Abstracts of the IAPSCON 2009 19th to 23rd November 2009

1 Madhu, Balamourougane, Deepak J Laparoscopic management of advanced paediatric Department of Pediatric Surgery, Sri Ramachandra Medical urology at SRMC- our initial experience College, Porur, Chennai – 600116, India. R. M. Manoj Kumar, Prakash Agarwal, R.K. Bagdi, Balagopal, Madhu, Balamourougane, Deepak J Aim: To evaluate the role of laparoscopic cholecystectomy (LC) Department of Pediatric Surgery, Sri Ramachandra Medical in the management of cholelithiasis in children. College, Porur, Chennai – 600116, India Methods: A retrospective review of our experience with LC for cholelithiasis at our institution, between April 2006 and We present our initial experience with 6 cases of advanced November 2008 was done. Data points reviewed included paediatric urology managed at our hospital from 2007 to 2009. patient demographics, clinical history, hematological The cases ranged from heminephrectomy, ureterolithotomy, investigations, imaging studies. operative technique, post laparoscopy assisted PUJ repair and laparoscopic operative complications, post operative recovery and Þ nal adrenalectomy. In our experience laparoscopy is feasible histopathological diagnosis. for advanced paediatric urology and has the advantage of Results: During the study period of 32 months, 18 children magniÞ ed visual Þ eld, early recovery and excellent post op (8 males and 10 females) with cholelithiasis were treated by results compared to open surgery. Though the initial operative LC. The mean age was 9.4 years (range 3 to 18). Seventeen time is more compared to open procedures, over a period of children had symptoms of biliary tract disease and 1 child had time with experience, the operative time will reduce. incidentally detected cholelithiasis during a ultrasonogram abdomen for unrelated cause. Only 5(27.8%) children had 2 deÞ nitive etiological risk factors for cholelithiasis and the Our initial experience with 2 cases of ARM remaining 13 (75.2%) cases were idiopathic. Sixteen cases had operated by Laparoscopic assisted anorectoplasty pigmented gallstones and 2 had cholesterol gallstones. All the R. M. Manoj Kumar, Prakash Agarwal, R.K. Bagdi, Balagopal, 18 patients underwent LC, 17 elective and 1 emergency LC. Madhu, Balamourougane, Deepak J The mean operative duration was 74.2 minutes (range 50-180). Department of Pediatric Surgery,Sri Ramachandra Medical Post operative complications occurred in 2 (11.1%) patients. College, Porur, Chennai – 600116, India The average duration of hospital stay was 4.1 days (range 3-6). Conclusion: Laparoscopic chloecystectomy is conÞ rmed to be Case 1- Preterm- 34 week, male baby, born by emergency LSCS a safe and effi cacious treatment for pediatric cholelithiasis. The – abruptio placenta. Antenatal scan at 20 weeks-normal. On cause for increased incidence of pediatric gallstones and their examination, Anal pit at the site of normal anus, depth - 5mm natural history need to be further evaluated. and surrounded by pigmented skin with radiating rugosity. X-ray showed dextrocardia. Echocardiography done on day1 4 of life revealed, dextrocardia, 3 pulmonary veins draining into First 200 cases of laparoscopy in a single unit: left atrium, 1 pulmonary vein draining into IVC – scimitar vein. Learning curve and beyond Ultrasound abdomen showed, right kidney not visualized in Satish Aggarwal, Arun Kumar, Simmi Ratan, Nitin Pant, Nitin its normal position. Sigmoid double barrel colostomy done on Borkar, Anjan Dhua, Mufti Gauhar, RN Goswamy, Raghunath day 1 of life. Post op course uneventful. MCU done at 6 months, Maulana Azad Medical College and Associated Lok Nayak and Small capacity bladder and Grade -5 vesico-ureteric reß ux. Lap GB Pant Hospitals, New Delhi, India. assisted pullthrough done. Post op course uneventful. Aft er 2 months planning for Cystoscopy, Colostomy closure and Aim and Introduction: This is a report of 200 laparoscopic Concomitant ureteric reimplantation with or without tapering. procedures in a single Paediatric Surgical Unit in a teaching Case 2 – LAARP done for 6 month old male child, for high hospital. The aim of presentation is to highlight the ever ARM. No associated anomalies. Post op course uneventful. expanding indications with justiÞ cation and to stress that Colostomy closure done aft er 2 months. Passing stools 1-2 once the learning curve is traversed, progress is rapid and times daily. Adequate weight gain present at 1 year follow up. most gratifying. Method: 200 patients underwent laparoscopic procedures 3 for diff erent indications: Appendicitis, Gall bladder disease, Laparoscopic cholecystectomy for cholelithiasis ingunal hernia, GERD, diaphragmatic hernia, mesenteric in children cysts, renal stones, non functioning kidneys, accessory urethra R. M. Manoj Kumar, Prakash Agarwal, R.K. Bagdi, Balagopal, in duplication urethra, undescended impalpable testes,

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 122 IAPSCON 2009 intersex disorders, sacrococcygeal teratomas, retroperitoneal was no other signiÞ cant morbidity or mortality. ganglioneuroblastoma, splenectomy for hemolytic disease, Conclusions: Airway anomalies are potentially life threatening Hirscsprung’s disease, high Anorectal malformation, and can cause signiÞ cant morbidity. A comprehensive program ovarian cyst, urachal cyst, undiagnosed abdominal pain of managing these children provides excellent results. Most etc. Thoracoscopic procedures were done like plication for children have an excellent chance of return to complete eventration diaphragm, oesophageal duplication cyst excision normalcy. and lung biopsy. Wolf laparoscopic set was used along with hand instruments of 3 mm and 5 mm. Age range was 47 days 6 to 14 years. Antigrade baloon dilatation in laparoscopic Results: There were 8 conversions. Time taken gradually assisted anorectoplasty came down. Indications have widened over the last one Ramanujam T.M., Nordaliza M, Srihari S, Yik YI, Rajah S, year in a signiÞ cant way. There were no anaesthesia related Syariz S, Rao HV complications. Port site infection was seen in 4 patients. Hernia University of Malaya Medical Centre, Kuala Lumpur, Malaysia recurred in 3 out of 124 patients. No change in testicular position or size was noticed in any. One case of eventration Objective: To present our technique of Laparoscopic assisted had a recurrence owing to faulty technique. One out of 5 HD anorectoplasty (LAARP) for High & Intermediate anorectal cases had to be converted because of wrong patient selection. malformations (HIARM). Conclusion: laparoscopy in children gives versatility to the Method: 15 term infants with HIARM were operated from 2003 surgeon. Several indications are coming up. Lap assisted to May 2009. Three had Down syndrome. Aft er a preliminary procedures hold a great promise in HD and Anorectal colostomy, LAARP was performed by 6 weeks to 5 months. malformations. Once the initial learning curve is mastered, the Eight had recto-prostatic urethral Þ stula, 2 had bladder neck progress is fast. Laparoscopic surgery is poised to become the Þ stula. 2 had rectobulbar Þ stula. No Þ stula in 3. The Þ stula was preferred approach to surgery in children. disconnected with Harmonic scalpel or epitome diathermy scalpel (9). A 3mm curved dissector was used to gently tunnel 5 behind the urethra under vision from above & by assessing Airway reconstructions in children from the perineal incision. In 12 infants Fogarty & Foleys Sanjay Rao (LM 379), Vinay Jadhav, Ashley D’cruz catheter were retrieved one aft er the other through the tunnel. Narayana Hrudayalaya, Bangalore, India The baloon was inß ated to dilate the tunnel under vision by withdrawing the balloon 1 to 1.5 cm at a time till the external Introduction: Airway anomalies-both congenital and acquired sphincter is reached. In three cases oesophageal balloon dilator - are associated with signiÞ cant morbidity and mortality. (1.2 to 1.5 mm) was used to dilate the entire tunnel gradually. With more children being ventilated in intensive care units, Urinary catheter was removed aft er 5 days. Regular dilation the incidence of these anomalies is on the increase. A airway was started aft er 12 days. Conversion to laparotomy was done anomaly program was initiated at our centre to care for these in 2. diffi cult children in a comprehensive manner. This presentation Results: 11 children are alive & well. One child died on day summaries our experience. 1 due to anaesthetic reason. Another had slide tracheoplasty Material and Methods: This is a retrospective study of a for tracheal stenosis at 9 months & died 3 months later due to cohort of children referred to our airway team for assessment RSV infection. 9 are on regular follow up. One child had anal and therapy. Records of these children were maintained stenosis & three had mucosal prolapse. One presented with and a review of these records forms the basis of this study. skin level stenosis aft er a year. Children aft er 2 to 3 years need Children with foreign bodies, non anatomical causes such bowel management program. as tracheobronchitis were excluded from the study. A total Discussion: Dilation from perineum by an expandable trochar of 32 children were included in this study. Causes of airway may traumatize the muscle complex. In our technique, dilation anomalies were subglottic stenosis 13,tracehal stenosis is performed under vision & the balloon dilates the tunnel 4,laryngomalacia 5,tracehobronchomalacia 13 and vascular uniformly. The muscle complex is preserved with minimal compression 4. These children were evaluated by a detailed disturbance to the anatomy. history, gastroesophageal reß ux studies and microlaryngoscopy and bronchoscopy examination. Other investigations such as 7 CT scans, echocardiogram, reß ux studies were performed Apert’s syndrome – A nine years follow up Growth asrequired. Several of these children had tracheostomies. Aft er and development a detailed assessment of airway structure and function, therapy Vimalakar Reddy, G. Ragahvendra Prasad, G. Rammohan, G. was planned. Therapy included surgery (laryngotracheoplasty, Satyanarayana, Deepak Sharma, Vijasekhar, Alladi Venkatesh tracheal resections, slide tracheoplasty etc.) in 20. There were 2 Dept. of Pediatric Surgery, Kamineni Hospitals, KIMS deaths-one from a cardiac related complication and the other Narketpally, Hyderabad, India from sepsis. Of the 30 children alive, 28 have normal airways restored. Two children are on long term tracheostomy. There Aims and Objective: To present twins with Apert’s Syndrome

123 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 followed up regularly. an important role in management especially in patients with Materials and Methods: Twins with Apert’s Syndrome were complicated disease. operated at the age of 50 days. the procedure performed was Craniectomy and frontoorbital advancement. The children 9 followed up regularly and Growth and development were A novel approach for prevention (? Treatment) of recorded. Both are going to School. Growth and development necrotizing enterocolitis: An experimental study would shown. Pre procedure MRI would be comared with on rats 8 year MR brain. Hand and foot reconstructive surgery has Prashant K. Adivrekar, Vijaya Raghavan, Bharati Kulkarni, yielded satisfactory functional results. A. H. Bandivadekar Conclusion: To present the growth and development of Paediatric Surgery, Nanavati hospital & NIRRH, Mumbai, Twins with Apert’s Syndrome following craniectomy and Maharashtra, India frontoorbital advancement. Aim: An increasing population of tiny newborns is now at 8 risk for developing necrotizing enterocolitis. Inadequate Management of hepatobiliary ascariasis in tissue oxygenation, bacterial overgrowth and enteral feeding children at a tertiary care referral center with immaturity are the risk factors for NEC. Human milk is Gowhar Nazir Mufti, Talat Masoodi, Khurshid Ahmad Sheikh an ideal complete food for newborn. Since feeding itself is a Department of Surgery, Kashmir Institute of Medical Sciences, contributory factor for NEC, add to that is the ileus associated India with sepsis, premature tiny newborns on ventilatory support are usually not feed anything orally. Moreover the pathology Aim: Ascaris Lumbricoides is the most common helminth in NEC involves the distal ileum and colon the most. Hence infesting humans and its manifestations are protean. Surgical we propose maternal milk through per rectal route (enema) to disease due to ascariasis is not restricted to the GIT alone due utilize the protective components of milk. to its wandering habit; hepatobiliary ascariasis constitutes a Material and Methods: Holtzman strain male rats, divided as major chunk of its morbidity and mortality. follows: Set 1: a) Sham Group, b) NEC group and c) Milk Group. Materials and Methods: The present study was conducted in a Set 2: Animals treated similar to set 1, however they would be combined prospective and retrospective manner over a period sacriÞ ced at the end of four weeks. Hypoxia would be produced of 7 years. 149 cases of up to 15 years of age were included in by placing the rats in a 100% CO2 chamber for 3 minutes. Rats the study. Patients were included on the basis of radiological were then reoxygenated for 6 minutes with 100% oxygen. The or operative evidence. All patients were managed as per set procedure would be repeated for three consecutive days. departmental protocol. Results: Mean weight gain for animals of set 2 were 80.33gms, Results: Most patients 89% were from rural areas, disease was 61.00gms and 81.66gms for sham, NEC and milk pretreatment more common in older children and both sexes were equally group respectively. There was statistical diff erence in weight aff ected. Seven clinical presentations were recorded, biliary gain between sham and NEC group (0.0129) and between NEC colic in 49%, cholangitis in 24%, obstructive jaundice in 7%, and milk pretreatment group (0.0024). acalculus cholecystitis in 7%, liver abscess in 7%, pancreatitis Histology: NEC group showed loss of normal architecture in 5%and biliary peritonitis in 0.7%.Ultrasonography was the with areas of ischemic necrosis, submucosal congestion, main diagnostic modality used for diagnosis and follow up. hemorrhage and occasional transmural involvement especially Conservative management was successful in 83% patients in ileum and colon. Milk pretreatment did help preserve the medical therapy alone was required in 69% and endoscopic cellular architecture. In set 2, NEC group revealed focal areas management was required in 14%. 17% patients required of loss of cellular architecture with mononuclear inß ammatory surgical intervention with the main indications being persistant inÞ ltrates. Healing process was especially evident in the colonic biliary ascariasis in 24%, biliary ascariasis with liver abscess in specimen. 20% and biliary ascariasis with calculi in16%.. Cholecystectomy Conclusion: Milk pretreatment through the per-rectal route with CBD exploration was most common procedure done in does provide immunity against the deleterious effects of 80% patients and operative drainage of associated liver abscess Ischemia/reperfusion injury and help preserve the histology was required in 20% patients. There was a 1.34% mortality in and cellular function besides maintaining the weight gain in our series. Reinfestation was seen in 4% patients on follow up. rats. Conclusion: Hepatobiliary ascariasis is common in high prevalence areas and a high index of suspicion should be 10 maintained when examining a child especially an older one Evaluation of blood levels of nitric oxide as a with symptoms of hepatobiliary disease. Grey scale real time means to differentiate neonatal hepatitis from sonography stands out as the diagnostic modality of choice. extra hepatic biliary atresia Conservative management is quite successful. Surgery still has P. Goel, K. Srivastava, N. Das, V. Bhatnagar

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Dept of Pediatric Surgery, AIIMS, New Delhi, India had LFT [total & direct bilirubin, SGOT, SGPT, Alkaline phosphotase, gamma glutamyl transferase, serum albumin Aim: With the currently available diagnostic modalities, and prothrombin time], ultrasonography and HIDA scan. Kasai many times it is not possible to differentiate between portoenterostomy was performed with age at surgery varying neonatal hepatitis and extra hepatic biliary atreisa without a from 45 days-123 days [median=62 days]. The liver function per-operative cholangiogram. In this study we have tried to tests were serially repeated at 2-3,6,9,12,15,18,21 months post evaluate the usefulness of nitric oxide levels in the peripheral operatively and HIDA scan was performed at 10-12 months blood as a marker of extra hepatic biliary atresia. of surgery. Methods: During the period June 2008 – May 2009 20 patients Results: The follow up ranges from 3 months -21 of infantile obstructive cholangiopathy were enrolled in this months[mean=11 months]. All patients had type III atresia study and were evaluated by pre-operative levels of nitric [patent gall bladder with atretic ducts-4/8, patent GB & CBD oxide in the peripheral blood. The nitric oxide levels were along with proximal atresia in 2/8, atretic GB & ducts in 2/8]. reflected by the serum levels of their stable metabolites 5 patients, more than 6 months postoperatively, were anicteric nitrate and nitrite. The nitrate was reduced to nitrite by with serum bilirubin< 1 mg%, had excretory HIDA and SGOT/ nitrate reductase and the nitrite levels assessed by the Greiss PT showed a declining trend, with near normal levels[mean reaction spectrophotometrically at 540nm. On the basis of an 53,63 IU/L respectively] at last follow up. Alkaline phosphotase operative cholangiogram 17 patients were diagnosed as extra & GGT, however, showed abnormally high values at last hepatic biliary atresia (Group I) and the remaining 3 patients follow-up [mean1218 IU/L, 525IU/l respectively]. 3 patients < had a patent bilio-enteric pathway (Group II) that could be 6 months postoperatively had total serum bilirubin varying successfully ß ushed; histopathology of the liver conÞ rmed from 2-4 mg%, Alkaline phosphotase and GGT were high the diagnosis of neonatal hepatitis. The mean levels of nitric [mean 1800,625 IU/L] oxide for each group were compared statistically and the Conclusions: Declining trends of serum bilirubin and SGOT/PT signiÞ cance of diff erence/p value calculated. aft er Kasai portoenterostomy are associated with abnormally Results: The mean age of the patients in the two groups high levels of alkaline phosphotase and GGT. The persistent was 2.79 months +/- 0.751 SD and 2.667 months +/- 0.577 SD elevation of ALP & GGT following Kasai may be suggestive respectively. The p value for this diff erence was 0.866 (>0.05); of ongoing intrahepatic cholestasis, it merits close follow up. the two groups were therefore comparable. The mean nitric oxide levels were 62.433 +/- 16.325 SD and 36.96 +/- 11.794 SD 12 respectively in Groups I and II. The p value for this diff erence Long term predictors of success after surgery in was 0.022 (>0.05); the diff erence was therefore signiÞ cant. The biliary atresia mechanism for this diff erence will be discussed. Madhavi Thakur, Anant Bangar, Prashant Kumar, Rajeev Conclusion: The blood levels of nitric oxide in patients Redkar of infantile obstructive cholangiopathy were found to be Paediatric Surgery, Lilavati Hospital & Research Centre, signiÞ cantly higher in cases of extra hepatic biliary atresia as Mumbai, Maharashtra, India compared to those with neonatal hepatitis. These preliminary results suggest that this may serve to pre-operatively Aim: To evaluate the long term predictors of success aft er Kasai diff erentiate extra hepatic biliary atresia from neonatal hepatitis portoenterostomy in children with biliary atresia.. and hence avoid a per-operative cholangiogram. However, a Material and Methods: A retrospective analysis of 23 larger study will be required to validate these results. patients over a period of 10 years was carried out. They were evaluated with respect to their clinical picture, liver 11 function tests and HIDA scan both pre-op and post-op. These Recovery of liver functions following Kasai various variables were compared between these two groups portoenterostomy for biliary atresia to help in an early prediction of success or failure following Puri Archana, Choudhary SR, Khushawa A, Chaddha R Kasai portoenterostomy. Also the complications of portal Kalawati Saran Children’s Hospital, Lady Hardinge Medical hypertension aft er a successful surgery were evaluated. College, New Delhi, India Results: Twelve patients had a successful outcome and 11 had an unsuccessful outcome aft er surgery. Serum bilirubin, Aims: Biliary atresia is a progressive fibrosclerosing HIDA scan, GGT and liver histology were found to be useful cholangiopathy of infancy. Recovery of liver function tests [LFT] in early prediction of success vs failure. Also the incidence following Kasai portoenterostomy has not been documented. of complications was determined in the so called successful The present study aims to review the results of serial LFTs in Kasai survivors. 8 patients with kasai portoenterostomy. Conclusion: HIDA scan and serum bilirubin levels before Material and Methods: During October 2007 –June 2009, 8 and aft er surgery, were the most useful predictors of success patients [males=4, females=4] of biliary atresia were operated vs failure in biliary atresia. Early prediction of success vs in the department of Paediatric surgery. All the patients failure will help to optimize treatment in both the groups with

125 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 regards their nutritional status and timely referral for liver distal penile in 1. One patient who had Arap type of bladder transplantation. agumentation had post operative obstruction due to adhesions and underwent re exploration and adhesionolysis. Continence 13 was deÞ ned as dry for more than 3 hours and partial continence Role of hepatic angioplasty in the successful was deÞ ned as dry for 1-3 hours and incontinence was deÞ ned treatment of Budd Chiari syndrome as patient dry for < 1hour. 3 patients are continent and 1 patient Madhavi Thakur, Anant Bangar, Prashant Kumar, Rajeev is partially continent. Vesicoureteric reß ux is not seen in any Redkar of these patients. Paediatric Surgery, Lilavati Hospital & Research Centre, Conclusion: Single stage complete repair with or without Mumbai, Maharashtra, India bladder agumentation is ideal procedure for patients presenting late in adolescence aft er failed initial closure. Continence was Aim: To study the usefulness and evaluate the outcome aft er achieved in 75% of cases using this procedure. hepatic angioplasty in children with Budd Chiari syndrome. Material and Methods: A retrospective analysis of 11 patients 15 with Budd Chiari syndrome was carried out. They were Experience with video assisted thoracoscopic diagnosed with the help of USG-Doppler, liver biospy and removal of pulmonary hydatid cysts in children MR venography. They were treated with hepatic angioplasty Rahul Kumar Gupta, Sandeh V Parelkar, Sanjay Oak, Beejal and balloon dilatation of the thrombosed veins followed with Sanghvi prolonged anticoagulation. Seth G.S.M. College and K.E.M. Hospital, Mumbai, India Results: Of the 11 patients, only 1 child had a portocaval shunt and an unsuccessful outcome in the early period of this Pulmonary hydatid disease is prevalent in many parts of world analysis. Six children had a favourable result in the immediate including India. In our small series of 5 pediatric patients, all period following hepatic angioplasty and continue to do well patients were diagnosed with clinical and radiological Þ ndings on follow up. One child died of hematemesis while awaiting on plain X –ray chest and CT (Computed Tomography) chest. angioplasty and one died of renal failure in the immediate post All of them received oral albendazole 10 mg/kg/day soon angioplasty period. Three children did not respond favourably aft er diagnosis except in one patient in which preoperative to angioplasty, had poor liver histology and had persistent diff erential diagnosis was bronchogenic cyst and lung abscess ascites requiring prolonged anticoagulation. (case 4). All underwent video assisted thoracoscopy. Simple Conclusion: Hepatic angioplasty and balloon dilatation is an endotracheal intubation was utilized in all cases. Complete eff ective and less invasive modality for the treatment of Budd thoracoscopic removal was successful in 3 cases, while Chiari syndrome in children. conversion to open thoracotomy was required in 2 cases. All of them showed rapid recovery except for one patient in whom 14 prolonged intercostal drainage was present for 2 weeks. The Single stage complete repair of bladder exstrophy average duration of procedure was 150 minutes and average in adolescence with failed initial closure length of hospital stay was 4.5 days except case 2, which was Vinay Jadhav, Sanjay Rao, Ashley D Cruz discharged on day 15 due to prolonged air leak. Histopathology Narayana Hruduyalaya, Bangalore-560100, India in all cases was suggestive of hydatid cyst. At mean follow up of 6 months, all patients are asymptomatic and doing well. Bladder exstrophy children presenting late with failed initial closure is not uncommon in Indian scenario. We present our 16 experience of single stage complete repair of 4 adolescent To compare the effi cacy of Intralesional Bleomycin patients with failed initial closure. with Sodium Tetradecyl Sulphate in treatment of Materials and Methods: 3 boys and 1 girl with age ranging Hemangiomas and Lymphangiomas from 8 to 21 years (mean age- 14 years) underwent standard M M Harjai bladder closure with penile disassembly technique for Base Hospital Delhi, Cantt 110 010, India epispadias repair as described by Grady and Mitchell along with bladder neck repair and bilateral ureteric reimplantation. Aim: Sclerosing agents have been tried as an alternative 2 boys had their bladder augmented in the same sitt ing due to surgical excision in the conservative management of to small Þ brotic bladder plate. Ileocystoplasty was performed lymphangiomas and hemangiomas. Sclerotherapy is eff ective in 1 patient and another patient underwent Arap type of in more than 90% of cases but not in involuting lesions. agumentation using non detubularized sigmoid segment with Sclerosing solutions are both tissue irritants and thrombogenic proximal end brought out as a temporary end colostomy. Other agents that provoke an inß ammatory reaction, which causes 2 patients had sigmoid cystoplasty aft er 1 year due to small Þ brosis and obliteration of vascular channels. Sclerosants capacity bladder. currently used are bleomycin, sodium tetradecyl sulphate as Results: The repair resulted in hypospadias in all the 4 1- 3% solution, steroids, OK-432 Þ brin glue and Interferon 2 children. Position of the meatus was coronal in 2 patients and alpha. We selected prospectively 120 patients to compare the

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 126 IAPSCON 2009 effi cacy of intralesional Bleomycin with Sodium Tetradecyl in 7, leucocytosis in 10, anaemia in 4 and skin discolouration Sulphate in treatment of Hemangiomas and Lymphangiomas in 4 children. Complications when sodium tetradecyl sulphate in our set up. was used were also minor and included 7 children with fever, Materials and Methods: Bleomycin powder (15U) was skin discolouration in 36, transient increase in swelling in 10 reconstituted with 15 ml normal saline, dilution (1U/ml). In and leucocytosis in 20 children. SigniÞ cant discolouration was children less than 1 year of age maximum dose was limited seen in patients when sodium tetradecyl sulphate was used in to 0.5-1 U/kg and in children older than 1 year and in adults; 21 patients of lymphangiomas and 15 patients of hemangiomas a dose of 1-15 units was injected intralesionally per session had skin discolouration using sodium tetradecyl sulphate. depending on the size of the lesion. A single dose of 15 U Conclusion: In our study although both the drugs were per session was never exceeded in our study and sclerosant found to be eff ective for sclerotherapy of hemangiomas and dosages were given at an interval of 14 days, depending on the lymphangiomas but given the various criteria used to asses local response. Sodium tetradecyl sulphate (SotradecolR) was the effi cacy; bleomycin was found to be more eff ective than injected as a (1-3 ml of 2% solution) in all the lesions depending sodium tetradecyl sulphate. on their size. All the lesions were initially aspirated followed by injection of the sclerosant. 17 Results: The maximum and minimum doses of bleomycin Evaluation and management of blunt abdominal given for lymphangiomas were 25 U and 210 U, the mean trauma in pediatric age dose being 119U while the maximum and minimum doses Deepak Kishore Kaltari, Sandesh V Parelkar, Sanjay N Oak, for hemangiomas were 30 U and 195 U (mean dose 121 U) Beejal Sanghvi, Rahul Gupta divided over a maximum of 15 doses. The total numbers of Seth G.S.M. College and K.E.M. Hospital Mumbai, India injections performed were 769 with a highest accumulative dose of 210 U in case of lymphangiomas and 195 U in case of Aim: 1. Study mode of injury and age distribution. 2. Study of hemangiomas. Reduction in the size of mass was usually seen frequency of solid organ injury. 3. To assess for feasability for by 2 weeks to 6 months of treatment in case of lymphangiomas non operative management based on clinical and radiologic using bleomycin, however the duration was much less in features. 4. To formulate protocol of management of blunt case of hemangiomas (2 weeks to 3 months). The duration abdominal trauma. was 4 weeks to 6 months in cases of lymphangiomas and 3 Materials and Methods: We reviewed the medical records weeks to 7 weeks in hemangiomas when sodium tetradecyl of 100 patients consecutively evaluated in the Department sulphate was used. Sodium tetradecyl sulphate was injected of Pediatric Surgery in a Tertiary care centre Hospital who in volume of 1-3 ml of 2% solution depending on the size of presented with Blunt Abdominal Trauma between August 2007 the lesion. Complete resolution or signiÞ cant improvement and June 2009. All diagnoses were conÞ rmed by ultrasound occurred in 80% (24) of hemangiomas and 73.3% (22) of (US), computed tomography (CT) and graded. The following lymphangiomas treated with bleomycin. The results were data were collected for all patients: age, sex, mechanism of 60% (18) both for hemangiomas and lymphangiomas who injury, associated injuries, delayed operation for intestinal underwent sclerotherapy using sodium tetradecyl sulphate. injuries, and morbidity and mortality related to intestinal Poor response rate was observed in 20% (6) of hemangiomas injury. Non-operative management was preferred in patients and 26.6% (8) in lymphangiomas of bleomycin group and 40% with stable vital signs, who were treated with IV Fluids (8) of hemangiomas and lymphangiomas in sodium tetradecyl and blood transfusions, strict bed rest, frequent physical sulphate group. Greater than 50% resolution was seen in 8 examinations, and 48 to 72 h of intensive care. Operative patients of bleomycin group and 6 patients of sodium tetradecyl therapy was performed in patients with shock in spite of ß uids sulphate group in hemangiomas and chances of more than 50% and blood transfusions and associated hollow viscus injury. resolution of hemangioma were 2.67 times odds than that with Result: Most of patient were managed by non-operatively, sodium tetradecyl sulphate. The chances of more than 50% those who required exploration were those who presented in resolution in lymphangiomas with bleomycin were 1.5 times shock at initial presentation, associated hollow viscus Injury. odds than that with sodium tetradecyl sulphate. The maximum There was mortality in two patients being managed non number of injections required for complete resolution were operatively in Hepatic injury. 10 and 15 in cases of hemangiomas and lymphangiomas Conclusion: Many studies over the years have conÞ rmed the respectively using bleomycin while it were 15 in all cases effi cacy and safety of this non-operative approach. With the of lymphangiomas and 13 in hemangiomas when sodium advent of evidence-based practice, over the next few years tetradecyl sulphate was used. Minimum number of injections we should be able to draw on prospective studies to develop required was 7 when bleomycin was used in hemangiomas protocols to enable effi cient use of resources and maximize and 10 for lymphangiomas. The same Þ gure was 10 and 12 for patient safety. The non-operative management of children sodium tetradecyl sulphate. The complications of bleomycin following blunt abdominal trauma is likely to remain the were all minor; fever in 15, transient increase in size of swelling standard of care.

