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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
April-June 2019
Volume 24 | Issue 2
Page Nos. 87-155

Online since Friday, March 1, 2019

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Pediatric surgery: Is it growing? Highly accessed article p. 87
Dhananjay Basak
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Synopsis of presidential address by Dr. Ketan Parikh p. 89
Ketan Parikh
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Review of laparoscopic management of mature cystic teratoma of ovaries in children p. 92
Maja Raicevic, Amulya Kumar Saxena
Ovarian cystic mature teratomas (OCMTs) are the most frequent ovarian tumors in childhood. This review aimed to determine the feasibility and safety of laparoscopic management of OCMT. Literature was searched for terms “mature,” “ovarian,” “teratomas,” and “laparoscopy.” Primary endpoints were age at surgery, laparoscopic and surgical technique, intraoperative complications, postoperative morbidity, and associated pathology. Literature search revealed 11 articles published between 1998 and 2014 that met the inclusion criteria. There were 105 (n = 95 unilateral; n = 10 bilateral) patients for this analysis, with mean age at surgery being 13 years. Four laparoscopic approaches were opted: gasless transumbilical laparoendoscopic single-site (LESS) surgery (n = 19), gasless multiport surgery (n = 24), single-incision laparoscopic surgery (SILS) (n = 3), and pneumoperitoneum multiport laparoscopy (n = 59). The 10 patients with bilateral OCMT underwent ovary-sparing surgery: LESS-assisted extracorporeal bilateral cystectomy in which tumors were punctured by a balloon catheter (n = 2), intracorporeal cystectomy for gasless multiport laparoscopy (n = 5) with use of endobags to prevent spillage, and transperitoneal multiport laparoscopy (n = 3). OCMT was associated with ipsilateral and unilateral ovarian torsion in five and bilateral ovarian torsion in one patient with bilateral OCMT. In four patients with unilateral OCMT, salpingo-oophorectomy was performed. Intraoperative complications were laceration of utero-ovarian ligament and bladder injury during a suprapubic port placement. The mean follow-up was 31.9 months. Patients with unilateral or bilateral OCMT can be offered ovarian-sparing surgery laparoscopically with one of the following techniques: LESS, SILS or multiport laparoscopy with pneumoperitoneal or gasless. Long-term follow-up of these techniques has shown no recurrence with low postoperative morbidity and low intraoperative complications.
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Anatomical explanations of the pathogenesis of proximal hypospadias p. 97
Smail Acimi
Aims: The aim of this study was to try to explain the pathogenesis of proximal hypospadias based on anatomical and histological findings. Methods: During 9 years, we performed systematic biopsies (in the lateral areas of the urethral plate, as well as under this plate) in 81 patients treated for proximal hypospadias. The histological study was performed by routine coloring, hematoxylin and eosin, and Masson's trichrome, which colors the collagen fibers in blue, and monoclonal antibody against alpha-smooth muscle actin. Results: There is a fibrosis tissue abnormally present on the ventral side of the penis. This tissue consists of a mixture of fibrous connective tissue, nerve nets, short vessels, and smooth muscle fibers. The penis' dartos does not contain smooth muscle fibers. These fibers can come from a blood vessel or spongy tissue which existed during the neonatal period in the distal part of the penis before disappearing. Conclusions: The proximal hypospadias is due presumably to avascular necrosis of the distal part poorly vascularized of the corpus spongiosum.
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A comparison of laparoscopic redo fundoplications for failed toupet and nissen fundoplications in children p. 100
Go Miyano, Masaya Yamoto, Hiromu Miyake, Keiichi Morita, Masakatsu Kaneshiro, Hiroshi Nouso, Mariko Koyama, Manabu Okawada, Takashi Doi, Hiroyuki Koga, Geoffrey J Lane, Koji Fukumoto, Atsuyuki Yamataka, Naoto Urushihara
Purpose: We compared laparoscopic redo fundoplications performed for failed laparoscopic Toupet fundoplication (LTF) and failed laparoscopic Nissen fundoplications (LNFs). Methods: Redo LTF (R-LTF; n = 4) and redo LNF (R-LNF; n = 6) performed between 2007 and 2014 were assessed retrospectively for severity of intraperitoneal adhesions on a scale of 0–3, identification/preservation of the anterior/posterior/hepatic branches of the vagus nerve (VN), complications, and outcome. Results: Redos were performed after a mean of 34 months in R-LTF and 32 months in R-LNF (P = ns) indicated for sliding hernia (n = 3; 2 with partial wrap dehiscence) and partial wrap dehiscence (n = 1) in R-LTF and sliding hernia (n = 6; 4 with partial wrap dehiscence) in R-LNF. The mean adhesion severity score was 1.5 in R-LTF and 2.5 in R-LNF (P < 0.05). The mean number of VN branches identified/preserved was 2.0 in R-LTF and 0.8 in R-LNF (P < 0.05). Mean operative times and mean blood loss were similar. Intraoperative complications were accidental local trauma (n = 1 in R-LTF and n = 3 in R-LNF, one requiring conversion to open repair) (P = ns). Gastric outlet obstruction developed in two R-LNF cases; both were managed conservatively. There have been no further recurrences to date. Conclusion: Although our series is small, adhesions were less, and identification/preservation of VN was easier during R-LTF.
