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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
March-April 2020
Volume 25 | Issue 2
Page Nos. 65-129

Online since Tuesday, January 28, 2020

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Fetal malformations and the pediatric surgeon Highly accessed article p. 65
Subhasis Roy Choudhury
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Presidential address p. 68
Ramesh Santhanakrishnan
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Management of intussusception in the era of ultrasound-guided hydrostatic reduction: A 3-year experience from a tertiary care center Highly accessed article p. 71
Mir Fahiem-Ul-Hassan, Gowhar N Mufti, Nisar A Bhat, Aejaz A Baba, Mudassir Buchh, Sajad A Wani, Shahid Banday, Mudassir Magray, Atif Nayeem, Sikandar Iqbal
Introduction: Ultrasound-guided hydrostatic reduction (HSR) is currently the initial management tool in the treatment of intussusception. HSR is, however, confronted with failures besides there are still a number of patients who primarily undergo surgical intervention for the management of intussusception. We undertook this study to assess the efficacy of HSR and also to look for factors demanding the surgical exploration in patients with intussusception. Materials and Methods: A total of 215 patients with intussusception from June 2014 to June 2017 were prospectively studied. HSR was carried out in 203 patients, which was successful in 187 and unsuccessful in 16. These two groups were compared using the Student's t-test. Significance was set at P < 0.05. Twelve patients undergoing surgery primarily were also assessed for the factors affecting the decision-making. Results: HSR was successful in 187 and unsuccessful in 16. The failed group was more likely to have symptoms over 24 h, appearance of crescent, and ≥10-cm length on ultrasonography (USG). Two of these patients had ischemic bowel, two had ileoileal intussusception, and eight had pathological lead points, whereas no obvious cause could be identified in the rest of the four patients. Among the 12 patients who were primarily operated, four patients had peritonitis and other four patients were neonates. Laparoscopic reduction was done in four patients. Conclusion: HSR is a safe and effective treatment modality for intussusception. However, it is met with higher failure rates in patients with risk factors such as delayed presentation, appearance of crescent on USG, and length >10 cm. The role of HSR is also dubious in situations such as neonatal intussusception, small-bowel intussusception, and multiple intussusceptions and also in preventing the future recurrence. Such patients ought to be managed by laparotomy or where feasible by laparoscopy. Furthermore, before embarking on HSR, peritonitis and bowel ischemia should be ruled out clinically and radiologically. In the suspicious cases of bowel ischemia, USG Doppler may be helpful.
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Nonavailability of ultrasound: Try stethoscope in pneumatic reduction p. 76
Ramesh Tanger, Aditya Pratap Singh, Arun Kumar Gupta, Dinesh Kumar Barolia, Arvind Kumar Shukla
Aim and Objective: This study aimed to finding alternative ways for centers with nonavailability of ultrasonography or fluoroscopy for nonoperative pneumatic reduction of intussusceptions. Materials and Methods: A total of 48 cases of intussusceptions were included in the study in-between October 2016 and March 2018. We tried stethoscope-guided pneumatic reduction using locally assembled equipment. The intraluminal pressure was monitored and maintained below 100 mmHg. A total of two attempts of 3 min each were allowed. We compared our results with the control group who have been performing laparotomy for every case of intussusception. Results: There were 35 males and 13 females in our study. The average age of the patients was 7.5 months. Intussusceptions were reduced in 38 (80%) patients but could not be reduced in 10 (20%) patients. Majority of the intussusceptions had symptoms of at least 2 days. There were no complications such as perforation in our study. Conclusion: Stethoscope-guided pneumatic reduction seems to be a feasible and alternative effective method for the treatment of intussusceptions in children where availability of ultrasonography and skilled radiologist with overburden of work is a great issue.
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Intralesional sclerotherapy with bleomycin in lymphatic malformation of tongue an institutional experience and outcomes p. 80
Gaurav Parashar, Gowri Shankar, Ravindra Sahadev, Ramesh Santhanakrishnan
Introduction: The management of lymphatic malformations (LMs) continues to improve with advancement in molecular genetics, imaging, and treatment options. However, the management of tongue LMs remains a challenge due to the location, function involved, and long-term disabilities. We propose injection sclerotherapy with bleomycin in the management of spectrum of tongue LMs. Methods: Children with LMs involving the tongue were prospectively treated with bleomycin sclerotherapy. Outcome measured was the efficacy of sclerotherapy, complications, and functional outcome. Results: A total of 11 children underwent sclerotherapy with bleomycin for varying tongue lesions. Excellent outcome was seen in children with macroglossia. Eight children with isolated (focal) lesions had a resolution of symptoms with a clearance of lesions. Specific complications related to bleomycin toxicity were not encountered in our series during the follow-up of 4 years. Conclusion: In our series, children with macroglossia had an excellent outcome with normalization of tongue size and function. Children with focal tongue lesions also had good to excellent outcome. We recommend treatment of tongue LM with bleomycin sclerotherapy as the first line of management. Ease of treatment, early intervention, and excellent response makes it a favorable treatment option.