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18 This is also the Þ rst case to undergo excision and ligation of Diagnosis of perforation peritonitis in children the Þ stula from the abdomen. Cholecystoduodenostomy was with blunt trauma abdomen: imaging or clinical performed for biliary drainage. Revision of biliary drainage acumen? on the 10th postoperative day for recurrence of the Þ stula was Rizwan A. Khan, I Ghani, Asmat followed by rapid recovery. Excision of the thoracic part of the J. N. Medical College Hospital, AMU, Aligarh Þ stula was performed a year later. The child is now10-years old & remains well. Aim: Bowel perforation following blunt abdominal trauma Discussion: CBBF is a rare malformation. About 18 cases are in pediatric age group is rare; diagnosis of these injuries in reported in the literature. Associated biliary tract anomalies children can be diffi cult and delayed. The purpose of this study are common and two types are recognised; absence of common is to present the diagnostic problems in children with bowel bile duct and obstruction to bile outß ow from the left lobe of perforation following blunt abdominal trauma. the liver. Based on the type of associated biliary tract anomaly Methods: From July 2003 to June 2009, 414 children had blunt and the pathology of the left lobe, a classiÞ cation of CBBF is trauma abdomen with forty one having bowel injuries. These proposed by the senior author of this paper (T.M. Ramanujam): 41 patients formed the basis of the study. Retrospective analysis Type I – CBBF with normal biliary tract, Type II – A & B, of the data was done to document the presentation, clinical CBBF with atretic, absent, or hypoplastic biliary tree &/or left features, Þ ndings of imaging modality (CT scan) and outcome lobe pathology. Probable embryogenesis for this anomaly is in these patients. There was an average follow up of 2 years. postulated based on abnormal biliary tract or the left lobe. Results: There were 29 were boys and 12 girls. The median Although, the accepted treatment is ligation of the Þ stula age at presentation was six years (range 2.5 to 9 years). Road by a thoracotomy, abdominal approach off ers the additional traffi c accident was the most common mode of injury. Fift een advantage of performing operative cholangiogram and biliary patients underwent laparotomy within 3 hours of presentation drainage if indicated. because of obvious bowel injury (Free air in plain x-ray or frank peritonitis). Twenty six patients were explored later 20 than 6 hours either because of positive CT scan Þ ndings or Caecal duplication mimicking intussusception ultimate progression to peritonitis. CT scan Þ ndings of these Nitin Borkar, Simmi Ratan, Arun Kumar, Satish Aggarwal 26 patients revealed that 3 had dye leak, 4 had free air and 12 Maulana Azad Medical College and associated Lok Nayak and patients had free ß uid and localized collections. Seven patients GB Pant Hospitals, New Delhi, India had “normal” scans, which were explored for development of peritonitis as assessed on serial physical examination. Aim and Introduction: To report a case of caecal duplication Conclusion: Gastrointestinal injuries due to blunt abdominal that presented as intussusception, and to highlight the trauma pose a management challenge. Diligent and serial importance of unusual diff erential diagnosis. clinical examination is the most eff ective diagnostic tool and Case Report: A 3 month old male infant presented with crying, that CT scan Þ ndings can only be of corroborative assistance. bilious vomiting and abdominal distension. Examination revealed tachycardia and a tender right iliac fossa mass. Plain 19 x-ray suggested intestinal obstruction. Clinical diagnosis of Congenital bronchobiliary fi stula: Report of a intussuception was made. Ultrasound showed a cystic lesion case, review of the literature and a proposed in the right lumbar region. The kidneys were normal. No classifi cation target sign was observed. Exploratory laparotomy revealed Ramanujam TM, Ramesh JC, Kumar G, Lum LCS an intra-mural cyst in the posterolateral wall of the caecum. Division of Paediatric Surgery and Departments of Radiology, The ileum was dilated proximal to the lesion. The appendix and Paediatrics, University of Malaya Medical Centre, 59100 was normal. The cyst was aspirated to reveal mucoid ß uid. Kuala Lumpur, Malaysia. The caecum was open to reveal sub mucosal cyst within the wall of caecum. The cyst was excised along with the caecum Purpose: We report the Þ rst case of congenital bronchobiliary and an ileo- ascending anastomosis performed. Post operative fistula (CBBF) diagnosed by using Magnetic Resonance recovery was uneventful. Histology showed a typical enteric cholangiopancreatography (MRCP) & propose a classiÞ cation. duplication cyst. Case Report: A neonate with intractable aspiration pneumonia Conclusion and Discussion: Intussuception is a common and copious bilious aspiration from the endotracheal tube was cause of intestinal obstruction in infancy. However, uncommon suspected to have CBBF. MRCP conÞ rmed the diagnosis and causes such as duplication cyst should be considered in HIDA scan indicated obstruction to the biliary tract. Operative diff erential diagnosis. Ultrasound may be helpful in suggesting cholangiogram revealed complete obstruction of the common an alternate pathology such as a cyst. The surgical approach bile duct and a bronchobiliary Þ stula arising from a dilated left could then be changed in favor of a laparoscopy, especially hepatic duct. In addition, the cholangiogram showed the biliary when ultrasound is suggestive of a cystic mass. In retrospect, radicals draining the entire left lobe of the liver to be abnormal. this case could have been managed by a laparoscopic assisted

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 128 IAPSCON 2009 approach. The cyst along with ileocaecum could have been were found to have rare causes. The clinical features, Chest delivered out through a port site and resection anastomosis xray Þ ndings, FNAC/ Histopathology, Microbiological reports could have been done outside. were speciÞ cally analysed. Hemogram, ESR, CXR, Mantoux, were carried out in all. 21 Results: CMV was found in3 cases, Histiocytosis in 6 cases, Central venous lines in pediatric age group: A Neuroblastoma 3, Cat Scratch disease in 1, metastatic disease single center experience in 2 remaining were non speciÞ c granulamatous and small Subhasis Saha cell tumors that could not be categorized into any speciÞ c The Calcutta Medical Research Institute, Kolkata, India pathology. No child with these diagnosis had any systemic Symtoms. Histiocytosis was confirmed by bone marrow Aims: The aim of this study is to highlight the importance of examination. Detailed histopathology would be presented. central venous access and discuss its feasibility in the pediatric Conclusion: Detailed examination and pathological search is age group. mandatory in all cases of cervical lymphadenopathy with non Methods: A retrospective analysis has been made of all the conÞ rmatory initial pathology, so as not to miss these speciÞ c patients aged between 1 day to 14 years, in whom a central rare causes. venous line has been inserted from May 2003 to June 2009. The method of insertion, the route of insertion, the indications and 23 complications, if any were studied. Long term follow up of Choledochal cyst – Single Results: 166 neonates, infants and children had to have a central centre experience venous access in our series. 14 children had insertion of depo Jiledar Rawat, Anshuman Sharma, Anand Pandey, S. N. Kureel, ports for administration of chemotherapy. In 12 children we A. Wakhlu, M. Maletha, I. Ahmad, Archika, Tanvir R Khan placed Hickman catheter for chemotherapy administration Department of Pediatric Surgery, CSMMU (Upgraded KG either as they could not aff ord the cost or early in our series Medical University), Lucknow, India when chemo port of pediatric size was not available. 15 patients had insertion of central venous lines for perioperative Aim: Choledochal cyst is an important cause of hepatobiliary monitoring. 55 babies, mostly neonates had line insertion for disorders in our country. The purpose of present study is to administration of total parenteral nutrition. The rest were sick evaluate its various modes of presentations, surgical methods babies who needed a central line for injecting antibiotics and and their outcome in children. intravenous ß uids. Most of the cases were done in OT under Materials & Methods: In this retrospective study, all patients G.A. A few cases were done at the bedside with sedation and with diagnosis of choledochal cyst were included, The data local anesthesia.There were no major complications. Minor included age, sex, modes of presentations, surgical technique, complications include anatomical incorrect placement, wound and outcome. Duration of follow up is one to six years. infection, sepsis. Results: Total number of patients was 35. Male to female ratio was Conclusion: Central venous line placement in neonates and 24:11. The mode of presentation was recurrent abdominal pain children is a safe and feasible procedure. It should be done (n=20), palpable lump (n=6), fever, nausea and vomiting (n=10), with ß uoroscopic guidance wherever feasible. Placing a line peritonitis (n=3) & jaundice (n=16). Choledocho- duodenostomy in neonates, particularly in premature babies requires special done in 12 patients, Roux-en-Y choledocho-jejunostomy in 18 expertise. patients and two were managed by cystojejunostomy. Three patients suff ered from severe att acks of cholangitis, of which one 22 was kept on external tube drainage following biliary peritonitis. Non tuberculous Cervical Lymphadenopathy in One patient expired due to severe uncontrolled cholangitis. The Children third patient, aft er roux-en-Y hepatico jejunostomy, developed Vimalakara Reddy, Depak Sharma, G. Rammohan, G. sub acute intestinal obstruction and terminal ileal gangrene for Raghavendra Prasad, G. Satyanarayana, K.Satyanarayana, which ileostomy was done. In follow up, all except one patient Alladi Venkatesh, Vijaysekhar are doing well. The follow up loss is 20%. Kamineni Hospitals and KIMS, Narketpally, Hyderbad, India Conclusions: Choledochal cyst is an important entity which may present in various ways, hence, early diagnosis and timely Introduction: Cervical is an extreme common pediatric surgical intervention should be emphasized. The outcome is usually reference. Tuberculosis remains the commonest next only to satisfactory. non speciÞ c lymphadenopathy. Uncommon and rare conditions continue to bowl pediatric surgeons. 24 Aims and Objectives: to present 18 cases of such rare cases on Choledochal cysts in children: Presentation, speciÞ c lymphadenopathy. treatment and outcome Materials and Methods: 168 cases of cervical lymphadenopathy Rizwan A. Khan, Imran Ghani, Dr. Asmat referred to the pediatric surgical unit were reviewed. 18 cases J. N. Medical College Hospital, AMU, Aligarh, India

129 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009

Aim: Choledochal cysts are dilations of the biliary tree. routine ultrasound. Ultra sound was done in 56 cases, all Incidence in Asian countries is high as compared to western were aft er 1995. 11 of 33 prior to 1995 had ultrasonographic population.This study was undertaken to analyze the evaluation and 6 had CT Scan. MRCP was done in 43 of 56 cases presentation, evaluation, management of children with seen aft er 1995. ERCP was done in 7 cases. Acute presentation choledochal cysts. was seen in 11 cases. All had Amylase / Lipase / Imaging Methods: Sixteen patients who presented to us were analyzed. conÞ rmed acute pancreatitis. 11 cases recorded choliithiasis. Patient demographics, presenting complaints, co-morbidities, Ultrasound had picked up all cases aft er 1995. Type 1 was diagnostic modalities used, biochemical abnormalities, recorded in 53, Type IV in 30, Choledochocele in 2 and Carolis in treatment, outcome and histopathological findings were 4. MRCP showed pancreas divisum in 4 cases, AJPBDS in 22 and studied. The follow-up included symptoms of cholangitis, long Channel in 13 cases. 79 complete excision of choledochal small bowel obstruction, hematological and biochemical tests. cyst was performed, Lilly’s procedure in 3 cases, Laparoscopic Results: There were 11 girls and 5 boys. The median age was excision and ex vivo choledochojejunostomy in 4 cases. 12 cases 7 years. Abdominal pain was the presenting symptom in 90% had established cirrhosis nd conÞ rmed in histology. 4 children of the children. Vomiting was present in 31% of children. during the follow up period showed Portal hypertension. There was hyperbilirubinemia in 25 percent of the patients. Complications recorded were wound infections in 11, Burst All the patients underwent ultrasound of hepatobiliary system. abdomen in one, Adhesive obstruction in 3, anastomaotic leak Seventy Þ ve percent patients had undergone CECT abdomen in 2 cases. Follow up records were available for 62 cases. More while only 31 % underwent MRCP. There were 12 cases of Type than 5 years 41, one to 5 years 13 and less than one year in 8. I while 4 cases of Type IV B choledochal cyst. All underwent All were alive aft er surgery. Long term complications recorded complete cyst excision with Roux-en-Y hepaticojejunostomy. were stricture in two, Portal hypertension in 4. Redo biliary Early complications included fever (31%), pain & vomiting anstomosis was performed in one. (12.5%). Late complications included persistent bile leak in Conclusions: Choledochal Cyst is being diagnosed early one patient. with ultra sound and MRCP picks up ductal anatomy and Conclusion: This study analysed small group of patients with aberrations. choledochal cyst. None has classical presentation. USG was the imaging modality of choice and was supplemented well by 26 CECT. MRCP was not done mainly because of cost constraints Cloacal exstrophy variant in a female child and also was technical diffi culties. Complete excision and Shalini Sinha, Nitin Borkar, Y. K. Sarin Roux-en-Y-hepaticojejunostomy gave good results with fewer Maulana Azad Medical College, New Delhi, India complications. Case Report: A female neonate with unusual cloacal exstrophy 25 and lumbosacral lipomeningomyelocoele weighing 2.3kgs was Choledochal cyts – Pre and Post MR era – born in our hospital. The normal looking vulva was displaced Experience with 89 cases posteriorly in the perineum that harbored a single oriÞ ce Vimalakar Reddy, G. Raghavendra Prasad, G. Rammohan, through which a catheter could be easily passed. The clitoris G. Satyanarayana, Deepak Sharma, Eswarchandra, was not biÞ d. She had a bladder neck (and probably a trigone). K. Satyanarayana She had two separate hemiuteri with separate vaginas that Kamineni Hospitals, KIMS Narketpally, Hyderabad, India opened by separate oriÞ ces on the two sides of cloacal plate lateral to the bowel plate; the vagina on the left side was too Introduction: Choledochal Cysts are not uncommon in short to bring it to the anterior abdominal wall. There was pediatric Surgical Practice. Imaging revolutionized diagnosis. evidence of hydrocolpos bilaterally. The ureteric oriÞ ces could MRI completely deÞ nes anatomy and picks up AJPBDS. not be visualized. She was also diagnosed to have S-shaped Aims and Objectives: To present the series of 89 choledochal fused hydronephrotic kidney on the left side on ultrasound; cysts.To stress the impact of MRCP in the management of the right renal fossa was empty. The bowel plate was separated Choledochal Cysts. and the tail gut was brought out as end colostomy. Side-to- Materials and Methods: records of all choledochal cysts seen side vagino-vaginostomy was performed and the right vagina and treated between 1984 and 2006 were studied. Clinical was brought out as a stoma on anterior abdominal wall. The presentation, Age of operation, Pre op Diagnostic evaluation bladder was closed over a small Foley’s catheter. The neonate and operative details and follow up were picked up for this was electively ventilated. As the urine output from urinary analysis. catheter was very meager, a percutaneous nephrostomy on Results: 58 were girls and 31 were boys. 21 cases were treated the hydronephrotic kidney on the 1st postoperative day. The before one year of age mostly aft er 2000. 24 cases were treated child could be weaned off the ventilator on 3rd postoperative before 5 years of age remaining aft er till 18 years of age. The day, and was started on feeds. But unfortunately, on the 4th unit also does adult Surgery. Jaundice was presenting symptom postoperative day, she died suddenly due to unexplainable in 9 cases and LFt showed raised bilirubin in 23 cases. Vague hyperpyrexia. pain was recorded in 34 cases. remaining were detected during Discussion: Classical Cloacal Exstrophy in the female child

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 130 IAPSCON 2009 usually has two hemiclitoris and the urethra is epispadiac. The recto vestibular Þ stula underwent single staged procedure. absence of these features makes this case rare. The presence of All the patients withstood surgery well. One patient required vaginal oriÞ ces higher up on the cloacal exstrophy plate is also conversion due to problem in gaining enough length for the unusual. Fusion anomalies of the Mullerian duct structures as distal rectum in a patient with rectovesical Þ stula so colostomy seen in this case are common and seen in upto 2/3rds of cloacal was closed and recited at a proximal splenic ß exure. The exstrophy patients. Crossed fused renal ectopia has also been complications were mucosal prolapse in (6 cases), anal stenosis known to co-exist. ( 3 cases), adhesive obstruction( 2 cases), distal rectal necrosis ( 1 case), Urethral diverticulum ( 1 case). On follow up with 27 Clinical Evaluation, Anal USG (ultra sonogram), CT pelvis, Segmental dialatation of small intestine (a case MRI pelvis, Manometry, Distal loopogram. The progress has report) been satisfactory and weight gain was adequate. Karthik S Bhandary, V. Kumaran, G. Rajamani, S. Kannan, N. Conclusion: The advantages of the reformed techniques are, Venkatesa Mohan, Muthulingam, R. Rangarajan transcutaneous bladder stitch provides excellent visualization, Coimbatore Medical College, Coimbatore, India traction over the Þ stula helps in dissection of the puborectalis, dividing the Þ stula without ligation is safe, railroading of hegars dialators over the suction canula creates adequate pull • 3 Yr old male child,Abdominal pain-on & off past 6 through channel saves time, makes procedure simpler with mths,Mainly around umblical region. Vomiting 2mths reproducible comparable reports. duration, Bilious. Abdominal distention-2mths duration. • Clinically-Vague mass felt in Right Hypochondrium, 29 Umblical region,Left hypochondrium. Our experiences with advanced minimally invasive • Soft in consistency, Freely mobile in all direction, Resonant surgery: Innovative approaches to percussion. Karthik S Bhandary, V. Kumaran, G. Rajamani, S. Kannan, • USG Abd- Segmental volvulus. N. Venkatesa Mohan, R. Rangarajan, Muthulingam Laproscopy-Dilatation of a segment of Ileum of about 15cm Coimbatore Medical College, Coimbatore, India from Ileocaecal junction. Which was resected and anastomosed • Histopathology revealed -Mulitple sections studied from Aim: To discuss the technical modifications of advanced the recived dilated segment shows nonneoplastic mucosa minimally invasive surgeries practised at our institute and & other layers of wall.Adequate ganglion cells seen.No analyse the post operative outcome and complications evidence of granuloma or Neoplasm associated. Segmental dilatation of the ileum (SDI), also termed ileal Materials and Methods: A retrospective and prospective dysgenesis or segmental megaileum, is characterized by a study from January1999 to May 2009 analyzing the modiÞ ed sharply deÞ ned and markedly dilated segment of the ileum maneuvers of advanced laparoscopic surgeries at the flanked by normal-caliber afferent and efferent bowel. Department of Paediatric surgery, Coimbatore Medical College Segmental dilatation of the ileum is a rare condition, with only Hospital. 125 published cases. Results: A total of 928 patients have undergone minimally invasive procedures Over the past 10 years. Advanced 28 laparoscopic procedures include rectopexy (7 cases), malrotation Laparoscopic assisted ano rectal pull through – (8), hiatus hernia (10), anorectal anomaly (40), nephrectomy reformed techniques (16), Hirschprung’s disease (30), adrenalectomy(2), pyeloplasty Karthik S Bhandary, V. Kumaran, G. Rajamani, S. Kannan, (7), choledochal cyst (5), infantile hypertrophic pyloric stenosis N. Venkatesa Mohan, Muthulingam, R. Rangarajan (5), hydatid cyst(3) and colovaginoplasty (2). Thoracoscopic Coimbatore Medical College, Coimbatore, India procedures totalled about 72 cases started with biopsy and subsequently progressed to thoracoscopic decortication Aim: To discuss the modiÞ cations of laparoscopic assisted (40 cases), congenital diaphragmatic hernia repair (13), anorectal pull through practised at our institute and analyse bronchogenic cyst excision (1), pericardiectomy (3). Our the post operative outcome and complications associated. conversion rate was around 5% in the years 1999-2000, which Materials and Methods: A retrospective and prospective study has come down to 3% from the year 2005 onwards. Conversions from January2001 to May 2009 analyzing Laparoscopically were for sliding hiatus hernia, ileal perforation, perforated Assisted Anorectal Pull-Through for High Anorectal adherent appendicitis, Meckel’s diverticulum and laparoscopic malformations (LAARP) at the Department of Paediatric nephrectomy. Our postoperative complications were fever surgery, Coimbatore Medical College Hospital. (15%) in a majority of the patients. One case of choledochal Results: A total of 40 patients have undergone Laparoscopically cyst developed bile leak, which was reopened, and Roux-En-Y Assisted Anorectal Pull-Through for Anorectal malformations hepaticojejunostomy was performed. A case of bronchogenic (LAARP). Male – 34 Female – 6, Age group -2 months to 6 cyst that developed pneumothorax aft er discharge improved years. Staged procedure was done in 39 patients, one case of with ICD. One mortality occurred in a case of thoracoscopic

131 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 decortication due to disseminated tuberculosis. exposure. It is a perfect method for the non-operative treatment Conclusion: Through the course of our work we ran into of pediatric intussusception. several diffi culties and with time circumvented these with our own modiÞ cations like,In nephrectomy retaining the lateral 31 peritoneal att achement of the kidney until we divide the vessels Spectrum of Duodenal Obstruction there by avoiding the need for a retracting port and an assistant. Bhat Nisar Ahmad For ligation of the ureter we employ Rhoeder’s knot. Antegrade Sheri Kashmir Institute of Medical Science, Srinagar Kashmir, stenting of the ureter for keeping the ureter open and to steady India it for uretero-pelvic anastomosis during pyeloplasty. Since complete disconnection of PUJ leads to confusion in orienting The duodenum is most common site of neonatal intestinal the ureter a small lateral bridge is retained till completion of obstruction, accounting for nearly half of the cases. Various posterior layer of suturing. Choledochal cysts are subjected to abnormalities causing duodenal obstruction include intrinsic excision followed by choledocho – duodenostomy due to the obstruction from web or complete bowel discontinuity and ease of the procedure as well as reduction in the number of extrinsic obstruction from annular pancrease, Ladd’s bands, anastomosis Cyst is retained for traction during anastomosis preduodenal vein & volvulus. Diagnosis is oft en simple & does as in pyeloplasty. Thoracoscopic decortication we have limiting not require any special investigation. In last one decade more ourselves to two ports of access with high pressure suction to than 40 pts of duodenal obstruction were seen in our institution, decorticate and use sponge holding directly to decorticate and three of them were very interesting. One of patients with retrieve tough peel. Our techniques have evolved over the time duodenal obstruction had a delayed presentation with unique and now we are able to save time, and improve the quality of complication of stone formation at the site of obstruction. life of our surgical neonates. we would like to throw light on Second case also had delayed presentation causing a severe the tips and techniques which have made a huge diff erence. malnutrition and third case although the diagnosis was simple but we were encountered with a rare case of duodenal 30 obstruction. Comparison of ultrasound-guided hydrostatic reduction and barium enema reduction of 32 intussusception in pediatric age group ERCP in management of CBD round worms in a Advait Prakash, Rahul K Gupta, Beejal Sanghvi, Sandesh V 3 year old child Parelkar, Sanjay N Oak Deepak Kishore Kaltari, Sandesh V Parelkar, Sanjay N Oak, Seth G.S.M. College and K.E.M. Hospital, Mumbai, India Beejal Sanghvi, Rahul Gupta Seth G.S.M. College and K.E.M. Hospital, Mumbai, India Aim: Currently the standard methods for therapeutic reduction of intussusception in children involve considerable use of Ascaris lumbricoides, or the common roundworms, has a ionizing radiation. In this study, an att empt is being made worldwide distribution but is mainly seen in Asian and Latin to assess feasibility as well as effi cacy of ultrasound guided American countries. The usual habitat is in the small intestine, hydrostatic reduction along with its comparison with reduction mainly in the jejunum. But if the worm load is high, which may by barium enema under ß uoroscopic guidance. go up to a thousand worms, the worms tend to migrate away Patients and Methods: The study is presently being undertaken from the usual site of habitat. We are presenting a rare case of with patients divided in two groups. Group 1: Barium reduction ascariasis infestation of hepato-biliary tract in a 3 years female group and group 2: USG Guided hydrostatic reduction group. child which was managed by ERCP avoiding open surgery. All children clinically suspected of having intussusception were evaluated by sonography. Those with positive Þ ndings 33 on sonography were included in the study. Excluded were Esophageal anastomosis medial to preserved the patients in shock, those with peritonitis, gross abdominal azygos vein in esophageal atresia with distension and recurrent intussusception. Criteria for successful tracheoesophageal fi stula: Restoration of normal reduction were disappearance of the intussusceptum and mediastinal anatomy and improved outcome passage of ß uid through the ileocecal valve. Post reduction Kumar Abdul Rashid, Madhukar Maletha, Tanvir Roshan Khan, sonography was used for conÞ rmation. Ashish Wakhlu, Jile Dar Rawat, Shiv Narain Kureel, Raj Kumar Results: The two methods were compared for rate of success, Tandon time consumed for reduction, complications and rate of Department of Pediatric Surgery, King George Medical recurrence. Sonographic hydrostatic reduction scored distinctly University, Lucknow, India over barium reduction on all the parameters. Conclusion: Ultrasound-guided hydrostatic reduction for Purpose: The purpose of our study was to prospectively pediatric intussusception is preferred because it is safe, study the technical feasibility and advantages of esophageal accurate, has a higher success rate, and avoids radiation anastomosis medial to the preserved azygos vein in neonates