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Radiologic evaluation of uterovaginal abnormalities in girls with congenital pouch colon p. 104
Niyaz Ahmed Khan, Nitin Pant, Amit Gupta, Rama Anand, Partap Singh Yadav, Rajiv Chadha, Subhasis Roy Choudhury
Background/Purpose: The radiologic investigations of 25 girls with congenital pouch colon (CPC), managed over 17 years, were retrospectively reviewed. In 13 girls who form the study group, the investigations provided information about the anomalous uterovaginal (UV) anatomy and these findings were studied. Materials and Methods: Age at presentation was 2 months to 10 years. The subtypes of CPC were Type I (n = 2), Type II (n = 9), and not recorded (n = 2). All patients had a double vagina and a unicornuate uterus on each side in the pelvis. The radiologic studies, performed at varying periods after surgery, included an intravenous urogram (IVU) (n = 4), micturating cystourethrogram (MCU) (n = 3), distal ileostogram/colostogram (n = 6), and magnetic resonance imaging (MRI) (n = 7). Results: IVU and MCU showed retrograde filling of the vaginas with contrast during micturition with a small-capacity urinary bladder and a relatively open bladder neck. The two vaginas were quite apart, but symmetrical in appearance and position. A distal dye study showed filling of the colonic pouch, its terminal fistula, and the two vaginas in six patients. Opacification of the bladder was seen in 3/6 girls, including one girl with left-sided Grade IV vesicoureteral reflux. MRI (n = 7) showed a monocornuate uterus on each side in the pelvis. The upper vaginas on each side were apart, being widely apart (n = 5) and somewhat closer (n = 2). The lower vaginas were closer with an intervaginal septum. Other findings were a widely open bladder neck and urethra in two girls with urinary incontinence and visualization of the terminal fistula of the colonic pouch (n = 2). The lumbosacral spine was normal in all patients. Conclusions: In girls with CPC, retrograde reflux of contrast into the vaginas during a distal dye study or an IVU/MCU may provide useful details of the anatomy of the vaginas. An MRI scan is recommended as essential for comprehensive evaluation of the anomalous UV anatomy.
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Co-existing pediatric ureteropelvic junction obstruction and vesicoureteric reflux: Prevalence and implications p. 109
Shalini Hegde, Prema Menon, Katragadda Lakshmi Narasimha Rao
Purpose: The purpose of this study is to ascertain the coexistence of ipsilateral vesicoureteric reflux (VUR) with ureteropelvic junction obstruction (UPJO) and to compare postpyeloplasty outcome in patients with and without associated VUR. Materials and Methods: Prospective study from 2014 to 2016 of consecutive children (n = 135) undergoing pyeloplasty. Data of patients without (Group 1) and with (Group 2) associated ipsilateral VUR were compared. Results: Thirty-five patients (25.9%) had ipsilateral VUR along with UPJO (Group 2). This group showed the following unique features: (1) Higher percentage of infants (31/35) compared to Group 1 (62/100) (P = 0.003) (2) VUR in the contralateral (normal) kidney in 21/35 (60%) cases and nil in Group 1 (3) Significantly less preoperative differential renal function in children above 1 year (P = 0.007) (4) Presence of renal scars (18 units) and pyelonephritic changes (6 units) in Group 2 at the 1-year follow-up dimercaptosuccinic acid renal scan. Both groups showed improvement in function 3 months after pyeloplasty with no statistically significant difference. Improvement in drainage on the renal scan was better in Group 1 at 3 months postoperative (P = 0.015) as well as between 3 months and 1-year follow-up (P = 0.052). Conclusion: The prevalence of VUR was 25.9% in this study and 33.3% in ≤1 year age group. There was a loss of function in delayed presenters with associated ipsilateral VUR. There was delayed drainage postpyeloplasty in patients with VUR. A preoperative voiding cystourethrogram should be done in children <1 year age before pyeloplasty so that associated VUR if detected can be concurrently managed along with pyeloplasty and preserve nephrons affected by the dual pathology.
