. Attention should be paid to save ampulla of Vater while repairing.


   A rare case of vascular malformation of small intestine presenting as acute gastro intestinal bleeding Top



   Category: GI E Poster Top


Venkatesh Kolla, Narendra Babu

Department of Pediatric Surgery, IGICH, Bangalore, Karnataka, India.

E-mail: kolla.venkatesh@gmail.com

Introduction: Vascular malformation involving abdominal viscera is a rare entity compared to other parts of the body. It is a rare cause for acute gastrointestinal bleeding in children.

Case Report: A 10 month old baby girl presented to our institute with history of malena and hematochezia on evaluation with CECT whole abdomen found to have mesenteric vascular malformation underwent selective angiogram which is negative for vascular malformation.child underwent laparotomy in view of continous bleed which showed a vascular malformation involving duodenum and jejunum underwent resection and anastamosis.

Conclusion: Vascular malformation of small intestine, a rare clinical entity in pediatric patients but are among the important causes of acute massive or chronic obscure lower gastro intestinal bleeding.


   Massive lower gastrointestinal bleeding- Meckel's diverticulum? Top



   Category: GI E Poster Top


Sandeep Kumar, Vijay Kundal, Pinaki R Debnath, Atul Meena, Shalu Shah, Amita Sen

Department of Paediatric Surgery, PGIMER and Dr. RML Hosspital, New Delhi, India.

E-mail: skjaglan2@gmail.com

Aim: We report a case of Meckel's Diverticulum Presenting As Acute Massive Lower Gastrointestinal Bleeding.

Methods: 5 years male child presented with massive bleeding per rectum since 1 day.Hemoglobin level dropped to 3 gm%.Patient required multiple blood transfusions, multiple ionotropic support and mechanical ventillation.Upper GI endoscopy and colonoscopy could not find any source of bleeding.Any radiological investigation could not be performed due to poor general condition. After stabilization, patient was taken for exploratory laparotomy for acute obscure overt bleeding with high risk consent.

Results: Meckel's diverticulum with ectopic tissue at tip was found to be the source of bleeding.In the absence of intraoperative enteroscopy, any other bleeding source was ruled out by thorough intraluminal bowel wash and transillumination examination of bowel and mesentry.Resection of Meckel's diverticulum with end to end ileal anastomosis was performed.No postoperative bleeding observed.Histopathology report is awaited.

Conclusion: Meckel's diverticulum presenting as acute massive lower gastrointestinal hemorrhage is unusual. In absence of definitive investigation, meckel's diverticulum should be considered among differential diagnosis.


   Congenital colonic stenosis diagnosed incidentally after accidental battery body ingestion Top



   Category: GI E Poster Top


KV Satish Kumar, Rahul Krishnan, Asha Thomas, Anil Kumar

Department of Paediatric Surgery, Baptist Hospital, Bengaluru, Karnataka, India.

E-mail: satishpushpa33@gmail.com

Colonic atresias account for 1.8 to 15 % of intestinal atresias. Colonic stenosis is caused by perforate membrane. A 1.5 year old boy presented with colonic obstruction without any pre-existing bowel symptoms. X Ray of abdomen showed features of distal bowel obstruction with a foreign body(battery) noted in left lower quadrant. He underwent emergency exploration with suspected battery induced colonic injury.

Methods: 1.5 year old boy presented with features of intestinal obstruction. Clinically , he was stable with mild dehydation and had visible intetinal peristalsis. Imaging showed features of colonic obstruction with foreign body in left lower quadrant. There was alledged history of battery ingestion few weeks ago.

Results: The junction of the distal descending colon & sigmoid colon was stenosed with a dilated proximal segment containing lithium battery and collapsed distal segment. Retrieval of the foreign body, resection of the stenosed segment and primary anastomosis was done. Biopsy showed a stenosed colon with normal ganglion cells. At discharge he was haemodynamically stable and tolerating oral feeds.

Conclusion: Congenital colonic stenosis as a rare and delayed presentation may mimic hirschprungs disease. Though batteries can induce intestinal stricture, in the index case the battery got entrapped in the stenosed segment.


   Malrotation with meckels diverticulitis with gangrene causing closed loop obstruction Top



   Category: GI E Poster Top


KV Satish Kumar, Rahul Krishnan, Asha Thomas, Naveen Thomas

Department of Paediatric Surgery, Baptist Hospital, Bengaluru, Karnataka, India.

E-mail: satishpushpa33@gmail.com

Aim: Intestinal malrotation, usually presents in the neonatal period. Delayed presentation beyond infancy is rare and may present diagnostic difficulty. Acute presentations beyond infancy are most likely due to volvulus. An adolescent girl 15 with intestinal obstruction had malrotation diagnosed on imaging, but the acute presentation was due to gangrenous meckel's diverticulum.

Methods: A 15 year old girl was admitted to emergency with dehydration and tender distended abdomen. Abdominal CT Scan and upper GI contrast studies suggested malrotation. After adequte resuscitation, patient underwent exploration for suspected malrotation with volvulus.

Results: Laparoscopy showed dilated congested small bowel loops with features of malrotation. Due to difficult visualisation a laparotomy was undertaken. In addition to classical malrotation, gangrenous tip of meckel's diverticulum was found entraping the ileo-caecal junction causing closed loop obstruction. Laparotomy, ladd's procedure, meckel's diverticulectomy & inversion appendectomy were done. Post-operatively she recovered well with partial wound dehiscence.

Conclusion: Delayed presentation of malrotation should be on the differential in patients with bilious vomiting. Awareness about the atypical presentations may reduce the time to accurate diagnosis of this disease and prevent extensive bowel gangrene. This is a rarest of delayed presentation of a pre-existing malrotation, unfolded by meckel's diverticular pathology.


   Infantile abdominal Castleman's syndrome as a cause of growth retardation: Rare insight to pathogenesis and management Top



   Category: GI E Poster Top


Md Imran, Vaibhav Pandey, SP Sharma, Arj Deo Upadhyay

Department of Paediatric Surgery, IMS, BHU, Varanasi, Uttar Pradesh, India.

E-mail: drimran05@gmail.com

Aim: Paediatric abdominal castleman's syndrome is extremely rare. We herein report an interesting case providing insight to its pathogenesis and management.

Methods: A 3year female, with history of Hypoxemic ischemic encephalopathy, presented with multiple abdominal masses with growth retardation presented to us since age of six months. Computed tomography showed two mass, one of size 8x5 cm in the lesser sac and other 2x1 cm near in the paracaval region near renal hilum. There was “arborizing” calcification suggestive of Castleman's syndrome but the biopsy was inconclusive. Laparoscopic excision of symptomatic lesser sac mass was performed. The histopathology showed Castleman's syndrome.

Results: The child in follow up showed surge in growth. Serum IL-6 levels (increased in early postoperative period), over period of six months it came to normal levels with growth surge in the child HIE can causes upsurge in proinflammatory cytokine IL-6 and it may lead to development of Castleman's disease. Then the lymph nodes affected by Castleman's disease may cause overproduction of IL-6 which in turn retards growth by inhibiting different hormones.

Conclusion: Hypoxemia may be an etiological factor for Castleman's syndrome and tumour excision may normalise the growth curve for the child.


   Study of validity of biomarkers in screening for neonatal sepsis Top



   Category: GI E Poster Top


Manoj Kumar Yadav, Sarita Chowdharys

Department of Paediatric Surgery, IMS, BHU, Varanasi, Uttar Pradesh, India.

E-mail: manojyadav2107@gmail.com

Objective: To compare and assess the diagnostic & prognostic values of C-reactive protein (CRP), high sensitivity CRP (hsCRP), interleukin-6 (IL-6) and procalcitonin (PCT) in neonatal sepsis.

Methods: 20 children with sepsis were recruited in the Department of Pediatric Surgery for a period of 1 year. The patients were divided into death group (n=6) and survival group (n=14). The serum PCT concentration, hs-CRP serum level and IL-6 serum concentration was tested in all 20 patients. Serum PCT, hs-CRP, and IL-6 were compared between the two groups. The prognostic performance of serum PCT, hs-CRP, and IL-6 in patients with sepsis was evaluated through sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC).

Results: The serum concentrations of PCT, hs-CRP, and IL-6 in the death group were significantly higher than those of the survival group on the day of hospitalization (P<0.05). The sensitivities of serum PCT, hs-CRP, and IL-6 to predict the mortality of septic patients within 4 weeks were 90%, 80%, and 80%, and the specificities were 68%, 60%, and 66%, respectively. The areas under the ROC curves were 0.8, 0.75, and 0.76.

Conclusion: The serum levels of PCT, hs-CRP and IL-6 were significantly elevated in the death group, which could be used as serological markers to predict the risk of death for sepsis patients.


   Laparoscopic suture??less herniotomy using tissue??sealing device for paediatric hydrocele Top



   Category: Laparoscopy E Poster Top


Vikesh Agrawal, Abhishek Tiwari, VK Raina, H Acharya, D Sharma

Department of Paediatric Surgery, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India.

E-mail: drvikeshagrawal@gmail.com

Aims: Laparoscopic herniotomy (LH) for hydrocele is an accepted procedure and provides advantages of contralateral diagnosis and repair with the same incisions. The suturing of patent processus vaginalis is associated with various complications. We describe suture??less herniotomy using tissue??sealing device for LH of hydrocele in children.

Methods: The study was carried out on a prospective group of 21 children presenting with hydrocele after 1 year age over a period of 2 years. All infants with hydrocele and complicated hydroceles were excluded. The technique involved peritoneal incision and sealing of hydrocele sac with tissue??sealing device.

Results: A total of 21 patients (28 hydroceles) were operated. The age ranged from 1 year to 14 years (mean age, 4 years). Ten right, 4 left and 7 bilateral hydroceles (2 diagnosed on laparoscopy) were operated. Operative time ranged from 15 to 32 min, with a mean time of 18 min. All patients were discharged after a hospital stay of 12 h. No recurrences were observed during the follow??up period. One patient had persistent hydrocele for 4 months which resolved spontaneously.

Conclusion: The laparoscopic suture??less herniotomy for paediatric hydrocele is a safe, secure and easy procedure which can reduce suture and suturing??related complications following LH in hydroceles.

[TAG:2] “Cyst with a twist” -volvulus due to jejunal duplication cyst and ovarian cyst torsion[/TAG:2]


   Category: Laparoscopy E Poster Top


KV Satish Kumar, Reshma Murali, Sujay

Department of Paediatric Surgery, Baptist Hospital, Bengaluru, Karnataka, India.

E-mail: satishpushpa33@gmail.com

Aims: Duplication cysts are rare congenital anomalies that can occur anywhere, small bowel being the commonest whereas ovarian cysts are the most frequently seen abdominal tumor.

Most midgut duplications present as intestinal obstruction or bleeding whereas most of ovarian cysts present as abdominal mass.

Methods: Case 1: A male neonate whose antenatal scans were suggestive of intrabdominal cyst and postnataly planned for elective excision was lost to follow up, presented at 11months with intestinal obstruction in shock.

Case 2: A female baby antenatally diagnosed to have large abdominopelvic cyst presented on day 3 of life with excessive cry and vomiting. Post natal USG revealed an ovarian cyst.

Results: Case 1 : Diagnostic laparoscopy showed a large duplication cyst with 360degree volvulus of jejunum. Detorsion of bowel followed by resection was done.

Case 2 : Diagnostic laparoscopy and detorsion of the ovarian cyst and ovarian cystectomy done.

Conclusion: Despite increasing accuracy of prenatal US, the antenatal diagnosis of an enteric duplication represents a diagnostic challenge as well as early diagnosis of ovarian cyst and serial monitoring of the cyst is necessary to prevent torsion.


   Complete urogenital nonunion: A rare case in nonpalpable undescended testis Top



   Category: Laparoscopic E Poster Top


Nitin Sharma, M Amin Memon, Shipra Sharma, JL Patel

Department of Paediatric Surgery, DKSPGI and Pt JNM Medical College, Raipur, Chhattishgarh, India.

E-mail: nitinsharma4you@gmail.com

Aim: Complete urogenital non-union in undescended testis is rare. The objective of this report is to share and highlight rarity of the condition.

Case Description: 10 month old male child presented with left sided non-palpable undescended testis. He was subjected to diagnostic laparoscopy and further management as per the standard protocol. It was seen that vas was running separate of the testis and entering into the deep ring to go into the inguinal canal . The testis was lying separate and isolated with vessels and visible epididymis with no communication with the vas. Keeping the possibility of long loop vas it was decided to trace the vas. The deep ring area was dissected and vas was traced down to find it ending blindly into a nubbin of tissue with continuation into the gubernaculum. Thus the diagnosis of complete urogenital non-union was made. As the opposite side was well descended and normal it was decided to remove the testis and the vas along with the nubbin of the tissue. Histopathology revealed dysplastic epididymal tissue into the blind ending vas and dysplatic testis.

Conclusion: complete urogenital non-union is extremely uncommon. It should be kept in the back of mind while operating undescended testis.


   Proximal focal femoral deficiency with undescended testis a rare case Top



   Category: Miscellaneous E Poster Top


Anup Balmukund Paliwal

Department of Paediatric Surgery, GMC, Chandrapur, Maharashtra, India.

E-mail: paliwal_anup@yahoo.co.in

Aim: We report a case of left proximal femoral focal deficiency (PFFD) with left undescended testis a rare presentation.

Methods and Results: Male infant first child of healthy nonconsanguineous parents. Family history and pregnancy were unremarkable.No history of maternal diabetes or exposure to any teratogenic agent. Full term ,normal delivery. Birth weight 3500 gm, length 50 cm, and occipitofrontal head circumference 34 cm. Physical examination revealed a shorter left lower limb compared to the right and left undescended testis. The right lower limb, upper limbs and face were normal.

Conclusion: Malformations of the lower limbs are rare and heterogeneous anomalies. Urogenital anomalies associated with it are rare. Needs evaluation for genetic cause for both. Not many cases reported in literature.


   Impaled objects in paediatric age group: Challenge and threat Top



   Category: Miscellaneous E Poster Top


Yadvendra Dheer, Sandeep Tiwari, Samir Misra, Digamber Chaubey, Om Prakash Purbey, Anita Singh

Department of Trauma Surgery, KGMU, Lucknow, Uttar Pradesh, India.

E-mail: yadusingh0071@gmail.com

Aim: To discuss the challenge faced in a rare case of penetrating injury sustain due to impalement of iron rod due to fall.

Methods: A three years old male child fall from the height of approximately 30 feet on iron rod at construction site. Rod had penetrated different anatomical regions and had entered from the posterior left thigh to exit from inguinal region to re-enter abdomen to exit from upper back just under the left scapula. He was rescued by on site construction worker by cutting the rod and was brought to ED on motorbike with iron rod in-situ.

