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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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   Table of Contents - Current issue
Coverpage
July-August 2020
Volume 25 | Issue 4
Page Nos. 193-262

Online since Wednesday, June 24, 2020

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EDITORIAL  

Pediatric surgery in rural India: Past, present, and future Highly accessed article p. 193
Ajay N Gangopadhyay
DOI:10.4103/jiaps.JIAPS_113_20  
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REVIEW ARTICLE Top

Laparoscopy during the COVID-19 pandemic: Absence of evidence is not evidence of absence Highly accessed article p. 195
Prabudh Goel, Ashoke K Basu
DOI:10.4103/jiaps.JIAPS_118_20  
From a local outbreak to a global pandemic, the severe acute respiratory syndrome-coronavirus-2 infection has spread across 210 borders to infect 2.5 million humans. There is an organized disruption in the routine hospital functioning to divert the available resources for effective crisis management; most of the departments have been split to carve out a “COVID task force.” The recommended indications for treatment of various medical conditions, medical procedures, and protocols have regressed on the evolutionary timeline. Newer recommendations are being released and updated regularly based on emerging evidence and experts' opinions. In view of exponential spread of the virus through routes already identified or those still elusive, the shedding of the virus during the incubation period, and lack of scientific evidence, the questions of “laparoscopy” or “no laparoscopy” assume importance. Herein, the evidence in literature pertaining to patient safety, efficient and effective utilization of hospital resources, and safety of health-care workers (HCWs) during the pandemic have been reviewed from the perspective of laparoscopy. The pathobiology of the virus including its survival properties and the different modes of transmission has been highlighted, and the relative risk to the HCWs between open and laparoscopic surgery dwelt upon. The recommendations from various international bodies have been discussed. Notwithstanding the absence of concrete evidence to exclude the possibility of bioaerosol-based transmission of the disease to the operating room staff, there is a multitude of other concerns which are addressed by avoiding the use of the laparoscope in the current scenario. Moreover, the absence of evidence is not evidence of absence; considering the high contagion and a long latent period associated with this virus, the onus is upon each individual surgeon to decide if one needs evidence of bioaerosol-based transmission or evidence in favor of safety before taking up 'laparoscopy' against 'open surgery'.
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ORIGINAL ARTICLES Top

Neonatal gastric perforation: Our experience and important preoperative and intraoperative caveats to prognosticate and improve survival Highly accessed article p. 201
Saurabh Shyam Garge, Geetika Paliwal
DOI:10.4103/jiaps.JIAPS_80_19  
Aim: Neonatal gastric perforation (NGP) is a rare, perplexing, life-threatening entity affecting neonates. We share our experience of operating upon cases of NGP s and highlight important points observed which may aid in further improving care of neonates, diagnosed with this entity. Materials and Methods: A retrospective analysis of all consecutive patients with NGP operated by the author, at various centers between January 2015 and December 2018, was carried out. We analyzed different variables for these and reached logical conclusions. Results: Between January 2015 and December 2018, we treated ten patients with gastric perforation. All the neonates were preterm, except one. Mean birth weight in our series was 1745 g (range 1300–2400 g). Deterioration in activity, worsening of sepsis, metabolic acidosis, increased ventilator requirements, and abdominal distension were prominent clinical features identified in all patients. All patients subsequently had massive pneumoperitoneum before surgery. Six patients had perforation along the greater curvature, two had perforation at the posterior wall, and two had near total gastric necrosis. We had four mortalities out of ten patients operated. Conclusion: NGP is associated with high mortality, especially in premature and low birth weight neonates. Severity of contributing factors in a premature predisposed neonate determines the severity of gastric necrosis, which in turn is an important prognostic factor. Certain preoperative signs can be useful and can aid in initiating preventive measures to curtail severity of the pathology.