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 132 IAPSCON 2009 diagnosed with esophageal atresia with tracheoesophageal 34 Þ stula (EATEF). The results were compared to the cases where Mandatory postoperative mechanical ventilation azygos vein was either not preserved or the anastomosis was after primary anastomosis in esophageal atresia: done lateral to the arch of preserved azygos vein. A prospective study Material and Methods: All patients with EATEF who Manu Arora, Uma Raju, Sheila Mathai, Firdaus Bhot underwent primary between January 2007 and July 2008 are Command Hospital (SC) Pune, India included in the study. The patients with long gap esophageal atresia with or without tracheoesophageal fistula were Aim: To evaluate if mandatory post-operative mechanical excluded. Patients were randomly divided in three groups ventilation to stabilize the primary anastomosis would prevent comparable with respect to the gestational age, age at anastomotic leak. presentation, sex, birth weight, associated anomalies and the Method: All neonates with esophageal atresia presenting to our gap between the pouches aft er mobilization: Group A (azygos hospital between January 2004 and June 2009 were included vein ligated and divided), Group B (azygos vein preserved in the study. Twenty six patients presented with esophageal with esophageal anastomosis lateral to the vein), and Group atresia in this period. All patients underwent detailed clinical C azygos vein preserved with esophageal anastomosis medial examination, chest x-ray, and echocardiography and ultrasound to the vein). All the patients were operated by extrapleural abdomen to look for associated anomalies. All these patients approach. The three groups were compared with respect to were divided into three groups as per Waterston’s classiÞ cation. operative time and early postoperative complications like The patients underwent right thoracotomy, ligation of Þ stula pneumonitis, anastomotic leaks and mortality. Odds ratio and and primary anastomosis. The measurement of the gap Chi square test were used for the statistical analysis. between the two esophageal ends, using a silk thread, was Results: A total of 134 patients were admitt ed in the study done before mobilization.. The anastomosis was done with 6 0 period of which 116 underwent thoracotomy and primary prolene. Mechanical ventilation for minimum period of forty- esophageal repair. Eleven patients with long gap esophageal eight hours was ensured for all the patients who underwent atresia with or without tracheoesophageal Þ stula and 7 patients primary anastomosis. The patients were heavily sedated and who expired before surgery were excluded. Group A had 35; Group B had 43 and Group C 38 patients. No signiÞ cant muscle relaxants were given where indicated during the period diff erence was observed in average operative time. Incidence of mechanical ventilation. of postoperative pneumonitis was higher in group A (28%) as Results: Antenatal ultrasound could not diagnose esophageal compared to group B (13.95%) and group C (11.62%) but not atresia in any of the patients although four of the mothers had statistically signiÞ cant (p > 0.005). Anastomotic leak occurred polyhydramnios. The birth weights ranged from 1.2 kg to 2.8 in 7 patients in group A (20%), 6 patients in group B (13.95%) kg with an average weight of 2.3 kg. 58% of patients were male and 4 patients (10.52%) in group C (p > 0.005). Anastomotic and rest females. 57% patients had associated anomalies, which leaks were 4 minor and 3 major in group A; 4 minor and 2 included congenital heart defects, rib and vertebral anomalies, major in group B and 3 minor and 1 major in group C. Mortality high arched palate, micrognathia, polydactyl, microtia and cleft was 5 in group A, 3 in group B and 2 in group C (p > 0.005). lip. The gap between the ends ranged from 0.5 cms to 4.5 cms. All patients with major anastomotic leaks in group A and Two patients developed anastomotic leaks (16%) in our study. group B expired aft er re-exploration with esophagostomy and Nine patients required minimal lower pouch mobilization feeding jejunostomy. One patient with major leak in group C of less than 1 centimeter, off them one patient developed also died aft er re-exploration and esophageal re-anastomosis. anastomotic leak. Using Waterston’s criterion, seven patients The minor leaks were managed conservatively and all of were in group A, nine in group B and ten in group C. Three them healed spontaneously. This was conÞ rmed by contrast patients expired. Two of them had major congenital anomalies esophagography and patients were allowed orally only aft er and the third weighed 1800 grams. All three who expired were complete healing at anastomotic site was documented. Severe in Waterston’s group C. pneumonitis and septicemia were other causes of mortality Conclusion: Mechanical ventilation aids in prevention of contributed by major associated anomalies. anastomotic leaks even in patients with long gaps between Conclusions: Preservation of azygos vein in primary repair the two esophageal pouches. Thus it improves the outcome in of EA with TEF reduces the incidence of mortality and patients with esophageal atresia and tracheo-esophageal Þ stula. postoperative complications. Although the difference in complication rates was not statistically signiÞ cant because 35 of smaller sample sizes of the three study groups, yet the Single stage combined repair of exstrophy esophageal anastomosis medial to the preserved azygos vein bladder—preliminary results restores the normal mediastinal anatomy and helps a tension Puri Archana, Choudhary SR, khushawa A, Chaddha R free esophageal anastomosis. The method is neither technically Kalawati Saran Children’s Hospital, Lady Hardinge Medical challenging nor more time consuming. A multi-center study College, New Delhi, India with larger sample sizes is needed for a statistically signiÞ cant comparison of the results. Aims: To study the feasibility of single stage repair in exstrophy

133 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 bladder as a primary procedure and as a secondary salvage Before I6th week Brain is smooth with hippocampal procedure for failed exstrophy bladder. The present study also sulcus and lateral cerebral fossa aims to assess the short term results of the same. I6th week Lateral sulcus,parieto occipital Patient and Methods: During march 2008- June 2009, 8 patients sulcus,calcarine sulcus of exstrophy bladder were operated in the Department of I8th week Parieto occipital sulcus Pediatric Surgery [6 males and 2 females]. They were divided 20 weeks Cingulate sulcus into 2 groups of 4 patients each. Group1 [age ranging from 24 weeks Inferior and superolateral sulci 7 months – 60 months] had single stage primary combined 32 weeks All important sulci repair, with bladder turn in, modiÞ ed cantwell ransley repair Conclusions: Corelation between fetal age and appearance with umbilicoplasty, bilateral herniotomy and bladder neck of sulci and gyri helps in knowing brain maturation there by tightening. Group II [age ranging from 14 months – 66 months] helps in knowing abnormality of fetal sulcation and gyrational had previously failed repairs. Preoperative renal functions, abnormality. ultrasonography, bladder capacity, presence of polyps, elasticity/compliance of the bladder and complications were 37 recorded. Assessments of the dry period was done at the 3rd, Biological sealants (fibrin glue) In Paediatric 6, 9, 12, 15th postoperative months. Surgery Results: The follow up ranged from 3 months – 15 months Satish Aggarwal, Arun Kumar, Simmi Ratan, Nitin Pant [median -13 months]. The preoperative RFT and USG were Maulana Azad Medical College and associated Lok Nayak and normal in all patients. Bladder capacity was 30-35 ml and GB Pant Hospitals, New Delhi, India 25-30 ml in group1& II respectively, hyperplastic mucosal polyps were seen in 3/4 patients each in group1 and II. Fibrotic, Aim and Introduction: To report our experience with 10 inelastic bladder was seen in one patient each in the 2 groups. cases where Þ brin glue was used for diff erent indications. To None of the patients had urethral Þ stulae or hypospadias while highlight its usefulness in selected cases. 2 patients in group II had urinary leak from abdominal wound Methods: Biological sealants were used for 10 cases: congenital which healed on 2 weeks of urethral drainage. The dry period chylothorax (1), bilateral perirenal lymphatic collection (1), in group 1 was 60-80 minutes at last follow up while it varied hypospadias (3), massive lymphatic cyst (1), wilms tumor from 20-45 minutes in groupII. (1), precious urinary anastomosis (3). The purpose was to Conclusion: Single stage combined repair is feasible both as ensure leakproof anastomosis or prevention of post operative a primary and secondary procedure. The early results are lymphatic leaks or hemostasis or promotion of wound healing. promising and bett er in the primary group. Commercially available sealant (Tisseal – Baxter) 1ml-2ml was used in all. Reconstitution was done as per product literature 36 either in a water bath or speciÞ cally designed machine. The Fetal Brain Maturation evaluation by morphological case with congenital chylothorax was initially treated medically examination and with chest tube drainage. G. Raghavendra Prasad, G. Satyanarayana, Susheelamma, Result: No untoward reaction occurred in any case. Chylothorax Gayatri, Chaitanya and peri renal lymphatic collections resolved with one Kamineni Hospitals, KIMS Narketpally, Hyderbad, India application. The cases with hypospadias (all re do cases) healed without complications except one which dehisced. All Introduction: Gyration is a phenomenon occurring late during the precious urinary anastomosis – appendix transplantation fetal development. Goes on to the end of pregnancy and even for ureteric replacement, Monti ileal replacement of urethra, later aft er birth. Sulci appear as grooves on the surface of brain. and traumatic urethrovaginal fistula – healed without Gyration proceeds with the formation of side branches of complications. sulci Timing of appearance of diff erent sulci is so precise that Conclusion: Fibrin sealants are good adjunct to surgery for gyration is considered to be reliable estimate of fetal age and haemostasis, promotion of wound healing. Selected cases brain maturation. It guides us regarding morphological and beneÞ t from its use although the cost is prohibitive. functional changes of developing brain in terms of treatment and protection of vital structures. 38 Aims and Objectives: To relate the fetal age and the appearance Chemical sphicterotomy for anal fi ssure- clinical of sulci and gyri on fetal brain. and manometric assessement Materials and Methods: Fetuses studied---SI X(6), aborted(KIMS). Shandip Kr Sinha, Anup Mohta, Sujoy Neogi, Swarup Das, Fetal age was estimated by Crown -rump length, Crown-heel Chhavi Ranu Gupta, Mamta Sengar, Vivek Manchanda length, Biparietal diameter, Head circumference, Abdominal Chacha Nehru Bal Chikitsalaya (affi liated to Maulana Azad circumference, Weight. Brain was removed by sagitt al and Medical College), Delhi, India coronal incision on the scalp and two parasagitt al incisions on vault. Sulci and gyri on brain were documented. Fissure-in-ano is a very common condition that causes suff ering Results: Normal anatomical appearance of sulci and gyri. out of proportion to the size of the lesion. Pathogenesis is

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 134 IAPSCON 2009 internal anal sphincter hypertonia, anodermal ischemia, and Introduction: Gastric Volvulus is a rare condition seen infancy chronic constipation. Chemical sphincterotomy” with various and childhood. Gastric Volvulus secondary to eventartion of compounds has been suggested and studied for the last 15 Diaphragm is the commonest. Acute gastric vovulus rquires years in adults and more recently in children. NTG 0.2% had urgent surgical intervention as ischemic necrosis of Stomach been used in few studies with conß icting results in pediatric is rapid and fatal. patients. This clinical trial was planned to study the impact Aims and Objectives: To present a series 9 cases of Gastric of 0.2% NTG on clinical and manometric proÞ le in pediatric volvulus treated by the team patients with acute anal Þ ssure. Materials and Methods: The records of gastric volvulus from Patients and Methods: All children who presented to OPD and 1985 to 2006 were retrospectively analysed. Age at presentation, diagnosed to have acute anal Þ ssure were included and advised presentation, diagnosis, procedure performed and outcome oral lactulose, sitz bath and local xylocaine jelly. Aft er detailed were the parameters of interest. consent and description of process, anal manomety was done. Results: 4 cases were seen in the neonatal period, 2 less than After initial manometry, 0.2% GTN paste was advised to one year, 3 between 6 and 9 years. Neonatal presentation all patients for six weeks for local application twice daily in acute distension with upper GI bleed. All were diagnosed as addition to sitz bath and oral lactulose. Aft er that oral lactulose NNEC with ileus. Pediatric Surgical referral picked up the was continued for sixteen weeks (if constipitation). Manometry classical radiographic signs with NG T in lower esophagus.. was repeated aft er six weeks and sixteen weeks. Main outcome The two children who presented at 6 and 11 moonths of age measure was time for painless defaecation. Adverse eff ects and presented with sudden vomiting.Initial treatment was as Acute failure of therapy were also noted. Gastroenteritis. Failure to improve imposed a radiological Results: Twenty Þ ve children were included in this study. evaluation and the classic radiograph sett led the diagnosis. Average age of the patients was 4.65 years with fourteen female Others presented with recurrent vomiting and upper GI series and eleven males. Painful defecation was the most common conÞ rmed the diagnosis. The eventartion was seen in 6 cases, presenting symptom with associated bleeding in sixty percent of Hiatus hernia in 3 and no cause was seen in one. 2 neonates children. Prenitroglycerine anal canal manometric pressure was had extensive gangrene of stomach and the remaining stomach in rang of 20 to 90 cm H2O(average 55Cm H2O).Treatment was could be saved. Other cases the stomach was viable. Two eff ective in 19 of these 25 patients with average time of painless neonates succumbed all others were alive. defecation of ten days. Anal manometry at 6 weeks showed Conclusion: High index of suspicion prior exposure to average pressure of 25cmH20. At sixteen week the symptomatic radiaographic pictures avoid loss of stomach and decrease relief was in 22 of the 25 patients but recurrence was seen in 4 mortality and morbidity. patients. Mean anal canal pressure was 30CmH2O. Conclusion: Local application of 0.2% NTG had been associated 41 with improvement in symptoms in acute anal Þ ssure in children Hepatoblastoma: Successful management and along with decrease in anal canal pressure. review of literature Manu Arora, YK Sarma, KK Upadhyay 39 Command Hospital (SC) Pune, India Gall bladder perforation presenting as acute abdomen: A report of three cases Aim: Hepatoblastoma is a rare paediatric solid tumor K. Saha, R. M. Shukla, D. Roy, PP. Mukhopadhyay affl icting the liver. We successfully managed two cases of Dept. of Pediatric surgery, NRS Medical College, Kolkata, India Hepatoblastoma in our institution in the recent past utilizing multimodal therapy. Gall bladder perforation presenting as acute abdomen is rare Method: Case one – Fourteen month old boy presented in in pediatric population, only few cases has been reported in Aug 2006 with lump right hypochondrium. On examination the literature. Here we are presenting three boys with a median the patient had hepatomegaly & X-Ray showed calciÞ cation age of 8 yrs who has been explored with a clinical diagnosis of in the region of the lump. USS and CECT gave evidence of a perforative peritonitis & found to have perforation in the gall 94 by 92 mm hyperechoic heterogenous mass in segment VI bladder in last two years. Clinical features, operative Þ ndings, and VII of liver. The patient was managed with neoadjuvant blood investigations, histopathological Þ ndings & outcome chemotherapy, right hepatectomy followed by adjuvant were studied in detail. chemotherapy. On follow up for two and half patient is doing well. Case two – Eleven month female child presented with fever 40 and lump right upper abdomen. Patient had hepatomegaly. Gastric volvulus in infancy and childhood: USG & CECT suggested hepatoblastoma. AFP was raised. The Experience with 9 cases patient was again managed with neoadjuvant chemotherapy, G. Raghavendra Prasad, G. Rammohan, G. Satyanarayana, right hepatectomy followed by adjuvant chemotherapy. On Deepak Sharma, Vijaysekhar, K. Satyanarayana, Eswarchandra follow up for two years there is no recurrence. Kamineni Hospitals, KIMS Narketpally, Hyderabad, India Result: Both children are on regular follow up with no

135 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 recurrence. Predicting the outcome of pediatric brain injury is diffi cult. Conclusion: Hepatoblastoma is a rare malignancy of the Prognostic instruments are not precise enough to reliably liver in children. Successful management involves optimum predict individual patient’s mortality and long-term functional implementation of multimodal therapy which was aff ected status. The purpose of this article is to provide a guide to the in these patients. strengths and limitations about the use of Hyperbaric Oxygen Therapy (HBOT) in treating pediatric patients with severe 42 brain injury. Impact of waiting time in hernia surgery Patients and Methods: We studied total 56 patients of head Sujoy Neogi, Shandip Kr Sinha, Vivek Manchanda, Swarup injury. Out of them 28 received HBOT.Only cases with severe Das, Chhavi Ranu Gupta, Mamta Sengar, Anup Mohta head injury {Glasgow Coma Scale (GCS) <8} with no other Chacha Nehru Bal Chikitsalaya (affi liated to Maulana Azad associated injury were included in the study group. Aft er an Medical College), Delhi, India initial period of resuscitation & conservative management (10 -12 days), all were subjected to three sessions of HBOT at 1 Introduction: Prolonged surgical wait times are a problem in week interval. This study group was compared with a control many health care systems because of large number of cases group of similar severity of head injury (GCS<8). att ending public sector hospitals. We studied data from our Results: The study and control groups were compared in terms hospital to determine if increased waiting period was related to of duration of hospitalization, GCS, disability reduction and complications and adverse outcomes in children of congenital social behavior. Patients who received HBOT were signiÞ cantly hernia. better than the control group on all the parameters with Methods: All congenital hernias operated from January 2009 decreased hospital stay, bett er GCS and drastic reduction in in the department of pediatric surgery were included in study. disability A questionnaire was prepared and att endants were contacted Conclusion: In children with traumatic brain injury, the either personally or by telephone. The information collected addition of HBOT signiÞ cantly improved outcome and quality included the demographic proÞ le of our patients, average of life and reduced the risk of complications. waiting time, and complications encountered during this waiting period (pain, obstruction, incarceration, emergency 44 visits, and emergency surgery). Parental satisfaction was also A new technique of neourethral coverage to assessed by a questionnaire. minimise urethrocutaneous fi stula in proximal Results: Total of 30 patients with inguinal hernia was operated hypospadias during this period, 22 (73%) male and 8 (27%) female. The Archika, Kureel Shiv Narain, Madhukar maletha, Tanvir Roshan average waiting time was 121 days. Patients with waiting Khan time of more than ninety days had to repeat investigations. Department of Pediatric Surgery, C.S.M. Medical University, There were complications in 10 (33%) children who were Lucknow, Uttar Pradesh, India waiting for surgery [pain in 7 patients (23%), incarceration in 3 patients (10%)]. There were no incidences of strangulation Aims: Urethrocutaneous Þ stula constitutes the most common and obstruction. complication after hypospadias repair. We report a new Conclusion: Pain was the commonest symptom children technique for neourethral coverage using scrotal septal had while awaiting surgery. There was a high rate of 10% dartos in patients with proximal hypospadias with the aim to incarceration in children with prolonged waiting period. minimise the possibility of urethrocutaneous Þ stula. There were fortunately no incidences of strangulation and Methods: In last one year total 11 patients, 4 penoscrotal obstruction. We conclude by saying that prolonged waiting hypospadias earlier grafted with Bracka technique and 7 period for surgery for hernia may be associated with lot of proximal penile hypospadias repaired with tubularised incised complications like pain and incarceration. Long waiting period plate urethroplasty, were treated with this technique. With a is inevitable in government hospitals, yet eff orts in the form of needle tip cautery, scrotal median raphe was incised exactly in day care surgery, should be introduced to reduce complications mid line from hypospadiac meatus to neutral point between resulting from long waiting period. anterior and posterior surface of scrotum. Then it was bisected upto the bulbospongiosus muscle in almost avascular plane 43 sparing the visible vessels on incised surface of scrotal septum. Role of hyperbaric oxygen therapy in management A long trapezoid shaped vascularised ß ap, based on posterior of severe paeditric head injury patients scrotal vessels, was harvested from scrotal septal dartos in Advait Prakash, Rahul K Gupta, Beejal Sanghvi, Sandesh V continuation with anterioinferior scrotal dartos so that it could Parelkar, Sanjay N Oak easily reach upto glans. Aft er completion of urethroplasty, the Seth G.S.M. College and K.E.M. Hospital, Mumbai, India neourethra was covered with the well vascularised scrotal septal dartos as a continuous sheet from hypospadiac meatus to Aim: A brain injury results in a temporary or permanent the tip of glans. Urethral repair was completed with glansplasty impairment of cognitive, emotional, and/or physical function. and midline skin repair.

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Results: Scrotal dartos ß ap provided adequate soft tissue for Aims and Objectives: To present our experience with seven neourethral coverage. Mild transient scrotal oedema occurred cases of incontinence treated using Gluteus Maximau ß ap. And in all patients and transient scrotal erythema occurred in to present detailed technique. one patients relieved on conservative treatment. One patient Materials and Methods: 111 cases of high anoraectal anomalies developed subcoronal fistula. Skin cover of penis was were followed up for more than 6 years. Forty four of these symmetrical and shape of penis aft er reconstruction is near had imaging evaluated and the correct postion of rectum in normal in all patients except in one patient having mild penile relation to levator was conÞ rmed. 7 children with gross fecal rotation. There was no scrotal skin necrosis. Cremastric reß ex incontinence were treated using Gluteus Maximus. 4 had was normal in all patients. There was no recurrent or residual bilateral Gluteus Maximus and 3 unilateral Maximus to wrap chordee. round the neoanus. Detailed post operative management Conclusion: Scrotal septal dartos ß ap based on posterior would be discussed. Pre and post procedure continence was scrotal artery is an eff ective alternative for neourethral coverage graded primarily based on patient and parents input rather in cases of proximal penile hypospadias and penoscrotal than digital examination. hypospadias. Results: Results and follow up would presented. Four out of seven could be trained eff ectively to prevent soiling in school 45 and the patient and the parents were satisÞ ed. Continence scores Immunohistochemistry in PUJ obstruction – too improved. Faradic stimulation and expert physiotherapist’s correlation with morphology help were used to make the child learn the tricks of contracting G. Raghavendra Prasad, G. Satyanarayana, Sudha gluteus to keep the neoanus closed. Three patients continue to Kamineni Hospitals, KIMS Narketpally, Hyderbad, India be incontinent although score show improvement. They are being trained. The last case was done 5 months ago. Introduction: Att empts to know the cause and pathomechanism Conclusions: Gluteus Maximus can be used a muscle ß ap to of PUJ obstruction have been unsuccessful. Many studies gross improve continence in High anorectal Anomalies. histology to neural staining have been done with litt le light on patho-mechanism of PUJ obstruction. NSE was earlier studied 47 in India. To conÞ rm or negate the popular concept of myoneural Interventional study on perioperative fluid in abnormality continues to baffl e the researchers. children Aims and Objective: To present our study of PUJ with GDNF, Cenita J Sam, Pavai Arunachalam NSE, MMP2, MMP 9 AND ICC Department of Paediatric Surgery, PSG Institute of Medical Materials and Methods: 22 paraffin blocks pf PUJ in Sciences & Research, Coimbatore, Tamilnadu - 641 004, India cases of PUJO with hydronephrosis were studied using immunohistochemistry for expression of ICC WITH c-KIT, Introduction: The traditional guidelines for peri-operative MMP2, MMP9, NSE and GDNF. 1O PUJ of fetal kidneys were ß uid therapy has undergone a change and according to NPSA also stained as controls. The protocol supplied with the narker [National patient safety alert, NHS] and the current pediatric was followed. anesthetic practice isotonic ß uid with low sugar or no sugar Results: There was increased expression of MMP2. MMP solution should be administered in the perioperative period 9 conssitently in most of PUJO with hydronephrosis. NSE because of the concerns of dangerous hyponatremia and Expression was inconsistent as compared with GDNF. ICC hyperglycemia with use of 5% sugar containing hypotonic expression was consistently less as compared to that of fetal ß uids. PUJ specimens. Aim: To compare the post operative sugar aft er 4 hours in two Conclusion: The last word in the patho mechanism of PUJ group of patients when they received either 5% sugar or no obstruction is yet to be discovered. sugar ß uid in the perioperative period. Methodology: Patients who underwent surgery in the 46 Department of Pediatric surgery, PSG Hospitals. Fasting was Gluteus maximus for fecal incontinence in high per ASA guidelines. Group A: N=29. This group received 5% anorectal a nomalies: A detailed technique sugar containing ß uid as either Isolyte P, Half DNS or DNS Vimalakar Reddy, G. Raghvendra Prasad, G. Rammohan, G. in the intraoperative and immediate postoperative period. Satyanarayana, K. Satyanarayana, Eswarchandra Group B: N=39. This group received no sugar containing Kamineni Hospitals, KIMS, Narketpally, Hyderabad, India isotonic ß uids such as normal saline or Ringer lactate in the perioperative period. Introduction: PSARP is almost accepted as the standard Inclusion criteria: 1. Age more than 1month and less than 15 surgical procedure for all high anorectal anomalies. Continence years, 2. Patients undergoing surgery more than 20 minutes. has not improved signiÞ cantly. Pediatric Surgeons are some Exclusion criteria: 1. Patients who had received preoperative how reluctant in using surgical procedures for improving fecal ß uids, 2. Unstable patients, 3. Patients with liver or renal failure. incontinence. Gracilis sling is a popular continence procedure. Group A: Blood sugar was estimated aft er 4 hours of surgery. Gluteus maximus is slowly gett ing into conÞ dence of surgeons. Group B: Blood sugar was estimated immediately aft er surgery