On presentation to ED, the patient was in shock, and was rested in right lateral position. The patient was shifted to OR after primary resuscitation measures, and intubated in right lateral position. All their anatomical regions explored simultaneously, thigh, abdomen and thorax. The impaled iron rod was extracted under vision. The patient had sustained jejunal perforation and mesenteric tear, diaphragmatic injury and lung injury apart from soft tissue and muscular injury in the thigh. All the organs injured were repaired primarily with strict hemostasis ascertained. Two units of PRBC were transfused per-op and post-op.

Results: The patient was extubated after surgery and was kept in HDU for post-operative monitoring. He was discharged on 10th post operative day in good health.

Conclusion: Penetrating injury in pediatric age group is rare but very lethal. Prompt action with early intervention is key of success.


   An odd foreign body bronchus Top



   Category: Miscellaneous E Poster Top


Nirmal Bhaskar, Prathap Somnath, C Sreekumar, Sarath Kumar Narayan, CN Vysakh, C Jinos Babu

Department of Paediatric Surgery, Government Medical College, Kozhikode, Kerala, India.

E-mail: nirmalbhaskar321@gmail.com

Introduction: Various types of foreign bodies are seen commonly in respiratory tract in children. Sometimes history, examination and X ray findings are confusing.

Aim: Study involves case of a rare foreign body retrieved in Paediatric Bronchoscopy.

Methods: There were total 135 Paediatric bronchoscopies done in the last 3 years in our department. A 1.5 year old child presented with history of aspiration of some foreign body, followed by respiratory symptoms. X ray showed one metallic foreign body in Right bronchus. On bronchoscopy, a LED bulb was retrieved with some difficulty from Right Bronchus.

Results: LED bulb is a very rare foreign body. Sometimes clear history may not be there. We should be very careful, especially if the terminals of the bulb are facing inwards.

Accidental damage to LED bulb may lead to spillage of broken pieces of LED bulb in the respiratory tract. Also metallic part of bulb may hook onto the walls and cause injury.

Conclusion: LED bulb is rare and a dangerous foreign body in bronchus. Even under expert hands, removal will be very tricky and dangerous.


   Incidence of wound infection in common paediatric day care surgeries following a no-antibiotic protocol: A viable recommendation for a public hospital in India Top



   Category: Miscellaneous E Poster Top


Saurabh Tiwari, Pratik Raut, Paras Kothari, Shalika Jayaswal, Abhaya Gupta, Vishesh Dikshit, Geeta Kekre

Department of Paediatric Surgery, L.T.M.M.C and L.T.M.G Hospital, Mumbai, Maharashtra, India.

E-mail: 12saurabh@gmail.com

Aims: The use of broad spectrum antibiotic administered intravenously 1 hour before incision is well established in preventing surgical site infection following major surgeries. The aim of our study is to determine the incidence of wound infection in paediatric day care surgeries where antibiotics were not used.

Methods: We reviewed all paediatric patients undergoing day care common procedures namely herniotomy, open orchiopexy, circumcision and other minor procedures at our institute in a public hospital between January 2015 and December 2016. Those with heart diseases, immunosuppression and those who had received antibiotics perioperatively for any reason were excluded. Surgical site infection (SSI) was classified as superficial or deep as defined by the Centre For Disease Control (CDC).

Results: A total of 576 paediatric patients underwent clean day- care procedures at our institute between January 2015 and December 2016, of which 478 patients met the inclusion criteria.2 (0.41%) of these had surgical site infection. 1 patient had serous discharge along the suture line while the other developed pus requiring debridement.

Conclusions: Clean day-care surgeries in children can be carried out safely without the empiric use of perioperative antibiotics even in the setting of a public hospital in a developing country.


   Is clitoroplasty required in all patients of congenital adrenal hyperplasia? Top



   Category: Miscellaneous E Poster Top


Kashish Khanna, M Bajpai, P Goel, SS Panda

Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: kash.modern@gmail.com

Background: Multiple studies have shown that not all patients of congenital adrenal hyperplasia (CAH) require clitoroplasty.

To assess the effect of orally administered steroids on the length of clitoris in CAH patients.

Methods: Retrospective study upon patients of CAH treated in our department over a period of 11 years. 17OHP levels and length of clitoris were assessed and compared before and during steroid therapy.

Results: The technique of measuring clitoral length will be described.

This study includes a total of 82 patients with CAH ranging from 3 months- 144 months, in whom 17OHP levels in the blood and clitoral length were present both before and under therapy. The 17OHP levels significantly decreased to normal level after treatment (p < 0.001) but the same phenomenon was not reflected in clitoral length of respective patients.

A decision to proceed for clitoroplasty was based on multiple factors including an objective assessment of the clitoral length after steroid treatment.

Conclusion: While the length of clitoris at presentation does not reduce, its further growth is arrested. When indicated, the option of surgery should be offered as soon as the endocrine axis is stabilized.


   Rare case of pediatric tail gut cyst Top



   Category: Miscellaneous E Poster Top


Rajasekhar Addagatla, Amita Sen, Vijay Kundal

Department of Paediatric Surgery, PGIMER and DR. RML Hospital, New Delhi, India.

E-mail: rajasekharaddagatla51@gmail.com

Aim: To discuss the management of Tail gut cyst (TGC)- a surgical rarety.

Methods: We report a case of 2 years old female child with TGC. Child presented with lower abdominal lump of one month duration with no other constitutional symptoms. On examination solitary intra abdominal lump of size 8cm and 6cm, non tender, firm, arising from pelvis was found. Digital rectal examination revealed non tender tense cystic mass posterior to rectum, upper margin not reachable, mucosa was free. Preoperative alfa feto protein was normal. CECT pelvis revealed 8.5cm and 6.5cm heterogenous cystic mass anterior to the sacrum? type IV sacrococcygeal teratoma . On exploration well defined cystic mass posterior to rectum and anterior to sacrum was found excised in toto along with coccyx thinking it as type IV sacrococcygeal tearatoma and sent for Histopathological examination (HPE).

Results: HPE revealed fibromuscular cyst wall lined by columnar ciliated epithelium with focal pseudo stratification.

Conclusion: Pediatric Tail gut cysts are very rare can present and masquerade as sacrococcygeal tearatomas.


   Role of caudal block in vasodilatation and its implications for genital Top



   Category: Miscellaneous E Poster Top


Dhruv Mahajan, Prabudh Goel, Minu Bajpai, Purnima Narsimhan, Puneet Khanna, Rahul Anand, Mani Kalaivani

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: 280691dhruv@gmail.com

Surgeries.

Aim: The role of caudal analgesia in formation of urethr o-cutaneous fistula formation after hypospadias repair has been a matter of controversy recently.



To study the vasodilatory effect of caudal block and its implications for genital surgeries in children.

Patients and Methods: Prospective study based on pediatric patients (n=63) undergoing elective infra-umbilical surgery under general anesthesia with caudal block. Parameters under study included resting and stretched penile length, penile volume (calculated from penile diameter noted at base, mid-penis and corona), scrotal temperature and capillary filling time (nail bed of great toe and sole); readings were taken prior to caudal, 10 minutes after caudal &amp; 20 minutes after caudal).

Results: Vasodilatation in response to caudal block was reflected by a significant elevation in resting penile length (mean: 3.76 to 4.35) at ten-minutes with a tendency to ameliorate at twenty-minutes (mean 4.12). Similar pattern was observed in penile volume (26.59@pre, 33.15@post-10 &amp; 30.30@post-20) and scrotal temperature (96.15-vs-95.70 0 F). The capillary filling times were reduced significantly at 10-minutes (0.58-sec-vs-0.79-sec) with a tendency to return towards normal at 20-minutes (0.63-sec).

Conclusions: Vasodilatation following administration of caudal analgesia is transient and starts to wean off at 20-minutes.


   Sirenomelia: A case report and review of literature Top



   Category: Miscellaneous E Poster Top


Shreya Tomar, Prabudh Goel, Minu Bajpai

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: shreya305@gmail.com

Aim: To describe our recent experience with a case of sirenomelia and conduct a review of published literature on the subject.

Materials and Methods: With the background of the index case, a PUBMED search with the search term 'sirenomelia' retrieved 2456 results that were screened by two investigators (SH &amp; PG) independently initially on the basis of title to include only reports of new cases. Subsequently, abstracts were screened by two investigators independently (SH &amp; PG). After excluding non-English articles (n=52), full-texts of articles published (n=206) were retrieved to generate a comprehensive source of information (SH, PG &amp; MB).

Results: The clinical presentation ,workup, management and outcome of a case of sirenomelia recently managed will be discussed.

The information collated from the available publications will be presented in an organized form.

Conclusion: Sirenomelia is an unfortunate, rare congenital fetal anomaly which is incompatible with life. In the absence of a textbook-based availability of literature on the subject, this systematic review will serve as a comprehensive source of information for knowledge and practical use.


   Improvement in the quality of post-operative discharge instructions following day-care surgery for congenital inguinal hernia, hydrocele and undescended testis by integrating quality improvement initiative with clinical care delivery Top



   Category: Miscellaneous E Poster Top


Pritesh Maheshwari, Prabudh Goel, L Levis Murry, Dhruv Mahajan, Ajay Verma, Minu Bajpai

Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: priteshmah@gmail.com

Aim: To achieve superior standards in the post-operative discharge instructions following day-care surgery for congenital inguinal hernia, hydrocele and undescended testis in a rural paediatric surgery centre by integrating quality improvement initiative with clinical care delivery.

Materials and Methods: Data collection: 50 consecutive patients operated for diseases under study were contacted on the evening of discharge from facility and encouraged to ask their unaddressed issues related to the surgery and patient care. Framing of SMART objectives. Analysis of problem and its possible solutions. PDSA (plan-do-study-act) cycle 1: simulation-based practice of administering post-operative instructions to parents. PDSA cycle 2: change in timing of administering post-operative instructions. PDSA cycle 3: compulsive bi-directional communication during administration of post-operative instructions. PDSA cycle 4: administration of a printed documents bearing all important instructions in local language in addition to PDSA cycle 3.

Results: A decline in the number of queries raised by the parents of patients on evening-calls was observed with each successive PDSA cycle. Detailed results of the individual steps will be presented.

Conclusions: The study design was instrumental in identifying and solving problems faced by parents at the point-of-care in a manner which does not recruit significant additional resources.


   Successful conservative approach to pancreatic transection Top



   Category: Miscellaneous E Poster Top


Garvita Singh, Satish Kumar Aggarwal, Rupa Banerjee, Gaurav Singh

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: garvitasingh429@gmail.com

Aims and Objective: Blunt trauma to the abdomen is a major cause of pancreatic trauma in children. We report a case of pancreatic transection following a fall that resulted in obstructive jaundice. Pancreatic transection was managed conservatively.

Case Report: A 13 years old boy presented with abdominal distension, vomiting and fever following blunt trauma abdomen due to fall. CECT done outside showed pancreatic transection between the head and uncinate process. The gallbladder was tensely distended with sludge and common bile duct was prominent. There was a fluid collection (?haematoma) around the intrapancreatic CBD. He was jaundiced with conjugated hyperbilirubinemia. An image guided cholecystostomy was performed which relieved obstructive jaundice. Bile through cholecystostomy was refed through NG tube. He was discharged and was reassessed for residual damage 2 months later. The fluid collection at the pancreatic transection had largely resolved and the CBD was normal. Cholecystostomy was removed. His distal pancreatic duct started dilating. He is currently under observation for pancreatic duct dilatation. He may require lateral pancreaticojejunostomy in future.

Discussion: The case represents successful conservative treatment of pancreatic transection. CBD obstruction with obstructive jaundice but no gross pancreatic ascites (contained pancreatic collection) led us to cholecystostomy alone in the beginning. Residual damage to pancreas is possible and needs close follow up.


   A simple technique to provide uniform gentle compression over penis including the glans Top



   Category: Miscellaneous E Poster Top


Rupa Banerjee, Satish K Aggarwal, Aparajita Mitra, Gaurav Singh, Muni Varma, Garvita Singh

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: dctrrupa@gmail.com

Aims: One of the most controversial aspects of hypospadias surgery is the election of an appropriate wound dressing. Dressing prevents postoperative edema and hematoma formation, maintaining the phallus in an upright position. We present a simple technique of hypospadias dressing including compression over glans.

Methods: Dressing is done using alginate which is cut according to size. Then one layer of gauze piece and elastoplast. In the region of glans we apply soft filling of neuro-cottons. This dressing is removed after 7 days.

Results: Reduced edema and no slippage of dressing are the additional advantages of this type of dressing.

Conclusion: Alginate dressing with gentle compression over the glans is really accurate for hypospadias dressing.


   Analysis of top 10 cited articles published in the Journal of Indian Association of Paediatric Surgeons over a 10-year period Top



   Category: Miscellaneous E Poster Top


Anjan Kumar Dhua, Prabudh Goel, Vishesh jain, Devendra Yadav, Minu Bajpai, Divya Jain

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: dhuaanjan@gmail.com

Aim: To identify, analyse and categorise the characteristics (type of article, country of origin, institution, authorship, topic and number of citations) of the articles published in JIAPS from 2008-2017, with particular focus on the top 10 cited articles.

Methods: The above characteristics of the individual articles were tabulated in a Google Spreadsheet. The number of citations of an article was obtained from 3 databases-CrossRef, Medline® and Google Scholar. A final tally was obtained after removing common entries in the databases.

Results: Total number of articles published was 613. There were 255 case reports, 190 original articles, 19 review articles followed by 149 articles consisting of brief communications. The top 5 countries of origin of the articles were India, United Kingdom, Turkey, Iran and Saudi Arabia with 526, 14, 9, 7 and 6 articles, respectively. The institution, authorship and topics of top 10 cited articles were noted.

Conclusion: Case reports are the most common type of articles published in JIAPS. Most of the articles originated from India, followed by the UK and middle-East countries. This analysis may provide insights to the editorial board and the members of IAPS about the trend of research and publications among the paediatric surgeons of India.


   Unusual association of high anorectal malformation with caecal duplication: A case report Top



   Category: Neonatal E Poster Top


Priya Shalini Lakra, KS Basu

Department of Paediatric Surgery, NRS Medical College, Kolkata, West Bengal, India.

E-mail: preahlakra@gmail.com

Aim: To report an unusual association of high anorectal malformation with caecal duplication.

Methods: A one day old male patient , body wt -1.8kg, premature, born of non consanguineous marriage presented with absence of anal opening. X ray erect abdomen showed triple bubble and indicated for exploratory laprotomy. Jejunal atresia type 2 with caecal duplication and colonic atresia were found. Jejunojejunal anastomosis with loop ileostomy and sigmoid loop colostomy was done.

Results: We lost the patient 10th post operative day due to sepsis.