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First-year follow-up of newborns operated for esophageal atresia in a developing country: Just operating is not enough! p. 206
Santosh Dey, Vishesh Jain, Sachit Anand, Sandeep Agarwala, Anjan Dhua, M Srinivas, Veereshwar Bhatnagar
DOI:10.4103/jiaps.JIAPS_88_19  
Purpose: To identify complications, their incidence and risk factors for their occurrence in patients of esophageal atresia (EA) in the 1st year after discharge following surgery. Materials and Methods: Cases of EA discharged after surgical intervention in the period of July 2011–July 2013 were considered a cohort. All data regarding demographics, investigations, surgical procedure, outcome, and follow-up were recorded. Results: Seventy-six such patients were discharged in the study period, six of whom were lost to follow-up, and hence, seventy patients were included in the study. Of these 70, 48 (69%) had esophageal continuity restored (46 EA + tracheoesophageal fistula [TEF]; 2 pure EA), while 22 (31%) had been diverted (3 pure EA; 8 EA + TEF following major leak; 11 long gap EA + TEF). Risk of developing any complication (except death) was 48/70 (68%; 95% confidence interval [CI] = 57.4–79.7). Twenty-six of 48 patients with esophageal continuity restored, demonstrated narrowing on contrast study (54%; 95% CI = 39.5–68.7) but only 18 of these 48 (37.5%) had dysphagia. Thirty-one of seventy had an episode of lower respiratory tract infection (LRTI) (44.2%; 95% CI = 32.3%–56.2%). Poor weight gain was observed in 27/70 (37%), and this was significantly common in diverted patients (63% vs. 25%; P = 0.009). Twenty-one of total 70 (30%) patients died within the 1st year following discharge. Conclusions: Sixty-eight percent of cases developed some complication, while 30% succumbed within the 1st year of life following discharge. The common complications were stricture, LRTI, and poor weight gain. All of these were common in diverted patients.
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Biliary reconstruction by isolated jejunal interposition loop: Our experience after excision of choledochal cyst p. 213
Somak Krishna Biswas, Kalyani Saha Basu, Sumitra Kumar Biswas, Hinglaj Saha, Subhankar Chakravorty, Jay Kishor Soren
DOI:10.4103/jiaps.JIAPS_95_19  
Background: Choledochal cyst is a fairly common hepatobiliary condition in pediatric surgical practice. For the most common type (type I), it is well established that the total excision of the cyst with an wide biliary-enteric anastomosis is key for long-term good result. Multiple options remain for biliary-enteric reconstruction after excision. Jejunal interposition loop reconstruction is thought to be the most physiologic. Materials and Methods: We have retrospectively reviewed the data of patients of type I choledochal cysts which were operated between January 2010 and September 2018 and undergone jejunal interposition loop reconstruction. Clinical presentation, investigations, operative procedure morbidity and complications were reviewed. Results: There were 33 patients, with a male-to-female ratio of 1:3 and a mean age of 4.63 years (mean ± standard deviation [SD] = 4.63 ± 2.98 years). The follow-up period ranged from 3 to 81 months (mean ± SD = 36.30 ± 19.24 months). There was no stricture or cholangitis. Reoperation required in one due to leak at biliary-enteric anastomosis leading to biliary peritonitis. One each had pancreatitis and prolonged ileus. Two bile leaks stopped spontaneously. Operative time and postoperative hospital stay were 228.78 ± 40.43 min (mean ± SD) and 8.96 ± 3.63 days (mean ± SD), respectively. Conclusion: Jejunal interposition loop reconstruction is safe and reproducible with acceptable morbidity. However, if this procedure is abandoned, the long-term benefits may remain ever elusive.