137 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 and again aft er 4 hours. The sodium was also estimated in this thorough literature search revealed less than 25 cases reported group aft er 4 hours of surgery. till date. It is an aggressive malignancy, and long-term survival Results: Both groups developed hyperglycemia (15%-27.5%) is rare [only 1 survival (13 years) has been reported]. Majority aft er 4 hrs. In group A: The mean sugar level for all patients was have a poorly diff erentiated histopathology and downhill higher and the severity was more with the mean of 166.88± 32.53 clinical course. This case is presented to highlight the diagnostic mgm/dl. In group B there was mild hyperglycemia with the dilemma. Moreover the tumor in this child is diff erent from mean of 135.16 ± 5.07 mgms/dl and the p value was < 0.001. In those reported in literature as it is low grade with no metastasis group B in spite of fasting for more than 6 hours and 30 minutes and the child is quite well preserved. on an average there was no hypoglycemia in the immediate and 4 hours post operative period and the sodium level was within 49 normal limits with a mean value of 137± 1.4 meq/l. Simultaneous occurrence of jejuno-jejunal Conclusion: The hyperglycemia associated with 5% sugar and ileo-ileal intussusception in a child: A rare solution causes osmotic diuresis and in addition it has been occurrence noted that in the presence of hyperglycemia the cerebral insult Jiledar Rawat, Anand Pandey, Naveen Chandra is more if there is hypoxia. In spite of the increased sodium Department of Pediatric Surgery, CSMMU (Upgraded KG content of NS and RL the sodium levels were within normal Medical University, Lucknow, India limits. This increased requirement of sodium can be explained by post operative ADH secretion. Hence we conclude that Aim: To present an unusual type of simultaneous occurrence isotonic no sugar ß uid is safer than ß uid containing 5% sugar in of jejuno-jejunal and ileo-ileal intussusception the peri-operative period as it causes only mild hyperglycemia Materials and Methods: A 10 year old boy presented to the and no hypoglycemia. department with complaint of pain in abdomen and no passage of ß atus and feces for last eight days. There was a lump in the 48 umbilical and the left lumbar segment. He was planned for Intra-renal neuroblastoma: A diagnostic dilemma emergency laparotomy. Shalini Sinha, Rupnayan Goswami, Y. K. Sarin Result: On exploratory laparotomy, a large jejuno-jejunal Maulana Azad Medical College, New Delhi, India intussusception, about 10 cm from the duodeno-jejunal junction and an ileo-ileal intussusception which was about 10 Case Report: We present a 7-year-old girl who came with cm from the ileo-cecal junction. Jejuno-jejunal resection and hematuria, fever and abdominal lump for 2½ months. On anastomosis was done for the proximal intussusception and examination, she had a large mass in the left lumbar region, the ileal intussusception was reduced manually. Postoperative period was uneventful. hard in consistency. Ultrasound and CT abdomen revealed Conclusion: Simultaneous small bowel intussusceptions are it to be a large malignant tumor arising from the left kidney an uncommon entity which may present in an unusual way, displacing the great vessels to the opposite side with no hence, the operating surgeon must be ready to encounter this calciÞ cations consistent with Wilms’ tumor. The left renal vein type of unusual presentation. If managed carefully, the results was obscured and there was loss of planes with the left psoas are excellent. muscle. Opposite kidney was normal. A trucut biopsy from the renal angle was reported as small round cell tumor with rosett e 50 formation and calciÞ cation suggestive of neuroblastoma. 24- Ureteral cyst associated with crossed fused hour urinary VMA was normal; bone scan and bone marrow ectopia and ipsilateral duplication: A rare anomaly were negative. While awaiting immuno-histochemistry (IHC) report; she was started on weekly chemotherapy for Wilms’ Roshan Chanchlani, Vikesh Agarwal, V. K. Raina tumor with Vincristine and Actinomycin-D. She received 2 Jabalpur Medical College, Jabalpur, India weeks of chemotherapy with deÞ nite response to therapy. However, the IHC of the trucut biopsy showed tumor cells to A Þ ve year old girl presented with large abdominal cyst. She be positive for NSE. As there was a major discrepancy between on investigations had crossed fused left ectopic kidney with the radiological and histopathological diagnosis; it was decided suspected Pelviureteric obstruction. On exploration ureteral to go ahead with surgical excision. At surgery, we found a huge cyst associated with crossed fused ectopia and ipsilateral tumor replacing the entire left kidney but sparing the upper duplication was found. The cyst was drained by its two pole. There were few hilar and infra-hilar lymph nodes which aff erent ureter and one eff erent ureter opening normally in to were sampled separately. Left nephroureterectomy was done. the bladder. The patient’s surgical management and literature Final HPE conÞ rmed Grade – I Neuroblastoma, nodes negative. search of this rare anomaly is discussed. The chemotherapy was changed to OPEC regime. She is still undergoing chemotherapy and has completed 3 cycles. She 51 is quite well preserved and is tolerating chemotherapy well. A series of 9 cases of cloaca with uterine didelphys Discussion: Intrarenal neuroblastoma is a rare entity that Vikesh Agarwal, Roshan Chanchlani, V. K. Raina clinically and radiographically may mimick Wilms’ tumor. A Jabalpur Medical College, Jabalpur, India

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9 cases presented with cloaca and were diagnosed to have bilious vomiting, left to right peristalsis and malnutrition. UGI uterine didelphys on USG, MRI, endoscopy. Six of these contrast was diagnostic in retrospect. All patients improved patients underwent composite reconstruction, two being single with Heineke and Mikulicz Pyloroplasty. On average follow staged without diversion. The pictorial demonstration of the up of one year all are doing well with growth and improved anomaly and points in reconstruction are discussed. and have nutritional status. Conclusion: Primary acquired gastric outlet obstruction during 52 infancy and childhood (Jodhpur disease) is not conÞ ned to a Jejunal proplase: An unusual complication of geographical area. Studies are needed to assess the etiological feeding jejunostomy factors for this rare disease. Sujoy Neogi, Chhavi Ranu Gupta, Shandip Kr Sinha, Anup Mohta, Mamta Sengar, Swarup Das 54 Chacha Nehru Bal Chikitsalaya (affi liated to Maulana Azad Lap. Appendicectomy (Personal experience) Medical College), Delhi, india T. J. Banerjee Institute of child Health, Kolkatta-17, India Post-operative feeding is a key issue which needs to be addressed for a successful outcome in surgical patients. Enteral Lap Appendicectomy done in 467 cases in between; 2000- nutrition is usually preferred over parenteral nutrition for a 2009. Age ranging from 2 yrs to 18 yrs. Among 467-32 cases number of reasons. Feeding gastrostomy and jejunostomy are had appendicular perforation and 21 cases had appendicular commonly performed surgical procedures to provide long abscess without perforation, 6 cases had appendicular lump, term enteral feeding. Witzel’s and Roux-en-Y techniques are mesenteric adenitis in 12 cases, ruptured graffi an follicle - 4 the preferred methods for jejunostomy. Even though these cases, endometriosis in 16 cases, Meckel’s diverticulum in 4 are simple techniques, they are associated with several major cases (One had perforation, histologically normal appendix and minor complications. We report a rare complication of in 32 cases). In our series 6 had conversion to open surgery. massive jejunal prolapse, in a malnourished child with Down’s All uncomplicated cases were discharged after 48 hours, syndrome, following Witzel’s jejunostomy. Jejunal prolapse as complicated cases were discharged within 7- 14 days. 3 a complication have been reported in few cases of Roux-en-Y patients had re-exploration for residual abscess, 6 patients jejunostomies but none have been reported following Witzel’s had port infection. Average operative time was 20 minutes for jejunostomy. uncomplicated cases was but in complicated cases operative time within l -11/2 hrs. Advantages and disadvantages of Lap. 53 Appendicectomy to be discussed. Primary acquired gastric outlet obstruction during infancy and childhood (jodhpur disease): Is it 55 spreading? Laparoscopic hernia repair: An emerging gold Shandip Kumar Sinha, Mamta Senegar, Sujoy Neogi, Swarup standard Das Satish Aggarwal, Nitin Pant, Nitin Borkar, Anjan Dhua, Arun Chacha Nehru Bal Chikitsalaya ( Affl iated to MAMC), Geeta Kumar, Simmi Ratan Colony, Delhi-31, India Maulana Azad Medical College and associated Lok Nayak and GB Pant Hospitals, New Delhi, India Primary acquired gastric outlet obstruction during infancy and childhood is reported Þ rst from northern part of India namely Aim and Introduction: Through an experience of over 130 Jodhpur. We report our experience with this disease. laparoscopic hernia repairs in children, the authors highlight Aim: To study clinical and pathological proÞ le of children with diff erent advantages over the traditional open repair and primary acquired gastric outlet obstruction during infancy discuss how laparoscopic hernia repair is poised to be the and childhood. future gold standard in hernia surgery. Materials and Patients: All patients with gastric outlet Method: 130 hernia units in 114 patients (47 days to 14 years; obstruction were included in the study. The patients with 94 boys, 20 girls) underwent laparoscopic repair by simple diagnosis with primary acquired gastric outlet obstruction circumferential incision of the peritoneum at the deep ring (32 during infancy and childhood were included. Demographic cases), incision and suture closure of the peritoneum (55 cases) profile (age,sex, address etc.) along with clinical history, or incision and partial excision of the distal sac and suture examination and management data were reviewed. closure of the peritoneum (27 cases). Three port technique was Result: Six patients with gastric outlet obstruction were used in all. They were followed up for recurrence, testicular included in study. Two were diagnosed as duodenal web position and size, other complications. and rest four had primary acquired gastric outlet obstruction Results: All operations were performed successfully with no during infancy and childhood. The age group was one to seven conversion. Hernia recurred in three cases. All recurrences years. There were three males and one female. All had non were in the initial 40 cases. There was no injury to the vas or

139 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 vessels in any case. The testes remained in scrotum in all with alternative to trans-anal pull through. It can be performed even no testicular atrophy in any case. There were 3 minor port site in long segment HD. Infants are bett er suited for this operation. infections requiring topical antibiotics. 15 cases had additional The cosmetic results are superb and functional results are Þ ndings that were dealt with in the same sitt ing. In 21% an comparable to standard trans-anal repair. asymptomatic contralateral hernia was found and was repaired in the same sitt ing. No hernia was found in three. 57 Conclusion: By laparoscopic techniques the chances of injury Technique of laparoscopic hernia repair simulating to the vas and vessels, testicular ascent or Þ xation to the scar open repair etc are nearly completely eliminated. Additional Þ ndings can Satish Aggarwal be addressed in the same sitt ing and the issue of bilaterality Maulana Azad Medical College and associated Lok Nayak and is dealt with most eff ectively. When no hernia is found the GB Pant Hospitals, New Delhi, India procedure is terminated thereby avoiding a possible blind inguinal exploration. Considering these advantages, the Aim: To present a technique of laparoscopic surgery that laparoscopic repair is likely to become a gold standard in simulates open repair. It incorporates all the key steps in hernia hernia care. Technically incision of the peritoneum at the deep repair i.e. division of the sac, partial excision and ligation of ring is essential. the sac. Methods: In one year period, 25 cases were operated by this 56 technique. Age range was 6 months to 13 years. The technique Laparoscopic assisted trans-anal pull through in has special signiÞ cance in boys. Three port technique was used. Hirschsprung’s disease Peritoneum over the vas and vessels was carefully incised Satish Aggarwal, Arun Kumar, Simmi Ratan, Nitin Pant, Nitin without using energy source. Circumferential incision was Borkar, Anjan Dhua completed. About 5 mm of the distal sac was excised. The ring Maulana Azad Medical College and associated Lok Nayak and was closed with Vicryl suture. Opposite side was also dealt in GB Pant Hospitals, New Delhi, India the same way if a hernia was found. Result: No conversion, no complications. Time taken was 39 Aim and Introduction: This is a report of our Þ rst Þ ve cases of minutes per hernia unit. Follow up is 1 month to one year. lap assisted trans-anal pull through operations. The aim is to Conclusion: A technique of lap hernia repair is presented with demonstrate the technique of laparoscopic bowel and rectum all the steps of the open operation. mobilization and its application in HD. Note: Video is meant to show the technical details. Method: Five patients (52 days to 6 years; 4 boys and 1 girl) were selected for laparoscopic assisted trans-anal pull through. 58 Contrast enema was performed in all to identify the transition Laparoscopic hernia repair in children: Does zone. Initial management was with bowel wash outs. Pull partial excision of sac make a difference in through was performed within 12 weeks in three and aft er outcome? 3 years in two. Four port technique with open insertion of Nitin Borkar, Simmi Ratan, Arun Kumar, Satish Aggarwal primary canula was used in all. Harmonic scalpel or Ligasure Maulana Azad Medical College and associated Lok Nayak and was used for dissection / hemostasis. Frozen section biopsy GB Pant Hospitals, New Delhi, India was done in all to identify the ganglionic bowel at pull through. Laparoscopic mobilization of the colon and rectum Aim: Division of the sac, ligation at the neck and partial was performed to ensure that the pulled through bowel would excision of the distal sac are essential steps in open hernia reach the anal canal without tension. Rectum was mobilized repair. Techniques of laparoscopic repair are not standardized. staying close to its wall until about 2 cm from the anal verge. An ideal laparoscopic repair should incorporate all the key Subsequent dissection and anastomosis was performed trans- steps. The aim of this study was to see if partial excision of anally. No covering colostomy was done. the sac makes any diff erence in the outcome of laparoscopic Results: In 4 cases the operation could be performed successfully hernia repair. with lap assistance. One case (6 yr boy) required conversion Methods: In one year period 50 cases (42 boys, 8 girls, 6 owing to gross dilatation and hypertrophy of the colon and months to 12 years) were randomized to undergo laparoscopic large vessels. In the four cases, the dissection was performed hernia repair by either of the two techniques: Gp I: incision of with precision staying close to bowel wall in the deep pelvis peritoneum and suture closure at the neck; GpII: incision and so that the trans-anal dissection could be minimized. There partial excision of the distal sac and suture closure at the neck. were three long segment HD and two rectosigmoid transition Standard three port technique was used with open canulation of HD. Time taken was 3.5 hrs (median). No blood transfusion the primary port. Outcome and complications were recorded in was required in any. Post operative recovery was uneventful. a pre set Proforma. Follow up (one month to one year) data was Feeding could be started within 24 hrs in two and 48 hrs in 2. also recorded for late complications, testicular position and size. No patient is incontinent. Results: All operations were successfully performed, there Conclusion: Laparoscopic assisted pull through is a logical being no conversion. Time taken was 31 minutes (median) per

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 140 IAPSCON 2009 hernia unit for group I and 39 minutes (median) for group II. Ovarian cysts are among most frequent intra-abdominal masses Size of the ring varied from 5 mm to 2 cm on the symptomatic in neonates. Ovarian cysts arise from mature follicle cells. units and from 3mm to 1cm on contralateral incidentally Most authors have recommended early surgery in neonates detected units. There were no operative or immediate post with ovarian cyst. Size of cyst and USG features of cyst are operative complications. There were three minor port site also considered as criteria for early surgical intervention. infections requiring topical antibiotics. On follow up there was There are no characteristic features on USG and CTscan no complication in either group. The testicular position was abdomen to differentiate between benign and malignant scrotal in all and the size was equal to the contralateral testis. ovarian lesions. Laparoscopic management has been recently There was NO recurrence in either group. There was no injury applied in management of ovarian masses in neonates as it is to vas or vessels in any patient. both diagnostic and therapeutic. We present 3 cases of ovarian Conclusion: Laparoscopic hernia repair in children can cyst in 7, 10 and 21days old neonate, which were managed incorporate all essential steps of open repair. However, partial laparoscopically. excision of sac does not make any diff erence in the outcome. It takes extra time and theoretically exposes the vas and vessels to 61 injury along a longer length. We conclude that it is not necessary Laparoscopic management of persistent mullerian to excise the sac partially during laparoscopic hernia repair. duct syndrome Advait Prakash, Rahul K Gupta, Beejal Sanghvi, Sandesh V 59 Parelkar, Sanjay N Oak Minimal access nephrectomy and Seth G.S.M. College and K.E.M. Hospital Mumbai, India nephroureterectomy in children: Our experience Rajashekhar T Patil, Rahul K Gupta, Beejal Sanghvi, Sandesh Persistent Mullerian Duct Syndrome (PMDS), characterized V Parelkar, Sanjay N Oak by the presence of mullerian structures in a virilized male, Seth G.S.M. College and K.E.M. Hospital Mumbai, India frequently presents as undescended testis, either intra- abdominal or within a hernial sac. We report a 10 months old Aims: We present our experience with minimal access infant with PMDS successfully managed by laparoscopy. At nephrectomies and nephro-ureterectomies in children. Our the age of 1.5 month the patient presented with left inguinal objective was to assess feasibility and effi cacy of minimal hernia and bilateral non palpable gonads in another centre. On access nephrectomies and nephro-ureterectomies in infants inguinal exploration, uterus and a gonad like structure along and children. with the hernial sac, were found. Left inguinal herniotomy was Patients and Methods: Over a period of 4 years 17 nephrectomies performed aft er reduction of uterus and gonad like structure. were performed in children aged 7 months to 12 years. 7 patients The karyotype was found to be 46 XY. Magnetic Resonance having dysplastic kidney with ectopic ureteric opening and 2 Imaging (MRI) abdomen and pelvis revealed a uterus like patients having posterior urethral valve with nonfunctioning structure posterior to urinary bladder but neither testis nor kidney underwent laparoscopic nephroureterectomy. 5 ovaries like structures could be visualized. At 10 months of age, patients underwent laparoscopic nephrectomy and 3 patients he was referred to us for further management. A laparoscopic underwent retroperitoneoscopic nephrectomy. single stage orchiopexy was done. Both testes were brought Results: 15 kidneys were removed with minimal access surgery to the scrotum by splitt ing the uterus in the midline and then and two patients required conversion. The average length of bringing the testes with the vas and att ached uterine tissue surgery was 130 minutes (90-200 minutes). The intra-operative into the scrotum. The aim of placement of well- vascularised blood loss was 45cc (20-70cc). None patients required blood testes in the scrotum was achieved as conÞ rmed on follow up transfusion. Average discharge time was post operative day colour doppler ultrasound at 6 months, which revealed normal 5. Analgesic used was minimal, all children enjoyed rapid vascularity. Laparoscopic surgical techniques for this condition recovery to full activity. are also discussed. Conclusion: Minimal access nephrectomy is viable alternative to open nephrectomy in children. However, further experience 62 with this technique is required to establish its effi cacy and Laparoscopic repair of Morgagni hernia in a case reduce the operating time. of Down’s syndrome Deepak Kishore Kaltari, Sandesh V Parelkar, Sanjay N Oak, 60 Beejal Sanghvi, Rahul Gupta Laparoscopic management of ovarian cyst in Seth G.S.M. College and K.E.M. Hospital Mumbai, India neonates Deepak Kishore Kaltari, Sandesh V Parelkar, Sanjay N Oak, We present a case of Morgagni hernia in a 9 months-old female Beejal Sanghvi, Rahul Gupta with Down’s syndrome who was undergoing evaluation for Seth G.S.M. College and K.E.M. Hospital Mumbai, India recurrent episodes of respiratory distress and respiratory tract

141 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 infections. Patient was also found to have deformed chest. The Radiological evaluation with USG and CT abdomen showed 2-dimensional echocardiography was normal. The diagnosis massive splenomegaly with a large cystic lesion surrounded was conÞ rmed by X-ray chest with nasogastric tube on both, by multiple small cysts within the splenic parenchyma. Rest antero-posterior and lateral view as well as on Computed of the viscera were normal. Diff erential diagnosis of Hydatid Tomography (CT) scan chest. The patient underwent cyst/ splenic pseudocyst/ splenic lymphangioma/ sequestrated laparoscopic repair of Morgagni hernia. Postoperative X-ray splenic rupture was made. Hydatid serology was negative. chest was normal. At present patient is asymptomatic and The child was taken up for surgical exploration aft er preop thriving well. Only twenty cases of Morgagni hernia in vaccination. At laparotomy, there was massive splenomegaly association with Down’s syndrome have been reported in (weighing 1.5 kgs) with a bosselated surface. Splenectomy was literature. Ours is the Þ rst case being managed laparoscopically done and a small spleniculus at the hilum was preserved. On in this rare association. cut section, there were multiple cysts containing straw colored ß uid. Histopathology revealed cystic lymphangioma of the 63 spleen. The child had an uneventful recovery and has been Laparoscopic management of patent urachal followed up for 2 months. fi stula in a paediatric patient Discussion: The spleen is the least common intra-abdominal Deepak Kishore Kaltari, Sandesh V Parelkar, Sanjay N Oak, site for the development of cystic disease. Cystic lymphangioma Beejal Sanghvi, Rahul Gupta is a rare non-parasitic cyst of the spleen. The utility of CT in Seth G.S.M. College and K.E.M. Hospital Mumbai, India diagnosis of splenic cyst has been proven in literature. The Þ nding of a large splenic cyst with associated multiple small A few cases of laparoscopic surgery for urachal remnant in subcapsular cysts is usually seen. The recommended treatment children has been reported in English literature. With recent is splenectomy. Marsupilisation alone can lead to recurrence developments in minimal invasive surgery, laparoscopic and is best avoided. In recent years laparoscopic splenectomy approach for urachal remnant in adulthood is recommended by for this condition has been introduced. A deÞ nite diagnosis some laparoscopic surgeons because of its technical feasibility depends on pathologic examination. Though several reports and safety as well as cosmesis. There is very limited literature of this entity are available in adult literature, very few have on laparoscopy in management of urachus in paediatric patient. been seen in children. We would be sharing our experience with complete laparoscopic management of complete patent urachus ( Urachal Þ stula ) in 66 a 7-years-old female child. Complete patent urachal Þ stula Malignant germ cell tumors: Outcome analysis is a rare entity in urachal abnormality and laparoscopic Shalini Sinha, Rupnayan Goswami, Gowhar Nazir Mufti, management in a 7year old patient has not been reported. B. V. Raghunath, Y. K. Sarin Maulana Azad Medical College, New Delhi, India 64 Lumbar hernia in children- experience with 5 cases Aim: To audit the outcome of patients with Malignant Germ Anup Mohta, Mamta Sengar, Sujoy Neogi, Swarup Das, Chhavi cell tumors (GCT) treated in a tertiary care center. Ranu Gupta, Shandip Kr Sinha, Vivek Manchanda Method: A retrospective study was performed by retrieving Chacha Nehru Bal Chikitsalaya (affi liated to Maulana Azad data from records of children with Malignant GCTs who were Medical College), Delhi, India treated from 1998 to 2009. The children with immature or mature teratomas were excluded from the study. Lumbar hernia are uncommon entity in pediatric age group. Results: 21 children (11F, 10M) with a mean age of 3.8 years We present our experience with management of 5 cases of were managed over a period of 11 years. Eleven (52%) children congenital lumbar hernia including two cases of lumbocostal had gonadal malignant GCTs and 10 (48%) had GCTs in hernia, an even more uncommon entity. extragonadal sites. Considerable delay in presentation seen in 11/21 (between 1 month to 5 years) was noted even with 65 a large mass. Misdiagnosis contributed to delay in 6 (28.6%) Intra-splenic cystic lymphangioma: A rare entity patients. Alpha-feto-protein, ultrasonography, CT-scan was Gowhar Nazir Mufti, Akshay Sharma, Shalini Sinha, Y. K. Sarin done in all patients. Pre-operative histopathological diagnosis Maulana Azad Medical College, New Delhi, India was obtained by FNAC or Trucut biopsy in 50% of patients. Eight patients had yolk sac tumors, 8 were unspeciÞ ed, 2 Case Report: We present a 12year-old girl who came with were dysgerminomas, 2 were mixed, and 1 had embryonal an abdominal lump of 2 years duration. There were no other germ cell tumor. Pre-operative chemotherapy was given in 7 symptoms and she was well preserved. There was no history (33%), which altered the histology from malignant to benign of trauma. On examination there was a huge, irregular mass in 4/7 (57%). All patients underwent surgical resection, and in the left hypochondrium with a bosselated surface reaching adjunct therapy was given to 17 patients; majority received upto the left iliac fossa which was moving with respiration. BEP protocol and none received radiotherapy. Only 1/3rd of

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 142 IAPSCON 2009 these children in the study completed the therapy. Three died in plans of repair so as to avoid an organ with poor angle, on therapy, 5 abandoned therapy soon aft er induction, and 2 dangle and erection. Although important for good function are still on therapy. Overall mortality was 31.25%, recurrence and appearance, it remains a relatively less known element rate was 23.5%, thus the disease free survival for 2 years 42.8%, of anomaly. and for 5 years being 14.2%. Method: In a prospective study between 1982-2009, 548 Conclusion: Poor results are multifactorial due to delayed consecutive cases of hypospadias were studied for existence presentation, non-compliance to therapy, misdiagnosis either of a drooping penis and horseshoe fold to Þ nd out incidence, by clinician or by histopathologist. Whether down-staging the understand its abnormal anatomy and a way to correct it. tumor by pre-operative chemotherapy and inadequate therapy Observations: Abnormality was found in 22% cases with thereof is a cause for poor outcome needs to be evaluated out any relationship to its severity. A cleft in suspensory further. The need to upgrade the surgical oncology facilities ligament and failure of its fusion in midline is responsible and training in our country is evident. for its appearance and can be corrected by correcting the same. Determining angle of erection should be part of normal 67 evaluation for adequate correction of the anomaly. It appears to Quality of care in Pediatric surgery be governed by a mechanism which is not linked with urethral Swarup Das, Anup Mohta, Sujoy Neogi, Shandip Kr Sinha, tubularization. Chhavi Ranu Gupta, Mamta Sengar, Vivek Manchanda Chacha Nehru Bal Chikitsalaya (affi liated to Maulana Azad 69 Medical College), Delhi, India Perianal Rhabdomyosarcoma: A case report K Saha, S Sen, PP Mukhopadhyay Aim: To study the factors at admission aff ecting the prognosis Dept. of Pediatric surgery, NRS Medical College, Kolkata, India of neonates in surgical NICU. Materials and Method: A prospective study was conducted for A boy aged 2yrs 6 months presented with an large ( 8cmx8cm) all patients admitt ed in surgical NICU. Factors at admission exophytic growth in the right half of the anal margin of 6 that may aff ect prognosis including gestational age, birth months duration. The mass was excised completely with 1cm weight, temperature, heart rate, respiratory rate, saturation, normal skin margin; histopathology of the excised mass was APGAR score, mode of transport, respiratory support, duration reported as Embryonal rhabdomyosarcoma, botroyed variety. of stabilization before surgery and outcome were recorded.The Though rhabdomyosarcoma is the 3rd most common neoplasm mid term data was evaluated. of childhood, perianal rhabdomyosarcoma is rare & it’s oft en Results: A total of 30 neonates were admitt ed including 8 confused with perianal abscess, polyp & condyloma. preterm and 22 low birth weight neonates. 4(13%) babies had moderate to severe hypothermia and 4(13%) babies presented 70 with shock. Only one baby was accompanied by doctor and was Primitive neuroectodermal tumor of the testis on assisted ventilation. 20(66%) babies had tachypnoea.18(60%) Swarup Das, Anup Mohta, Mamta Sengar, Nita Khurana neonates were operated within 24hrs of admission while Chacha Nehru Bal Chikitsalaya (affi liated to Maulana Azad 12(40%) neonates required stabilization beyond 24hrs before Medical College), Delhi and Department of Pathology, Maulana surgery. The overall mortality in the study group was10(32%). Azad Medical College, India The statistical analysis shows association of gestational age, birth weight, hypothermia, shock and assisted respiration Primitive neuroectodermal tumors are a group of tumors that at admission.No correlation was found with respect to birth arise from pluripotent neuroectodermnal cells. It is considered order, parental age, duration of stabilization before surgery in diff erential diagnosis of round cell tumours. It is uncommon and accompanying physician and mortality. in pediatric age group and testicular origin is very uncommon. Conclusion: The neonatal mortality is aff ected by birth weight, We discuss successful management of a one and half year gestational age, stabilization before and during transfer to male child who was operated upon as a testicular tumour and operating hospital. Political motivation is required to improve histopathology showed it to be Primary PNET of testis. facility. 71 68 Rarer variants of Congenital pouch colon Penile Ptosis in hypospadias: An ignored element Puri Archana, Choudhary SR, Jain Prashant, Chaddha R of deformity Kalawati saran children’s hospital, Lady Hardinge Medical Govind Datar College, New Delhi, India KEM Hospital, Pune - 411011, India Aim: Congenital pouch colon has been described as the Problem Background: Penile drooping, like penile torque, is rare regional variant in the new international Krickenbeck oft en associated with Hypospadias. It requires to be included classiÞ cation of anorectal malformations. This report describes