Conclusion: Cases of caecal duplication amongst all enteric duplication is rare. Reports of low anorectal malformation have been reported earlier. But high anorectal malformation with caecal duplication has not been reported till now worldwide . Moreover this is the second case that is being reported from Indian subcontinent regarding association of colonic atresia and high anorectal malformation.


   A rare case of nasopharyngeal teratoma: Successful management with multidisciplinary approach Top



   Category: Neonatal E Poster Top


Ankur Mandelia, Anita Singh, M Ravi Shankar, Puneet Goyal

Department of Paediatric Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India.

E-mail: drankurmandelia@gmail.com

Aim: Teratomas of oropharyngeal cavity in neonates are specifically referred to as epignathus. We present a case of large nasopharyngeal teratoma who presented to us with respiratory distress and feeding problems.

Methods: A male baby, born to third gravida mother by normal vaginal route, was observed to have a large facial malformation for which he was referred to our institute on 4th day of life. Baby had a large intra oral mass with large extra-oral component occupying almost the entire oral cavity. Baby had mild respiratory distress and stridor. Computerized tomography (CT) revealed a heterogenous enhancing mass arising from the hard palate and extending to nasal cavity (base of sphenoid) and oral cavity and composed of bone, fat and soft tissues.

Results: Surgical excision was planned. Endotracheal intubation was achieved by direct laryngoscopy by felexomatallic endotracheal tube and airway was secured. Tumor was dissected all around till base of sphenoid and complete excision was done. Post operatively baby was ventilated for 24 hours and required oxygen support for 5 days. Histopathological examination was suggestive of a mature teratoma. Special cleft palate compatible bottles were initially used for establishing oral feeding. At 9 months, follow up, baby is asymptomatic and is planned for cleft palate repair at around 1 year of age.

Conclusion: Nasopharyngeal mature teratomas are mostly benign but should be considered an emergency condition as they lead to airway obstruction. Multidisciplinary approach with involvement of neonatologists, anaesthesiologists, pediatric surgeons and otolaryngologists is required. Early surgical excision is the key to successful management.


   When Fryn met Edward two rare syndromes in a single patient Top



   Category: Neonatal E Poster Top


V Shankar Raman, VK Singh, Santosh Dey, Nikunj Nandan

Department of Paediatric Surgery, Army Hospital, Pune, Maharashtra, India.

E-mail: shankyafmc@yahoo.com

Fryns syndrome is a rare disorder with only a few hundred cases described so far . Initially reported by Fryns et al in 1979, the diagnostic guidelines were laid down by Fryns in 1987, which included a combination of these major features :-

  1. Hydramnios in 2nd trimester of pregnancy with normal fetal growth
  2. Distinct craniofacial anomalies including coarse face, flat nasal bridge, poorly shaped auricles, etc
  3. Narrow thorax, hypoplastic and widely placed nipples
  4. Distal limb hypoplasias or absent nails
  5. Internal malformations including diaphragmatic defects with lung hypoplasia, malformations- cerebral, GI and genito-urinary
  6. External malformations including cloudy cornea, microophthalmia, short neck with nuchal folds.


A narrow definition of Fryns syndrome says 4 out of the above 6 features to be present, while a broad criterion suggests that 3 out of 6 is sufficient 3. Several other authors have made modifications in these criteria as per their observations of various cranial & cardiovascular malformations.

We present a combination of two rare disorders seen together ie Fryns Syndrome along with Edwards Syndrome. To the best of our knowledge, such a combination has not been documented till date.


   Mesenteric cyst presenting as a rare cause of neonatal intestinal obstruction Top



   Category: Neonatal E Poster Top


Devendra Soni

Choithram Hospital and Research Centre, Indore, Madhya Pradesh, India.

E-mail: devendrasoni83@gmail.com

Mesenteric cysts are rare benign intra-abdominal tumors with an incidence of 1 case per 250,000 hospital admission. Because of variable and non-specific clinical symptoms and signs, they are discovered either accidentally during an abdominal radiological examination done for other indications or during laparotomy for the management of one of the complications. Mesenteric cysts very rarely present as a cause of intestinal obstruction in newborns.

We report a case of 2 days old newborn, who presented with intolerance to feeds and bilious vomiting. Skiagram of abdomen showed small bowel dilatation with multiple air fluid levels and absent gas shadow in rectum, suggestive of intestinal obstruction. On evaluation with CT abdomen, there was a non-enhancing cystic lesion seen at ileo-cecal junction associated with luminal narrowing of ascending colon. On surgical exploration, there was a mesenteric cyst (~5cm) near terminal ileum causing intestinal obstruction. Limited right hemicolectomy was done and ileo-ascending anastomosis was performed. Postoperative recovery was uneventful. Histology was consistent with mesenteric cyst.


   Small stump of colovesical fistula may lead to bigger problems: A case report Top



   Category: Neonatal E Poster Top


Manika Boipai, Ramesh Tanger, Vinita Chaturvedi

Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India.

E-mail: manika.212@gmail.com

Aim: A case report on an unusual presentation of pouch colon with inappropriate fistula ligation.

Methods: A 5 month follow-up case of male ano-rectal malformation with Congenital Pouch Colon type IV, presented with complaints of frequent dysuria. Patient had undergone exploratory laparotomy with transfixation of colovesical fistula, excision of pouch and end colostomy at the age of 2nd day of life.

Patient was catheterized first .On examination a non-tender, soft cystic lump was palpable per abdominally. On perineal examination a boggy swelling was noted that caused bulge in perineum .CECT abdomen showed a 39 x 36 x 74mm cystic mass in pre-sacral and perineal region suggesting sacrococcygeal teratoma. Alpha feta protein level was also normal. Patient was explored first by perineal approach .There was a mucous filled dilated redundant pouch with fistulous connection to bladder; this was completely excised by abdomino-perineal route. Colostomy mobilization and pull down with anoplasty was also done in same sitting.

Results: Patient's symptoms were relieved following surgery and there was no recurrence reported during follow up.

Conclusion: Pouch colon should be completely resected out especially type IV during neonatal surgery, to avoid such unusual complications.


   Neonatal appendicitis is already a very rare presentation and with this age, needs documentation Top



   Category: Neonatal E Poster Top


Manoj Yadav, Vaibhav Pandey

Department of Paediatric Surgery, IMS, BHU, Varanasi, Uttar Pradesh, India.

E-mail: manojyadav2107@gmail.com

Materials and Methods: We present a case of appendicular perforation with ileal gangrene in a 7 days old neonate. This case was done in Department of Pediatric Surgery, Institute of Medical Sciences, BHU, Varanasi.

Results and Observation: A 7 days old male neonate is not passing stool since birth, bilious vomiting and abdominal distention since 3 days. On examination, abdomen is distended; tenderness is present. On digital rectal examination, rectum is empty. We plan exploratory laparatomy with appendicectomy with resection of gangreneous ileum with double barrel ileostomy was done under GA. Histopathology revealed gangreneous changes – gangreneous enteritis.

Discussion and Conclusion: Appendicitis is the most common cause of acute surgical abdomen in children and adults but very rare in infants and neonates. Appendicular perforation in neonatal age (our patient age is 7 days) may represent an underlying disease and therefore hirschprung disease, cystic fibrosis and isolated form of necrotizing enterocolitis limited to appendix should be ruled out. Nonspecific clinical features and lowcomplications like perforation and peritonitis thus increasing the morbidity and mortality. Appendicular perforation leading to peritonitis is a life threatening condition in neonates.


   Veil in the mouth Top



   Category: Neonatal E Poster Top


Abirami Krithiga, Lavanya K, Harish Jayaram

Department of Paediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India.

E-mail: drabiramikrithiga@gmail.com

Aim: To present a rare congenital anomaly which can cause feeding issues and failure to thrive.

Methods: We present 3 cases of oral synechia. Patients presented in the newborn period with poor mouth opening. The synechiae were divided using cautery with local anaesthetic spray. Case 1 had membranous band between the gums. Case 2 had thick fibrous bands between the incisor region and molar region of the gums, the child had associated cleft palate and micrognathia. Case 3 presented late at 2 months of age with failure to thrive and poor mouth opening. The infant was found to have thick bands in the molar region of the gums. The patients were fed in the immediate post operative period.

Results: Case 1 is on 2 year follow up and thriving well. Case 2 and 3 are tolerating oral feeds and are on close follow up.

Conclusions: Oral synechiae are a rare presentation. They need a high index of suspicion. They can be managed using local anaesthesia as these patients are high risk for general anaesthesia. Feeding is established early. They need long term follow for cleft palate, Temporomandibular joint anomalies.


   CPAP Belly syndrome versus Jodhpur disease: Diagnostic dilemma in a neonate Top



   Category: Neonatal E Poster Top


Shishir Kumar, Sujoy Neogi, Aravindh Radhakrishnan

Department of Paediatric Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India.

E-mail: shishirjha1610@gmail.com

Aim/Purpose: We present a case of a premature, low birth weight (1.8 kg) newborn with gastric outlet obstruction.

Methods: The baby received bubble CPAP due to respiratory distress and feed intolerance. Despite discontinuation of the CPAP he continued to have gastric distension that was not relieved on nasogastric drainage. There was no evidence of pyloric stenosis on ultrasonography. The child underwent exploratory laparotomy due to non-improvement on conservative management. There was no other abnormality seen apart from hugely distended stomach. We performed a Heincke- Miculikz pyloroplasty keeping in mind the entity of Jodhpur disease.

Results: The child had an uneventful post-operative course and is asymptomatic at 6-month follow-up.

Conclusion: We conclude that Jodhpur disease can manifest in neonatal age.


   Pneumo-omentocele: A sign of silent lethal neonatal transverse colon perforation Top



   Category: Neonatal E Poster Top


Simmi K Ratan, Ravinder Naik Noonavath, Shasank Shekhar Panda, Anju Verma, Sujoy Neogi

Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: nravindernaik6@gmail.com

Aim/Purpose: We report a rare presentation, pneumo-omentocele, on radiological imaging due to transverse colonic perforation in a neonate.

Methods: A 21-day-old preterm, very low birth weight (1.4kg) female neonate presented with complaints of bilious vomiting and upper abdominal distension of 10-day duration. Plain abdominal erect X-ray of this child revealed the presence of marked abnormal featureless gas within boundary of hepatic shadow well outside the bowel outline. On exploration, a transverse colonic perforation was detected; transverse colostomy and mucous fistula were performed. The patient had to undergo a re-exploration for fecal fistula that revealed 2 distal ileal perforations that necessitated creation of a loop ileostomy and closure of distal ileal perforation.

Results: The child had an uneventful post-operative course and is waiting 2 weeks after discharge for stoma-closure.

Conclusion: Pneumo-omentocele is a rare presentation of gastrointestinal perforation in new born. Surgical opinion should always be sought in a case of abnormal localised extra luminal gas shadow in the right upper quadrant overlapping hepatic shadow in abdominal radiographs.


   Rare causes of neonatal intestinal obstruction-prompt exploration is the key Top



   Category: Neonatal E Poster Top


Kanika Sharma, Sachit Anand, Anjan Dhua, Prabudh Goel, Jeeva Sankar, Minu Bajpai, Prasenjit Das

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: kanika_medico@yahoo.com

Objectives: To highlight 2 rare cases of neonatal intestinal obstruction (NIO) and the importance of swift evaluation and prompt surgery to prevent catastrophic consequences.

Cases Report: Case 1: A full-term boy was admitted to the NICU for observation for a birth injury. On the 7th day of life, he started having bilious vomiting and abdominal distension. On examination, the abdomen was distended with visible bowel loops. A skiagram of the abdomen showed dilated bowel with a cut-off. At laparotomy, internal herniation through a congenital defect in the sigmoid mesocolon was noted. After reducing the herniated bowel the mesocolic defect was closed. Recovery was uneventful.

Case 2: A preterm (33 weeks gestational age) female baby, developed bilious vomiting starting from day 3 of life. The radiograph showed features of intestinal obstruction. At laparotomy segmental ileal dilatation was noted with distal collapsed distal bowel. Resection-anastomosis was curative.

Conclusion: Two rare case of NIO are reported. These 2 cases again re-emphasize the adage that bilious emesis in neonate is synonymous with NIO unless proved otherwise. Prompt surgical management is imperative for a favorable outcome.


   A rare case of broncho-oesophageal fistula with pulmonary agenesis: Always be ready for surprises Top



   Category: Neonatal E Poster Top


Neel Aggarwal, Pramod K Sharma, Sugandh Aggarwal, Nirpex Tyagi, Devendra K Gupta

Department of Paediatric Surgery, Super Specialty Pediatric Hospital and Post Graduate Teaching Institute, Noida, Uttar Pradesh, India.

E-mail: drsharmapramod@gmail.com

Aim: We hereby present a rare case of oesophageal atresia with broncho-oesphageal fistula, partial pulmonary agenesis and gastric duplication with the aim of reinforcing the need to be prepared for surprises in neonatal surgeries.

Case Detail: 36 weeks preterm, 1.8 kg male neonate presented at 12 hrs of life. Antenatal scan showed hypovolemic right hemi-thorax with ipsilateral mediastinal shift and polyhydramnios. On right posterolateral thoracotomy agenesis of right upper and middle right lobe of lung was seen. Lower oesophageal pouch was seen to open in right lower bronchus instead of trachea. Due to long gap between two ends cervical and abdominal oesophagostomy was planned. On laparotomy a non-communicating 2x 3 cm cystic duplication was found along the greater curvature of the stomach which was excised.

Discussion: Unilateral pulmonary agenesis is very rare with an estimated frequency of 1:15000 autopsies. Association of pulmonary agenesis with EA/TEF is reported in only 37 cases till date. Life expectancy is shorter than normal in isolated pulmonary agenesis and only 16 survival in cases of EA/TEF associated with pulmonary agenesis has been reported till date. Only 17 cases has been reported till date in literature of TEF associated with foregut duplication cyst out of which only three cases underwent removal of cyst at the time of TEF repair.


   Beware of bulky/ weeping umbilicus at birth-think before you clamp Top



   Category: Neonatal E Poster Top


KV Satish Kumar, Sreeraj Asok, Simran

Department of Paediatric Surgery, Baptist Hospital, Bengaluru, Karnataka, India.

E-mail: satishpushpa33@gmail.com

Aim: The Vitello Intestinal Duct (VID) normally closes between 5th and 7th weeks of intra embryonic development. Failure of complete resorption of duct can lead to intra-abdominal (Meckel's diverticulum, vitelline cyst) or umbilical lesions (umbilical fistula, umbilical sinus and umbilical polyp). A case of Hernia of cord and Patent VID is presented.

Methods: 2 Newborn babies with bulky umbilical cord (hernia of cord) and Bulky cord stained with meconium were diagnosed at birth. The babies were otherwise well with no associated anomalies. A patent VID and a Hernia of cord were diagnosed clinically.