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Clinical presentation and surgical management of neonatal tumors: Retrospective analysis p. 85
Shailesh Solanki, Prema Menon, Ram Samujh, Kirti Gupta, KL N. Rao
Aims: Neonatal tumors (NTs) include a group of diverse neoplasms. In this study, we reviewed our data for clinical presentations, management options, and outcome. Materials and Methods: All patients from 0- to 1-month age presenting with solid tumors, from 2006 to 2018 were studied. The gender, presentation, location, type of tumor, and management were analyzed. The final diagnosis was made with histopathology in all cases. Hemangiomas and lymphangiomas were excluded from the study. Results: A total of 32 neonates were studied. The most common tumor was sacrococcygeal teratoma (SCT,16) followed by teratoma at other sites including two cases of fetus-in-fetu, soft-tissue sarcoma (STS, 4), mesenchymal hamartoma (2), hemangioendothelioma (2), and other rare tumors. Three tumors were diagnosed antenatally; of whom, two were neither visible externally nor palpable. Complete surgical excision was done for all except in a case of ovarian cyst where near-total cystectomy was done. No patient received chemotherapy or radiotherapy. Six patients had postoperative complications, including two who had local recurrence requiring excision. There was one mortality. All the other patients are doing well during follow-up. Conclusion: NTs have varied presentations. SCT and STS were the most common benign and malignant tumor, respectively. Early diagnosis and complete surgical excision are often curative for all, regardless of the pathology with the minimal role of chemotherapy or radiotherapy.
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Urinary tract infection in pediatric patients on clean intermittent catheterization via a mitrofanoff port with reused catheters – Any association with catheter sterility? p. 91
Cenita James Sam, Cindrel T Jagadeesan, Sudipta Sen, Pavai Arunachalam, B Appalaraju, Praseetha T Das
Objective: The objective of this study is to find out whether the reused catheters for clean intermittent catheterization (CIC) are colonized before insertion and its association with urinary tract infection (UTI). Materials and Methods: This is a study conducted on 28 pediatric surgery patients who are on CIC via a Mitrofanoff port and who were reusing catheters, in a tertiary care private medical college hospital for 6-month period. Catheters to be used for the next catheterization were sent for culture along with urine culture. A questionnaire was utilized to assess CIC practice and UTI. Results: Diseases of patients were: neurogenic bladder and exstrophy–epispadias and posterior urethral valve. Twenty-one of them had an augmented bladder. Hydronephrosis was present in ten and vesicoureteral reflux (VUR) in five. Their mean duration of CIC was 5.3 years. Of 28 catheter tip samples, 16 catheters were colonized with organism. Of the 28 urine culture samples, 17 cultures were positive and all were asymptomatic except one. Of the 16 positive catheter samples, only 9 had positive urine culture; four of them had grown different organisms and five of them had the same organism, and even in these five, single organism was seen only in three. Urine culture grew Gram-negative organism in 85%, but catheter grew Gram-positive organism in 46%. No difference was found in the variables between both groups such as hydronephrosis, VUR, and augmented bladder. Conclusion: Reused catheters were colonized in 57% of the study patients, but reused catheter may not be the cause of culture positivity or UTI in the study population.
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Evaluation of effect of propranolol on serum vascular endothelial growth factor and tissue inhibitor of metalloproteinase-2 levels in infantile hemangioma p. 96
Anand Pandey, Abhishek Singh, Wahid Ali, Anurag Srivastava, Archika Gupta, Shiv Narain Kureel, Jiledar Rawat, Ashish Wakhlu
Background: Infantile hemangioma is the most common tumor of infancy. Currently, propranolol is a preferred drug for treating hemangioma. The exact mechanism of action of propranolol is not known. In this study, we attempted to assess whether propranolol has any effect on vascular endothelial growth factor (VEGF) and tissue inhibitor of metalloproteinase-2 (TIMP-2) over a period of time, and if it is there, how long it affects it. Materials and Methods: Propranolol was administered in the dosage of 2–3 mg/kg. The first serum sample was collected before starting the propranolol treatment. Thereafter, samples were collected at monthly intervals up to a total of six samples. The samples were assessed for TIMP-2 and VEGF using enzyme-linked immunosorbent assay kit. Results: The duration of this study was from June 2016 to November 2017. The total number of patients in this study was 15. Thirteen patients responded to treatment. The mean age of patients was 7.1 months. The mean value of baseline VEGF was 0.234 ± 0.059 and that of TIMP-2 was 1.338 ± 0.679. As compared to baseline value, the P value was statistically not significant in any of sequential values. In category-wise analysis, apart from statistically significant value in the 6th month in excellent category and good response category in the 1st month, all other values did not reveal any significant change in VEGF analysis. The analysis of TIMP-2 revealed a significant change in the levels from Sample 2 to Sample 6 in the excellent response group; however, the levels did not show a specific trend either increasing or decreasing. Conclusion: Despite its beneficial action in regression of hemangioma, the exact mechanism is yet to be identified. The exact duration of treatment needs further evaluation.