143 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 three unusual cases of congenital pouch colon, two with Y evisceration, post op NNEC in one and septicemia in 6 were duplication of colon and one with duplicated microcolon with the complications encountered. 8 neonates died postoperatively distal colonic atresia. and 13 are alive. One child 24 years of age was treated for Discussion: Case 1 &2 represent Y duplication of colon with adhesive obstruction. 11 neonates were evaluated with SOFA, CPC. The plausible explanation to this occurrence, based on APACHE II/ III AND, CRP, PCT nad TNF polymorphism. embryological development is highly speculative. It seems Analysis of test would be presented. that there is caudal duplication of terminal end of midgut Conclusions: Meconium peritonitis is a rare cause of neonatal with hind gut non development due to obliteration of inferior surgical abdomen. Meconium ileus, atresias are oft en associated mesenteric artery. In case 1 the Y duplication occurred at the conditions. Mortality continues to be high. level of ileocecal junction [ midgut level] whereas in case 2 it occurred a litt le lower almost at the level of right one third of 73 transverse colon with 2 limbs of Y opening into the pouch. Mediastinal masses of infancy and childhood – In case 3 wherein baby had type 1 CPC with duplicated Experience with 61 cases microcolon there seems to be caudal duplication of midgut G. Raghavendra Prasad, G. Rammohan, G. Satyanarayana, at the level of ileocecal junction. The superior limb retains the Eswarchandra, Deepak Sharma, Phaneeswar, Pavani blood supply [ileo colic branch of superior mesenteric artery] Kamineni hospitals, KIMS, Narketpally, Hyderbad, India and diff erentiates into a micro colon with appendix, cecum, ascending and right one third of transverse colon. The inferior Introduction: Mediastinal tumours have not changed over limb in absence of ileo colic branch of superior mesenteric artery years. They continue to be approached on their position on and vascular insult of inferior mesenteric artery develops into chest radiographs. SpeciÞ c Symptoms and signs and speciÞ c a type I CPC. radiographic Þ ndings are rarely seen and rarely conÞ rmatory. Aims and Objectives: To present varied presentation of 72 mediastinal masses with analysis of 61 cases. Meconium peritonitis: A single center experience Materials and Methods: The records of 61 cases of mediastinal G. Raghavendra Prasad, G. Satyanarayana, Deepak Sharma, masses were retrieved and analysed. Age, sex, primary Rammphan, Alladi Venkatesh, Pavan Kumar, Vijay Sekhar presentation, plain radiographic findings, imaging signs Kamineni Hospitals and KIMS, Narketpally Hyderbad, India of advanced imaging, operative peculiarities, post op complications and outcome were the targeted parameters. Introduction: Meconium peritonitis is a rare cause of neonatal Results: there were 26 brochogenic cysts, 9 teratoma, 4 primary acute abdomen. Preoperative prediction so as to make the lymphomas, 14 duplication cyasts, 2 pericardial cysts, 3 paediatric surgeon get mentally prepared to face the lesion primary intrathoracic neuroblastomas, chronic abscesses 2 is necessary. and remaining were anterior meningoceles. Most of them Aims and Objectives: To present 21 cases of meconium were asymptomatic, were suspected on plain radiographs. 12 peritonitis, with regards to clinical presentation, radiographic had respiratory symptoms, dysphasia in 3 cases and upper gi Þ ndings, operative Þ ndings and issues and post operative bleeding in one. All were operated successfully. One child had complications and out come. osteomyelitis and one child CSF leak through chest tube. This Materials and Methods: The records of 21 cases of meconium child had meningitis and succumbed to that. Operative details peritonitis treated from 1985 were analysed. The parameters of bronchogenic cysts between aorta, esophagus and bronchus studied included clinical presentation, radiographic Þ ndings, would be detailed. operative Þ ndings and issues and post operative complications Conclusion: Millenium has not brought any new change in and out come. the approach to mediastinal mass. Most of them are seen as Results: All neonates presented with bilious vomiting, imageology decided lesions and accessed keeping this in mind. abdominal distension and constipation and sepsis. All were treated as sepsis before referring to pediatric surgeon. Average 74 time of referral was 5 days but as late as 3 weeks is not Management of Intravascular thrombus in Wilms uncommon. Plain radiograph showed fee air, air ß uid levels, tumor calciÞ cation, honey comb sign in 3, scrotal calciÞ cation were Syariz S, Ramanujam TM, SrihariS, Nurdaliza MB, Ariffi n W common. Ascites was mistaken for nephrotic syndrome in one. University of Malaya Medical Centre, Kuala Lumpur, Malaysia Operative Þ ndings showed generalized suppurative meconium peritonitis in 12, chronic adhesive type in 5 and giant cystic Aim: To discuss the incidence, management and complication meconium peritonitis. 5 neonates had associated atresias. of tumor thrombi in children from 1991 to 2008. Two had meconium ileus and two later were diagnosed to Method: 76 cases of Wilms tumor were treated. 5 had bilateral have rectal aganglionosis. Laparotomy, adhesiolysis, drainage, tumors. Age range: newborn to 10 years. CT scan & Color resection and anastomosis wherever required were the Doppler US were the diagnostic tools. 14 (18.4%) had thrombus procedures performed. 3 neonates developed enterocutaneous in the renal vein and/or IVC. In one it extended to the right fistula, wound infection in 4, one had dehiscence with atrium, and pulmonary artery. All received chemotherapy

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 144 IAPSCON 2009 aft er biopsy. Laparotomy was performed in 13 and median 76 sternotomy in one. Thrombus was found in 9. IVC was slinged Laparoscopic inguinal hernia repair in paediatric proximal & distal to the renal veins in 6, the supra hepatic cava age group: Our recent experience in 2 and common iliac veins in one. A child pulmonary artery Rahul Kumar Gupta, Sandeh V Parelkar, Sanjay Oak, Beejal thrombus developed acute respiratory distress. At sternotomy Sanghvi the entire lung Þ eld appeared white, probably due to diff use Seth G.S.M. College and K.E.M. Hospital, Mumbai, India pulmonary micro-emboli. In three the thrombus was ß oating in IVC. In bilateral disease, thrombus inÞ ltrated the IVC down Aim: Retrospective analysis of prospectively collected data to the common iliac. Cavectomy below the left renal vein was of paediatric patient underwent laparoscopic inguinal hernia performed. A left sided tumor, the thrombus extended from repair in this series. the infra-hepatic cava to iliac bifurcation and into the right Methods: A retrospective review was performed of the renal vein. Complete removal was not possible. In another, the prospectively collected data of 125 laparoscopic internal ring thrombus in renal vein extended into IVC & adherent laterally closures in 61 children (aged 30 days to 11years, median 1.9 for 1.5cm. Thrombus was conÞ ned to the renal vein in 3 and years) from May 2008 to June 2009. The internal ring was was excised with the tumor. closed with 3-0 nonabsorbable suture. Both extracorporeal and Results: Preop chemotherapy lysed the thrombus in 5/14 (35%). intracorporeal methods of knott ing were used. All patients were One died. 13 recovered. Incomplete removal was done in one. asked to come at 1 week as well as 6 weeks postoperatively for Discussion: Preoperative chemotherapy is helpful. Cavectomy routine follow up. is possible in right side tumor due to good collateral circulation Results: The contra lateral patent processus vaginalis was on the left . present in 12 % [7/ 61] of children. Follow up range was 75 from 1 week postoperatively to 12 months. There were total MMP 2, MMP 9 and TIMP in neuroblastoma and 2 recurrences (1.6 % [2/125], 1 in boy and 1 in girl) and 1 hepatoblastoma - correlation with clinical stage hydroceles 0.8 % (1/ 125). There was 1 metachronus hernia but and survival no testicular atrophy. Mean operating time was 23 minutes for unilateral and 29 minutes for bilateral hernias. G. Raghavendra Prasad, G. Satyanarayana, Pavani, Sudha Conclusion: Laparoscopic inguinal hernia repair is technically Kamineni Hospitals, KIMS Narketpally, Hyderabad, India easier and there is no need of dissection of vas and vessels. The risk of metachronous hernia is deÞ nitely reduced. It is Introduction: Matrix metalloproteases and TIMP are well cosmetically bett er. Although recurrences were more common studied in wound healing as primary extracellular matrix earlier, now they are much less. Thus it can be said that modulating cytokines. There role is being explored in tumour laparoscopic inguinal hernia repair appears to have less morbid metastasis. Adult tumour studies are many and studies in results than open herniotomy and can be used as routine childhood tumour are very few. Few Japanese studies are procedure in paediatric age group. available both in neuroblastoma and brain tumours. Aime and objectives: To present our experience with MMP2, 77 MMP 9 and TIMP in neuroblastoma and hepatoblastoma. Materials and Methods: Paraffi n blocks 11 of neuroblastoma Experience with video assisted thoracoscopic and 4 of hepatoblastoma were analysed regarding expression removal of pulmonary hydatid cysts in children of MMP2, MMP9 and TIMP. Two pathologists were involved. Rahul Kumar Gupta, Sandeh V Parelkar, Sanjay Oak, Beejal They were performed using monoclonal antibodies using the Sanghvi protocol decribed by the manufacturer. Expression was graded Seth G.S.M. College and K.E.M. Hospital, Mumbai, India subjectively into mild, moderate and extensive expression. Clinical Stage and behavior was correlated with grade of Pulmonary hydatid disease is prevalent in many parts of world expression. including India. In our small series of 5 pediatric patients, all Results: Both Neuroblastoma and Hepatoblastoma showed patients were diagnosed with clinical and radiological Þ ndings MMP 2 ans MMP 9 expression with inconsistent variation on plain X –ray chest and CT (Computed Tomography) chest. both in the tissue and between specimens. Mostly the MMP2 All of them received oral albendazole 10 mg/kg/day soon and MM9 were tumour normal tissue interface and TIMP aft er diagnosis except in one patient in which preoperative was in the tumour. The staining were compared with wound diff erential diagnosis was bronchogenic cyst and lung abscess studies of our own series. Early stages showed relatively less (case 4). All underwent video assisted thoracoscopy. Simple expression as compared with advanced stages. No correlation endotracheal intubation was utilized in all cases.Complete with survival. TIMP expression was highly inconsistent to thoracoscopic removal was successful in 3 cases, while draw any conclusion. Our previous study on cytogenetics in conversion to open thoracotomy was required in 2 cases. All neuroblastoma of the same cases would be compared. of them showed rapid recovery except for one patient in whom Conclusion: MMP2, MMP 9 and TIMP mighy be future targets prolonged intercostal drainage was present for 2 weeks. The of prognostiÞ cation if done in large numbers. average duration of procedure was 150 minutes and average

145 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 length of hospital stay was 4.5 days except case 2, which was management of congenital short colon (CSC). discharged on day 15 due to prolonged air leak. Histopathology Methods: All patients of CSC admitt ed to our department in all cases was suggestive of hydatid cyst. At mean follow up during a period of 10 years (1997-2007) in whom the WC of 6 months, all patients are asymptomatic and doing well. was performed have formed the basis of this study. Out of total 137 patients admitt ed with CSC in the study period, 78 window colostomy was done in 125 patients. These patients Isolated retroperitoneal hydatid cyst with scrotal were retrospectively studied and the data sheets were extension masquerading as obstructed inguinal analyzed regarding complications related to WC and the hernia in a child management off ered. 5 patients expired before the procedure Rizwan A. Khan, R. S. Chana, Tapan was undertaken, and transverse colostomy was done in 7 cases J. N. Medical College Hospital, AMU, Aligarh, India of incomplete CSC. Results: Eighty six patients were followed-up after WC Aim: Hydatidosis aff ects almost every region of the body. and underwent all stages of management (WC followed by Although adults are mostly aff ected, children also suff er from coloplasty and ileostomy and ileostomy closure in the last the disease especially in endemic area. Here we present a stage).The procedure was associated with some distressing 9-year-old child with a retroperitoneal location of hydatid cyst complications. Stenosis of the window colostomy needing with scrotal extension which presented a diagnostic dilemma dilatation was seen in 20 patients. 16 patients had minor vis-à-vis obstructed inguinal hernia. prolapse of the pouch, while 6 of the patients had signiÞ cant Methods: A 9-year-old boy presented to our emergency with amount of prolapsed pouch needing revision procedures.17 complaints of left sided scrotal swelling for one day. On patients had signiÞ cant peri-ostomy excoriation. The overall examination, a mass approximately 3 × 2 cm in diameter was mortality related to the procedure was 9.6%. identiÞ ed in the left groin, his testes were in the scrotum, and Conclusion: Window colostomy in the cases of CSC is a simple there was no silk sign. Ultrasonography (US) showed a thin- surgery, can be done with minimum anaesthesia time in a sick walled, anechoic, unilocular cystic mass in the left scrotum neonate and provides adequate decompression. There are with a dumb-bell shaped extension of the swelling in the some problems associated with window colostomy. However retroperitoneum. CECT was done which also supported the the procedure is short, easy to perform, and is life-saving and sonographic Þ ndings. provides adequate time period to allow weight gain and be Þ t Results: Patient was explored through left transverse incision. for second stage surgery. It eventually does not aff ect the Þ nal The operative diagnosis was hydatid cyst because we identiÞ ed outcome in these patients with congenital short colon. the germinative membrane and liquor of a hydatid cyst aft er opening the cyst wall Total cyst excision was performed aft er 80 dissection of the cyst. Patient was discharged 1o days later Single stage combined repair of exstrophy without any complications. bladder—preliminary results Conclusion: There are many reports in literature of isolated Puri Archana, Choudhary Sr, Khushawa A, Chaddha R retrovesical and retroperitoneal hydatid cyst in adult patients. Kalawati Saran Children’s Hospital, Lady Hardinge Medical Our case has many Þ rsts including the scrotal extension of an College, New Delhi, India isolated retroperitoneal hydatid cyst, sudden appearance of scrotal extension presented diagnostic dilemma and the age Aims: To study the feasibility of single stage repair in exstrophy group of our patient. bladder as a primary procedure and as a secondary salvage procedure for failed exstrophy bladder. The present study also 79 aims to assess the short term results of the same. Ten years experience with window colostomy Patient and Methods: During March 2008- June 2009, 8 patients as a preliminary diversion procedure in cases of of exstrophy bladder were operated in the Department of congenital short colon Pediatric Surgery [6 males and 2 females]. They were divided Tanvir Roshan Khan, A.Wakhlu, J D Rawat, S N Kureel into 2 groups of 4 patients each. Group1 [age ranging from Department of Pediatric surgery, CSMMU (Upgraded KGMC). 7 months – 60 months] had single stage primary combined Lucknow, India repair, with bladder turn in, modiÞ ed cantwell ransley repair with umbilicoplasty, bilateral herniotomy and bladder neck Aim: Congenital short colon (CSC) is an unusual abnormality in tightening. Group II [age ranging from 14 months – 66 months] which a pouch like dilatation of a shortened colon is associated had previously failed repairs. Preoperative renal functions, with ano-rectal malformation (ARM). The clinical features and ultrasonography, bladder capacity, presence of polyps, anatomical features are very well described in the literature elasticity/compliance of the bladder and complications were but the management remains difficult and controversial. recorded. Assessment of dry period was done at 3, 6, 9, 12, 15 The present paper aims to study the eff ectiveness of window months postoperatively. colostomy (WC) as preliminary diversion procedure in the Results: The follow up ranged from 3 months – 15 months

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[median -13 months]. The preoperative RFT and USG were Aims and Objectives: To present detailed analysis of 68 normal in all patients. Bladder capacity was 30-35 ml and neonates with various neck lesions presenting with respiratory 25-30 ml in group1& II respectively, hyperplastic mucosal distress. polyps were seen in 3/4 patients each in group1 and II. Fibrotic, Materials and Methods: The records of last 25 years were inelastic bladder was seen in one patient each in the 2 groups. screened for neck lesions in neonatal period. 68 neonates had None of the patients had urethral Þ stulae or hypospadias while respiratory distress.All of them had respiratory distress with 2 patients in group II had urinary leak from abdominal wound evidence of tracheal obstruction. which healed on 2 weeks of urethral drainage. The dry period Results: Thyroid, Teratoma, Lymphangioms, hemangiomas, in group 1 was 60-80 minutes at last follow up while it varied Teratoma, Rhabdomyosarcoma, Histiocytosis, Parapharyngeal from 20-45 minutes in group II. abscess, Intratracheal hemangioma constituted list of the Conclusion: Single stage combined repair is feasible both as causes. Most of them required an urgent surgical intervention. a primary and secondary procedure. The early results are Lymphangioma with or without acute inß ammation was the promising and bett er in the primary group. commonest lesion. Para and retropharyngeal lymphangioma were the most diffi cult to excise and recurrence was also 81 common. Neonatal thyroid teratoma had dramatic response Neonatal esophageal lesions presenting with to thyroidectomy. dysphagia other than EA with TOF Conclusion: Massive and inflammed neck lesions with G. Raghavendra Prasad, G. Satyanarayana, Deepak Sharma, respiratory distress oft en require urgent surgical intervention Vijay sekhar, Rammohan, Vimalakara Reddy Kamineni Hospitals, KIMS, Narketpaly, Hyderbad, India 83 Open vs. Laparoscopic appendectomy in children: Introduction: Swallowing diffi culty is commonly seen in EA A single center experience with TEF. Other surgical causes of neonatal dysphagia are rare. Vimalakar reddy, G. Raghavendra Prasad, G. Rammohan, G. Aims and Objectives: To present experience with 14 cases of Satyanarayana, Deepak Sharma neonatal dysphagia die causes other than EA with TEF. Kamineni Hopitals, KIMS Narketpally, Hyderabad, India Materials and Methods: A total of 14 neonates were treated from 1985 till 2006 for dysphagia. Clinical presentation, Introduction: Laparoscopic appendectomy has become popular imaging Þ ndings and treatment and outcome were analyzed by aggressive surgical marketing. Unexpected complications, retrospectively from the case records. conversions, cost and time continue to be problematic in lap Results: Achalasia was seen in 4, muscular hypertrohy in 3, web appendectomy. in 2, duplications in Þ ve cases. All presented with diffi culty in Aims and Objectives: To compare open conventional swallowing but sucking well. Drooling of saliva was seen in appendectomy and laparoscopic appendectomy in children. all. Esophageal atresia was considered in all. Imaging helped Materials and Methods: Records of 50 consecutive laparoscopic to diagnose. Antenatal diagnosis was done in two cases. 8 were appendectomies and age matched 100 open appendicectomy boys and 6 were girls. Myotomy was done in 4, esophageal were analysed for duration, complications, post pain, return substitution in 2, excision of diaphragm in 2,Excision of to school and the cost. Duplication in 4, Endoscopic dilatation in two. 2 children Results: Age, sex, pre op sett ings did not diff er much in both died.2 children had recalcitrant strictures Þ nally requiring the groups. Average time for laparoscopic appendectomy substitution. One child with achalasia required second surgery. was 1½ to 2 hours while open appendectomy was 20 min Conclusion: Neonatal esophageal lesions other than TE is to 35 minutes. Accidental intestinal injuries were seen in 3 uncommon. Awareness is essential to investigate and correct laparoscopic appendectomy group. While, no such injuries the anomaly. were encountered in open appendectomy. Appenedicular artery slippage was seen in one case of laparoscopic 82 appendectomy. Stump handling remains cumbersome in Neonatal neck lesions presenting with respiratory laparoscopic appendectomy. Surgeon was never comfortable distress: A 25 years experience and conÞ dent. Two cases were converted. Cost was one and G. Raghavendra Prasad, G. Satyanarayana, Deepak Sharma, half times more in lap group. The size of scar in open was G. Rammohan, Alladivenkatesh, Eswarchandra, J. Vijayasekhar single and three small port site scars in lap group. Pain was Kamineni Hospitals, KIMS, Hyderabad, India more in Þ rst 24 to 48 hours in laparoscopic appendectomy as assessed by three pain scoring systems. On demand analgesic Introduction: Neck lesions, massive, acutely inß amed, very requirement was almost double in lap group. close to trachea or extending to superior mediastinum oft en Conclusion: Laparoscopic appendectomy although present with respiratory distress in the neonatal period. contemporary and popular, unexpected injuries, pain, cost Immediate active medical and surgical intervention might be continue to be unfavorable factors to become universally in order. accepted procedure.

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84 with 19 pediatric liver transplants carried out during this time. Ovarian masses in pediatric age group- Our Material and Methods: Data of children referred for liver experience transplantation and those that undergo the procedure Chhavi Ranu Gupta, Mamta Sengar, Anup Mohta, Shandip Kr are maintained in the centre. This study is a retrospective Sinha, Vivek Manchanda, Sujoy Neogi, Swarup Das study of this cohort of 19 patients who have undergone Chacha Nehru Bal Chikitsalaya (affi liated to Maulana Azad liver transplantation procedure. The same core group also Medical College), Delhi, India performed 2 more LTx at another institution earlier-these too have been included in the study. Those that were on the waiting Aims: Primary cyst and tumors of ovary are uncommon in list and succumbed have also been looked at separately. pediatric age group. Majority of these masses are not malignant. Results: Nineteen children underwent LTx. The age ranged from 8 months to 7 years (median 20 months). Weights ranged Our aim was to Þ nd out the clinicopathological proÞ le of the from 3.5kg to 21kg. There were 5 girls. Cause of liver disease patients presenting to us with ovarian masses over the last was biliary atresia in 11, metabolic disease in 5,choledochal three years. cyst, fulminant hepatic failure and cryptogenic cirrhosis in Methods: Five children were operated for ovarian mass in the 1 each. One child received a cadaveric organ while the rest last Þ ve years with. They had a varied presentation – abdominal received live donor graft s-from mothers in 15,2nd degree distention, abdominal mass, antenatally diagnosed abdominal relatives 2 and altruistic 1. The cadaveric graft was a whole mass, virilization, acute abdomen. Their ages ranged from 1 liver graft . 17 children received left lateral segment graft s while month to 11 years at the time of presentation. 1 received a full left lobe. All children received a tacrolimus Conclusions: Ovarian masses have a varied presentation. based immunosuppresion. Overall, there were 4 early post-op Though ovarian masses are less common in childhood than deaths (with in 28 days of graft ing)-all these in the early part other pathologies, still they should be kept in mind when of the series. 3 more children died later (severe pulmonary managing a female child. hypertension and shunting 6 weeks post op, cyclosporin ’ 85 toxicity 8 moths post LTx and Burkitt s lymphoma 3 years post LTx). Overall, survival is 70%. However, 9 of the last Papillary carcinoma of thyroid in childhood 10 cases (follow up of 11/2 years to 3 months) are alive and T. Dorairajan well-suggesting that the team is over the learning curve. The Chennai, India oldest survivor is now into his 11th year post LTx. He is well, goes to normal school and is like any other child of his age. Four and a half year male child was referred with a history of All the remaining 11 children are well and have no major a lump in the right Side of the middle of neck of six months problems. They are at age appropriate stages of development duration. A biopsy of the lesion was done by the referring and schooling. There has been no major donor morbidity. One Pediatrician and the report stated ‘thyroid tissue‘ in the lymph donor require re-exploration on post op day 1 for bleeding(no gland. Further investigations like Doppler study of the thyroid source was found) and one had a bile leak that responded to and neck glands showed multiple lesions in the thyroid and 3 weeks to external drainage. neck glands suggestive of multi centric papillary carcinoma Conclusions: This study demonstrates that LTx is an eff ective of thyroid. A para- thyroid sparing total thyroidectomy and and feasible option for children with end stage liver disease. radical right neck dissection done. Child is awaiting whole Improving outcomes suggest a maturing of the protocols. For body Radio iodine scanning and further treatment. The child the large pool of children with biliary atresia and other end will require life-long Thyroxine medication. stage liver disease, LTx off ers an excellent chance of recovery and a good quality of life. Increasing numbers will also force 86 down costs and make the procedure and aftercare more Pediatric liver transplantation-an experience of aff ordable. 19 cases Sanjay Rao, AJ D’Cruz, V Jadhav, R Aggarwal, S Mohanty 87 Narayana Hrudayalaya, Bangalore, India Paediatric surgery teaching for undergraduate -medical students: An institutional experience Introduction: Liver transplantation is an established and Sadasivan Jagdish, Bibekanand Jindal perhaps the only modality of treatment for patients with end Jawaharlal Institute of Postgraduate, Medical Education and stage liver failure. High costs, absence of a cadaveric donation Research, [JIPMER] Puducherry, India program and general apathy amongst the medical community has contributed to poor penetrance of Liver Transplant in india. Aims: To asses the effi cacy of paediatric surgery teaching for The few established program in existence are all predominantly medical students in a medical institution over a period of 10 adult programs. pediatric transplants remain infrequent. A years. program of pediatric liver transplantation was initiated at our Methods: One semester was allott ed for teaching paediatric hospital in end 2005. This report summarizes out experience surgery to medical students Objectives were drawn up