Results: A patent VID and Hernia of Cord were identified and repaired through a trans-umbilical approach, soon after birth. Recovery was uneventful. At one year following surgery, baby was asymptomatic and thriving well.

Conclusion: An awareness of these conditions are important to prevent inadvertent transection during cord clamping in neonates. Early recognition is important as delayed diagnosis is associated with significant morbidity. The cosmetic appearance with trans-umbilical approach is excellent. Keeping the cord sufficiently long during cord clamping is emphasised, especially in babies with bulky umbilicus.


   Intravesical phallus in patient with cloacal exstrophy- Case report Top



   Category: Neonatal E Poster Top


Rishabh Jain, Mamta Sengar

Department of Paediatric Surgery, Chacha Nehru Bal Chikitsalaya, New Delhi, India.

E-mail: mamtasengar@gmail.com

Aim: Presenting an extremely rare case of cloacal exstrophy with intra vesical phallus.

Case Details: 2 kg newborn presented to our tertiary care centre for defect in abdominal wall. Careful examination of patient confirmed the diagnosis of cloacal exstrophy. Gender assignment could not be done at time of initial assessment as no evidence of external genitalia could be seen on abdominal and perineal examination.

Peroperatively on careful examination of cloacal plate, phallus could be identified at site of hemibladder fusion.

Results: Intravesical phallus in patients with cloacal exstrophy is a very rare condition. Less than ten cases have been reported in the literature till now.

Conclusion: If no evidence of external genitalia are seen on examination of patient with cloacal exstrophy, possibility of intra vesical phallus should always be kept in mind.


   Sacrococcygeal teratoma transforming to pancreatic ductal carcinoma? Top



   Category: Surgical Oncology E Poster Top


Sandeep Kumar, Amita Sen, Pinaki R Debnath, Vijay Kundal, Atul Meena, Shalu Shah

Department of Paediatric Surgery, PGIMER and Dr. RAM Manohar Lohia Hospital, New Delhi, India.

E-mail: skjaglan2@gmail.com

Aim: A case report of Sacrococcygeal Teratoma transforming to Pancreatic Ductal Carcinoma.

Methods: 23 days old female child,first presented with Sacrococcygeal swelling since birth.USG-s/o sacrococcygeal Teratoma,Serum α Feto Proteins(αFP)>1210ng/ml.At Day of Life-30,En Block excision of type II sacrococcygeal Mass+ Coccygectomy done.Histopathology s/o Mature Sacrococcygeal Teratoma.Patient followed up with serial serum αFP levels and clinical examination.After postoperative fall in serum αFP levels,At age 10 months,serum αFP recorded as 872.1ng/ml.CECT s/o-Heterogenous mass in sacrococcygeal region-likely recurrence.Wide local excision of recurrent tumor done.

Results: Histopathology s/o Teratoma with somatic malignant transformation(Pancreatic ductal carcinoma).Patient referred to cancer centre.But Patient was lost to follow up for 5 months.Patient presented with huge recurrent sacrococcygeal mass with necrosis and slough.After stabilization,standard adjuvant chemotherapy for malignant SCT-PEB regimen started under strict vitals monitoring.After 1st Cycle of chemotherapy,patient developed bone marrow depression,fever with poor general condition.G-CSF started,blood transfusions and resuscitation done but we lost the child.

Conclusion: Pancreatic Ductal Carcinoma arising from Sacrococcygeal Teratoma is an extremely rare entity with very poor prognosis.Clear guidelines for adjuvant therapy need to be framed.


   Two rare cases of mediastinal thymic teratoma presenting in paediatric age group Top



   Category: Surgical Oncology E Poster Top


Rishabh Jain

Department of Paediatric Surgery, Chacha Nehru Bal Chikitsalya, New Delhi, India.

E-mail: rjainngmc@gmail.com

Aim: To present two rare cases of paediatric thymic teratoma and to report its clinical and pathological findings, to evaluate the surgical approach and long term follow up. Mediastinal teratomas account for only 7-11% of extragonadal teratomas, most of it arises from Thymic gland .We describe 2 pediatric cases of 2 yr old male child and 12 yr old male child with mediastinal teratoma presenting with fever ,cough and rt sided chest pain , haemoptysis , Dyspnoea in our hospital.

Case Study Methods: 2 yr old male child presented with complaints of fever , cough, Rt sided chest pain since a month. Patient had a history of significant weight loss . Serum AFP was in normal range . Xray chest showed Non Homogenous opacity present in upper and mid zones Rt lung. CECT chest showed heterogeneously enhancing mediastinal mass 36*39mm,well circumscribed with prominent septae position with foci of calcification present .Patient underwent rt lateral thoracotomy and 6 cm mass was found densely adherent to the lungs ,sternum anteriorly and pericardium posteriorly .Origin of the tumour was from the Thymus and was cystic containing fluid.

Another patient 12 yr old male came with cough since 6 months and haemoptysis with epistaxis with occasional dyspnoea since 2 days. CT chest was done which showed Multilocular cystic mass with thick enhancing walls and internal septations seen in pre Aortic region of anterior mediastinum. Median sternotomy was done in which large solid mass -10*9 cm in superior mediastinum adjacent to thymus was found and excised.

Review of Literature: Mediastinal teratomas are germ cell tumors arising from ectopic pluripotent stem cells that failed to migrate from yolk endoderm to the gonad. Most common differential diagnosis for chest wall mass in children is cavernous hemangioma, PNET/ Ewing's sarcoma, rhabdomyosarcoma, osteosarcoma and chondrosarcoma. They account for approximately 25% of anterior mediastinal masses in children.

Results: Both patients are being followed for a year and serum AFP has been done in surveillance with CT abdomen. The biopsy report of mass came out to be Mature cystic teratoma in one and Immature cystic teratoma in another. On follow up of patient since one year there has been no incidence of Recurrence.

Conclusion: Mediastinal teratomas are germ cell tumours located in the anterior mediastinum, representing the most common extra-gonadal germ cell tumors. These tumors arise from chest wall and may have both intra and extra-thoracic components.The treatment of choice for benign mediastinal teratomas in children <15 years is total surgical excision and there is no role of radiotherapy. Recurrence of these tumors has not been reported after complete resection; therefore, long term prognosis is excellent.


   Embryonal sarcoma of liver: A rare tumor with uncommon presentation Top



   Category: Surgical Oncology E Poster Top


Shishir Kumar, Anju Verma, Yogesh Kumar Sarin

Department of Paediatric Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India.

E-mail: shishirjha1610@gmail.com

Aim/Purpose: To report successful multimodal management of iatrogenically ruptured large embryonal sarcoma of liver in a pre-adolescent boy.

Methods: A 12- year old boy was brought to us with an iatrogenic injury to liver during diagnostic laparoscopy for a provisional diagnosis of hydatid cyst in a surgical gastroenterology unit. At presentation, the child was anaemic, and had ascites with bipedal edema. Radiological investigations were suggestive of right hepatic mass with haemorrhage and echogenic ascites. Right hepatectomy was done and hisptopathology was suggestive of Embryonal sarcoma of liver. He received 9 cycles of adjuvant chemotherapy (VAC- Vincristine, Actinomycin D and Cyclophosphamide) and whole abdomen radiotherapy ( 21 Gy in 14 fractions).

Results: He has had an event free survival of one month.

Conclusion: Although minimal access surgery has made inroads in pediatric surgery oncology, dealing such rare tumor by the inexperienced could be disastrous. One should keep malignancy in differential diagnosis when dealing with unusual presentations of intra-abdominal space-occupying lesions.


   Extra hepatic hepatoblastoma: An extremely rare occurrence Top



   Category: Surgical Oncology E Poster Top


Shishir Kumar, Aravind Radhakrishnan, Raghav Narang, Yogesh Kumar Sarin

Department of Paediatric Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India.

E-mail: shishirjha1610@gmail.com

Aim/Purpose: To report an extremely rare extrahepatic occurrence of hepatoblastoma.

Methods: A 6-year-old boy presented with asymptomatic epigastic lump of 3 months duration that was separate from the liver. Ultrasonography revealed a retroperitoneal, heterogeneously hypoechoic retroperitoneal lesion of 8*7 cm separate from liver. Trucut biopsy revealed Fetal type hepatoblastoma. He received neoadjuvant chemotherapy (Cisplatin, Doxorubicin) for 4 cycles, followed by surgical excision of mass. The mass was confined to lesser sac and was nourished by the capillary vessels in the lesser sac. The mass was capsulated and was adhered mildly to the lesser omentum. Histopathology revealed Fetal type hepatoblastoma, positive for Hepar -1 and CK 8/18. The patient has received 6 cycles of chemotherapy till now.

Results: The patient has been on adjuvant chemotherapy and there have been no signs suggestive of recurrence till the time of reporting.

Conclusion: This is an extremely rare case of isolated hepatoblastoma arising from extrahepatic tissue. The best treatment for a long-term cure is complete resection of the primary tumor combined with chemotherapy.


   Rare para-testicular masses in the pediatric population Top



   Category: Surgical Oncology E Poster Top


Mehak Sehgal, Sachit Anand, Anjan Kumar Dhua, Devendra Kumar Yadav, Sudheer Arava

Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.

E-mail: kanu.sachit@gmail.com

Aim: Pediatric para-testicular masses can range from benign to malignant lesions. We report two cases with surprising pathological diagnoses, which had implications in subsequent management.

Cases Report: (a) A 2-year-old boy presented with a painless left-sided inguinoscrotal swelling and diagnosed as encysted hydrocele. The child was planned for herniotomy.

Intraoperatively, a firm fibro-fatty mass, was found to be arising in the left para-testicular location and extending superiorly along the cord structures. A gross total resection was performed. Histopathology revealed this as a fibrous hamartoma of infancy.

(b) A 1-year-old boy with a history of left-sided scrotal swelling was found to have a 5x5 cm left sided para-testicular mass and a suprapubic nodule. The child was started on chemotherapy after a provisional diagnosis of rhabdomyosarcoma was made on tissue biopsy. Due to inadequate response to chemotherapy, the child underwent excision of the mass, which was found to adhere to the skin and surrounding tissues densely. Left orchidectomy with excision of the mass was done. Histopathology confirmed the mass to be cellular angiofibroma.

Both the cases have now kept in surveillance for local recurrence.

Conclusion: A pediatric surgeon must keep a wide array of differential diagnosis while treating a para-testicular lesion.


   Inflammatory myofibroblastic tumour in infant presenting with abdominal mass Top



   Category: Surgical Oncology E Poster Top


Ritesh Kumar, Rajasekhar Addagatla, Sandeep Jaglan, Vijay Kundal, Amita Sen

Department of Paediatric Surgery, PGIMER and Dr. RML Hosspital, New Delhi, India.

E-mail: ritesh.mgims@gmail.com

Aim: Reporting inflammatory myofibroblastic tumour an uncommon neoplasm in infancy.

Methods: In june 2019 one case of inflammatory myofibroblastic tumour was reported which was analysed for maternal history ,tumour histology,clinical management and outcome.

Case Report: 4 month child presented with right & mid abdomen lump for 2 month.General condition of patient was good .P/A -large firm mass approx size of 14cm x 12 cm was palpated in rt lumber and umbilical region which was mobile in both directions. Beta-Hcg was < 0.1 and AFP- 92.5 , CECT W/A- large hypodense lesion predominantly in right side .Exploratory laparotomy showed lobulated mass of approx 12 cm x 11 cm in mesentery , which was excised with adjacent ileum and end to end anastomosis done. Patient recoverd well in post operative period. Histopathological examination showed epithelioid inflammatory myofibroblastic tumour with desmin , CD68 and SMA ( focal ) positive.

Results: Patient recovered well in post operative period and is under our follow up for 1 month.

Conclusion: IMT is rare neoplasm in infant. These tumors are difficult to distinguish from other neoplasms based on radiographic imaging , with good prognosis if excised completely.


   What is new in the latest PRETEXT update? Top



   Category: Surgical Oncology E Poster Top


Ankur Bhardwaj, Ajay Verma, Anjan Kumar Dhua, Prabudh Goel, Minu Bajpai

Department of Paediatric Surgery, AIIMS, New Delhi, India.

E-mail: ankur.sprout@gmail.com

Aims: To review the literature on updates in PRETEXT classification to clearly define the factors for risk stratification, treatment of liver tumors in children.

Methods: A thorough manual and Medline search was conducted to review the existing literature on updates in PRETEXT classification, with key words: PRETEXT, Updates, and Hepatoblastoma. Consensus Updates of COG, SIOPEL, JPLT(2005, 2017) were reviewed.

Results: The most recent published version of PRETEXT was made in 2017. The modified SIOPEL definition & criteria will be discussed. The differences regarding definitions of annotation factors such as vascular involvement, multifocality, rupture, extrahepatic extent of tumor, metastases will be highlighted.

USG remains the imaging modality of choice for primary assessment.

New criterias added to adjust variations in hepatic venous anomalies & IVC involvement will also be discussed.

Conclusion: An updated version of PRETEXT staging has been provided that will be utilized in forth coming trial of Pediatric Hepatic International Tumor Trial (PHITT).


   Mature sacrococcygeal teratoma with intraspinal extension in a neonate-a rare finding Top



   Category: Surgical Oncology E Poster Top


Rishabh Jain, Mamta Sengar, Parveen Mann

Department of Paediatric Surgery, Chacha Nehru Bal Chikitsalya, New Delhi, India.

E-mail: rjainngmc@gmail.com

Aim: To present a Rare case of Sacrococcygeal teratoma with intraspinal extension.

Methods-Case Details: One month old female presented with an antenatally diagnosed large perineal mass. Patient had bilateral paraparesis and fecal incontenance. Her anal opening was anteriorly pushed. Radiological investigations were consistent with Sacrococcygeal Teratoma, Altmann type 1. Also there was b/l Hydronephrosis and retention of urine due to compression of bladder by the mass. There was intra-spinal extension of tumor up to L 2 vertebra and significant widening of sacral canal. The serum AFP levels were normal for age.

Excision of gluteal part of mass was done. Intraspinal part of tumour was entering through widened hiatus just above coccyx. As even with posterior laminectomy and wider exposure, it was very difficult to differentiate the cord structures and neural elements, decision of leaving the intraspinal component for later intervention was taken. Histopathology was confirmative of mature teratoma.

Results: - Postoperatively patient developed signs of meningism and succumbed to resistant seizures.

Conclusion: The pre-operative imaging serves to guide for prognosis and challenges expected with excision. Intra-spinal extension of mature SCT is extremely rare and could be a result of antenatal growth of tumor. A SCT with intraspinal extension as high as L2 is not reported till now.