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Giant colonic lithobezoar: A rare case report p. 103
Jayalaxmi Shripati Aihole
Bezoar is defined as the accumulation of undigested foreign bodies or nutrients in the gastrointestinal tract. Lithobezoar, the accumulation of stones in the digestive tract, is commonly seen in the stomach. We report a case of giant colonic lithobezoar in a child.
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First report of treatment with pancreas-sparing duodenectomy in a child with primary intestinal lymphangiectasia p. 106
Tugba Acer-Demir, Ibrahim tgn, Figen zay
Pancreas-sparing duodenectomy (PSD) is a known surgical technique used in patients with duodenal pathologies in the adult age group. We present a 3-year-old female patient with intestinal lymphangiectasia who underwent PSD. This is the first case in which this surgical technique was used in childhood. We believe that PSD can be used in the pediatric age group for benign pathologies. Introducing a stent to the common bile duct and the main pancreatic duct is not a requirement, especially if the ampulla is preserved as a “button” duodenal patch.
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Median cleft lip with nasal dermoid: A rare occurrence p. 110
Lalit Agrawal, Arshad Afeez Khan, Naveen Khubchandani, Sarfaraz Sheikh Ali
Median cleft lip with nasal dermoid is a very rare occurrence. Midline nasal dermoid results from the abnormal fusion of embryological processes. They can present as asymptomatic midline nasal swelling, infection, or meningitis due to intracranial extension. Median cleft lip also results from failure of fusion of embryological processes and can be complete or incomplete or associated with other congenital anomalies or as a part of syndrome. We present a rare combination of both in a 7-month-old female child who was surgically treated.
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Rapunzel syndrome in a 3-year-old boy: A menace too early to present p. 112
Mritunjay Kumar, Madhukar Maletha, Sakshi Bhuddi, Rashmi Kumari
Rapunzel syndrome is a rare type of trichobezoar with an extension of the hair into the small bowel. Clinical presentation is deceptive and vague, ranging from asymptomatic abdominal mass to gastrointestinal perforation. There are only few cases reported in literature, with the youngest age being 3 years. We present the case of a 3-year-old male child presenting with Rapunzel syndrome and features of subacute intestinal obstruction.
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Splenogonadal fusion – A rare anomaly p. 115
Santosh V Patil, Priya Santosh Patil, Vibhu D Sharma, Sudhakar S Jadhav
Splenogonadal fusion (SGF) is a rare congenital anomaly. Less than 200 cases of SGF have been documented till date. We present a case of 14-year-old male patient with swelling in the left scrotum for 3 years. Left orchidectomy was done. Histopathology showed ectopic splenic tissue surrounding testicular parenchyma suggestive of SGF. This rare congenital malformation may occur due to the proximity of developing gonad and spleen, resulting in abnormal connection between them during gestation. SGF presents a diagnostic challenge preoperatively; however, recent imaging methods can aid with the diagnosis. SGF as a rare cause of testicular swelling should be kept in mind and evaluated to avoid unnecessary orchidectomy.
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Perforation peritonitis secondary to intestinal mucormycosis in a boy with type I diabetes mellitus p. 118
Abdul Haque M. Quraishi, Aishwarya Peshattiwar, Girish Umare, Avishek Bannerji
Intestinal mucormycosis is a rare fungal infection reported more commonly in immunocompromised patients, premature infants, diabetics, transplant recipients, prolonged use of corticosteroids, or in conditions associated with an increased availability of serum iron such as acidosis or deferoxamine administration and carries a high mortality rate. We report the case of a 14-year-old boy with diabetes mellitus, who presented with atypical clinical features. He was diagnosed as intestinal mucormycosis and was treated successfully with surgical and antifungal management.
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Limb salvage in an extensive, complicated vascular lesion of the arm in an infant p. 121
Veerabhadra Radhakrishna, Chittur Narendra Radhakrishnan, Harish Kumar Kabilan, Ashok Basur Chandrappa, Srikanth Vasudevan
When a vascular lesion involving a limb poses a hazard to the life, treatment options are excision or amputation of the limb. Although excision can be hazardous, limb salvage with vascular control is the best treatment option. We report limb salvage in an infant with an extensive infected congenital hemangioma complicated with consumptive coagulopathy.
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Testicular volume in a cohort of prepubertal Indian children p. 126
Mahmood Dhahir Al-Mendalawi
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Surgeon-assisted continuous transversus abdominis plane block a feasible option for perioperative pain relief in pediatric surgical patients with spinal deformities p. 126
Deepak Dwivedi, Saurabh Sud, Shalendra Singh, Rakesh Sharma
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Primary carcinoid tumor in a retroperitoneal teratoma in a child p. 128
Mahadevappa Kiran, Rajalakshmi Tirumalae, Attibele Mahadevaiah Shubha, Kanishka Das
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