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 148 IAPSCON 2009 and course content decided. Teaching learning methods in PUJ obstruction. The authors refute this assumption by were dilectic classes with multimedia as well as practical presenting 11 cases. In 8 the function improved following demonstrations.. An evaluation was done at the end of the nephrostomy leading to successful pyeloplasty. In three cases course.The process of evaluation kept changing depending on function did not improve – leading to nephrectomy. the experience. An att empt was made to correlate individual Method: 11 cases of poorly functioning (<15% on DTPA) student att endance with the performance in the evaluation. kidneys with PUJ obstruction were subjected to nephrostomy Results: The att endance for paediatric surgery classes exceeded to see if functional recovery takes place. Minimum duration 80 percent on an average. Each batch had an initial period of of nephrostomy was 4 weeks and maximum 12 weeks. apathy followed by regular att endance. The att endance of Functional assessment was carried out by DTPA scan or individual students correlated well with their performance biochemical measurement of creatinine clearance in 24 hr in the examination at the end of the course. The system of urine sample. Diff erential function was calculated by sending evaluation started as short notes type followed by multiple nephrostomy urine and urethral urine in separate containers. choice questions. At present the evaluations done by single After a minimum of 4 weeks of nephrostomy drainage, word or single line answer type of questions. There were several pyeloplasty was performed if functional recovery could be problems in conducting the course which will be brought out demonstrated. at the time of presentation. Results: Eight out of 11 renal units showed functional recovery Conclusions: Paediatric surgery classes are fairly well att ended. following nephrostomy. Following pyeloplasty further Paediatric surgery teachers need to be trained in undergraduate recovery was demonstrated by follow up DTPA scans in 6 of teaching. A uniform curriculum needs to be adopted by the them. No complications were noted. Hypertension was seen paediatric surgery fraternity in 5 (controlled by medication in all). In 3 of them it improved aft er surgery. 88 Conclusion: Poorly functioning kidneys with PUJ obstructions Predictibility of different parameters in childhood have potential for functional recovery. It can be assessed by a appendicitis nephrostomy before pyeloplasty. PP Mukherjee, S Maitra, D Roy, K Saha Basu, K Saha, SK Biswas, B Mukkherjee, 90 Dept of Pediatric Surgery, NRS Medical College and Hospital, Pulmonary sequestrations of infancy and Kolkata, India childhood: Experience with 42 cases G. Raghavendra Prasad, G. Satyanarayana, G. Rammohan, This is a retrospective study of 117 appendicectomies in Depak Sharma, Eswarchandra, Vimalakar Reddy children done over a period of 17 years from 1992 to 2008 by a Kamineni Hospitals and KIMS, Narketpaly Hyderbad, India single surgeon in combined institutional and private practice. In all a-leucocute count with diff erential counts, a comment Pulmonary sequestrations are rare lung lesions. Oft en treated on peripheral blood Þ lm for toxic granules and band cells, as pneumonias ad respiratory infections. C-reactive protein estimation (if needed on two serial Aims and Objectives: To present the experience with 42 occasions) was done. Along with this, a targeted ultrasound cases of pulmonary sequestrations from 1984 to 2007. To of abdomen to detect appendicitis and to exclude other stress the point commonest presentation non speciÞ c, CXR pathologies was done. In selected cases urine microscopy was positive, lower respiratory infection, and systemic artery when also done. Postoperatively all the appendices were subjected to demonstrated conÞ rms the diagnosis. histopathological examination to corroborate with clinical and Materials and Methods: A total of 42 cases of conÞ rmed other parameters. This study will discuss and try to elaborate pulmonary sequestration were treated from 1984 till 2007. Age whether these parameters were at all helpfull or not to diagnose of presentation, presenting symptom, radiographic Þ ndings appendicitis in clildren. and complications were retrospectively studied. Results: 4 presented as neonates, 29 before 5 years of age, 13 89 till 18 years of age.Comonest presentation was respiratory PUJ obstruction in poorly functioning renal units: infection with or without distress. Foreign body was seriously Is nephrectomy really indicated? considered in 4 cases and bronchoscopy was performed. CT Satish Aggarwal, Nitin Pant, Nitin Borkar, Arun Kumar, Simmi Angio conÞ rmed systemic artery involvement. Lobectomy Ratan cured all. One child died in the post op period due to septicemia Maulana Azad Medical College and associated Lok Nayak and and two had bronchopleural fistula, which responded to GB Pant Hospitals, New Delhi, India conservative treatment. Conclusions: Pulmonary sequestrations need to be excluded Aim and Introduction: Radionuclide renography showing < in all children with recurrent lower respiratory infections. 15% function is oft en taken as an indicaton for nephrectomy Demonstration of systemic artery is conÞ rmatory.

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91 and intermediate anorectal malformations with that of MRI Prognostic factors of esophageal atresia and Þ nding and to compare it form traditional staged procedure. tracheoesophageal fi stula with special reference Material and Method: Forty postoperative patients of anorectal to histipathological study malformation were evaluated by MRI during March 2007-July A. N. Gangopadhyay, Punit Srivastava, S. P. Sharma, D. K. 2009. Age of patients was ranging from 3 yr to 25 yrs. Patients Gupta, Vijai Datta Upadhyaya, Vijayendra Kumar were distributed into three groups. Good (Group 1, n=14), fair Institute of Medical Sciences, BHU, Varanasi, India (Group 2, n=12), poor (Group 3, n=14) - on the basis of Kelly’s clinical score of incontinence. These patients were correlated Aims and Objective: To study the histopatohlogical Þ nding of with MRI Þ nding in terms of - the degree of development of the both upper esophageal pouch and lower tracheoesophageal puborectalis, external sphincter, levator hammock muscle, Þ stula tract in respect of lining epithelium, muscle arrangement anorectal angle, eccentric position of rectum and rectal diameter glands, presence of nerve tissue (nerve bundle and ganglion and were compared with normal. cells) and presence of tracheo bronchial remnants to the other Result: The proportions of fair or poor development of the reported series. To correlate the histopathological Þ nding to muscles were 21%in Group 1, 29% in Group 2 and 48.27% in the late complications in the follow up. Group 3. Development of sphincteric muscle was found to be Material and Methods: The study was carried out in 53 patients signiÞ cant factor in study. The diff erence in the anorectal angle from May 2007 to June 2009. A circumferencial tissue of 1 mm to measured on sagitt al MRI images between patients in group 2 mm thickness cut from the both lower esophagous and upper 1 and group 2 or group 3 was signiÞ cant. Patient with single pouch were taken for biopsy. In histopathology we looked for stage operation were 70% in group1, 20% in group2, 10% in type of epithelial lining, muscle arrangement, mucous gland group 3, while 40% in group 2 and 60% in group 3 patients and neural tissue (ganglion and nerve bundle) and presence were undergone three stage operation in study. of any tracheobronchial remnant i.e. respiratory epithelium Conclusion: Our study concluded that the results of single and cartilage. The muscle arrangement were divided into 3 stage procedure seem to be bett er than staged operation in categories i.e. normal, poorly oriented completely disorganized terms of anal continence and which has been proved clinically according to the degree of disorganization. Patients were and also supported by MRI Þ ndings. followed properly and grouped according to Desjardin classiÞ cation 93 Result: In the histopathological Þ nding, the epithelial lining Comparative study of Color Doppler & Laparoscopy of both upper and lower esophagus were predominately in diagnosis of non palpable testis squamous epithelium except in 1 case of upper pouch where D.K. Gupta, A. N. Gangopadhyay, Punit Srivastava, Vijai Datta gastric type epithelium was found in focal areas. Arrangement Upadhyaya, S. P. Sharma, Zaheer Hasan of muscle coat was poorly or completely disorganized more Institute of Medical Sciences, BHU, Varanasi, India in lower Þ stulous tract than the upper pouch. More mucous gland found in the Þ stulous tract than upper pouch. Nerve Objective: Non palpable testis in children is common bundles found more in upper pouch than the Þ stula. Few diagnostic problem. Color Doppler has more or less equivalent ganglion cells also seen in histopathological Þ nding of Þ stula. results with that of CT scan or MRI scan. In present study we No tracheobronchial remnant was found in Þ stulous portion compared the sensitivity and speciÞ city of color Doppler with in our study. that of laparoscopy. Conclusion: Patients with poorly or completely disorganized Material and Method: This is a prospective study conducted in muscle coat presented with features of esophageal dysmotility the Dept of pediatric surgery, IMS, BHU, Varanasi between 2007 (in Desjardin’s group of good and fair) in the follow up. A to 2009. A total of 40 cases were included in study, aged between good numbers of patients presenting with late complications 1 to 14 yrs out of which 26 were unilateral and rest 14 was like GER, dysphagia, stenosis or dysmotility had abnormal bilateral non palpable testis. Colour Doppler was performed histopathology at the site of anastomosis in the form of in all cases in supine position. Intra-abdominal, inguinal abnormal musculature neural tissues retro-abdominal areas were seen carefully. Subsequently Laparoscopy was performed for conÞ rmation and treatment. 92 Result: Colour Doppler detected 24 out of 28 bilateral Post operative MRI evaluation of Anorectal undescended testes (Sensitivity 85%) and 19 out of 26 unilateral malformation with clinical correlation non-palpable testes (Sensitivity73%). Laparoscopic evaluation A. N. Gangopadhyay, Punit Srivastava, S. P. Sharma, D. K. of bilateral non-palpable testes detected all 25 testes of 14 Gupta, Vijai Datta Upadhyaya, Vijayendra Kumar patients (sensitivity 89%). All are found proximal to deep Institute of Medical Sciences, BHU, Varanasi, India ring within 3 cm from deep ring. In unilateral non-palpable testis laparoscopy detected 20 out of 26 situated proximal to Aims and Objective: The aim of study was to correlate the deep ring(Sensitivity 92%).In 4 cases testes were not found long term clinical outcome of single stage surgery for high inside abdomen (vanishing testes) which was conÞ rmed by

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 150 IAPSCON 2009 laparotomy. In 1 case atrophic testes was found inside inguinal Department of Pediatric Surgery, All India Institute of Medical canal vas and vessels was seen entering into the deep ring, Sciences, New Delhi, India which was conÞ rmed by inguinal exploration. Conclusion: We concluded that although sensitivity of color Purpose: To retrospectively evaluate the outcome of children Doppler in detecting non-palpable testes is 80%. It is non with antenatally detected unilateral(U/L) pelviureteric junction invasive and low cost but it fails to detect retroperitoneal and obstruction(PUJO) in terms of relative function, drainage testicular nubbins which otherwise can be visualized and patt ern and pelvicalyceal dilatation. simultaneously treated by laparoscopy. Though color doppler Methods: Children with antenatally diagnosed U/L is not essential for diagnosis but it allays the anxiety of patients hydronephrosis, postnatally unequivocally proven to be due and their parents without impacting much dent on the pocket to PUJO, with a normal contralateral kidney were evaluated. of parents. Hence, Laparoscopy is gold standard for both The children had been followed up with serial ultrasonography localization and treatment of non palpable testes and renograms as per institutional protocol. The children were divided into early pyeloplasty (those who underwent 94 pyeloplasty at presentation) and conservative (who were Success and complication rates of endoscopic managed conservatively). Children in conservative group who third ventriculostomy for hydrocephalus: A series required pyeloplasty during follow up, constituted the delayed of 10 patients pyeloplasty group and those who are still being managed conservatively constituted the no surgery group. The outcome A. N. Gangopadhyay, D. K. Gupta, Punit Srivastava, Vijai Datta was compared in between these groups. Upadhyaya, S. P. Sharma, Vijayendra Kumar Results: A total of 30 children with a mean follow up of 43.3 Institute of Medical Sciences, BHU, Varanasi, India months were enrolled in the study. Of the 30 patients, 10 had undergone early pyeloplasty and the rest 20 were managed Aims and objective: Conventional treatment of hydrocephalus conservatively. Of these 20 patients, 8 had undergone delayed is drainage of excess C.S.F. by diff erent types of shunting.Now pyeloplasty and the rest 12 constituted no surgery group. non communicating hydrocephalus is increasingly treated by Overall, 60% of patients underwent surgery till the end of endoscopic third ventriculostomy.The procedure of ETV has study period. The renal function in early pyeloplasty and gained popularity over the last 2 decades in large part because conservative group was maintained or improved in 28 of 30 of improved endoscope optics, high intensity lighting systems, patients. Delayed pyeloplasty was able to restore the function in and miniaturized CCD cameras. To assess the success and those operated for fall in function. The change in renal function complication rate for hydrocephalus treated by ETV. was not statistically signiÞ cant (p= 0.4) in between the early Material and Methods: ETV procedures were performed in and delayed pyeloplasty groups. 10 patients (mean age 1 yrs) over 1 year. All the cases were Conclusions: The conservative management of PUJO in renal idiopathic aqueductal stenosis.It was explained to the patient unit with good function does not lead to deterioration in the that ETV procedure was being performed in lieu of replacement function even when delayed pyeloplasty is performed for of a shunt. Each patient understood that a shunt procedure deterioration in renal function or other symptoms. This was would be recommended in advent of clinical failure.The possible as the patients of conservative management were determination of anatomical eligibility for ETV was based on closely followed up and pyeloplasty performed at the Þ rst CT scan. indication. Results: 8 pts.(80%) continued to be shunt free aft er the primary ETV operation (mean follow up 8 months).1(10%) patient 96 with clinically failed primary ETV procedure have persistent Effect of tumor spill on recurrence rate and CSF leak from stitched line and managed conservatively with outcome in patients with Wilms’ tumor: Results close follow up.One patient (10%) who ultimately failed ETV, of AIIMS-WT 99 study requiring a CSF shunt procedure in <1 month. S Agarwala1, M Bajpai1, V Bhatnagar1, M Srinivas1, S Bakshi2, Conclusion: Endoscopic third ventriculostomy for non AK Gupta3, S Dattagupta4, VK Iyer4, SR Mathur4, BK Mohanty5, communicating hydrocephalus is a well tolerated procedure DK Pawar6, MK Arora6, DK Gupta1 that has a high likelihood of achieving shunt free existence. All Departments of 1Pediatric Surgery, 2Medical Oncology, patients undergoing ETV should be followed for at least 1 year 3Radiology, 4Pathology, 5Radiotherapy and 6Anesthesiology. All period in the advent of delayed failure. India Institute of Medical Sciences, New Delhi, India

95 Background/Purpose: Tumor spill is a known factor for Treatment Strategies and long term outcomes recurrence and overall poorer outcome in patients with Wilms’ of antenatally detected unilateral pelviureteric tumor (WT). This study was undertaken to evaluate the eff ect junction obstruction of spill on recurrence rate, overall survival(OS) and recurrence Vishesh Jain, Ajay Verma, Sandeep Agarwala, Veereshwar free survival (RFS). Bhatnagar Methods: Prospective cohort study from June 1999 through

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December 2006. Treatment was according to the AIIMS-WT 12/15 without recurrence survived (OS 83.3%; MST 55.9; 95CI 99 protocol. Any spill was classiÞ ed as stage 3 and treated 39.3-71.7). This diff erence was signiÞ cant(p=0.04). There were accordingly with three durgs (Actinomycin D, Vincristine and 12 patients (66.7%) in stage-3 disease of whom none developed Doxorubicin) and radiotherapy. Statistical analysis was done recurrence and only one died(OS 91.7%;MST 67m; 95CI applying appropriate tests of signiÞ cance. 55.7-78.3). Of the 6(33.3%) stage-4 disease, 3(50%) developed Results: Hundred WT patients, in the age range 4 months to 96 recurrence and all these 3 died(OS 16.7%;MST 22.3m; 95CI months(median 24m) were enrolled. There were 97 favorable 8.4-36.3)( RFS 50%; MST 14.3m;95CI 9.7-18.9). This diff erence histology tumors and 3 anaplastic tumors. There were 21%, 6%, in the 5-year OS(p= 0.018) and 3-year RFS(p= 0.02) between 52%, 12% and 9% patients in stage I-V respectively. Preoperative stage-3 and stage-4 patients was signiÞ cant. chemotherapy was given to 54 patients of whom 8 (14.8%) had Conclusion: The prevalence of IVT was 13.5% and most of tumor spill while upfront resection was done in 46 patients them(77.8%) required thrombectomy despite pre-operative of whom 12 had spill (26.1%). Overall tumor spill occured in chemotherapy. The 5-year OS in patients with IVT was 20% of patients. Four of these 20 (20%) developed recurrence poor(42.9%). The OS was signiÞ cantly (p=0.04) lower for while 9 of 80 (11.3%) without spill developed recurrence. This those developing recurrence. The 5-year OS and 3-year diff erence was not signiÞ cant (p = 0.29). Three of the 20 with RFS was signiÞ cantly lower (p=0.018 and 0.02 respectively) spill and 12 of 80 without spill died. The OS and RFS for those for patients with stage 4 disease as compared to stage-3 in with spill was 85% (Mean survival time[MST] 63.2m; 95CI 56.3- patients with IVT. 69.8) and 80% (MST 65.5m; 95CI 48.7-82.2) respectively. The OS and RFS for those without spill was 85% (MST 70.4m; 95CT 98 55.3- 85.6) and 88.6% (MST 55.9m; 95CI 49.9- 61.9) respectively. Telomerase activity in Wilms’ tumor Conclusions: Preoperative chemotherapy does decrease the Devendra Kumar Yadav, S. Agarwala, V. K. Iyer, N. Singh, risk of spill. Tumor spill does not lead to signiÞ cantly increased R. Kar, M. Bajpai, V. Bhatnagar, DK Gupta risk of recurrence (p= 0.29) and it does not signiÞ cantly eff ect Department of Pediatric Surgery, Pathology, Biochemistry, All the OS (p= 0.91) or RFS (p= 0.28) in children with wilms’ tumor. India Institute of Medical Sciences, New Delhi-110029, India Spill should still be avoided as it will upstage the patient, increasing the cost, duration and morbidity of treatment. Background and Purpose: Telomerase expression has been proposed as a tumor marker associated with poor outcome in 97 a number of adult and pediatric malignancies. This study was Long term outcome of children with Wilms tumor undertaken to examine the telomerase activity in wilms’ tumor. having intarvascular thrombus Material and Methods: Telomerase activity was studied G Moorthy1, S Agarwala1, S Bakhshi2, M Srinivas1, M Bajpai1, on the tumor tissue obtained from cases of Wilms’ tumors V Bhatnagar1, DK Pawar3, MK Arora3, AK Gupta4, DK Gupta1 registered and treated at the hospital from February 2006 Department of 1Pediatric Surgery, 2Medical Oncology, through February 2007. Telomerase activity was done using 3Anaesthesiology, 4Radiodiagnosis, All India Institute of Medical the PCR ELISA kit. Statistical analysis was carried out using Sciences, New Delhi, India STATA 9.0. Data were presented as number (%) and median (range) as appropriate. The diff erence in proportions were Aims: To evaluate the prevalence of inferior venacaval compared using chi-square / Fisher exact test. The diff erences thrombus (IVT) in Wilms tumor(WT) and determine their in medians were compared using Wilcoxan Ranksum test. long-term outcomes. Methods: Prospective case control study Overall survival was calculated using Kaplan-Meier method of all children of WT with IVT from June 1999-December 2008. and it was reported as survival rate (95% CI). The p value <0.05 Preoperative Ultrasound(US)-Doppler was done in all patients. is considered statistically signiÞ cant. All patients with IVT received 4-6 weeks of preoperative Results: Twenty-four specimens from 22 cases (2 were bilateral) chemotherapy and were then operated upon. The 5-year were studied. Using 0.2 as cut-off for positive telomerase overall survival(OS) and 3-year recurrence-free survival(RFS) activity, 19 of 24 samples were positive (79.2%) and 5 of 24 of all patients and according to stage and recurrence status (20.83%) were negative. Four of these 5 negative samples were were analyzed using Kaplan-Meier survival analysis and from patients who had received pre-operative chemotherapy. appropriate tests of signiÞ cance applied using SPSS. Log Rank The median telomerase activity in the tumor tissue was 0.649 test of signiÞ cance with value < 0.05 was considered signiÞ cant. (range of 0.031-2.382). Telomerase activity in adjacent normal Results: Eighteen of 133 patients of WT had IVT on pre- kidney tissue was 0.265 (range 0.012-0.714). This diff erence was operative US-Doppler study(prevalence of 13.5%). The age signiÞ cant(p = 0.0001). There was no signiÞ cant diff erence of range of these patients with IVT was 8m-84m(mean 44.9). In telomerase activity with respect to stage of tumor(p= 0.829), 14/18(77.8%) thrombectomy was required, while in 4 it had response to pre-operative chemotherapy (p= 1.0), tumor resolved completely by the time of nephrectomy (as conÞ rmed histology(p = 0.08), recurrence(p = 1.0) and overall survival pre-operative Doppler and operatively). Overall 12/18 survived (p= 0.774). (OS 42.9%; mean survival time[MST] 44.4;95CI 27.6-61.2). Three Conclusion: Telomerase activity was found positive in 79% of 18(16.7%) developed recurrence and all these died while cases of wilms’ tumor. Telomearse activity was signiÞ cantly

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 152 IAPSCON 2009 more in the tumor tissue as compared to adjoining normal 100 tissue (p = 0.0001), it could not be signiÞ cantly correlated with Sacrococcygeal malignant germ cell tumor with stage of tumor, response to pre-operative chemotherapy, tumor intra-spinal extension histology, recurrence and overall survival. R. Garg, S Agarwala, S. Bakhshi, M Srinivas, M Bajpai, V Bhatnagar, DK Gupta 99 Department of Pediatric Surgery and Medical Oncology, All Pulmonary metastasectomy: Is it a safe and viable India Institute of Medical Sciences, New Delhi 110029, India option in children? S. Panda, S Agarwala, B. Jindal, S. Bakhshi, M Srinivas, Background: Neurological involvement due to intra-spinal M Bajpai, V Bhatnagar, DK Gupta, S. Agarwala extension in SC-MGCT has rarely been reported. Department of Pediatric Surgery and Medical Oncology, All Aim: To evaluate the incidence, presentation, management and India Institute of Medical Sciences, New Delhi 110029, India the outcome of patients of sacrococcygeal malignant germ cell tumor (SC-MGCT) with intra-spinal extension. Background: Most pulmonary metastases in children with solid Material and Methods: Case records of all cases of SC-MGCT tumors resolve with chemotherapy with or without radiation treated by us, from 2001 to 2008, were reviewed to identify therapy. Indications for pulmonary metastasectomy are very cases with vertebral involvement and intra-spinal extension. few and in them there is always the question of usefulness with They were evaluated in terms of their presentation, response to regards to complications and ultimate outcome. therapy, extent of surgical resection, recovery of neurological Aims: To evaluate the surgical management, complications symptoms and outcome. All received chemotherapy (PEB and the outcome of patients who underwent thoracotomy for regime) pre-operatively with surgical resection and completion pulmonary metastasectomy. post-operative chemotherapy. Materials and methods: Case records of solid tumor patients Results: Of the 31 cases of SC-MGCT, 5 (16%) had intra-spinal who underwent pulmonary metastasectomy in the period extension, age ranged from 12 – 84 months (median 24 m). Four September 2001 to April 2009 were reviewed to evaluate patients had Altman 3 and one Altman 2 disease. Four of the 5 the disease distribution, number of thoracotomies, type of (80%) had stage 4 disease with bilateral pulmonary metastases resection, complications and ultimate outcomes in terms of while 1 had stage 3 disease. The intra-spinal extension in all recurrences and event free survival. patients was detected on contrast CT scan and was noted to Results: During this time period, 23 patients (8 Wilms extend into the sacral canal through the vertebral foramina [WT], 6 Osteosarcoma [OSa], 4 hepatoblastoma[HB], 2 or vertebral erosion. The tumor then extended cranially into malignant germ cell tumors[MGCT], 1 each of malignant the lumbar canal. While one patient had no neurological mesenchymal tumor[MMT], Ewing’s sarcoma[EW] and symptoms, the other 4 (80%) had bilateral lower limb weakness rhabdomyosarcoma[RMS]) underwent a total of 33 and 1 (20%) had urinary and fecal incontinence as well. All the thoracotomies (14 unilateral, 8 bilateral and 3 re-thoracotomy) tumors responded to pre-operative chemotherapy with the for the removal of 120 pulmonary metastases (ranging from 1 intra-spinal tumor and the pulmonary metastases resolving to 20 metastases /patient). Of these 33 thoracotomies, 1 was completely and the primary shrinking in size. Gross complete negative and 1unresectable. While one patient underwent local resection could be achieved in 4 (80%) while in one there pneumonectomy, there were 10 lobectomies, 6 wedge resections was minimal residue left adherent to the sacrum. Partial sacral and the remaining sub-pleural resections of metastases. Repeat excision of S-3,4,5 was done in one. All were histologically thoracotomy for recurrence of pulmonary metastases was done endodermal sinus tumors. Neurologic recovery was complete in 3 patients (2 WT and 1 OSa). All patients of WT, MGCT, in all, except for persisting neurogenic bladder in one. This RMS, EW and MMT underwent unilateral thoracotomies. patient is dry on CIC. In the follow-up of 3 – 32 m, all were Five of 6 (83%) of Osteo Sa and 3/4 (75%) HB underwent alive with no recurrence. bilateral metastasectomies. Post-operatively there was one Conclusions: SC-MGCT presenting with neurologic defecits pneumothorax and one wound infection among the 33 due to intra-spinal extension is usually advanced disease. thoracotomies. There were 7 recurrences among the 22 (31.8%) These patients respond well to chemotherapy and surgical patients excluding the one unresectable patient. Recurrences resection and most recover completely from their neurologic were observed in 2/8 (25%) WT, 2/6 (33%) OSa and 3/4(75%) involvement. HB. Off these 23 patients there were 6 deaths giving an overall survival rate of 74%. The mean event free survival was 33.8 101 months (range 9m – 132 m). Conclusion: Thoracotomy and pulmonary metastasectomy Role of a refluxing lower ureteral stump in is a safe and viable option in indicated patients, even when preserving the contralateral solitary functioning done bilaterally. It results in acceptable event free survival rate kidney in these patients who are otherwise doomed to progressive Shubha AM, Prasanna Kumar AR, Saleem KM, Deb M, Das K disease and death. St. John’s Medical College Hospital, Bangalore-560034, India