   Inflammatory pseudotumor of kidney in a child: A rarity Top



   Category: Surgical Oncology E Poster Top


Rupa Banerjee, Satish K Aggarwal, Aparajita Mitra, Gaurav Singh

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: dctrrupa@gmail.com

Aims: Inflammatory pseudotumor (IPT) of kidney is a benign tumor that has been reported in virtually every anatomical position, but rarely in kidney. We report a case of IPT of kidney in a seven year old boy.

Case Report: A 7 years old otherwise fit and well boy developed bilateral lax hydroceles about 6 months prior. The hydroceles resolved spontaneously. However, an ultrasound examination done on self-prescription revealed a left lower polar renal mass. He had no history of fever, weight loss, hematuria or dysuria. Abdominal examination revealed no palpable lump in left lumber region and bilateral kidney were not palpable. CT angiography revealed a very well marginated hypo-dense mass in the antero-inferior cortex of left kidney. The vascular anatomy revealed single renal vein and artery dividing into upper and lower poles. CT chest was normal. With a differential diagnosis of Wilms tumor/ RCC he underwent left renal exploration. Intra-operative findings revealed a well-defined well encapsulated rounded solid mass in the lower pole, very close to the lower division of left renal vein. The mass was enucleated with intact capsule along with part of surrounding parenchyma and sent for frozen section. It revealed benign lesion. The kidney was then repaired. Histopathology confirmed presence of large number of inflammatory cells with tumor cells in storiform pattern. No transcapsular infiltration was noted. Immuno-histochemical examination showed tumor cells positive for vemintin, SMA and ALK-1 and final diagnosis of IPT was made. There is no recurrence in one year follow up.

Conclusion: IPT is an extremely rare lesion in children and is difficult to differentiate from malignant tumor. Only eight cases have been reported till date. Thus to our knowledge the present case represents the ninth case of IPT of kidney. Frozen section pathology helps in renal preservation. CT angio is helpful in planning partial nephrectomy or tumorectomy.


   Malignant rhabdoid tumour of the liver: A case report Top



   Category: Surgical Oncology E Poster Top


Muni Varma, Satish Aggarwal, Dipesh Goel, Gaurav Singh, Rupa Banerjee, Garvita Singh, Chandrika Kalagotla

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: drmunivarma@gmail.com

Aim: To present a rare case of a ruptured and bleeding malignant rhabdoid tumour of the liver.

Case Report: An eight month old boy who was unwell for 2 weeks with fever, poor appetite, abdominal fullness and vomiting suddenly became very pale and distended. His Hb was 4gm% and USG revealed haemoperitoneum and an exophytic calcified ruptured mass from the left lobe of liver. CECT revealed a hyperdense mass predominantly occupying Segment IV A, B of the liver with areas of calcification and satellite lesions in Segment II with associated rupture along the inferior surface of the liver and multiple enlarged necrotic lymph nodes in the celiac and peri-pancreatic regions. The child underwent emergency left hemi-hepatectomy. There were no peritoneal deposits. Large haemoperitoneum was evacuated. He had a turbulent post op course associated with persistent high blood tinged drain output, hypokalemia, hypoalbuminemia, deranged coagulation profile and fall in Hb. CECT was repeated to see for haemorrhage from cut liver surface but none could be seen. He required ventilatory support. Slow bleed continued with further drop in Hb. which prompted repeat exploration but no significant surgical bleed was found. He went downhill. HPE showed Malignant Rhabdoid tumour of the liver. Prognosis was explained and the parents took him LAMA.

Discussion: Malignant rhabdoid tumour is an extremely rare liver tumour in children. It carries very high mortality. Our case represents a rare form of presentation – rupture with haemoperitoneum. CT appearance was suggestive of malignant solid tumour with necrotic LNs (celiac) – quite unlike Hepatoblastoma.


   Lipoblastoma – Case report of a rare tumor in childhood Top



   Category: Surgical Oncology E Poster Top


KV Satish Kumar, Ravindra Reddy, Hariprasad

Department of Paediatric Surgery, Baptist Hospital, Bengaluru, Karnataka, India.

E-mail: satishpushpa33@gmail.com

Aim: Lipoblastomas are benign soft tissue tumors (of embryonic fat) occuring in children aged below 3 years. Though rarely reported in children beyond 8 years of age, a large lipoblastoma of forearm in a 10 year old boy is presented here, highlighting the diagnostic difficulties and importance of complete surgical excision.

Methods: A ten year old boy presented with a diffuse painless swelling over the right forearm, which was gradually increasing in size for the past 3 years. The right forearm was diffusely enlarged with an illdefined swelling over the the flexor aspect of the right forearm. There were no vascular or neurological deficits. Ultrasound and CT scan were suggestive of liposarcoma or lipoblastomatosis and Core needle biopsy was inconclusive.

Results: Patient underwent incisional biopsy and frozen section showed evidence of benign lesion. Complete surgical excision was possible and post-operative recovery was uneventful. The final biopsy was confirmative of benign adipocystic tumor/ lipoblastoma. Patient recovered well with no deficits and free of recurrence, 1 year after surgery.

Conclusion: This case demonstrates fallacies in diagnostic modalities and need for clinical correlation and frozen section in pediatric extremity soft tissue tumor. Complete resection is feasible as they are well encapsulated.


   A unique case of neonatal neuroblastoma with normal urinary catecholamines Top



   Category: Surgical Oncology E Poster Top


KV Satish Kumar, Hariprasad Gnanavelu, Asha Thomas

Department of Paediatric Surgery, Baptist Hospital, Bengaluru, Karnataka, India.

E-mail: satishpushpa33@gmail.com

Aims: Neonatal Neuroblastoma have excelllent prognosis. The prognosis is based on local stage and biological factors, such as amplification of nMYC gene. A unique case of Neonatal neuroblastoma, with favourable biological factors and negative urinary catecholamines, successfully resected laparoscopically is presented.

Methods: A day 2 baby boy with a single umbilical artery, was incidentally noted to have a right adrenal mass on ultrasound. He was followed up clinically and further imaging to characterise the lesion.

Results: On serial ultrasound imaging there was increase in size and vascularity, suggesting possibility of neoplasia. Urinary catecholamines were normal. A CT scan was suggestive of malignant lesion. A laparoscopic right adrenalectomy was done at 4 months of age and histology was undifferentiated neuroblastoma. Since the immunohistochemisrty was negative for nMyc oncogene, further adjuvant therapy was not offered. Follow up imaging at 1 year showed no recurrence and child is well.

Conclusion: Solid adrenal masses in neonates are rare in neonates. Lower stage disease is mostly seen in screen detected cases. In the index case, the tumor was detected incidentally on evaluating for anomalies associated with single umbilical artery. Surgery only therapy is feasible in Neonatal neuroblastomas as majority belong to low risk group.


   Chyle leak after gross total resection of abdominal neuroblastoma Top



   Category: Surgical Oncology E Poster Top


Shalini Mishra, Sandeep Jain, Gauri Kapoor

Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India.

E-mail: sshalu92@yahoo.com

Background: Surgery for abdominal neuroblastoma is challenging involves dissection around the aorta which is interspersed by the abdominal lymphatics. We wish to highlight the incidence and management of postoperative chyle leak.

Methods: Seventeen patients (mean age 4.1 years, range 2months to 11years) underwent surgery for abdominal neuroblastoma between November 2014 and May 2019. Their hospital records were analysed retrospectively and studied for incidence of chyle leak and its treatment, delay in chemotherapy and survival.

Results: The incidence of post-operative chyle leak was 17.6% (3/17). Chyle leaked for a median of 14 days and the median drain volume was 450ml. All patients were managed conservatively except 1 who needed lymphangiography followed by re exploration. Conservative treatment included fat free diet with MCT oil in all, injection Octreotide in 2 patients and TPN in 1 child. Adjuvant chemotherapy was not delayed in any patient and survival was same for patients with and without chyle leak.

Conclusion: Chyle leakage after surgery for abdominal neuroblastoma can be managed conservatively and does not compromise further the oncological treatment and outcome. Intraoperative measures to minimize the incidence include use of clips and harmonic scalpel, and spraying of had fibrin glue over the tumor bed.


   Intra lobar pulmonary sequestration with giant feeding artery from abdominal aorta: Antenatal diagnosis and post natal management considerations Top



   Category: Thoracic E Poster Top


Ankur Mandelia, Divya Kushal Singh, Anita Singh, Puneet Goyal

Department of Paediatric Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India.

E-mail: drankurmandelia@gmail.com

Aim: Pulmonary sequestrations accounts for 0.15 to 6.4 percent of congenital lung malformations. We report a case of intralobar pulmonary sequestration which was diagnosed antenatally and had a giant feeding artery arising from the abdominal aorta.

Methods: The antenatal USG of a 24 year old primigravida revealed a triangular echogenic area in left lung, supplied by a feeding artery from the descending aorta. A male baby, weighing 2.7 Kg was delivered by LSCS at 38 weeks of gestation. The baby developed respiratory distress soon after birth. CT thorax revealed abnormal blood supply of posterior basal segment of left lower lobe, arising from descending aorta, with shunting into left pulmonary vein and further to left atrium. The feeding vessel was abnormally large and was almost half of the diameter of the aorta. There was small area of collapse-consolidation in the posterior basal segment. Echocardiogram revealed a 3 mm sized patent foramen ovale.

Results: Left postero-lateral thoracotomy revealed a non-ventilated sequestrated segment in left lower lobe. It was supplied by a large aberrant arterial feeder arising from below the diaphragm. Aberrant artery was dissected carefully, doubly ligated and divided. Left lower lobectomy was done. Baby required mechanical ventilation for 12 hours post-surgery and was extubated on post-operative day 1. Histopathology revealed findings consistent with lung sequestration. Baby has been followed up till 10 months of age and is asymptomatic.

Conclusion: Antenatal diagnosis of congenital lung malformation helps in careful planning of perinatal care and also facilitates early diagnosis and management. Surgical resection in a case of pulmonary sequestration requires vigilant identification, dissection and ligation of the aberrant feeder artery to avoid complications.


   Posterior mediastinal cyst in an infant masquerading as congenital lobar emphysema Top



   Category: Thoracic E Poster Top


Ankur Mandelia, Divya Kushal Singh, Kirti Naranje, Amit Rastogi

Department of Paediatric Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India.

E-mail: drankurmandelia@gmail.com

Aim: We present a case of posterior mediastinal cyst with unilateral hyperinflation of the lung mimicking congenital lobar emphysema (CLE).

Methods: A 2 months old baby, weighing 3.4 Kg, presented to the emergency with a history of cough and rapid breathing for past 2 weeks. Chest skiagram at admission revealed hyperinflation of the left lung with a mediastinal shift towards the right, suggesting a diagnosis of left CLE. An urgent CT thorax was done which revealed a posterior mediastinal cyst of size 26x13x28 mm, which was causing focal attenuation of the left main bronchus, resulting in hyperinflation of both the lobes of left lung with mediastinal shift towards the right.

Results: An urgent thoracotomy was planned. On thoracotomy, the left upper and lower lobe of lung were hyperinflated and a posterior mediastinal cyst of size approx. 3 x 4 cm in close apposition with the left main bronchus, oesophagus, arch of the aorta and left pulmonary artery was seen. The cyst was dissected all around and excised. The left lung decompressed after cyst excision with normal excursion on ventilation. The baby was gradually weaned and extubated after 24 hrs. On histopathology, the diagnosis of the bronchogenic cyst was confirmed. At six months follow up, the child is asymptomatic, and chest x-ray is normal.

Conclusion: A routine CT scan in all cases of suspected CLE may be helpful to rule out extrinsic obstructive causes of CLE. Key point for radiological differentiation is that CLE commonly involves left upper lobe with compression of adjacent lung while obstructive lobar emphysema due to compression of main bronchus causes hyperinflation of whole lung.


   Is early intervention and referral to pediatric surgeon needed in cases of empyema thoracis? Top



   Category: Thoracic E Poster Top


Gali Divya, Vijay Kundal, Amita Sen

Department of Paediatric Surgery, PGIMER and DR. RML Hospital, New Delhi, India.

E-mail: galidivya55@gmail.com

Aim: To know the importance of intervention in early stages of Empyema.

Methods: We have retrospectively studied 23 patients of Empyema which were referred to us from department of pediatric medicine from July 2016 to June 2019. All of them were initially managed by tube thoracostomy.After clinical assessment,pre operative work up was done and then proceeded to decortication either open/VATS.Post operative results were observed.

Results: All 23 patients underwent decortication.Fibrinolytic through ICD was given in 9 cases(39%).8 cases were referred with in 3 weeks, remaining after 3 weeks of diagnosis.Mean age of presentation is 6.5 years.13 were males & 10 females.10 right sided and 13 were left .18 cases were managed by open decortication and 5 by VATS, 12 cases were initially assessed by thoracoscopy before proceeding to open/ VATS.Hospital stay after VATS was 3 days and 7 days in open decortication.

Conclusion: VATS is advantageous than open decortication but is possible only in early stages.Hence early intervention and referral to Pediatric surgeon optimises care.


   Empyema- A rare sequelae of diesel ingestion in a child: A case report Top



   Category: Thoracic E Poster Top


PS Madhulika, A Narendra Kumar, S Srinivas

Department of Paediatric Surgery, Osmania Medical College, Niloufer Hospital, Hyderabad, Telangana, India.

E-mail: drpsm.mch@gmail.com

Aim: To present a Rare case of chemical pneumonitis with Empyema and it's management.

Introduction: Chemical pneumonitis refers to the aspiration of any compound that is an irritant to the lungs. The more soluble agents tend to involve the upper respiratory tract, whereas less soluble agents reach the distal airways.

Methods and Results: We are reporting a case of 10years old girl who developed empyema secondary to accidentally ingestion of Diesel and presented to us with respiratory distress and lower respiratory tract infection. The child was stabilized, evaluated and diagnosed with chemical pneumonitis with Empyema of left lung. Through Right Posterolateral Thoracotomy approach thoracic cavity entered and intraoperatively right middle lobe was noticed to be densely adherent to lower lobe along with thick pus filled cavity, Right middle Lobectomy was done. Post operatively child recovered well and discharged with monthly follow up.

Conclusion: Diesel ingestion and aspiration is an uncommon cause of chemical pneumonitis, and aspiration leading to empyema is an even rarer occurrence. Importance should be given to history taking when evaluating a case of acute respiratory distress and should be admitted and evaluated for respiratory system and gastrointestinal tract sequelae.


   Spontaneous resolution of large CCAM: A rare presentation Top



   Category: Thoracic E Poster Top


Shishir Kumar, Shasanka Shekhar Panda, Aravind Radhakrishnan

Department of Paediatric Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India.

E-mail: shishirjha1610@gmail.com

Aim/Purpose: We present a case of a one year old boy who presented with respiratory distress due to empyema, was diagnosed as CCAM and later spontaneous resolution of CCAM was seen while awaiting surgery.

