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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 2021
Volume 26 | Issue 2
Page Nos. 71-138

Online since Thursday, March 4, 2021

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Professor T. Dorairajan Highly accessed article p. 71
VR Ravikumar, V Raveenthiran
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New horizon in understanding of pediatric surgical diseases Highly accessed article p. 73
Ashoke Kumar Basu
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Airborne infections and emergency surgery: The COVID-19 pandemic perspective p. 76
Varun Suresh
COVID-19 which emerged in Wuhan, China has rapidly spread all over the globe and the World Health Organisation has declared it a pandemic. COVID-19 disease severity shows variation depending on demographic characteristics like age, history of chronic illnesses such as cardio-vascular/renal/respiratory disease; pregnancy; immune-suppression; angiotensin converting enzyme inhibitor medication use; NSAID use etc but the pattern of disease spread is uniform – human to human through contact, droplets and fomites. Up to 3.5% of health care workers treating COVID-19 contact an infection themselves with 14.8% of these infections severe and 0.3% fatal. The situation has spread panic even among health care professionals and the cry for safe patient care practices are resonated world-wide. Surgeons, anesthesiologists and intensivists who very frequently perform endotracheal intubation, tracheostomy, non-invasive ventilation and manual ventilation before intubation are at a higher odds ratio of 6.6, 4.2, 3.1 and 2.8 respectively of contacting an infection themselves. Elective surgery is almost always deferred in fever/infection scenarios. A surgeon and an anesthesiologist can anytime encounter a situation where in a COVID-19 patient requires an emergency surgery. COVID-19 cases requiring surgery predispose anesthesiologists and surgeons to cross-infection threats. This paper discusses, the COVID-19 precautionary outlines which has to be followed in the operating room; personal protective strategies available at present; methods to raise psychological preparedness of medical professionals during a pandemic; conduct of anesthesia in COVID-19 cases/suspect cases; methods of decontamination after conducting a surgery for COVID-19 case in the operating room; and post-exposure prophylaxis for medical professionals.
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Awareness of common pediatric surgical entities among practicing Indian pediatricians p. 89
Santosh Kumar Mahalik, Akash Bihari Pati, Kanishka Das
Aim: Common pediatric surgical entities often get a delayed referral to the pediatric surgeon in the average Indian scenario. This study was conducted to assess the awareness about management of select common pediatric surgical entities among practicing pediatricians. Materials and Methods: An online multiple-choice questionnaire consisting of twenty questions related to the diagnosis and management of common pediatric surgical entities encountered by pediatricians in their routine office practice was prepared, and the electronic link was circulated among the practicing pediatricians of India. Each question had one correct response. Results: One hundred and seventy-five responses were obtained, collated, grouped, and analyzed. Overall, 35% of all responses were correct. Individually, 56% of respondents marked 51%–75% of answers correctly; only 7% scored above 75%. Some clinical observations were disparate: 65% were unfamiliar with preputial adhesions and 51% would discharge a preterm neonate with inguinal hernia without a surgical consult. There is a tendency toward unnecessary imaging (60% – localization of undescended testis, 91% – wet umbilicus, and 51% – postanal dimple) and overzealous medical management (propranolol for the involuting hemangioma). However, 82%–88% concurred on the standard conservative or surgical management in index conditions such as hypospadias and umbilical problems. Conclusion: There was a concurrence in the principles of management of common pediatric surgical entities between pediatricians and pediatric surgeons in 35%. Misdiagnosis, unwarranted investigations, overzealous medical management, and delayed surgical consults figured in 65%. A systematic professional interaction between the physicians and surgeons would facilitate a coordinated management. A larger study would yield more meaningful data.
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Anephric neonate and evolution of our study on intestinal dialysis p. 94
Uday Sankar Chatterjee
Purpose: Intestinal dialysis for end-stage renal disease (ESRD) is a proposed renal replacement therapy, and studies are going on worldwide to make it practicable. We are also doing the same study in our institution and would like to share our experience in managing an anephric neonate with intestinal dialysis in the perspective of our ongoing study of intestinal dialysis since 2010. Patients and Methods: We did double-ended jejunostomy in an isolated loop of the jejunum keeping the main tract intact with jejunojejunal anastomosis in this anephric neonate. Following that, we started irrigation with peritoneal dialysis fluid from the 3rd postoperative day (POD) in that jejunal loop through jejunostomy. Results: This patient had no uremic features since re-admission and showed better laboratory and clinical outcomes with combined jejunal loop and colonic dialysis for 7 days. However, the patient died on the 9th POD following severe hypoglycemia. Conclusions: From this study, it seems intestinal dialysis, with necessary modifications done in our subsequent patients, which might be recommended for ESRD in children as well as in adults.