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Aim: To review the effi cacy of the reß uxing lower ureteral general/ local anaesthesia. A 22 G silastic (Vygon –Lederß ex) stump as a cutaneous stoma in preserving function of catheter was inserted over a guide wire and anchored with contralateral solitary renal units in children with various Þ ne silk sutures. Catheter care and usage were as per CDC uropathologies. guidelines and the nursing and resident staff were instructed Material and Method: Nephrectomy with the ipsilateral regarding the same. The lines were prospectively followed ureteric stump brought out as a cutaneous stoma was up from placement to removal / death of patient with interval performed in 12 males for various uropathologies resulting clinical and targeted laboratory surveillance as indicated. The in a contralateral solitary functioning renal unit between 2006 case records were reviewed to tabulate the following details - 2009. The mean age was 32.7 months (8 mos. - 8 yrs.); the – demographic data (age, sex, maturity), primary diagnosis, primary pathology included PUV (6),neurogenic bladder(3) indication, operator designation, surveillance, catheter change, and primary VUR(3).10/12 presented with recurrent UTI ; 8 complications, indwelling line days and patient outcome. had associated acute renal failure of which 2 required dialysis. Results: There were 56 neonates (39 males, 17 females), 16 of 2 were hypertensive, one presented with an encephalopathy. whom were preterm (mean GA-32 wks). The mean birth wt. Bilateral VUR was seen in 3/6 with PUV, 3/3 with neurogenic was 2.05 kg (775-3100 gms ). Primary diagnosis included index bladders and 2/3 with primary VUR. One child with PUV had medical(NEC,RDS,sepsis etc in 24) and surgical(TEF,CDH,abd no VUR. Renal function tests, USG, MCU, DMSA and diagnostic wall defects, ARM, etc. in 32)states while the indication cystoscopy were used to document the renal pathology and for access was for diffi cult/prolonged IV access(38) or for lower urinary tract. Other interventions included vesicostomy/ TPN(18).31 were placed electively; they were performed by the fulguration of PUV/ ureteric reimplantation/ CIC as deemed resident trainee in 40 and the consultant in 16. The procedure necessary. Nephrectomy (Lt.-7, Rt.-5) was done for non- was done in the OR in 47 and in the ICU in 9. In 2 neonates functioning kidney with recurrent UTI/hypertension. The weighing below 1 kg, the device was directly inserted into the distal ureteral stumps were retained as reß uxing cutaneous femoral vein. The total no of line days were 721, the average ureterostomies to serve as a pop off mechanism during bladder indwelling time was.12.9days (1-20 days) Catheter change over contraction. All patients were followed up at the dedicated a guidewire was never employed; instead, 4 had sequential paediatric nephrourology clinic with serial clinical, biochemical bilateral line placements. The catheter associated blood stream and radiological monitoring. infection (CABSI) rate was 9.7/1000 line days. Other events Results: At an average f/u of 12 mos (3 – 36 mos), 11/12 are included initial transient limb oedema (5), recurrent catheter asymptomatic with no breakthrough UTIs; one is lost to follow- blocks (5) and catheter displacement (7). up. They have occasional wett ing per stoma but are socially Conclusion: Sapheno femoral venesection and CVAD continent. Of the 8 who had presented with ARF, the S.Creat placements in term and preterm neonates is a technically sound is normal in 4, mildly elevated in 1 and 2 have progressed procedure in trained hands with minimal risk of nosocomial to CRF and await renal transplant. The serial DMSA scans infection and morbidity. Strict adherence to stringent CDC conÞ rm preserved renal function in all the renal units. None guidelines is mandatory for optimal outcome. had signiÞ cant stomal complications; they were managed by both the parents and older children with minimal discomfort 103 and good social acceptance. Outcome of primary vesicoureteric reflux in Conclusions: Retaining the reß uxing lower ureteral stump as children beyond the age of 5 years a cutaneous stoma eff ectively protects a solitary functioning Kotaiah MT, Deb M, Shubha AM, Prasanna Kumar AR, Saleem contralateral kidney. It provides a low-pressure pop off KM, Das K mechanism during bladder contraction and reduces the St. John’s Medical College Hospital, Bangalore-560034, India frequency of recurrent UTI. The procedure is simple and the stoma is well tolerated. Aim: This prospective study aimed to analyse the clinical course and outcome of primary vesicoureteric reß ux (VUR) 102 beyond Þ ve-yearsof age. Central venous access device in neonates: A Material and Methods: 22 patients with primary VUR who prospective audit were managed conservatively beyond 5 years of age were Kattepura S,Varik RS, Raghu SR, Prasanna Kumar AR, Shubha identified and prospectively followed up at a dedicated AM, Saleem KM, Deb M, Das K Paediatric Nephrourology Clinic Their charts were reviewed St. John’s Medical College Hospital, Bangalore-560034, India and demographic, clinical, radiological, laboratory, surgical details and follow up data were recorded. The data was Aim: Central Venous Access is a vital component of critical care analyzed using descriptive analysis. in sick neonates. This study aimed to audit the use of central Results: 22 children were recruited in this study. 12 males venous access devices (CVAD) in neonates from 2007-09 at a and 10 females. 10 had unilateral while 12 had bilateral VUR tertiary health care centre. yielding 33 reß uxing renal units. The breakup by IRS grading Methods: CVAD were placed in neonates for various of VUR was as follows: Gr. 1 – 3, Gr. II - 6, Gr. III – 8, Gr. IV – 9 indications through a sapheno femoral venesection under and Gr. V – 7 renal units. The average age at diagnosis was

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5.6 years. The majority (20/22) had presented with a single that it should also be considered in the diff erential diagnosis in episode or recurrent episodes of urinary tract infection (UTI). babies with clinical signs of torsion of left testis and obstructed 1 presented in acute renal failure and 1 was detected during or strangulated inguinal hernia as well. evaluation for nephrotic syndrome. At an average follow up of 4 years,14/ 22 children required surgical intervention The average 105 age at surgery was 6.8 years ( 6 – 13 years)and the average An unusual case of transabdominal impalement duration between diagnosis and surgical management was 2 injury in a child years (0 – 13 years) Of 14 children (23 renal units), 3 (3 renal Rizwan A. Khan, R. S. Chana, Tapan units)had a nephrectomy for a non functioning kidney with J. N. Medical College Hospital, AMU, Aligarh, India UTI at diagnosis while the rest 11 (20 renal units) underwent ureteric reimplantation for recurrent breakthrough UTI (8/11) Aim: Abdominal impalement injuries in children are oft en and progression of scars(3/11). 10/33 renal units in 8 children rare, but when they do occur they are associated with serious showed complete resolution of reß ux ( Gr. I – 2, Gr. II – 4, Gr. injuries. Prehospital management and transportation is quite III – 3, Gr. IV – 1) with conservative measures.One child with a challenge. Here we present a 7-year old child who sustained bilateral Gr. V VUR, who had presented with ARF and diff usely impalement injury to his abdomen by a hooked rod. scarred kidneys has developed chronic renal failure. All the Methods: A 7-year-old boy presented to our emergency with rest have been asymptomatic; have normal creatinine levels complaints of impaled hooked rod in his right upper abdomen and no progression of renal scars. when he fell from a tree. Patient remained hanging from the Conclusion: Sponataneous resolution of primary VUR is still hooked rod which was ultimately disengaged off the tree trunk. possible in a signiÞ cant number beyond 5 years of age though At presentation he was hemodynamically stable. the higher grades of reß ux are more likely to eventually require Results: Patient was explored through right upper transverse surgical therapy.Children diagnosed late with primary VUR incision which revealed no visceral or vascular injury. The and preserved renal function may be safely given a trial of hooked rod was removed. Patient went home aft er 5 days. conservative management with uroprophylaxis under close Conclusion: The possibility of escaping intra-abdominal supervision and strict follow up injury is very rare aft er impalement injury. In our case the mechanism of injury prevented such a rare occurance. 104 Operative intervention is required in all cases for a decisive Left-sided strangulated Amyand’s hernia and safe management. presenting as testicular torsion in an infant Rizwan A. Khan, Prof I. Ghani, Dr. Tapan 106 J. N. Medical College Hospital, AMU, Aligarh, India A controlled study for evaluating a non-invasive modality for detection of contra-lateral patent Aim: The Þ nding of an appendix in the hernial sac, termed processes vaginalis in children with unilateral as Amyand’s hernia, is a rare presentation with a reported inguinal hernia incidence of 1% of cases of inguinal hernia repair. We report Manu Arora, Rochan Pant, Ajay Dabbas an extremely rare case of a left -sided inguinal hernial sac Command Hospital (SC) Pune, India containing perforated appendix mimicking testicular torsion. Methods: A ten-month-old male baby presented with Aim: Congenital inguinal hernia is one of the commonest complaints of enlarged and reddened left testis for past 10 condition for which patients in the paediatric age group are hours. The onset was sudden with no history of previous subjected to the knife. It has been observed that 10% of patients such swelling. The cord in the inguinal regions also appeared of unilateral inguinal hernia go on to develop metachronous thickened. Based on the history of sudden onset and presence hernia necessitating a second anaesthesia and surgery. The gold of symptoms for 10 hrs, inguinal exploration was planned standard for detecting Congenital Patent Processes Vaginalis thinking it as a case of left testicular torsion. The cord structures (CPPV) is laparoscopic evaluation. Various authors have also appeared a litt le bulkier and on litt le handling pus came out described non-invasive method as ultrasonography as a mode from torn hernial sac. There was no evidence of torsion of the for diagnosing CPPV. This study compared laparoscopic cord or the testis. The appendix was markedly thickened and visualization of CPPV with Ultrasound diagnosis of CPPV. inß amed and its tip was adhered to the apex of the hernial sac Method: All the children up to 12 years of age and presenting and a ß oppy cecum with unilateral inguinal hernia at our institute between Results: Appendectomy, herniotomy, thorough lavage July 2006 and June 2008 were included in the study. The and cecopexy was done and incisions were closed. In the ultrasonography was done using a linear array probe of 7.5 postoperative period the baby recovered well except for MHz on Siemens machine. Aft er the entire inguinal canal superÞ cial wound infection. from the external ring to the internal ring was visualized, the Conclusion: Left sided complicated Amyand’s hernia in an diameter of the internal ring was measured. All the children infant is a very rare clinical entity. We stress, through this report, were taken up for the diagnostic laparoscopy and simultaneous

155 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 laparoscopic repair of the hernia. were normal. Cystogenitoscopy revealed bladder with cervical Results: A total of 108 children presenting with unilateral opening was seen communicating with rectum. This anomaly inguinal hernia were included in the study. The sensitivity, is classiÞ ed as Type-B posterior cloaca. Right now patient specificity, positive predictive value, negative predictive underwent right PCN for right pyonephrosis and awaiting value and the accuracy of the ultrasonography for detecting deÞ nitive management of cloaca. the contra lateral patent processes were calculated against the laparoscopy. Most of the children, 70 (64.8 %), were between 2 108 and 6 years of age. In 62 (57.4%) cases the width of the processes Wilms’ tumor: An audit at the internal ring was measured at 4 mm or less. In only 6 Gowhar Nazir Mufti, Vivek Manchanda, Shalini Sinha, Y. K. (9.7%) of these patients the processes was found patent at Sarin laparoscopy whereas in 56 (90.3%) of them the processes was Maulana Azad Medical College, New Delhi, India closed at the internal ring. Thus the internal ring of 4 mm or less had a high negative predictive value. If the internal ring Aim: To audit the outcome in patients with Wilms’ tumor was less than 4mm, patent processes was unlikely and hence treated in our hospital. contra lateral exploration was not indicated. Method: A retrospective study was performed in the Conclusion: Thus ultrasonography had a high negative department of pediatric surgery by retrieving data from Þ les predictive value in detection of CPPV. If on high resolution of operated children with Wilms’ tumor over a decade (1998 ultrasonography the internal ring diameter in less than 4 mm, to 2007). Management protocols were changed from NWTS for the CPPV does not exist on that contra lateral side and child the Þ rst 8 years to UKCCG (akin to SIOP) in 2007. is unlikely to ever develop hernia on the contra lateral side. Results: Twenty seven patients (22 boys, 5 girls), with a mean Hence contra lateral exploration is not indicated in children age at presentation of 34 months, had unilateral Wilms’ tumor with internal ring of less than 4 mm on the contra lateral side. in 26 (96.3%) and bilateral in 1 (3.7%). Twenty-three (85%) children were treated as per NWTS protocol and 4(15%) as 107 per SIOP protocol. Stage wise distribution revealed Stage I Unusual variants of cloaca- Six cases n=15, Stage II n=5, Stage III n= 4, Stage IV n= 2, Stage V n= 1. Rajashekhar T Patil, Rahul K Gupta, Beejal Sanghvi, Sandesh Primary nephrectomy (PN) was done in 23 children of whom V Parelkar, Sanjay N Oak 2 had concurrent IVC phlebotomy to remove thrombus/ part Seth G.S.M. College and K.E.M. Hospital Mumbai, India of inÞ ltrated vessel. In the PN group, gross total resection was done in all except 2 patients (92.6%). Primary chemotherapy (PC) Cloaca is the most complex deformity in female anorectal, was given to 4 patients, of which one had Stage V Wilms’ tumor. vaginal and urogenital malformations. It is deÞ ned as a defect Only 2 (7.4%) patients in this series received post-operative in which the rectum, one or two vagina and urinary tract radiotherapy. Major intra-operative tumor spill was seen in 3 converge in one common channel. We present rare variants of (13%) and major hemorrhage leading to death on table in 1 cloaca. Case1, presented at 1year, had pouch colon for which (4%). Local recurrence occurred in 2 (8.7%), distant metastases illeostomy was done. Cystogenitoscopy revealed a common in 3 (13%). 5-year disease-free-survival was seen in 12 (44%). No channel with urethra and rectal opening anteriorly, with two intra-operative complications occurred in the PC group. Non- separate vaginae opening on either side of midline posteriorly. compliance to treatment was seen in 6 (22%) patients overall. Case 2, underwent right transverse colostomy at three months Conclusion: Poor results reflect overenthusiastic surgical age. Cystogenitoscopy revealed 2cm common channel, two excision in large tumors that resulted in macro/ micro spillage. vaginae and two cervix, and rectal opening on the septum on Other reasons included delay in starting post-operative medial side of left vagina. Both patients underwent posterior chemotherapy from delay in histo-pathological reporting, sagitt al anorecto-vagino-urethroplasty both the patients are on erratic chemotherapy/ non-compliance, non-availability/non- rectal washouts and dry for 10-12hours. Case 3 is 1 day child aff ordability of drugs, and delay in radiotherapy due to apathy with ambiguous genetalia with posteriorly placed anus and of radiotherapists & anesthetists. Primary chemotherapy to all ambiguous external genetalia. On ultrasonography uterus, patients is recommended. ovaries and bladder could not be visualized. Karyotyping was 46-XX. Cystogenitoscopy revealed absent bladder and 109 absent vagina. Patient is awaiting deÞ nitive procedure. Case Spontaneous pre-operative rupture of upper 4 and 5 were monozygotic twins born at 32 week of gestation, esophageal pouch in a neonate with Type C one of which was still born. Both twin A and B had smooth esophageal atresia perineum, absent urethral, vaginal and anal opening with Simmi Ratan, Nitin Borkar, Anjan Dhua, Nitin Pant, Arun Kumar, abnormal phallic development. It is a lethal malformation. Satish Aggarwal Twin A succumbed on day 2 postnatally. Case6 was having Maulana Azad Medical College and associated Lok Nayak and single opening present well posterior to the site of normal anal GB Pant Hospitals, New Delhi, India opening with abnormal phallus like structure anteriorly with urethral opening in it. Karyotype was 46-XX. 17-OH levels Aim and Introduction: A hitherto undescribed spontaneous

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 156 IAPSCON 2009 pre-operative rupture of the upper esophageal pouch in a barium swallow, 2-dimensional echocardiography and a neonate with type C oesophageal atresia is being described. computerised tomograph (CT) scan were performed in all Case Report: A two days old neonate referred from another patients. Nine patients had a division of the vascular ring. hospital with diagnosis of esophageal atresia with distal in which 3 had aortopexy and one had reimplantation of the esophageal Þ stula on plain chest radiograph was admitt ed pulmonary artery & correction of bronchial stenosis elsewhere. in our nursery with severe respiratory distress. An urgent Two had correction of pulmonary artery sling & tracheoplasty. radiograph at our centre detected large pneumothorax which Results: Three infants died - Septicemia post surgery 1, was decompressed using chest drain. Following its stabilization hemorrhage during laser ablation of granulation 1 & during over next 4 hours, the baby was taken up for thoracotomy. At surgery for correction of aorto-pulmonary window 1. Six exploration, no obvious source of air leak was detected and patients had rapid improvement in symptoms within 1-2 weeks in view of consolidated upper lobe, the pneumothorax was aft er surgery with the remaining patients improving over a 3-6 att ributed to the spontaneous rupture of a lung bulla. Primary months period. One had dysphagia for 9 months. esophageal repair after ligation and division of tracheo- Conclusion: Vascular arch anomalies are rare and needs a high esophageal Þ stula was relatively easy as both pouches were degree of suspicion for diagnosis. Barium swallow proved to almost overlying each other. Postoperative recovery was Þ ne for be the most reliable investigation to detect the presence of a Þ rst 24 hours following which salivary leak was noticed through vascular ring with a consistent feature of either anterior and/ the chest drain that grew in magnitude relatively rapidly. Re- or posterior induration of the esophagus. thoracotomy was performed 48 hours post-operatively and surprisingly, the anastomotic suture line was found to be 111 intact. On further exploration a full thickness longitudinal Thoracoscopic repair of congenital diaphragmatic rent of about 1 cm in length was detected on the posterior hernia in newborn: Lessons learnt aspect of the upper esophageal pouch near the thoracic inlet, Subhasis Saha, Hiralal Konar, Subir Basu Thakur which was probably missed at the Þ rst surgery on account of The Calcutta Medical Research Institute, Kolkata, India its high posterior location. Esophagostomy and gastrostomy was done following dismantling of the anastomosis. However, Aims: We att empted thoracoscopic repair in a case of left sided the neonate succumbed to sepsis within 48 hours of surgery. congenital diaphragmatic hernia (Bochdalek) in a 2day baby. We Discussion: No case of this type has been reported in the att empt to share our experience in this presentation. English literature. The case highlights the need for a good Methods: Thoracoscopic reduction of hernial contents was pre-operative evaluation of neonates with esophageal atresia done, followed by primary repair of the diaphragmatic hiatus and application of gentle pre-operative suction pressures to with 3-0 silk interrupted endosutures. The baby was doing prevent such complications. well post-operatively for 2 days following which there was a partial recurrence. A part of the stomach herniated back into the 110 thorax, associated with loosening of two of the sutures of the Vascular arch anomalies and tracheo-esophageal diaphragmatic repair. Laparotomy revealed a hugely distended compression in children stomach with total obstruction at the duodenal level by Ladd’s Ramanujam TM, Yik YI, Srihari S, Lum SL, Jessica d’Brune, bands. Ladd’s procedure was done, accompanied with repair Kumar G, Sazila AS, Abdullah B of the diaphragmatic rent. Division of Paediatric Surgery, Department of Surgery, Results: The baby had an uneventful recovery thereaft er. Paediatrics & Radiology, University of Malaya Medical Centre, Conclusion: Symptomatic Ladd’s bands requiring formal Kuala Lumpur, Malaysia Ladd’s procedure concomitant with repair of congenital diaphragmatic hernia is not very common. When we repair Introduction: The pathology, management & outcome of the diaphragmatic rent thoracoscopically, it is diffi cult for us children with symptomatic vascular ring over a 20 year period to assess the extent of organic obstruction to the intestinal was analysed. tract. But in a slightly older child this element can be ruled Method: 12 children (7 males, 5 females) were analysed out from history. retrospectively. The median age was 6 months (3 -36 months). Four patients had double aortic arch, 3 had right-side descent 112 with left ligamentum, one aberrant right subclavian artery, Thoraco- abdomino Spinal (multi compartment) three pulmonary artery slings and one had right aortic arch Fetus in Fetu with A phased presentation - ? First with retro-esophageal descent. 10 children presented with Case Report respiratory symptoms and 2 with dysphagia. The associated Vimalakar Reddy, G. Raghavendra Prasad, G. Rammohan, conditions were cleft lip and palate (1), right bronchial stenosis G. Satyanarayana, Deepak Sharma, Eswarchandra, Jaydip (1), Tracheal stenosis with trifurcation (2), eventration of Ray Choudhary diaphragm (1) and Di George syndrome (1). The associated Kamineni Hospitals, KIMS Narketpally, Hyderbad, India cardiac anomalies were bicuspid aortic valve, ventricular septal defect and aorto pulmonary window. Chest radiography, Introduction: Fetus in Fetu, although, a rare condition is quite

157 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 familiar to pediatric Surgeons. But a phased presentation and group 2 developed hepaticolithiasis on follow up despite a multi compartment presentation is never published. {Google well functioning B-EA. Search} Conclusions: 1. In the management of CDC with IHD Aims and Objectives: To present A multi compartment, fetus dilatation, it is more important to identify sites of ductal in fetu presenting in phases from neonatal period to 3 years stenosis around the hilum and extend the B-E A proximal to Case Report: A neonate was diagnosed to have intrathoracic these sites of stenoses. 2.Contiguous fusiform IHD dilatation mass lesion antenatally. Post natal evaluation revealed intra (Group-1) frequently resolves following wide B-E A at the thoracic fetus in fetu. No intra abdominal component was conß uence. 3. However, signiÞ cant cystic IHD ectasia persists seen at that time. Intrathoracic mass removed in toto. The in group 2 despite being clinically asymptomatic following child was asymptomatic till 3 years of age when he developed a wide hilar B-E A. Long term follow-up is mandatory for progressive weakness in lower limb. This was diagnosed as delayed complications related to stasis within these cysts. 4. Polio myelitis. An adult neurologist diagnosed intra spinal The understanding of this concept is more important than space occupying lesion. MR evaluation revealed an intra classifying anatomy according to Todani’s classiÞ cation scheme. spinal extradural mass from T12 to L5-S1. There was a huge retroperitoneal mass with calciÞ cation. The intra spinal mass 114 was removed via L1 TO L5 laminectomy and a day lateral A potentially life threatening complication Itraabdominal component was excised. The mass had Þ nger, following esophageal exclusion and bypass for brain like material, Fat and a small spine like process.The child corrosive injury-presentation, management and recovered 90 % function. Follow up for 6 years no recurrence prevention nad the child is running and active. Richa Lal, Jayant R., Anu Behari Conclusion: Multi compartment, Fetus in fetu with phased Sanjay Gandhi Post Graduate Institute of Medical Sciences, presentation is being reported. Lucknow, India

113 Aim: Surgical exclusion of the esophagus with substernal Todani’s classifi cation re-visited: Type I fusiform bypass for corrosive injuries is indicated in select situations vs. type IV-A choledochal cyst wherein excision of the native esophagus is technically unsafe Richa Lal, R. Phani Krishna, Ashish Verma, R.K. Gupta because of prior perforation, mediastinitis, dense adhesions Sanjay Gandhi Post Graduate Institute of Medical Sciences, at carina or trachea-esophageal Þ stula. This case illustrates Lucknow, India an unusual and a potentially life threatening complication of surgical exclusion of the retained native esophagus. Its clinical Introduction: The distinction between type 1-fusiform and presentation, surgical management and prevention is discussed type IV-A choledochal cyst (CDC) is unclear in the Todani’s in the light of available literature. classiÞ cation and oft en creates confusion. This prospective Methods: A 3 year old baby boy underwent emergency end study addresses this debate on the basis of pre and post cervical esophagostomy, decompressive gastrostomy & feeding operative cholangiograms. jejunostomy following esophageal perforation sustained Material and Method: Twenty eight patients (age<18 years) during esophageal dilatation for corrosive stricture. Three with CDC and intrahepatic ductal (IHD) dilatation were months later, a substernal gastric pull up was performed, the prospectively studied by pre and post operative cholangiograms. native esophagus being retained in situ with both ends divided The preoperative configuration of extrahepatic and IHD and suture closed. One year following the gastric pull up, dilatation was classiÞ ed into 2 major groups: (1) Contiguous the boy presented with 4 weeks history of repeated episodes upstream dilatation (n=18), (2) Upper tract dilatation associated of fever, tachypnea and an expiratory stridor on exertion or with hilar stenoses (n=10). Contiguous upstream dilatation in crying. An upper GI endoscopy and Barium swallow did not group 1 was further sub-classiÞ ed as: a) Fusiform extrahepatic reveal any anastomotic stricture or delayed gastric emptying dilatation contiguous with fusiform intrahepatic dilatation which could predispose to recurrent pulmonary aspiration. (n=14) and, b) Cystic extrahepatic dilatation contiguous with Subsequent contrast enhanced CECT scan of the chest revealed fusiform intrahepatic dilatation (n=4). A wide biliary-enteric a size 6 cms.X 11cms. posterior mediastinal cystic structure anastomosis (B¬EA) at the confluence was performed for causing anterior and lateral displacement of the trachea with group 1 anatomy. For group 2 anatomy, the anastomosis was lumen compromise. A diagnosis of mediastinal mucocoel of extended proximal to the conß uence and site of stenosis onto the retained native esophagus was made. The mucocoel was the extrahepatic left and right duct. excised by a right posterolateral thoracotomy. At surgery, the Results: All patients have been clinically asymptomatic (follow mucocoel was found to contain frankly purulent ß uid and an up duration: 6 months¬-8 years). On post operative MRCP, ulcerated mucosa with signiÞ cant adhesions to the mediatinal 78% patients in group 1 showed signiÞ cant reduction in IHD structures. dilatation (>50% of preoperative diameter) while all patients Results: The early postoperative course was marked with in group 2 had persistent upper tract ectasia. One patient in features characteristic of tracheomalacia which gradually