Methods: Initial management was by intercostal drain and intravenous antibiotics. CT scan confirmed the diagnosis of CCAM (both micro and macro cystic) of left lower lobe. Subsequently, there was spontaneous resolution of empyema and CCAM prior to surgical intervention.

Results: The patient has been on follow up for last 6 months, and asymptomatic.

Conclusion: Our case illustrates post natal spontaneous resolution of large CCAM, which is rare.


   Atypical cause of fever in a case of diverted TEF Top



   Category: Thoracic E Poster Top


Anju Verma, Sujoy Neogi, Aravindh Radhakrishnan, Shashanka Shekhar Panda, Simmi K Ratan

Department of Paediatric Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India.

E-mail: anju_v2006@rediffmail.com

Aim/Purpose: To present a postop case of diverted TEF with atypical cause of fever.

Methods: One and a half year old female child, a post op case of right posterolateral thoracotomy, ligation of TEF, cervical esophagostomy and feeding gastrostomy, waiting for definitive surgery has been brought to us with complaints of fever and runny nose. The baby was treated with antihistaminics and antibiotics suspecting upper respiratory infection. After a week of therapy, the complaints persisted. A chest radiogram was done which appeared grossly normal. ENT consultation was also sought to rule out tonsillitis and adenoids. Indirect laryngoscopy was reported normal. 2 days later child developed blood stained discharge from cervical esophagostomy. A repeat chest radiography revealed a radio opaque shadow shaped like an ear-ring in the soft tissue of the neck away from tracheal air shadow along with infiltrates in the right lung field.

Urgent esophagoscopy and retrieval of upper pouch foreign body was done.

Results: Child improved gradually and now doing well and waiting for definitive surgery.

Conclusion: A strong suspicion of foreign body ingestion must be held in such children presenting with recurrent respiratory tract infections.


   Thoracotomy for empyema thoracis: Relevant as ever, as timely referral is still a concern Top



   Category: Thoracic E Poster Top


Nirpex Tyagi, Pramod K Sharma, Sugandh Aggarwal, Neel Aggarwal, Devendra K Gupta

Department of Paediatric Surgery, Super Specialty Pediatric Hospital and Post Graduate Teaching Institute, Noida, Uttar Pradesh, India.

E-mail: drsharmapramod@gmail.com

Aim: To study the demographics of patients of empyema thoracic and asses the need of thoracotomy in such patients.

Materials and Methods:- All the patients diagnosed with empyema thoracis over a period of two years extending from 01 August 2017 to 31st July 2019 were included in the study. Medical records were reviewed retrospectively and various parameter including duration of symptoms, imaging findings, culture & sensitivity profile, hospital stay, outcomes and recurrences were noted and analyzed.

Results:- Total of 54 patients (male- 37, female-17 ) aged between 1.5 months and 9 years were enrolled. 53 patients were initially managed with ICD insertion and 21 of these further needed thoracotomy & decortication. The delay till reaching the tertiary care level was between 5 days to 55 days. Most culture were sterile followed by bacterial aetiology.

Conclusion:- No age is immune to empyema thoracis, as youngest one presented at our institute with empyema was 1.5 months old. The ratio of the patients needing decortication was significantly higher mostly because of the delay the in seeking tertiary care leading to empyema getting organized. Thoracotomy and decortications can be performed safely with good functional outcomes.


   Thoracic neurenteric cyst presenting with bleeding per rectum in an infant: An unusual presentation Top



   Category: Thoracic E Poster Top


Sujoy Neogi, Aravindh Radhakrishnan, Shishir Kumar, Shasanka Shekar Panda, Yogesh Kumar Sarin

Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: dr.sujoyneogi@gmail.com

Background Information and Aim: -Neurenteric cysts are one of the rare varieties of enterogenous duplication cysts that present within first 5 years of life. We report a 9-month-old male with posterior mediastinal neurenteric cyst who presented with unusual symptom of recurrent gastrointestinal bleeding and intractable anemia along with respiratory distress.

Case Report:-A 9-month-old boy presented with history of passing fresh blood per rectum on and off without abdominal pain or bilious vomiting or fever. There is history of recurrent respiratory infections in the past. On examination, he was dyspneic with rib retractions, malnourished, pale with gross scoliosis, pigeon chest, crowding of ribs and decreased air entry in the right hemi-thorax. Upper and lower GI endoscopy was unremarkable. Abdominal ultrasonogram was normal. Chest X-ray revealed a large space occupying lesion in the right side of chest. CT chest revealed a large, multi - septated cystic lesion occupying most of the right thorax with widened vertebral canal and a few thoracic hemi-vertebrae. MRI could not be done in pre-op period in view of general condition. Right lateral thoracotomy with complete excision of the cyst was done. Biopsy revealed neurenteric cyst type- A as per Wilkins and Odom classification. Child became asymptomatic in the post-operative period.

Conclusion:-Neurenteric cysts are rare causes of thoracic cystic space occupying lesion. They can present in unusual ways such as bleeding per rectum or as causes of chronic blood loss resulting in anemia. Complete excision of the cyst is curative.


   Mathieu repair as a rescue for failed snodgrass repair Top



   Category: Urology E Poster Top


Gursev Sandlas

Department of Paediatric Surgery, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.

E-mail: drgursev@gmail.com

Aim: To assess the durability of the Mathieu Repair in large coronal fistulas following a failed TIP/Snodgrass Repair.

Methods: Retrospective analysis of a prospectively maintained database was done to collect data for Mathieu Repair done for Coronal Fistula was done.

Selection Criteria: Inclusion Criteria – Operated c/o Hypospadias with TIP primary repair with a coronal fistula

Exclusion Criteria –Primary Hypospadias

Multiple Fistulas

Hypospadias Cripple.

Results: Total Patients: 10 Age Range : 6 yrs to 14 yrs Diagnosis: Coronal Fistula in an Operated TIP repair Average Operative Time: 65 Minutes [Range 40 minutes to 80 minutes] Average Post Operative Stay : 3 days [Range 2 days to 4 days] Complications: 1 wound infection, Treated conservatively.

Conclusions: Mathieu Repair is a feasible option for repair of large coronal fistulas following TIP repair and gives an excellent outcome with a high success rate.


   Maggots complicating circumscision Top



   Category: Urology E Poster Top


Akshay Prasad, Koushik Saha, Dipak Ghosh, Janki Bisht, Subhankar Chakravorty

Department of Paediatric Surgery, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India.

E-mail: akshay.prasad@yahoo.co.in

Aims: India is country of diversities and circumcision is performed for religious belief and medical conditions. Complications following circumcision ranges from minor to serious problems .For religious purposes, circumcision is mostly done by untrained circumciser in developing countries. Maggots is a rare complication .This can be prevented by maintaining sterility and performance of procedure by trained professionals preferably in hospital .

Methods: A 2 year boy presented to our hospital who underwent circumcision 15 days back with pus discharge and pain performed by untrained personnel .Maggots were seen coming around the circumference of penis and its number increased on manipulation. Debridement was done and maggots were picked and dressing done . With due course of time the wound healed and patient was referred to plastic surgery department for aesthetic purpose.

Results: -Circumcision is most common surgery performed in developing countries for religious purposes. However due to paucity of literature on maggots following this common surgery it is believed that it is a rare complication. Proper sterilization and trained personnel can reduce this complication.

Conclusion: Lack of literature and report of sole case in Bangladesh about this rare entity should be highlighted in developing countries. Proper training to religious and medical circumciser should be given.


   Klippel feil syndrome with crossed fused renal ectopia with pelviureteric junction obstruction: A rare association Top



   Category: Urology E Poster Top


V Shankar Raman, Santosh Dey, Pratyush Madhur

Department of Paediatric Surgery, Army Hospital, Pune, Maharashtra, India.

E-mail: shankyafmc@yahoo.com

Klippel Feil syndrome (KFS) is a rare congenital condition with a reported incidence of 1 in 42,000 new-borns with a slight female preponderance; M:F being 1:1.3 . It comprises of skeletal deformities characterized by the fusion of various cervical and occasionally thoracic and lumbar vertebrae . KFS is also associated with genitourinary, musculoskeletal, neurologic and cardiac anomalies . We report a rare case of Type 3 Klippel Feil Syndrome with Crossed Fused Renal Ectopia (Left to Right) and Pelvi-ureteric junction obstruction (Right).


   Prune belly syndrome: Modified monfort abdominoplasty Top



   Category: Urology E Poster Top


Gyanendra, Manish Kumar Gupta, Sunil Kumar Singh Gaur, Rajat Piplani, Enono Yhoshu, Intezar Ahmed

Department of Paediatric Surgery, AIIMS, Rishikesh, Uttarakhand, India.

E-mail: gyanendra.rims@gmail.com

Aim: To discuss alternate technique of Modified Monfort abdominoplasty.

Methods: Two-year-old male patient with anterior abdominal wall muscle laxity, bilateral undescended testis and dilated urethra, was managed with modified Monfort abdominoplasty and bilateral orchidopexy. In this technique, instead of taking incision vertically, low horizontal incision taken along with transposing the umbilicus.

Results: This technique well accepted by parents and give better results. There is risk of partial abdominal wall necrosis, as happened with our case. Patient doing well in follow up.

Conclusion: There are various techniques of abdominoplasty for prune belly syndrome, we modified it to improve the aesthetic results by using a classical abdominoplasty approach. Few published studies have also accepted this technique well.


   Challenges in management of Wilm's tumor: Impact of subject, source and support system: 15 years experience from a tertiary care centre in Northen India Top



   Category: Urology E Poster Top


Shrey Jain, MS Ansari, Priyank Y, Sarita Syal

Department of Urology, SGPGI, Lucknow, Uttar Pradesh, India.

E-mail: shreyjain992@gmail.com

Aims: To study clinical characteristics, treatment outcome and challenges faced in treating Wilms tumor in Indian patients.

Methods: Retrospectively data from 2003-2018 was studied. Treatment protocol included CECT abdomen with USG guided biopsy. Neoadjuvant chemotherapy for potentially advanced tumors. Radical or partial nephrectomy followed by adjuvant therapy.

Results: Total 60 patients presented with wilms tumor. 50% presented after age of 5 years. 64% were underweight. Average size of tumour was 10cms for each stage.

Only 33% parents had their graduation completed. 60% families had no permanent source of income. 80% of the patients used some kind of state sponsored economic assistance.

39 out of 60 patients underwent upfront surgery and 11 of them received ACT. 16 patients received NACT out of which 11 had partial response and 5 had no response.

The estimated 5 years survival rate was 84%, 80%, 66%, 60% and 50% for stage I, II, III, IV and V respectively. On multivariate analysis size of tumor, stage of disease and response to chemotherapy were independent factors affecting survival.

Conclusion: Although multimodality treatment has significantly increased survival in wilms tumor but in low income population there are other challenges which restricts full utilization of these new approach.


   Single stage total reconstruction in cloacal extrophy: Myth or reality Top



   Category: Urology E Poster Top


Nitin Sharma, M Amin Memon, Shipra Sharma, JL Patel

Department of Paediatric Surgery, DKSPGI and Associated Pt JNM Medical College, Raipur, Chhattishgarh, India.

E-mail: nitinsharma4you@gmail.com

Aim: Evaluation of outcome of single stage total reconstruction in Cloacal Extrophy.

Methods: The data from Jan 2007 to March 2019 was evaluated. Cases operated after June 2014 were prospective while those before were retrospective. Single stage total reconstruction was defined as bladder closure with augmentation using caecal patch+bladder neck repair+urethroplasty+primary ileoanorectoplasty without colostomy without osteotomy. Those with incomplete data, doubtful diagnosis or multi stage reconstruction were excluded. The outcome parameters considered were wound infection, urinary leak, dehiscence and condition at discharge.

Results: 12(8 prospective and 4 retrospective)cases were studied. Mean age at presentation was 48 hours(Range:0 hour–336 hours). Associated anomalies were seen in 8(67%). Mean age at surgery was 49 hours(Range:24-360 hours). Mean operating time was 138 minutes(Range124-240 min). Immediate outcomes parameters could be evaluated in the prospective limb, Long term outcome could not be evaluated. One case had parietal wall dehiscence which required secondary suturing, 4 cases had wound infection. Dehiscence of urethroplasty was seen in one. Complete dehiscence of the bladder closure was seen in one.

Conclusion: Cloacal extrophy is a complex anomaly requiring highly technical reconstruction. The standard management protocol is yet to be proposed. Single stage total reconstruction can be offered to these cases.


   Renal fungal mass masquerading as renal cell carcinoma: A new species? Top



   Category: Urology E Poster Top


Md Imran, Vaibhav Pandey, SP Sharma, Arj Deo Upadhyay

Department of Paediatric Surgery, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India.

E-mail: drimran05@gmail.com

Aim: Primary renal fungal infection in an immunocompetent child is rare. Herein we aim to describe an extremely aggressive renal fungal infection mimicking as renal cell carcinoma

Methods: A 12year male, without any past medical history presented with dull pain and left flank mass. Computed tomography suggested mass from right kidney suggesting renal cell carcinoma. The biopsy showed necrosis with mixed inflammatory infiltrate and fungal hyphae and no malignant cell. A cystoscopy was performed which showed whitish flakes in bladder coming out of the left ureteric orifice. The microscopy and culture confirmed it to be fungal hyphae but the strain could not be identified. The child was given itraconazole on which he showed improvement and mass regressed and he was discharged. Child presented in follow up at fifteen days with anuria. Repeat cystoscopy showed bladder full of fungal colonies and the colonies were blocking the right ureter also.

Results: Nephrostomy drained only partial and child died in the post-operative period.The infection was extremely aggressive but the strain was non-identifiable by phenotypic methods. Gene sequencing has been used; results are awaited.

Conclusion: This could be first case of fungal infection by a new species in an immunocompetent child.


   Bladder exstrophy -Two rare variants Top



   Category: Urology E Poster Top


Saurabh Tiwari, Pratik Raut, Paras Kothari, Shalika Jayaswal, Abhaya Gupta, Vishesh Dikshit, Geeta Kekre

Department of Paediatric Surgery, L.T.M.M.C and L.T.M.G Hospital, Mumbai, Maharashtra, India.

E-mail: 12saurabh@gmail.com

Aims:- To provide overview of clinical features, diagnosis and management strategies in rarer variants of bladder exstrophy which in itself is complex anomaly.

Methods:- 2 variants have been presented here i) 2.9 kg male full term baby came with abnormal defect in lower abdomen with polypoidal mass with malformed genitalia antenatally diagnosis being gastroschisis with bladder exstrophy Clinical examination revealed features of cloacal bladder exstrophy-bifid scrotum with single opening in bladder plate, midpenile hypospadias with glans and penile structure on right side ii)1 year female child was brought with continuous dribbling of urine from perineum since birth and lower abdomen midline swelling bulging on straining. Clinical examination had features of covered bladder exstrophy- absent umbilicus, lower abdomen midline bulging on straining, overlying skin normal. perineum and urethral opening anteposed.