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High-resolution ultrasound study of morphological changes of the pylorus in the postoperative cases of infantile hypertrophic pyloric stenosis p. 98
Mriganka Guria, Dipak Ghosh, Janki Bisth, Swadha Priya Basu, Kaushik Saha
Aims: The aim of this study was to find & compare the pyloric Canal Length (CL), Pyloric muscle thickness (MT) by using the High Resolution Ultrasonography (HRUS) in Preoperative & postoperative period (after Ramstedt Pyloromyotomy) for Infantile Hypertrophic Pyloric Stenosis (IHPS). Methods: From January 2018 to June 2019, we have performed HRUS for 40 patients of clinically diagnosed cases of IHPS. & Ultrasonography machine: Phillips HD 7 machine & Alpinion E-CUBE with 3-12MHz linear probe, 3.5-5 MHz curvilinear probe and 5-7.5 MHz sector probe were used. The sonographic criteria for positive IHPS are Pyloric muscle thickness (MT) > 3 mm, pyloric Canal length (CL) >14 mm. Postoperative MT & CL at 2 month, 4 month & 6 month were determined and results were analysed with the preoperative pyloric parameters. Statistical analysis used: Mean and standard deviation of values were obtained by using Microsoft excel and statistical significance was analysed by regression study of grouped variables showing p – value by Microsoft excel. Results: Pyloric parameters (MT & CL ) gradually attain normal values over months and 80 % of patients showed resolution of pyloric MT & CL values by 6 months. MT assessment shows statistical significance at six months scan ( p- value <0.05). Conclusions: Serial postoperative HRUS in IHPS cases show gradual ( mostly by 6 months) resolution of pyloric parameters ( MT & CL ) to normal. MT appears to be a consistent parameter for serial assessment.
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Coccygectomy for chronic refractory coccygodynia in pediatric and adolescent patients p. 102
Hisham Almohamady Almetaher, Mohamed Awad Mansour, Mohamed Ali Shehata
Aims: Coccygodynia (also known as coccydynia and coccyalgia) described for the first time by Simpson in 1859. It is a disabling pain in the coccyx usually provoked by sitting or changing position from a sitting to a standing position. Treatment started with adjustment of ergonomics as specialized cushion for sitting, application of local heat, and oral analgesics. The aim of this study was to assess the results of total or partial coccygectomy for patients suffering from chronic refractory coccygodynia and not improving on conservative treatment in pediatrics and adolescents. Methods: The study included 22 patients, 8 of them with chronic refractory coccygodynia not responding to conservative management underwent partial or total coccygectomy using Key's surgical exposure after good preoperative preparation. Results: This study included 5 females (62.5%) and 3 males (37.5%), their ages ranged from 7 to 15 years. The results were excellent in 75% of patients and good in the remaining cases. The mean length of hospital stay was 1.43 ± 0.98 days. No significant intraoperative or postoperative complications were reported. The parents were satisfied in almost all cases in the long term follow up. Conclusions: Coccygodynia is a disabling problem, especially in pediatric patients. Coccygectomy is a feasible management option and has a favorable outcome when performed for an appropriate indication.
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Laparoscopic Inguinal Hernia Repair in Children: To Cut or Not to Cut is the Question? p. 107
Kirtikumar J Rathod, Rupesh Sikchi, Ayushi Vig, Avinash Jadhav, Rahul Saxena, Manish Pathak, Pradeep Bhatia, Arvind Sinha
Context: Laparoscopic repair of pediatric inguinal hernia is gaining popularity, however there is no consensus about the technique of operation. Aims: The aim of the study was to compare the results and complications of two techniques of laparoscopic pediatric hernia repair. Settings and Design: This retrospective study was conducted at the Department of Pediatric Surgery in All India Institute of Medical Sciences (AIIMS), Jodhpur. Subjects and Methods: All children who underwent laparoscopic inguinal hernia repair at AIIMS, Jodhpur, during the period of September 2016–March 2019 were retrospectively studied. Parameters studied included age, gender, side of hernia, technique used, operating time, complications, and hospital stay. Patients were divided into two groups depending on whether the hernial sac was divided or not divided before taking a purse-string suture. Statistical Analysis Used: Student's t-test and Fischer exact test were used to analyze data. Results: A total of 114 patients were included in the study. The median age was 36.4 months. Hernial sac was divided before suturing in 53 patients, while sac was left intact in 61 patients. The mean follow-up was 11.4 months (range: 4–16). Age, gender, side of hernia, complications, and hospital stay were comparable in both groups. There was a significant difference between the mean operating duration in patients who underwent division of hernia sac compared to patients in whom the sac was not divided before putting purse-string suture (92.5 min [45–150] vs. 65.7 [30–90], respectively, P = 0.0101). Hernia recurrence (3.8% in Group A vs. 1.6% in Group B) was comparable in the two groups. Conclusions: Laparoscopic pediatric hernia repair done with or without dividing the peritoneal sac gives comparable results, however operative duration is less if sac is not divided.