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Role of urinary transforming growth factor beta-b1 and monocyte chemotactic protein-1 as prognostic biomarkers in posterior urethral valve p. 219
Pranay Panigrahi, Sarita Chowdhary, Shyamendra Pratap Sharma, Rakesh Kumar, Neeraj Agarwal, Shiv Prasad Sharma
DOI:10.4103/jiaps.JIAPS_104_19  
Background: Posterior Urethral Valves (PUV) are the most common cause of congenital LUT obstruction in males. Biomarkers of glomerular or tubular injury may be of particular value in predicting the need for surgical intervention or in tracing progression of chronic kidney disease. Measurement of biomarker in urine is relatively easy. Aim: To evaluate the changes in values of urinary Transforming Growth Factor Beta 1(TGF-B1) and Monocyte Chemotactic Protein (MCP-1) before and after valve ablation and its prognostic value in Posterior urethral valve. Material and Method: This prospective study was conducted from September 2016 to August 2018. The study group included 20 consecutive male babies with the diagnosis of PUV treated and followed up versus equal numbers of age matched control without any renal or urinary tract disease. Pre-operative urine samples were collected in Operative room. Cystoscopy and valve ablation was done. Follow up was done clinically by urinary stream and radiologically with VCUG. Follow-up was planned at 1 month, 3 months and 6 months following cystoscopic valve ablation. All collected urine samples were centrifuged at 10,000 rpm for 20 minutes. Supernatant was collected and two divided aliquots were stored at -200c to be thawed on the day of assay. Optical density of each well was recorded at 450 nm and 540 nm A p-value of <0.05 was considered to be statistically significant. Result and Discussion: Out of 20 cases of PUV, 14 (70%) cases were 1st born males of their family. The median age at the time of valve ablation in PUV cases was 2.5 (1.20-3.87) years.. Most common symptoms are fever and UTI. The preoperative median serum creatinine level was 1.65 mg/dl(1.22-2.42) pre-ablation, and fall significantly after ablation. Median eGFR level (calculated) was 25.635 (16.38-35.40) and after 6 months was 71.490 (45.44-96.93). Preoperative median MCP1 in PUV cases was 147.2 (82.8-512.5) and significant difference was also found in 1st, 3rd and 6th months after surgery (p<0.001, p=0.004 and p=0.002).Preoperative median TGF-B1 level was 197.8 pg/ml (79.9-386.4). There was no statistically significant change in TGF-B1 level at preoperative to 1 month and preop to 3 months after surgery but at 6 months after surgery the median TGF-B1 level significantly decreased as compared with preoperative TGF-B1 level. Conclusion: TGF β1 and MCP1 can be considered as prognostic urinary biomarkers in patients of PUV and can be used to specify and counsel patient's attendant regarding possibility of ESRD and need for further intervention.
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Diversity of spectrum and management of animal-inflicted injuries in the pediatric age group: A prospective study from a pediatric surgery department catering primarily to the rural population p. 225
Rafey Abdul Rahman, Umesh Kumar Gupta, Shashank Agrawal, Prabudh Goel, Muniba Alim
DOI:10.4103/jiaps.JIAPS_114_19  
Introduction: Animal-inflicted injuries continue to be a major health problem worldwide. In developing countries, the outcome of such injuries, especially in children may be poor. Aim: The study aimed to evaluate the diversity of spectrum and management of animal-inflicted injuries in the pediatric age group. Materials and Methods: This was a 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 such as age and sex, animal species involved, provoked/unprovoked, mechanism of injury, time of injury, prehospital care, injury-arrival interval, pattern and type of injury, trauma score, body region injured, treatment given and complications were collected and analyzed. Results: Fifty-two children with animal-inflicted injuries were included, constituting <1% of all trauma cases seen during the study period (male:female = 2:1). The mean age of the cohort was 9.65 years. Domestic animals were responsible in 41 children (78.84%) and wild animals in 11 children (21.16%). Dog bite was the most common (57.69%). Penetrating injury was observed in 40 (76.9%) and blunt injury was observed in 12 (23.1%). The musculoskeletal system was the most common organ-system injured affecting 36 children (69.23%). Thirty-five children (67.3%) after minor treatment were discharged. Seventeen children (32.7%) required admission. Thirty-four children (65.38%) underwent surgical procedures. Wound debridement was the most common procedure performed. Wound infection was observed in 20 children (38.46%) and was significantly higher (P < 0.01) in delayed presenters. The length of hospital stay for the admitted children ranged from 3 to 28 days. Conclusion: Animal-inflicted injuries are rare in children and have a wide spectrum of presentation. Severe injuries require extensive resuscitation and expert surgical care. Mild injuries can be managed conservatively with the use of proper dressings, antibiotics, and analgesics.