Results:-i) Entire colon was well delineated in rectal dye study and patient underwent transverse colostomy. ii) Blood investigations and urology workup was done Patient discharged with plan for definitive elective repair.

Conclusion:- Variants of the bladder exstrophy complex are quite uncommon and constitute about 8% of all the cases. The treating clinician must be aware of these variants and complexity of their presentation and different ways of management.


   Anterior urethral valve: Experience from a tertiary care institute in India Top



   Category: Urology E Poster Top


Shishir Kumar, Simmi K Ratan, Shasanka Shekhar Panda, Sujoy Neogi, Yogesh Kumar Sarin

Department of Paediatric Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India.

E-mail: shishirjha1610@gmail.com

Aim/Purpose: Anterior urethral valve (AUV) is the most common congenital obstructive disorder of male anterior urethra after posterior urethral valves (PUV). We describe our experience and follow up of our patients diagnosed with AUV over 6 years.

Methods: We retrospectively identified 8 patients who presented at our Department between 2013 to 2018 with AUV, as compared to 350 patients who were diagnosed with PUV. We evaluated age, initial presentation, biochemical and imaging (ultrasonography, MCUG), micturition pattern and follow up.

Results: Average age of presentation was 8 years (1 month to 12 years). The commonest clinical presentation was weak stream of urine. Age at initial surgical intervention ranged from 1 month to 12 years. The patient with associated PUV developed end stage renal disease. The longest follow up was of 4 years. Most common ultrasonographic finding was bilateral hydronephrosis with distended bladder. One patient was diagnosed with megalourethra.

Conclusion: We conclude that AUV should be kept as a possibility in children presenting with weak stream of urine. A high degree of suspicion is required for diagnosis. Complication rates and progression to renal failure are high, so a long term and regular follow up is recommended focusing on renal and bladder function. The entity can be managed endoscopically with good end results.


   Ureteral obstruction masquerading as pelviureteric junction obstruction in infants and children: An intraoperative surprise Top



   Category: Urology E Poster Top


M Aishwarya, S Kumaravel, Bibekanand Jindal, Krishna Kumar, Bikash Kumar Naredi

Department of Paediatric Surgery, JIPMER, Puducherry, India.

E-mail: aishwaryamalla61@gmail.com

Aim: To review our experience on mid-ureteral obstruction diagnosed as Pelviureteric junction obstruction preoperatively.

Introduction: Ureteral obstruction caused by ureteric stenosis or valve or retrocaval ureter is a rare entity.

Methods: A retrospective review of all ureteral obstruction cases from 2016 to 2019.We report three cases of ureteral obstruction.one child was symptomatic and other two were antenatally diagnosed with hydronephrosis. Preoperative Diuretic Renogram of all three showed severely impaired function with obstructive drainage. As one child had doubtful hydroureteronephrosis on one of the multiple sonograms and Retrograde Pyelogram was suspicious of Retrocaval ureter, CT Urogram was done. Intraoperatively we found ureteral narrowing at midureter with proximal Ureter dilatation in all three cases. Two children underwent open surgery and one child underwent laparoscopic excision of narrowed ureteric segment with uretero-ureterostomy. Biopsy of all cases showed urothelium with smooth muscle hypertrophy.

Conclusion: Despite the availability of advanced imaging modalities, a high index of suspicion is required to diagnose ureteral obstruction for early intervention to preserve renal function. Surprises on table may lead to difficulty in access for good repair. Laparoscopic approach is safe and feasible in mid ureteric valve obstruction too.


   New born megalourethra with corpora cavernosa hypoplasia Top



   Category: Urology E Poster Top


Taha A Daginawala, Shivaji B Mane, Yogendra Sanghvi, Prathamesh More, Hussain S Kotawala, Natasha Vageriya, Hemangi Athawale

Department of Paediatric Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India.

E-mail: taha.daginawala@gmail.com

Megalourethra is a rare congenital disorder of anterior urethra and erectile tissue of penis. It mainly appears in two types—a milder scaphoid type and severe fusiform type. Fusiform type is commonly associated with congenital anomalies of various systems of the body. Megalourethra normally presents in older child with penile enlargement or swelling and can be excised successfully. This unusual case of megalourethra presented as a newborn with massive enlargement of penis but extremely thin shaft because of hypoplasia of corpora cavernosa and with acute retention of urine. Management than was staged with initial urinary diversion and later achievement of decrease in penile length and increase in thickness followed by definitive repair at one year with successful outcome.

This clinical picture and stage wise management of newborn megalourethra is first of its kind reported in literature.


   Urethral atresia: A rare case report Top



   Category: Urology E Poster Top


Taha A Daginawala, Shivaji B Mane, Prathamesh More, Hussain S Kotawala, Natasha Vageriya, Hemangi Athawale

Department of Paediatric Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India.

E-mail: taha.daginawala@gmail.com

Congenital urethral atresia is a rare anomaly, defined as complete urethral obstruction at distal end of prostatic urethra. Urethra distal to obstruction is hypoplastic.

Survival in fetus with urethral atresia is only possible if there is any alternative communication present like patent urachus, vesicocutaneous fistula or fistula to rectum. Survival with good outcome is also seen in patient in whom fetal vesico-amniotic /peritoneo-amniotic shunts done before 20 weeks gestation.

We will discuss a case of a 15 days male child who came with features of patent urachus and no h/o passage of urine from urethral meatus. Urethral caliberation was possible upto bulbomembranous junction, posterior urethra could not be negotiated. Hence vesicostomy was done and at 1year 7 months excision of atretic segment with bridging of of gap between anterior and posterior urethra with transverse prepucial island flap was done. Recovery was uneventful.


 Atlas More Details">   Step-by-step mini PCNL in children: A video atlas Top



   Category: Urology E Poster Top


MS Ansari, MS Ansari, Sarita Syal, Ravi Banthia

Department of Urology, Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India.

E-mail: ansarimsa@hotmail.com

Aims: The aim of the miniaturization of PCNL is to reduce complications such as blood loss, intraoperative -postoperative pain and hospital stay. On the other hand it is believed that a small calibre tract is less injurious to nephrons.

In the present video the authors describe their technique of mini-PCNL step by step in a simple and comprehensive way.

Methods: Mini-PCNL is performed under general anaesthesia. After introduction of anaesthesia with the patient in the lithotomy position, retrograde ureteral catheterization is performed with 4 Fr. ureteral catheter to fill the collecting system during percutaneous access. Then, the patient is repositioned in the prone position. Adequate padding of the pressure points is done to prevent pressure induced injuries and neuropraxias. Posterior calyx is accessed by bull eye technique of puncture. Puncture tract dilatation is performed with single step dilator, followed by placement of the sheath. The most preferred sizes of sheath and scope are 16 Fr. and 12 Fr. respectively. Stone disintegration is usually performed with laser.

Results: Stone free rate of mini-PCNL is comparable to conventional one in select cases with lesser complication rate and shorter hospital stay.

Conclusions: Mini PCNL is safe and effective treatment for paediatric renal calculi and is associated with less morbidity and shorter hospital stay.


   Creation of subdartos-pouch in orchiopexy – Points of technique Top



   Category: Urology E Poster Top


Akhilesh Kumar, SN Kureel, Archika Gupta

Department of Paediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India.

E-mail: akumarms781@gmail.com

Aims: To report modified technique of subdartos-pouch-creation to eliminate difficulties associated with conventional technique.

Methods: We used modified technique of subdartos-pouch-creation in 111 patients undergoing orchiopexy in last five-years. After adequate testicular mobilisation, through same inguinal incision, instead of using finger, comparable to contralateral testicular-size, gauze-mountedsponge-holding-forceps tip was advanced inscrotal-sac. It was heldin position by assistant to provide scaffold forsubdartos-pouch-creation. Through 3-4mm incision nearanterior surface of scrotal neck,adequate size space was created between scrotal-skin and dartosover mounted-gauze scaffold with the help ofhemostatic-forceps. Incision was made in dartos to expose mounted-gauze surface. Mounted-gauze was grasped with hemostatic-forceps. Withdrawal ofsponge-holding-forceps facilitated delivery of hemostatic-forceps tipthroughinguinoscrotal wound to inguinal canal. Gubernaculum was graspedto pull and place testis in already created subdartos-pouch avoiding any testicular torsion. Both scrotal and inguinal incisions were closed as in standard procedure.Outcome was measuredin terms of complications.

Results: There wasno injury to any structure. Creation of enough subdartos-space to accommodate testis was possible in all including redo orchiopexy.

Conclusions: Use of mounted-gauze for subdartos-pouch-creation during orchiopexy is simple and reproducible technique that helps in safe creation of enough subdartos-spaceeven in redo orchiopexy.


   Three-dimensional Laparoscopic heminephrectomy in non-functioning renal duplex moiety: A case series Top



   Category: Urology E Poster Top


Rujuta Shah, SV Parelkar, BV Sanghvi, RK Gupta, KP Mudkhedkar, DP Makhija, MP Khobragade, S Soundharya

Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India.

E-mail: rujutas84@gmail.com

Introduction: Jordan and Winslow(1993) successfully carried out the first pediatric laparoscopic heminephrectomy. Minimal invasive surgery has taken over the conventional open heminephrectomy with the biggest advantage being the avoidance of multiple incisions for nephroureterectomy. Minimally invasive heminephrectomy can be performed by conventional laparoscopic, 3D laparoscopic or robotic assisted.3D vision provides excellent image definition, resolution, magnification, depth & volume perception, precision and clear visualisation of the vasculature of both moieties; thereby making excision of the adherent non functioning moiety with its ureter much safer .Also, intra operatively, clear visualization of the entire non functioning moiety ureter upto VUJ and associated preservation of vascular integrity of the other functioning moiety ureter are added advantages.

Case Series: We present 5 cases of 3D laparoscopic upper polar heminephrectomy for non functioning upper moieties for duplex systems with upper polar ureterocele/ectopic ureter during period of 1year.With age ranging from 6m-6years ;all patients were operated using a 10mm(3D) camera port with two working instruments.Mean operative time was 180minutes. All patients had uneventful recovery post operatively.

We recommend 3D upper polar heminephrectomy for treatment of non functioning upper polar duplex moiety.


   Detubularized isolated ureterosigmoidostomy – A continent diversion (atta pouch) Top



   Category: Urology E Poster Top


Soundharya S, Sandesh V Parelkar, Beejal V Sanghvi, Rahul K Gupta, Kedar Mudkhedkar, Rujuta Shah, Deepa Makhija

Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India.

E-mail: soundharya.s@gmail.com

Introduction: Ureterosigmoidostomy (US) has regained popularity in recent times due to its modifications which reduce the complications. One such modification is the Detubularized isolated ureterosigmoidostomy (DIUS) or the Atta pouch which works on the principles of detubularization, abolishing RAIR, isolation of rectal and urinary segments and minimizing the contact of urine with colonic surface. We report the case of a 6 year old girl who was poorly managed for a common cloaca and needed a DIUS for continent urinary diversion.

Description: A 6 year old girl operated for common cloaca as an infant presented with urinary incontinence and severe perineal excoriation. She had undergone a PSARVUP with a diversion stoma in a single sitting at the age of 2 months. About one month later she had undergone a colostomy closure. She now had urinary incontinence but was continent for stools and had a very poor quality of life. On local examination , there was a single large cavity in the introitus. We offered a DIUS or Atta pouch for this child. On one year follow up, she is continent and has a significantly improved quality of life.


   Anterior urethral stricture in boys: A journey revisited Top



   Category: Urology E Poster Top


Priyank Yadav, Ravi Banthia, Naveen Kumar, Sarita Syal, MS Ansari

Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

E-mail: priyankmamc@gmail.com

Aim: Pediatric anterior urethral stricture (AUS) surgery is one of the most difficult reconstructive tasks in pediatric urology. In this article we reviewed the etiology and management of AUS in boys over last 25 years.

Methods: A retrospective study was performed on 168 boys with AUS who underwent treatment at our institute between January 1992 and January 2017. Mean age was 12.43 ± 5.17 years (Range: 1-18years). The diagnosis was made on history of poor stream, dribbling and/ or incontinence along with characteristic pattern on uroflowmetery and it was confirmed radiologically with retrograde urethrogram and micturating cystourethrogram. Success was defined as satisfactory voiding along with radiological evidence of reestablishment of urethral continuity.

Results: Following were the subtypes of AUS: Meatal stenosis (n=14,8.3%), Penile urethral stricture(n=87, 51.7%), Bulbar urethal stricture (n=41,24.4%), Multifocal stricture (n=16,9.5%) and Panurethral stricture (n=10,5.9%). The causes of AUS were Iatrogenic (n=102 ,60.7%) [including valve fulguration (n=29, 17.3%), catherization (n=37, 22.0%), hypospadias repair (n=28,16.6%), cystoscopy (n=4,2.3%), anorectal malformation repair (n=4, 2.3%)], Idiopathic (n=61, 36.3%) and Inflammatory (n=5, 2.9%).

The surgical procedures performed were meatoplasty (n=11, 6.5%), meatotomy (n=7, 4.1%), DVIU (n=88, 51%), end to end urethroplasty (n=39, 23%) preputial/ penile skin tube urethroplasty (n=4, 2.3%) and BMG urethroplasty (n=21,12.5%). DVIU was successful in 35% after 1 session and 71% after multiple sessions. Overall success rate for AUS was 82% at a mean follow up of 1.5 years.

Conclusion: Management of the pediatric AUS should be tailored according to individual case merit. Outcome of DVIU is inferior to non-endoscopic management.


   Obstructive megaureter causing acute obstructive anuria in a case of PUV Top



   Category: Urology E Poster Top


Rupa Banerjee, Satish K Aggarwal, Aparajita Mitra, Gaurav Singh, Muni Varma, Garvita Singh

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: dctrrupa@gmail.com

Aims: Posterior urethral valve is a known cause for hydroureteronephrosis with or without vasico-ureteric reflux. The present case shows sudden anuria due to obstructive megaureter of dysplastic kidney in a case of PUV.

Case Report: An antenatally diagnosed case of bilateral hydroureteronephrosis with PUV underwent cystoscopic valve ablation on D2 of life. Further investigations revealed right non-functioning kidney with dilated ureter. He was well till 19 months of age when he presented with acute onset facial swelling, decreased urine output for 24 hours and complete anuria for 12 hours and culture positive UTI. USG revealed a large cystic mass behind the bladder pressing the bladder and left kidney also was grossly dilated with echogenic debri. Cystoscopy revealed near total bladder neck obstruction by an extrinsic compression from behind the bladder (right lower dilated and obstructed ureter). An emergency right lower ureterostomy and left high loop ureterostomy was performed. In follow up right nephroureterectomy was performed – the lower ureter had no opening in the bladder. Mucosal excision of the lower most part of dilated right ureter was carried out in the area immediately behind the bladder; the left ureterostomy was converted to into a Sober's ureterostomy. The lower ureter on left was narrow (possibly VUJO). His creatinine improved and is on regular follow up.