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Stenting antegrade via veress needle during laparoscopic PyeloplastY (“SAVVY” Technique) p. 117
Ramesh Babu, Apurva Arora, Niranjan Raj
Aim: The aim of the study is to report the outcomes of different stenting techniques during laparoscopic pyeloplasty (LP). Materials and Methods: This study was a retrospective audit of duration of stenting, complications encountered, and operative outcomes of LP in children older than 3 years. Results: Retrograde cystoscopic prestenting took significantly longer time (17.2 min) and the presence of stent hindered in anastomosis. Antegrade stenting without guide wire took longer time (9.6 min), and in some, there was difficulty in negotiating distal ureter. Antegrade stenting over guide wire, through a 14-gauge intravenous cannula, took significantly less time (7.3 min) although the cannula got kinked and the stenting was difficult in some as the length of the cannula was short and it did not reach anastomotic site. “Stenting Antegrade Via Veress needle during laparoscopic pyeloplastY” (“SAVVY” technique) favored by authors has the least stenting duration (4.8 min) and minimum failures (P = 0.01, ANOVA). The needle is wide enough to pass a 4-Fr stent and long enough to reach the anastomotic site. Conclusion: SAVVY technique saves time during LP with least failures and is a useful stenting technique in children.
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Management strategy of meconium ileus-outcome analysis p. 120
Abhishek Kumar Singh, Anand Pandey, Jiledar Rawat, Sudhir Singh, Ashish Wakhlu, Shiv Narain Kureel
Background: Meconium ileus (MI) is defined as an intestinal obstruction caused by the impaction of inspissated meconium in the terminal ileum. In this study, we have evaluated the nonoperative management of patients of simple MI without fluoroscopic support –an important requisite of the Noblett's criteria. Besides this, surgical management in cases of failed conservative management and complicated MI was also assessed. Materials and Methods: This was a retrospective observational study. Various clinical and radiological parameters were evaluated. Conservative management included the use of water-soluble contrast diatrizoate meglumine and diatrizoate sodium. In case of nonpassage of meconium in 24 h from first intervention, exploratory laparotomy with ileostomy was performed. All complicated MI underwent exploratory laparotomy with creation of stoma as and when needed. Results: The duration of this study was 6½ years. Twenty-five neonates of MI were admitted. Of these, 22 had simple MI and remaining three had complicated MI. Eighteen neonates responded to the conservative management. In four neonates, who did not respond, exploratory laparotomy was performed. All three neonates having complicated MI underwent exploratory laparotomy. One patient expired in follow-up. Conclusion: MI is an important neonatal emergency, which needed immediate attention of a pediatric surgeon. Proper evaluation of the patient, careful application of principals of conservative management, and timely surgical intervention may fetch satisfactory results.
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Tethered cord syndrome-role of early surgery p. 124
Deepti Vepakomma, Nitin Kumar, Anand Alladi
Purpose: 1. To evaluate the clinical course and effects of surgery on preexisting neurodeficits. 2. To address the issue of timing of intervention. Materials: A prospective study at department of pediatric surgery, Bangalore Medical College and Research Institute and other hospitals from 2013 to 2017. Results: There were 44 patients. Over 3/4 presented with a cutaneous marker while 9 had deficits and no markers. The commonest marker was a swelling on the back. 1/3 of infants had neurological sequelae while almost all midline older children presented with bowel/bladder/gait disturbances. All underwent detethering. Post-operative complications were minor and self-limiting. None of the children had associated Chiari malformation and 2 had a syrinx which at last follow up has been static and shown no clinical signs. Recovery was mostly seen in infants and only in one older child. Conclusion: Most of the patients with lipomeningomyelocele have early onset deficits and is recommended to operate at diagnosis. Children presenting with only deficits need to be evaluated for tethered cord syndrome but generally show poor or no recovery of deficits. Early prophylactic detethering is safe, feasible and advisable.