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Influence of interstitial cells of cajal in congenital ureteropelvic junction obstruction p. 231
Tanmay Pande, Santosh Kumar Dey, Karunesh Chand, Prateek Kinra
DOI:10.4103/jiaps.JIAPS_115_19  
Background: The etiopathogenesis of congenital ureteropelvic junction obstruction (UPJO) has been inconclusive in spite of the numerous studies carried out to find the possible causative factor. The results of different studies have been conflicting and contradictory. It has been postulated that the interstitial cells of Cajal (ICC) are the pacemaker cells located in the ureteropelvic junction (UPJ) and regulate the peristalsis in this region. Paucity of these cells may be one of the causative factors for congenital UPJO although there is no clear consensus on this issue. Therefore, the present study has been carried out to ascertain the role of ICC as one of the possible etiological factors for congenital UPJO. The aim of this study is to first identify the presence of ICC at UPJ, second to compare the average number of ICC in congenital UPJO with a control population without UPJO, and third to ascertain whether any correlation exists between the number of ICC and postoperative improvement in function of the affected kidney. Materials and Methods: A total number of 30 patients who underwent dismembered Anderson-Hynes pyeloplasty for congenital UPJO between June 2016 and November 2017, were compared with seven controls who underwent nephroureterectomy for various other reasons. The specimen was subjected to immunohistochemistry (IHC), and a quantitative comparison was made for the ICC between cases and controls. The preoperative and postoperative function was evaluated by renal diuretic scintigraphy. Results: The disease was more common among males in the ratio of 6.5:1, and there was a predominance of the left-sided involvement. In the studied cases, the average number of ICC seen for every high-power field (hpf) was 4.86 ± 0.76/hpf, whereas in control it was 11.74 ± 0.86/hpf (P = 0.04). The postoperative outcome, as measured by the improvement in split renal function, did not have any correlation with the number of ICC. Conclusion: The ICC are present at the UPJ and can be detected by immunohistochemistry due to their CD117 positivity. These cells are significantly low at this site in cases of congenital UPJO when compared to controls without any obstruction. The number of ICC bears no correlation to the postoperative improvement in function.
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CASE REPORTS Top

Giant gastric polyp in peutz–Jeghers syndrome: Report of a case p. 236
Divya Murali, Anjan Kumar Dhua, Vishesh Jain, Veereshwar Bhatnagar, Rohan Malik, Rajni Yadav
DOI:10.4103/jiaps.JIAPS_54_19  
Peutz–Jeghers syndrome (PJS) is inherited as an autosomal dominant disorder presenting as hamartomatous polyps in the small bowel, mucocutaneous pigmentation and with a predisposition to develop cancer. We report a case of PJS, with an adenomatous giant gastric polyp. The purpose is to highlight that adenomatous giant gastric polyp may be an extremely rare presentation of PJS. Awareness of this possibility will help us in not missing out these atypical cases of PJS.
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Mucosa-coring salvage (MU-CO-SAL) appendicectomy: A useful technique in the management of neglected appendicular mass p. 239
V Raveenthiran, R Abhinav Bharadwaj
DOI:10.4103/jiaps.JIAPS_84_19  
In the presence of an appendicular mass, surgery is generally limited to the drainage of abscess. Scientific literature is sparse and controversial as to how the ongoing sepsis despite the drainage of appendicular abscess should be managed. Deliberate appendicectomy in the presence of mass formation is often not recommended as it may cause collateral damage to the adherent bowel loops. The authors describe a useful technique of doing appendicectomy by stripping the mucosa alone, leaving behind the adherent muscular cuff undisturbed. This technique is given an acronym “mucosa-coring salvage (MU-CO-SAL) appendicectomy.” This article is intended to draw the attention of pediatric surgeons to this useful technique, which remains underutilized despite being described almost a decade ago.
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Multiple atypical esophageal foreign bodies in an infant p. 242
Roma Varik, Attibele Mahadevaiah Shubha, Kanishka Das
DOI:10.4103/jiaps.JIAPS_101_19  
Foreign body ingestion is a common accidental emergency in children. We report an unusual case of multiple blunt and sharp esophageal foreign bodies in a female infant probably associated with homicidal intent and its management.