Conclusion: To our knowledge this is the first case of PUV with acute obstructive anuria due to obstructive megaureter.


   Persistent posttraumatic urinoma managed by minimal invasive techniques Top



   Category: Urology E Poster Top


Shasanka Shekar Panda, Aravindh Radhakrishnan, Arka Banerjee, Sujoy Neogi, Simmi K Ratan

Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India.

E-mail: drshasankaiims06@gmail.com

Background and Aim:- Renal injury following blunt torso trauma in children is a known complication. Although non vascular injuries such as renal contusions and lacerations are conservatively managed, there is controversy regarding management of peri-nephric urinoma. We report a case of a 7 year old girl with blunt abdominal trauma who presented with post traumatic, symptomatic peri-nephric urinoma who was managed by minimal invasive techniques.

Case Report: A 7 year old girl who sustained blunt abdominal trauma and had undergone exploratory laparotomy, splenectomy and pancreatic approximation elsewhere, presented to us on post-op day 15 with complaints of high grade fever. She gave history of hematuria in the initial days post injury. On examination, she was hemodynamically stable but febrile. Abdomen was soft with fullness in left lumbar region. Grade III surgical site infection of the midline suture site. Pelvic drain and left flank drains revealed purulent output. Labs revealed anemia, high total leucocyte count, elevated drain fluid amylase and microscopic hematuria. Drain fluid culture grew Acinetobacter sp. She was managed with culture sensitive intravenous antibiotics, analgesics, and high protein diet. Drains were removed once the outputs were nil. Intermittent fever and left flank pain persisted. Contrast enhanced Computed Tomography abdomen revealed a hypo-enhancing inferior pole of left kidney with a peri-nephric collection of size 3.1x5cm; Normal opacification of left pelvi-calyceal system and ureter. No intra-peritoneal collection. An ultrasound guided left peri-nephric pigtail catheter was placed which continued to drain approx..100-150 ml of clear urine daily for the next 2 weeks. Fever and flank pain improved but in view of the persistently high output from the peri-nephric pigtail, cystoscopic left DJ stenting was done. The drain output decreased gradually and the pigtail was removed. DJ stent was removed after 6 weeks. Follow up after 6 months revealed an asymptomatic child with a normal ultrasound and renal dynamic scan.

Conclusion: -Cystoscopic DJ stent insertion must be attempted in all cases with symptomatic urinoma not settling with percutaneous drainage. Open surgical repair might not be warranted in children presenting with post-traumatic non-vascular renal trauma.


 Spigelia More Detailsn hernia with bilateral undescended testes: A rare variant of Raveenthiran syndrome">   Congenital spigelian hernia with bilateral undescended testes: A rare variant of Raveenthiran syndrome Top



   Category: Urology E Poster Top


Gaurav Singh, Rupa Bannerjee, Muni Varma, Satish Kumar Aggarwal

Department of Paediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India.

E-mail: gauravpsurg86@gmail.com

Aim: To present successful management of a rare association of a congenital spigelian hernia with bilateral undescended (impalpable) testes.

Case Report: A 4 month old boy, a known case of bilateral undescended (impalpable) testes and intermittent right lower abdominal swelling (diagnosed as abdominal wall hernia) was brought to paediatric emergency with complaints of excessive cry, poor feeding and irreducible right lower abdominal swelling. A diagnosis of obstructed right inguinal hernia was made. However the swelling was not in the typical location – inguinoscrotal, rather it was higher – just lateral to the rectus border midway between umbilicus and symphysis pubis.

Emergency exploration was done through a right inguinal incision. No superficial ring was present. On opening the inguinal canal a spigelian hernia was seen coming off the deep ring then turning around the conjoint tendon and dissecting between internal oblique and external oblique aponeurosis. Gut was edematous and compressing the testicular vessels. Hernia could not be reduced from inguinal approach. Hence, additional laparotomy was done and reduction was done by push and pull technique by incising on the fascia transevrsalis to enlarge the deep ring. The gut was viable. Hernial sac was closed . Testicular vesels were oedematous and testis dusky – compressed by hernia. Vas and vessels were mobilized and right testis fixed in the scrotum. Deep ring was narrowed by transversalis fascia repair. The left testis was impalpable. Child was discharged after establishing feeds.

Three months later, a diagnostic laparoscopy was performed for left impalpable testis. Normal looking vas and vesels were seen entering a closed deep ring. On left inguinal exploration a nubbin was found. It was excised and HPE revealed atrophied testis but no dysplasia.

Conclusion: Spigelian hernia is rarely seen in children. An association with ipsilateral undescended testis has been reported by Raveenthiran. Association with bilateral undescended (impalpable) testes is hitherto unreported.


   Ureteral obstruction masquerading as pelviureteric junction obstruction in infants and children: An intraoperative surprise Top



   Category: Urology E Poster Top


Aishwarya M, Bibekanand Jindal, S Kumaravel, G Krishna Kumar

Department of Paediatric Surgery, JIPMER, Puducherry, India.

E-mail: aishwaryamalla61@gmail.com

Aim: To review our experience on mid-ureteral obstruction diagnosed as Pelviureteric junction obstruction preoperatively.

Introduction: Ureteral obstruction caused by ureteric stenosis or valve or retrocaval ureter is a rare entity.

Methods: A retrospective review of all ureteral obstruction cases from 2016 to 2019.We report three cases of mid-ureteric obstruction with different mode of presentation and difficulty in their management. One child was symptomatic and other two were antenatally diagnosed with hydronephrosis. Preoperative diuretic renogram of all three showed severely impaired function with obstructive drainage. As one child had doubtful hydroureteronephrosis on one of the multiple sonograms and retrograde pyelogram was suspicious of retrocaval ureter, CT Urogram was done. Intraoperatively we found ureteral narrowing at midureter with proximal ureter dilatation in all three cases. Two children underwent open surgery and one child underwent laparoscopic excision of narrowed ureteric segment with uretero-ureterostomy. Biopsy of all cases showed urothelium with smooth muscle hypertrophy.

Conclusion: Despite the availability of advanced imaging modalities, a high index of suspicion is required to diagnose ureteral obstruction for early intervention to preserve renal function. Surprises on table may lead to difficulty in access for good repair. Laparoscopic approach is safe and feasible in mid-ureteric valve obstruction too.


   Obstructed hemivagina, uterus didelphys associated with ipsilateral absent kidney (Herlyn werner wunderlich syndrome). Case report and embryological correlation Top



   Category: Urology E Poster Top


KV Satish Kumar, Udaya Samarakkody, Sridharan Jayarathnan, Poppy Redman

Department of Paediatric Surgery, Baptist Hospital, Bengaluru, Karnataka, India.

E-mail: satishpushpa33@gmail.com

Aims: Adolescent girls presenting with recurrent abdominal pain coinciding with menstruation (Dysmenorrhoea) is a common condition. Herlyn Werner Wunderlich syndrome (HWWS) is a rare mullerian anomaly occuring with concurrent wolffian anomaly. 13 year old girl, with single kidney presented at puberty with dysmenorhhoea, On Investigations she had HWW Syndrome and was managed successfully.

Methods: Thirteen year old girl, had recurrent presentations with abdominal pain to emergency. An ultrasound showed, right adnexal cyst and MRI Scan showed didelphic morphology of the uterus/cervix/vagina with hematocolpos, haematometra and hemato salphinx, on the right side.

Results: A perineal exploration under anaesthesia revealed normal female genitalia with diffuse bulge/ cystic swelling noted on the right side proximal to hymen. There was a vaginal septum completely occluding the right hemivagina and the left hemivagina was compressed but normal and patent. The septum was excised draining 500mls of brownish fluid. The child recovered well after surgery.

Conclusion: Herlyn Wunder Wunderlich Syndrome is a combined mullerian and wolffian anomaly which is a rare cause of dymenorhoea in girls. Due to unfamiliarity, a delayed diagnosis is likely. MRI Scan should be considered if there is evidence of pelvic abnomality on ultrasound, particularly when associated with preexisting renal anomaly






 

Top
Print this article  Email this article

    

 
  Search
 
  
 
    Similar in PUBMED
    Article in PDF (5,474 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Feasibility of p...
    Category: UC Cha...
    Conjoined thorac...
    Category: UC Cha...
    The role of urin...
    Category: UC Cha...
    Bracka urethropl...
    Category: UC Cha...
    Comparison of hi...
    Category: UC Cha...
    Assessment of di...
    Category: UC Cha...
    Role of abdomina...
    Category: UC Cha...
    Mini-Perc for re...
    Category: Swapna...
    Evaluation of su...
    Category: Swapna...
    Role of urinary ...
    Category: Swapna...
    Comparative outc...
    Category: Swapna...
    Pippe salle clit...
    Category: Swapna...
    Characteristics ...
    Category: Swapna...
    To assess adequa...
    Category: Swapna...
    Vesicoscopic ure...
    Category: Swapna...
    Study of renal s...
    Category: Swapna...
    Comprehensive re...
    Category: Swapna...
    A comparative st...
    Category: KK Sha...
    RNA sequencing r...
    Category: KK Sha...
    Intra-abdominal ...
    Category: KK Sha...
    The outcome of c...
    Category: KK Sha...
    Local instillati...
    Category: KK Sha...
    Spleen preservin...
    Category: KK Sha...
    Role of MRCP and...
    Category: KK Sha...
    Role of MRCP and...
    Category: KK Sha...
    Liver resections...
    Category: KK Sha...
    Minimal invasive...
    Category: KK Sha...
    ACE-inhibitors&#...
    Category: Experi...
    LED OT lights an...
    Category: Experi...
    Evaluation of ne...
    Category: Experi...
    Transanal endore...
    Category: GI Lon...
    Alimentary dupli...
    Category: GI Lon...
    Study of differe...
    Category: GI Lon...
    Factors affectin...
    Category: GI Lon...
    Primary transana...
    Category: GI Lon...
    Early outcomes i...
    Category: GI Lon...
    Long-term follow...
    Category: GI Lon...
    Puestow procedur...
    Category: GI Lon...
    Profile of Ileal...
    Category: GI Lon...
    Retrospective st...
    Category: GI Lon...
    An alternative t...
    Category: GI Lon...
    Twenty years of ...
    Category: GI Lon...
    To study if gall...
    Category: Hepato...
    A novel risk pre...
    Category: Hepato...
    Pancreatico-bili...
    Category: Hepato...
    Early diagnosis ...
    Category: Hepato...
    IHPS beyond lapa...
    Category: Laparo...
    A comparative st...
    Category: Laparo...
    Robotic surgery ...
    Category: Laparo...
    Role of laparosc...
    Category: Laparo...
    Management of in...
    Category: Laparo...
    Robotic surgery ...
    Category: Laparo...
    Role of Ipsilate...
    Category: Laparo...
    Diversity of spe...
    Category: Miscel...
    Common cloaca- A...
    Category: Miscel...
    Quality of life ...
    Category: Miscel...
    Spectrum of Neo-...
    Category: Miscel...
    Pilot study of p...
    Category: Miscel...
    Analysis of resu...
    Category: Miscel...
    A fool with a to...
    Category: Miscel...
    Rising disgruntl...
    Category: Miscel...
    Outcome of anten...
    Category: Neonat...
    Septic screening...
    Category: Neonat...
    Germ cell tumour...
    Category: Surgic...
    The outcome of o...
    Category: Neonat...
    Differentiated t...
    Category: Surgic...
    Functional bladd...
    Category: Surgic...
    The hidden progn...
    Category: Surgic...
    Extragonadal ger...
    Category: Surgic...
    Chest wall tumor...
    Category: Surgic...
    Rare presentatio...
    Category: Thorac...
    Thoracoscopic pr...
    Category: Thorac...
    Rare Type II var...
    Category: Thorac...
    Sharp foreign bo...
    Category: Thorac...
    Assessment of lo...
    Category: Urolog...
    Penile anthropom...
    Category: Urolog...
    Effect of preope...
    Category: Urolog...
    Rectus abdominis...
    Category: Urolog...
    DSD management -...
    Category: Urolog...
    Comparison of ou...
    Category: Urolog...
    Modified Durham ...
    Category: Urolog...
    Interstitial cel...
    Category: Urolog...
    Modified Jone...
    Category: Urolog...
    Modified Snodgra...
    Category: Urolog...
    Experience with ...
    Category: Urolog...
    Dorso-ventral tr...
    Category: Urolog...
    Vesico-ureteral ...
    Category: Urolog...
    Twenty year expe...
    Category: Urolog...
    Clinical aspects...
    Category: GI Sho...
    Laparoscopic and...
    Category: GI Sho...
    Primary psarp in...
    Category: GI Sho...
    Martin's mod...
    Category: GI Sho...
    Antegrade stomal...
    Category: GI Sho...
    Surgical interve...
    Category: GI Sho...
    Compare suction ...
    Category: GI Sho...
    Prospective comp...
    Category: GI Sho...
    Appendicitis in ...
    Category: GI Sho...
    Single-port sing...
    Category: GI Sho...
    Ultrasound-guide...
    Category: GI Sho...
    Patterns and out...
    Category: GI Sho...
    Antroplasty as a...
    Category: GI Sho...
    Microbial drug r...
    Category: GI Sho...
    Minimally invasi...
    Category: GI Sho...
    To study the eti...
    Category: Hepato...
    Robot assisted d...
    Category: Hepato...
    Laparoscopic ...
    Category: Laparo...
    Laparoscopic hyb...
    Category: Laparo...
    Appendicitis in ...
    Category: Laparo...
    Simplified lapar...
    Category: Laparo...
    Laparoscopic app...
    Category: Laparo...
    Impalpable undes...
    Category: Laparo...
    Laparoscopic pye...
    Category: Laparo...
    New novel method...
    Category: Laparo...
    Sexual assault i...
    Category: Miscel...
    Therapeutic appr...
    Category: Miscel...
    Morbidity in sur...
    Category: Miscel...
    Outcome of anten...
    Category: Miscel...
    Patterns and pri...
    Category: Miscel...
    Antenatally diag...
    Category: Miscel...
    A study of nutri...
    Category: Miscel...
    Knots that can g...
    Category: Miscel...
    Utility of invol...
    Category: Miscel...
    Post tracheo-eso...
    Category: Neonat...
    Ano rectal malfo...
    Category: Neonat...
    Role of transana...
    Category: Neonat...
    Mediastinal fore...
    Category: Neonat...
    Use of vacuum dr...
    Category: Neonat...
    Gastroschisis re...
    Category: Neonat...
    Sacrococcygeal t...