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Solid pseudopapillary neoplasm of the pancreas in a pediatric patient with associated urogenital anomalies p. 129
Rashi Sharma, Haimanti Sarin, Meera Luthra
We report a case of a 9-year-old girl presented to the outpatient department with abdominal pain and diagnosed as solid pseudopapillary neoplasm (SPN) with urogenital anomalies. SPN can occur in children with extrapancreatic abnormalities, especially urogenital abnormalities, so these anomalies should be looked for in children diagnosed with SPN and vice versa.
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A new operative approach for long-gap esophageal atresia p. 132
Abdellatif Nouri, Amine Ksia, Bochra Bouzaffara, Oliver Munsterer, Saida Hidouri, Jamila Chahed, Lassaad Sahnoun, Mongi Mekki
Surgical management of long-gap esophageal atresia (LGEA) remains challenging. Yet, there is a consensus among pediatric surgeons to preserve native esophagus. We used a new surgical technique to successfully manage three children diagnosed with LGEA. This technique consists of a combined thoracic and cervical approach to the EA repair using the patient's native esophagus. All patients initially had had gastrostomy and continuous upper pouch suction while awaiting surgery. This new technique has the potential to become the choice method in LGEA management.
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Anorectal malformation associated with klippel–Feil syndrome: A rare association p. 135
Gurmeet Singh, Archika Gupta, Ajay Kumar Verma, Anand Pandey, SN Kureel
Anorectal malformations (ARMs) are a complex group of malformations associated with various congenital anomalies. Klippel–Feil syndrome (KFS) is characterized by fusion of cervical vertebrae, short neck, torticollis, and/or facial asymmetry and very rarely associated with ARM. In the presence of cervical vertebral anomalies in ARM, one should search for the presence of KFS as an association. If this anomaly is found to be associated, caution is needed during positioning for examination, surgery, during laryngoscopy, and intubation due to risk of neurological damage. We hereby present a very rare association of KFS with ARM with solitary kidney and ipsilateral vesicoureteral reflux.
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Hypospadiac urethral duplication- A rare variant and novel use of snodgrass urethroplasty p. 138
Rahul Saxena, Manish Pathak, Arvind Sinha
Urethral duplication is a spectrum of congenital anomalies that is more common in males, but very little is known about the possible reconstruction methods and their outcome. Hypospadiac urethral duplication is a variety treated with onlay preputial flap. We report a 3-year-old patient of hypospadiac duplication who was treated with a single-stage urethroplasty. An excellent cosmetic and functional outcome were achieved by dorsal to ventral urethra-urethrostomy and novel application of tubularized incised plate technique for urethroplasty.
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Female hypospadias-need for clarity in definition and management p. 141
Yogesh Kumar Sarin, Parveen Kumar
We report a 6-year-old girl with female hypospadias and discuss the definition and management of the entity.
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Testicular mixed germ cell tumor in a newborn child: A rare case p. 144
Aditya Pratap Singh, Ramesh Tanger, Deepika Mishra, Maryem Ansari, Arun Kumar Gupta, Arvind Kumar Shukla
Testicular tumors are rare in children but highly treatable and usually curable. Seminomas are extremely rare in prepubertal children. Among nonseminomatous germ cell tumors, the most common are teratomas and yolk sac tumors. Mixed germ cell tumor (MGCT) contains more than one germ cell component. MGCT is very rare in prepubertal age group. Here, we are presenting a case of MGCT in a newborn child with a review of literature. It is the first reported case in the world literature.
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Surgical surprise during posterior sagittal anorectoplasy: A rectal duplication p. 147
Kashish Khanna, Devendra Kumar Yadav, Vikram Khanna, Samir Kant Acharya
An 8-month-old boy with anorectal malformation (ARM) was incidentally found to have double rectal pouches during posterior sagittal anorectoplasty. The distal blind-ending pouch was excised, and the larger proximal pouch was tapered and anorectoplasty performed. The excised pouch was confirmed as rectal duplication cyst. One must be aware of such uncommon associations with ARM.
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A rare case of transverse testicular ectopia p. 150
Mrinal Arora, Jaswinder Kaur, Rajeev Kulshreshtha
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Compromised ventilation in an infant caused by a defective connector of endotracheal tube p. 151
Deepak Dwivedi, Navdeep Sethi, Subhasish Patnaik, Rajeev Singh
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Skim milk preparation for the management of chylothorax developing after congenital diaphragmatic hernia repair p. 153
Sachit Anand, Vishesh Jain, Sandeep Agarwala, Mayank Priyadarshi, M Jeeva Sankar
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Extrinsic vessel associated with ureteropelvic junction obstruction p. 154
Prema Menon, Katragadda Lakshmi Narasimha Rao
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