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Refractory congenital chylous ascites: Role of fibrin glue in its management p. 245
Rahul Saxena, Biangchwadaka Suchiang, Manish Pathak, Arvind Sinha
DOI:10.4103/jiaps.JIAPS_123_19  
Chylous ascites is the accumulation of triglyceride-rich lymph in the abdomen. Its occurrence during the infantile period is quite rare. Congenital chylous ascites (CCA) is one, which occurs in children <3 months of age, due to maldevelopment of the lymphatic system. There is no clearly defined treatment protocol for CCA; however, the use of medium-chain triglycerides (MCT)-based diet or total parenteral nutrition (TPN) with octreotide has been successful. Failure of conservative management, however, leads to surgical exploration to deal with those leaking lymphatics. In our case, we had initially given a trial of managing the child with MCT-based diet followed by a TPN along with octreotide. However, the failure of both leads us to operate the child during which we incorporated the use of fibrin glue over the leaking mesenteric lymphatic vesicles, which ultimately led to the resolution of the chylous ascites.
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Kluth type IIIb9variant of esophageal atresia p. 248
Rahul Gupta, Ankit Singh, Arun Kumar Gupta
DOI:10.4103/jiaps.JIAPS_134_19  
We, herein, present an extremely rare case of an esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) with additional perforated membrane at the lower one-third of fistula. A neonate presented with difficulty in breathing and excessive frothing from the mouth. Radiograph with red rubber catheter in situ(obstruction at 10 cm from the gum margins) suggested EA with distal TEF. During thoracotomy, after ligation of fistula, a 6 Fr infant feeding tube was introduced into the distal esophagus which revealed obstruction at the lower one-third. An esophagotomy was performed; a membrane with opening at the center was identified. Following its excision, the esophageal end became dusky necessitating esophagostomy and feeding gastrostomy. A high index of suspicion for membranous obstruction at the lower one-third of fistula should be kept in mind while dealing with EA with distal TEF.
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Giant phyllodes tumor in ectopic breast tissue p. 251
Umesh Bahadur Singh, Jai K Mahajan, Kim Vaiphei
DOI:10.4103/jiaps.JIAPS_137_19  
Breast masses are uncommon in children and adolescents. Ectopic breast tissue is further uncommon and may be present in locations such as the face, back, and thigh. A 12-year-old female child presented with a hard, nonmobile lump in the right breast. On exploration by submammary incision, the lump was found to be below the pectoralis major muscle and had no communication with the overlying orthotopic breast tissue. Histopathological examination revealed a well-encapsulated biphasic lesion, with features characteristic of a phyllodes tumor. We report a hitherto unreported case of aberrant breast tissue lying under the pectoralis muscle and containing phyllodes tumor.
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IMAGES Top

Isolated asternia: An extremely rare entity p. 254
Sachit Anand, Kanika Sharma, Minu Bajpai, Prabudh Goel, Manisha Jana
DOI:10.4103/jiaps.JIAPS_223_19  
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LETTERS TO THE EDITOR Top

Massive ovarian edema: An extremely rare cause of ovarian mass in a 7-year-old girl p. 256
Nidhi Mahajan, Arti Khatri, Niyaz Ahmed Khan, Natasha Gupta
DOI:10.4103/jiaps.JIAPS_111_19  
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Distal loop colonoscopy-assisted transanal excision of retained spur after duhamel's procedure p. 257
K Senthamizhselvan, Pazhanivel Mohan, Bikash Kumar Naredi, Barath Jagadisan
DOI:10.4103/jiaps.JIAPS_122_19  
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Bladder exstrophy with anovestibular fistula: A rare presentation p. 258
Enono Yhoshu, Jai K Mahajan
DOI:10.4103/jiaps.JIAPS_139_19  
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Trivial trauma causing large intramuscular hematoma in a child with undiagnosed vascular Ehlers–Danlos syndrome p. 259
Prateek Hongal, Akshay B Kalavant
DOI:10.4103/jiaps.JIAPS_147_19  
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Posterior urethral valves consensus p. 261
Shilpa Sharma
DOI:10.4103/jiaps.JIAPS_157_19  
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