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Routine use of circumferential ‘Doughnut’ biopsy in pull through surgery for hirschsprung's disease: Advantages and limitations p. 111
Govind V S. Murthi, Oliver G Townley, Richard M Lindley, Marta C Cohen
Aims: The aim of this study was to review the use of the on-table “doughnut” biopsy for frozen section assessment of bowel in the operative management of Hirschsprung's disease (HD). Methods: This was a single-center retrospective review of doughnut histopathology reports, operation notes, and slides from 2010 to 2017. Data were assessed for the presence of transition zone (TZ) features and the subsequent decision as to the level of pull-through. Results: Fifty-five patients had a doughnut biopsy taken as part of their intraoperative frozen section histopathology for pull-through for HD during the study period. Forty-eight required a single doughnut, six required a second more proximal doughnut, and one required a third doughnut. Of the 55 first doughnuts, 37 were identified as normal bowel, 17 were TZ, and not defined in the report in one case. Of the 17 TZ doughnuts, 8 were accepted for pull-through and 7 underwent second doughnuts (normal = 4 and TZ = 3). The third doughnut (one case) was normal. TZ was accepted for pull-through in 10/54 (18.5%) patients despite the use of a doughnut. However, TZ was avoided in six (11.1%), where the single-point biopsy was “normal.” Conclusions: The doughnut allows the entire circumference of pull-through level to be assessed, enabling TZ identification that can be missed by single seromuscular biopsies. This allows identification and avoidance of TZ pull-through, although sometimes, it is accepted for other reasons.
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Rare paratesticular masses in children p. 117
Mehak Sehgal, Sachit Anand, Anjan Kumar Dhua, Devendra Kumar Yadav, Sudheer Arava, Adarsh Barwad
Pediatric paratesticular mass is common in pediatric surgical practice, and they could be because of an underlying encysted hydrocele, a teratoma, or an epididymal cyst. Furthermore, a malignant lesion such as rhabdomyosarcoma should be ruled out. Rare entities, such as fibrous hamartoma of infancy and cellular angiofibroma, are rarely encountered. We report two such cases of paratesticular masses with these rare pathologies.
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Multidisciplinary management for intestinal obstruction by gel ball ingestion p. 120
Shruti Tewari, Swathi Chigicherla, Rahul Deo Sharma, Rajeev Redkar
Foreign body ingestion is common in young children. Very few cases require surgical exploration for removal. We report a case of superabsorbent gel ball ingestion causing intestinal obstruction, managed by a combination of endoscopic and open surgical removal under intraoperative ultrasound guidance.
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Surgical occlusion of leaking bronchus by a serratus anterior flap in a child with langerhans cell histiocytosis p. 123
Lokavarapu Manoj Joshua, Ashok Rijhwani, Manish Kumar Gupta, Enono Yhoshu, Gyanendra Chaudhary
Langerhans cell histiocytosis is an uncommon disease of childhood. Intrathoracic transposition flaps have been described for a management of number of conditions. We discuss our experience of the use of serratus anterior flap for the obliteration of a pulmonary bulla with a communicating airway, in a 1½-year-old pediatric patient with multisystem Langerhans cell histiocytosis who presented with recurrent pneumothorax with empyema due to rupture of bullae.
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Multiple esophageal duplication cysts in a toddler: A rare scenario p. 126
Parveen Kumar, Yogesh Kumar Sarin
The foregut duplication cysts are rare congenital malformation and are usually “solitary” midline noncommunicating mediastinal structures. We present a 2-year-old asymptomatic boy having multiple noncommunicating foregut cysts in the neck as well as the thorax.
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Vaginoplasty with oxidized cellulose in mayer–rokitansky–küster–hauser syndrome p. 128
Mila Torii Corrêa Leite, Márcia Emília Francisco Shida, Claudia Cristina Takano
Mayer–Rokitansky–Küster–Hauser syndrome (MRKHS) is the major cause of vaginal agenesis. Vaginoplasty with oxidized cellulose has been used by gynecologists as a surgical option in vaginal agenesis; however, it is not very widespread among pediatric surgeons. A case of MRKHS who underwent vaginoplasty with oxidized cellulose is reported here.
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Jejunojejunal intussusception at birth: A rare clinical scenario p. 131
Penchalaiah Majjari, KS Kumar, Girish Gururaja
We report a case of intussusception presenting as bilious vomiting in a term neonate. Intussusception should be considered as a differential diagnosis even in the neonatal period. Ultrasound scan may help in early diagnosis. This condition needs to be operated early as delayed treatment may lead to bowel necrosis.
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Congenital melanocytic nevus with scrotal mass: A diagnostic dilemma p. 133
Tanmay Motiwala, Kirtikumar J Rathod, Avinash Jadhav, Minhaj Shaikh, Poonam Elhence, Bharat Paliwal, Arvind Sinha
Congenital melanocytic nevus is deposition of pigment producing cells of melanocytic lineage in the dermis. We present an extremely rare case of congenital melanocytic nevus with a scrotal mass associated with deposition of melanin in the brain. The mass may mimic like a testicular tumour on clinical presentation.
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Patterned abdominal wall bruise: An indicator of severe intra-abdominal injury p. 136
SP Chinmay, Akshay B Kalavant
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Insight into posterior urethral valve management p. 137
Ramesh Babu, VV S. Chandrasekharam
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