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 158 IAPSCON 2009 resolved. At 9 months post surgery, the patient is doing Aims: To share our experience of dealing with a newborn satisfactorily. with severe respiratory distress due to an unusual variant of Conclusion: 1. Though it is conventionally believed that congenital lobar emphysema. prior mucosal destruction in corrosive injuries prevents Methods: A newborn term male child came to us with severe mucocoel formation, this case illustrates that a mucocoel may respiratory distress born out of non-consanguinous marriage. form following esophageal bypass for corrosive injuries. 2. X-ray chest showed hyperinß ated right lung with apparent Esophagectomy rather than esophageal bypass should be the cystic spaces, with mediastinal shift to the left so much so preferred operation especially for benign diseases. 3. Should that the left lung was not seen. CT scan of thorax revealed a a bypass be necessitated in select situations, the lower end of multicytic lesion of the entire right lung. The radiologist was of retained native esophagus may be drained into a roux-en-y the opinion that the lesion was a congenital cystadenomatoid loop of jejunum to prevent mucocoel related complications. 4. malformation of the entire right lung. At thoracotomy we found The retained native esophagus should be periodically screened a huge emphysematous right middle lobe with bronchomalacia, with imaging following esophageal bypass. but apparently normal right upper and lower lobe. Results: Following right middle lobectomy, the baby did very 115 well and ventilatory requirements rapidly improved and was Stridor but no tracheobronchial foreign body – extubated within 48 hours. tracheostomy is saving grace Conclusion: CLE of isolated right middle lobe is a rare entity. Singh VP, Bhatti W, Ghosh DN The CT pictures were also apparently suggestive of entire right Department of Paediatric Surgery. Christian Medical College pulmonary involvement which was also not quite usual. and Hospital. Brown Road. Ludhiana-141008, Punjab, India 117 Objective: To study the clinical course, treatment and outcome Renal tuberculosis in infancy presenting as life in a set of patients with stridor but with no foreign body in threatening hematuria tracheobronchial tree. Anjan Dhua, Nitin Pant, Nitin Borkar, Simmi Ratan, Nita Methods: In a set of patients with stridor; the history and Khurana, Satish Aggarwal Þ ndings are suspicious of a tracheobronchial foreign body. Maulana Azad Medical College and associated Lok Nayak and Unlike typical foreign body aspiration(FBA), these patients GB Pant Hospitals, New Delhi, India behave differently. During anaesthesia, while holding a mask to oxygenate they continue to have stridor and their Aim and Introduction: To report a case of renal tuberculosis in saturation doesnot rise to 100%. Since there is a possibility of infancy that presented as life threatening hematuria. FB, a bronchoscope is inserted. With the scope in situ, they Case Report: We present an infant aged 40 days with acute drop their saturation rapidly. As the picture is confusing the onset painless severe hematuria, which initiated a week earlier. scope is usually withdrawn and the patient kept on mask Radiological investigations (USG & CT) revealed a mass in ventilation. The saturation never picks up. Therefore more left renal pelvis. The right kidney was normal. Possibilities of att empts at scopy are made leading to similar results. Usually a vascular lesion or a clot were entertained. Urine culture was the patient’s condition deteriorates and they arrest or have a sterile. Coagulation proÞ le was normal. Hematuria subsided near arrest. The saving grace then is a tracheostomy. In the past for two days but recurred again and this time it was massive 10 years, we have dealt with 7 such patients. Tracheostomy was with passage of clots per urethra. The child required blood performed with an appropriate size tube. All needed ventilation transfusion. As a life saving measure the left kidney was post procedure. They had a prolonged post operative course surgically explored. Grossly the kidney was enlarged and tense and needed steroids and strong antibiotics. When stable a re- with some areas of haemorrhage. The pelvis was full of clots. bronchoscopy was done and no FB was detected. The mean On opening the pelvis clots came out and fresh uncontrollable hospital stay was 14 days. All 7 survived. bleeding started from within. Packing was tried but failed. Results: With tracheostomy, the outcome is favorable in this No deÞ nitive lesion responsible for bleeding could be found. set of patients. Nephrectomy was performed as a life saving measure. The Conclusions: We suggest that every time a bronchoscopy hematuria stopped and the child made an uneventful recovery. is carried out with stridor and an uncertain history of FBA, Histopathology revealed granulomatous lesion with caseation a suitable size tracheostomy tube should be available. suggestive of renal TB. Patient is now on 6-month treatment Tracheostomy is thus a saving grace in these patients course according to the WHO protocol (2HRZE/4HR). He is well on 6 weeks follow up. A family survey was done to see if 116 there is an index case in the family. However, no case was found. Respiratory distress in a newborn: An unusual Discussion: Tuberculosis of the genitourinary tract is one of the presentation late reactivation or complications of pulmonary tuberculosis Subhasis Saha, Ashok K Basu, H Konar, S Basu Thakur which is most prevalent in young adults and middle aged. The Calcutta Medical Research Institute, Kolkata, India According to the reports from the world, renal tuberculosis is

159 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 extremely rare in children. It has not been reported in children vesicostomy had poor bladder function. younger than 5 years. In the year 1997 in India, 9 children Conclusion: 1) Antenatal diagnosis has a definite role in with renal tuberculosis in the age range of 5 to 12 years were the management 2) vesicostomy diminishes the chance of reported. Gross haematuria was the commonest clinical Þ nding functional recovery of bladder. 3) upper tract damage can be in these children. divided in two groups primary, and secondary due to late management. 118 Re-do PSARP in Anorectal malformation: A report 120 of six cases. Single surgeon’s experience Intra-renal neuroblastoma: A diagnostic dilemma Debasish Mitra, Sanghamitra Bhattacharyya Shalini Sinha, Rupnayan Goswami, Y. K. Sarin Park Childrens Centre for treatment and research, Kolkata, Maulana Azad Medical College, New Delhi, India Apollo Gleneagles Hospital, Kolkata, India Case Report: We present a 7-year-old girl who came with Aims and Objective: Two common complications aft er surgery hematuria, fever and abdominal lump for 2½ months. On for Anorectal malformation are stenosis and incontinence. examination, she had a large mass in the left lumbar region, Majority of incontinence are due to wrong placement of the hard in consistency. Ultrasound and CT abdomen revealed gut. Stenosis is mainly due to loss of vascularity of the gut. it to be a large malignant tumor arising from the left kidney Materials and Method: from 2000-09, 6 cases were included displacing the great vessels to the opposite side with no in the study. 2 had stenosis and 4 had incontinence. In 3 cases calciÞ cations consistent with Wilms’ tumor. The left renal vein patients had colostomy. In other 3 cases colostomy was closed was obscured and there was loss of planes with the left psoas in 1 patient and in 2 patients deÞ nitive operation was tried muscle. Opposite kidney was normal. A trucut biopsy from the earlier without colostomy. In 2 cases the primary operation renal angle was reported as small round cell tumor with rosett e was a complete failure. formation and calciÞ cation suggestive of neuroblastoma. 24- Result: All six cases had good outcome. The Þ rst and the hour urinary VMA was normal; bone scan and bone marrow last patient had a tampered perineum due to an att empt for were negative. While awaiting immuno-histochemistry (IHC) anoplasty outside without colostomy. Though the perineal report; she was started on weekly chemotherapy for Wilms’ musculature could be identiÞ ed, some muscles were replaced tumor with Vincristine and Actinomycin-D. She received 2 by Þ brous tissue. 1 case had mild constipation and required weeks of chemotherapy with deÞ nite response to therapy. weekly enema and the last patient has only 2 months follow However, the IHC of the trucut biopsy showed tumor cells to up and has very minimal leak. be positive for NSE. As there was a major discrepancy between Conclusion: 1) colostomy has a deÞ nite protective role for the radiological and histopathological diagnosis; it was decided the anastomosis, 2) one stage operation must be done with to go ahead with surgical excision. At surgery, we found a huge adequate preoperative assessment 3) assessment should be tumor replacing the entire left kidney but sparing the upper done regarding outcome before colostomy closure. 4) re-do pole. There were few hilar and infra-hilar lymph nodes which surgery should be done as early as possible. were sampled separately. Left nephroureterectomy was done. 119 Final HPE conÞ rmed Grade – I Neuroblastoma, nodes negative. Prognostic assessment in patients of with The chemotherapy was changed to OPEC regime. She is still posterior urethral valve and its correlation with undergoing chemotherapy and has completed 3 cycles. She age at presentation is quite well preserved and is tolerating chemotherapy well. Discussion: Intrarenal neuroblastoma is a rare entity that Sanghamitra Bhattacharyya, Debasish Mitra clinically and radiographically may mimic Wilms’ tumor. A Park Childrens Centre for Treatment and Research, Kolkata, thorough literature search revealed less than 25 cases reported Apollo Gleneagles Hospital, Kolkata, India till date. It is an aggressive malignancy, and long-term survival is rare [only 1 survival (13 years) has been reported]. Majority Aims and Objective: We all know that in PUV early the have a poorly diff erentiated histopathology and downhill presentation worse the prognosis. But it is always not true. clinical course. This case is presented to highlight the diagnostic Because early diagnosis (mainly the antenatal diagnosis), has dilemma. Moreover the tumor in this child is diff erent from completely changed the picture. Neonatal management has bett er chance of bladder compliance. those reported in literature as it is low grade with no metastasis Materials and Method: From 2003-09, 22 cases were included and the child is quite well preserved. in the study. Cases were divided into two groups: neonatal and 121 others. The patients in the neonatal group include ante natal diagnosis and neonatal presentation with voiding diffi culty. Anorectal malformation with genital ambiguity Other group includes patients with varied presentation. Jui Mandke, A. Raut, S. Jadhav, D. Kittur, R. Vora Result: Antenatally diagnosed patients had good outcome SJKC Trust’s Paed. Surg. P.G. Institute, SANGLI (Maharashtra), regarding bladder function, compliance. The patients having India

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Aim: To present a rare case of anorectal malformation with Results: The patient recovered and is doing well at 6 months genital duplication and ambiguity. follow up. Method: A 12 hour old baby with ARM presented with Conclusion: One has to be aware of unusual Þ ndings while ambiguous genitalia and duplication of female genitalia. The operating for CDH. passage of urine and meconium per patent common channel suggests persistent cloaca. A high sigmoid colostomy was done, 124 the baby was investigated for other congenital anomalies and Right congenital diaphragmatic hernia associated evaluated for future management. with ano-rectal malformation– 1st case in Paediatric- Results: Uneventful recovery from emergency colostomy. Surgery literature Awaiting further management. Amit Raut, J. Mandke, V. Sarode, S. Jadhav, R. Vora, Ila Conclusion: This case represents a rare variant of persistent Meisheri cloaca with genital ambiguity and duplication. S.J.K.C. Trust’s, Paed-Surgery, P.G. Institute, SANGLI (Maharashtra), India 122 Bilateral congenital diaphragmatic hernia- bilateral Aim: Right sided congenital diaphragmatic hernia associated central defect: A case report with Anorectal malformation is unknown.We present our Amit Raut, J. Mandke, V. Sarode, S. Patil, R. Vora, S. Jadhav, experience in management of 1st such case. Ila.Meisheri Methods: One and half hours hours male baby presented Sushrut Jadhav Kinderchirurgie Charitable trust’s, P.G. Institute, to us with history of absent anus. X ray chest and abdomen SANGLI (Maharashtra), India and later on invertogram were done. X-ray chest revealed right sided congenital diaphragmatic hernia. Invertogram Aim: Bilateral congenital diaphragmatic hernia is a rare entity revealed intermediate type ARM. Baby was completely with poor prognosis. We present a case of bilateral congenital asymptomatic in relation to CDH, did not have respiratory diaphragmatic hernia managed successfully. distress or cyanosis etc. Loop sigmoid colostomy for ARM Methods: One and half years male presented with history of was then done. At age of 4 weeks right CDH repair was done, cough and fever on and off since birth. Chest-X-ray revealed by thoracic approach. At age of 7 weeks Posterior Sagitt al obliterated bilateral cardio-phrenic angles, with rounded Ano-Rectoplasty was done.At age of 12 weeks colostomy opacities on either sides.USG and C.T.Scan chest revealed closure was done. right and left lobe of malformed liver herniated through Results: Baby had uneventful recovery aft er surgeries for both anterior diaphragmatic defect. Diagnostic laparoscopy revealed the anamolies and is doing well on 7 months follow-up till date. bilateral diaphragmatic‘ bilateral central defects’ through Conclusion: Right Congenital diaphragmatic hernia associated which the right and left lobes of liver were herniated.Both the with Ano-rectal malformation--This is the 1st case in Paediatric- diaphragmatic defects were repaired by abdominal approach. Surgery literature. Results: Patient had uneventful recovery, and is doing well on follow up. 125 Conclusion: Bilateral congenital diaphragmatic hernia is a rare Congenital prepubic sinus entity and bilateral central defect is rarest. Such cases can be Jui Mandke, A. G. Gujar, A. Raut, V. Sarode, S. Jadhav, R. managed successfully with favourable outcome. Vora, I. Meisheri. SJKC Trust’s Paed. Surg. P.G. Institute, SANGLI (Maharashtra), 123 India Congenital diaphragmatic hernia: A rare presentation with torn sac and intestinal Aim: To study the nature of midline prepubic sinus. obstruction Method: An 8 year old male child presented with a midline Jui Mandke, A. Raut, S. Jadhav, S. Kaddu, R. Vora, I. Meisheri prepubic sinus since birth. It had no discharge from it. The SJKC Trust’s Paed. Surg. P.G. Institute, SANGLI (Maharashtra), sinus was explored, found to end blindly and was excised. India Histopathology revealed a lining of transitional epithelium. Results: Complete cure. Aim: To present a rare presentation- of Left sided CDH. Conclusion: Abortive dorsal duplication of urethra. Method: A month old male baby presented with recent onset of breathlessness. Chest X ray revealed a Lt. sided CDH. On 126 exploration, there was an anterolateral defect containing left Cystic lymphatic malformation of left gluteal area: lobe of liver, stomach and bowel loops. The small bowel loops A case report herniated through the torn sac had constricting adhesions Jui Mandke, V. Sarode, A. Raut, S. Jadhav, S. Patil, I. Meisheri around them, causing incomplete obstruction. The Lt. CDH SJKC Trust’s Paed. Surg. P.G. Institute, SANGLI (Maharashtra), was repaired. India

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Aim: To present a case of cystic lymphatic malformation at a over perineum and rt. Lower limb which had got infected rare site. with extensive areas of necrosis, haemorrhage with loss of Method: A 2 ½ year old male child presented with a large local tissue causing anorectal stenosis and retraction of anus. swelling in his Lt. Gluteal area since birth which had suddenly To avoid fecal contamination of the wound,diverting loop increased in size aft er a trivial trauma. Doppler USG of the sigmoid colostomy was done and blood transfusion was given swelling revealed a low ß ow rate of the ß uid contained in the to correct anaemia. swelling with multiple loculi. Complete excision was done. Results: Awaiting control of perineal infection, then will The histopathology report revealed it to be a cystic lymphatic require management of the hemangioma as well as colonic malformation. pull through. Results: No recurrence was seen at 4 months of follow up. Conclusion: A rare presentation of diffuse capillary Conclusion: A cystic hygroma in the gluteal region has no hemangioma over perineal region with extensive loss of local embryological basis and this case is a deÞ nite exception to tissue which may lead to anal stenosis. the rule. 129 127 Hirschprung disease with anorectal junction Detailed surgical technique of LDLT stenosis: An extremely rare association of G. Raghavendra Prasad, G. Rammohan, Satyanarayana, functional and partial mechanical bowel Takada, Subba Rao obstruction Kamineni Hospitals, KIMS Narketpally Hyderbad, India Kumar Abdul Rashid, Tanvir Roshan Khan, Madhukar Maletha, Shiv Narain Kureel, Nuzhat Husain Introduction: Liver transplantation is conÞ ned a few centers. Department of Pediatric Surgery, King George Medical Detailed surgical technique is rarely seen at a time. University, Lucknow, India Aims and objective: To present all components of Live Donor Liver Transplanation. Graft harvesting, Recipient hepatectomy Hirschprung disease with anorectal malformation is very graft placement and hepatic venous, portal vein HA and biliary rare and anorectal junction stenosis is a super-rare anorectal reconstruction. anomaly. We describe the case of a 4 day old neonate referred Materials and Methods: Our institute is into Liver with diagnosis of rectal atresia. Clinical examination, instead, transplantation. Detailed surgical technique would presented. was suggestive of anorectal junction stenosis. Contrast enema All LDLT are alive. All graft s were thoroughly evaluated radiography revealed a long narrow segment of sigmoid for volume, vascular anatomy, biliary ductal system. Graft between dilated distal rectosigmoid and grossly dilated was harvested using CUSA and back table prep was done to proximal colon with a transition zone at descending- sigmoid prepare the graft for vascular and biliary anstomosis. Recipient junction. Radiographic Þ ndings were conÞ rmed on exploratory hepatectomy rarely needed blood transfusion. Anhepatic phase laparotomy and biopsy proved ganglion cells only in proximal and cold ischemia were kept to the minimum. Graft was palced colon. No ganglion cells were found either in the narrow using standard protocol. All received post op Pangraf as the segment or in the dilated rectosigmoid. Therefore, Hirschprung immunosuppressant. Post op evaluation of the graft was done disease was proved histopathologically in a case of clinically by serial LFTs and Colour Doppler. CBD was stented routinely diagnosed anorectal junction stenosis. To the best knowledge for 3 weeks. Infections were carefully looked for and preventive of the authors, no case of this association has been reported measures were taken for CMV, Pneumocytis. previously in the literature. We present a case of this extremely Results: All recipients of LDLT are alive. One required ERCP rare combination of functional and partial mechanical bowel post operatively. obstruction with interpretation of clinico-radiological Þ ndings. Conclusion: LDLT is a viable option for ESLD. Technique is presented in detail. 130 Ileal foreign body with unusual presentation—3 128 cases Diffuse perineal hemangioma: A case report Jui Mandke, A. Raut, S. Jadhav, R. Vora, D. Kittur, I. Meisheri Jui Mandke, V. Sarode, A. Raut, S. Patil, S. Jadhav, R.Vora, SJKC Trust’s Paed. Surg. P.G. Institute, SANGLI (Maharashtra), I. Meisheri India SJKC Trust’s Paed. Surg. P.G. Institute, SANGLI (Maharashtra), India Aim: To study 3 cases of foreign body in ileum with complication. Aim: A rare case of diff use perineal hemangioma. Method: Three cases were studied—1. Four year old male Method: A case of 2 month old female child presented with presented with peritonitis and on exploration was found to lesion over perineal region and Rt. Lower limb since birth. have an ileal perforation due to a long wooden splinter which On examination, there was diff use capillary hemangioma he might have swallowed. 2. Five year old female, a known case

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 162 IAPSCON 2009 of operated ileal atresia, presented with a 50p coin impacted at really need treatment? the anastomotic site with intestinal obstruction. 3. Four year old with migration of needle from ileum into the peritoneal cavity. 133 Results: All three patients had to be explored and necessary Paraspinal dermoid cyst mimicking as lateral surgical procedure was carried out. meningocoele Conclusion: Ileal symptomatic foreign bodies requiring Amit Raut, J. Mandke, V. Sarode, S. Patil, S. Jadhav, R. Vora, exploration are rare. Ila Meisheri S.J.K.C.Trust’s, Paed-Surgery, P.G. Institute, Sangli 131 (Maharashtra), India Jodhpur disease: Our experience of fi ve cases Amit Raut, J. Mandke, V. Sarode, S. Patil, D. Kittur, S. Jadhav, Aim: Dermoid cyst usually presents as midline swelling. Here Vora, Ila Meisheri we present a case of para-spinal Dermoid cyst. S.J.K.C. Trust’s,Paed-Surgery, P.G. Institute, SANGLI Methods: Eight years old male presented with a swelling (Maharashtra), India over right lumbar para-spinal region, 2 cms lateral to midline, 5x4x3 cms, tender, soft , cystic, and non reducible.Tuft of hair Aim: To present Þ ve cases of Jodhpur disease –A variety of present over lumbar spine and also scanty hair over swelling gastric outlet obstruction, Þ rst reported at Jodhpur in1997. seen. Bony spur palpable in L-4 region, Spina-biÞ da occulta-L-4 Methods: Five cases presented, at ages between 2 years and region. There was no neurodeÞ cit.MRI-spine-no intraspinal 10 years as gastric outlet obstruction, predominantly male sex. pathology. On exploration,it turned out to be infected Dermoid Presenting symptoms and signs were non bilious vomiting, cyst containing hair. Histopathiological examination conÞ rmed constipation, dehydration, epigastric fullness, visible peristalsis the diagnosis of Dermoid cyst. etc. Upper gastro-intestinal contrast studies showed large Results: Patient had uneventful recovery and is doing well stomach and increased gastric emptying time. On exploration, on follow up. it was interesting to note that there was no pyloric muscle Conclusion: 1) Para-spinal Dermoid cyst is a rare entity. 2) It hypertrophy, no extra-luminal or intra-luminal obstruction, may mimic as lateral meningocoele, speciÞ cally when spina- no scarring. All patients were cured by Heineke-Mikulicz biÞ da is present. pyloroplasty. Results: All patients had uneventful recovery and symptom 134 free follow-up. Extrahepatic portal hypertension in children: A Conclusion: In cases presenting as Gastric outlet obstruction in new technique of selective shunt in cases with childhood, there has to be a high index of suspicion for Jodhpur cavernomatous transformation of portal and disease- a primary acquired condition. splenic vein Archika, Kureel Shiv Narain, Madhukar Maletha, Tanvir Roshan 132 Khan Incidental mini-valves; Do these valves really need Department of Pediatric Surgery, C.S.M. Medical University, treatment? Lucknow, Uttar Pradesh, India Amit Raut, J. Mandke, S. Jadhav, D. Kittur, Ila Meisheri S.J. K.C Trust’s, Paed-Surgery, P.G. Institute, Sangli Aims: We reported a new surgical alternative of preservation (Maharashtra), India of terminal tributaries of splenic vein and its anastomosis with left adrenal vein or left renal vein in cases where endoscopic Aim: To study the cases of urinary anomalies with incidental sclerotherapy was not feasible and extension of cavernomatous mini-valves and whether these valves really need treatment. malformation up to splenic vein obviated mobilisation of Methods: We studied cases in which mini-valves were splenic vein for a conventional splenorenal shunt. incidently detected in 7 urological cases which actually Methods: Six patients from 7 years to 11 years of age were presented / diagnosed as other urological conditions as PUJ selected for surgery. Preoperative CT Angio demonstrated obstruction- unilateral / bilateral, VUJ obstruction, etc. MCU cavernomatous extension of portal vein up to splenic vein and done previously in these cases did not reveal dilated post the patt ern of terminal tributaries of splenic vein at splenic –urethra, but follow-up cystoscopy during stent removal hilum. Splenectomy was done with premeditated plan of revealed post urethral mini valves. These were cystoscopically preservation of terminal tributaries of splenic vein, which were fulgurated successfully. Cystoscopy videos att ached. of adequate calibre. Short middle tributary was cannulated for Results: All 7 patients had uneventful recovery, and are doing measurement of preoperative portal venous pressure before well on follow-up. and aft er the shunt procedure while longer upper and lower Conclusion: 1) Cystoscopy has a deÞ nitive, diagnostic as well tributaries were utilised for creation of end to end splenoadrenal as therapeutic role in managing post urethral mini-valves, anastomosis and end to side splenorenal anastomosis obviating even those which are not diagnosed on MCU. 2) However the need of mobilization of cavernomatous splenic vein off the question remains whether incidentally detected mini-valves pancreatic bed.

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Results: To achieve more than 50% reduction in portal venous V. R. Ravi Kumar, G. Rajamani, Vijaya Giri pressure, end to end splenoadrenal anastomosis was enough Dept. of Paediatric Surgery, Coimbatore Medical College in 4 patients while combined end to end splenoadrenal Hospital, Coimbatore, India anastomosis and end to side splenorenal anastomosis was needed in two patients. Size of splenic tributaries and Three children who had recurrent adhesive obstructions in the left adrenal vein for anastomosis ranged from 5 to 7 mm. immediate post operative period were surgically corrected by Intraoperative shunt patency could be checked by ß ushing long intestinal tubing. The cases were duplication cyst, Meckel’s the heparinised saline through cannula in middle tributary of perforation and Duhamel surgery for Hirschsprung’s disease. splenic vein. Shunt patency was demonstrated in all patients Two of these three had long intestinal tube threaded form the on follow up at 6 month and 1 year interval with color Doppler base of the appendix aft er appendicectomy upto the jejunum study. Recurrent mild hematemesis occurred in one patient and the tube brought out of the abdominal wall. The third aft er six month due to drug induced ulcer as seen on endoscopy. chid had the tube inserted through jejunostomy and threaded Conclusion: Premeditated preservation of tributaries of splenic into the caecum. These tubes were removed on the tenth day. vein and its anastomosis with adrenal vein can obviate the need A fourth child with meconium peritonitis with dense post of splenic vein mobilization off the pancreatic bed. operative adhesions was also corrected with tubing inserted through the appendicular base. Intestinal tubing has been done 135 earlier and most have been inserted through the oral route for Congenital diaphragmatic hernia with jejunal atresia minor adhesions. This surgical procedure is done for dense VK Gopi adhesions on the operation table to prevent recurrence. PVS Hospital, Calicut, India 139 New born presented with respiratory distress since birth Recto-Urethral fi stula in Anorectal malformation, and had to ventilate for stabilisation. Further evaluation is it mandatory to close?: A study of 20 cases suggested proximal jejunal atresia associated with congenital Amit Raut, J Mandke, S Jadhav, R Vora, D Kittur, Ila Miesheri diaphragmatic hernia. Surgical correction was successful and S.J.K.C. Trust’s,Paed-Surgery P.G. Institute, Sangli baby went home. (Maharashtra), India

136 Aim: To study whether recto-urethral fistula ligation is H2 receptor dependent ilial peptic ulcer in mandatory in cases of recto-urethral fistula in Anorectal intestinal duplication malformations. VK Gopi Methods: We studied 20 patients of high and intermediate PVS Hospital, Calicut, India Ano-rectal malformations with recto-urethral Þ stula. In all these cases recto-urethral fistula was not ligated after its Sven year old chil was treated for recurrent att acks of abdominal division from rectum, as usually done in PSARP. There was pain bleeding per rectum and failure to thrive. For the tha last no urinary leakage nor any other complications in immediate two years. He was dependent on h2 receptor antagonist and post-operative period. We further evaluated our patients post- he can’t spent even twelve hours with out medication.he was operatively by symptoms, micturating cysto-urethrography investigated and operated for ilial tubular diverticulum with and by cystoscopy. The parameters studied were stream of large ileal peptic ulcer. Histology of resected segment showed urine, urethral caliber, urethral diverticum and stricture if any. gastric epithelium.post operatively child is doing well. Results: All patients had uneventful recovery. None of the patients had any symptoms related to urinary system nor 137 had any evidence of diverticulum or stricture urethra during VP Shunt related intraperitoneal complications follow-up. VK Gopi Conclusion: It is not mandatory to close the recto-urethral PVS Hospital, Calicut, India Þ stula during management of Anorectal malformations, more- over it avoids urethral complications. Author encountered three types of intraperitoneal complications: 1. Shunt as inguinal hernial content, 2. ileal 140 penetration and intestinal obstruction, 3. Shunt induced Recto vestibular H fi stula intussusception. V. R. Ravi Kumar, G. Rajamani, Vijaya Giri Dept. of Paediatric Surgery, Coimbatore Medical College 138 Hospital, Coimbatore, India Long intestinal tubing for recurrent adhesive obstructions in the immediate post operative 8 cases of rectovestibular Þ stula were seen. Three were in the period neonatal period and the rest were in older children. All the

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 164 IAPSCON 2009 neonatal cases needed surgical excision and reconstruction segment, recirculating loops and construction of intestinal of perineal body and the rectum and vagina. Two of the older valves have been reported to slow down the transit and improve children the Þ stula healed on conservative treatment. The other absorption. Isoperistaltic colon interposition using 8-15 cm three in the older children group needed surgical excision of segment of colon with 50% success is found to be a bett er the Þ stulous tract. These tracts were lined by granulation tissue. procedure. Tapering enteroplasty in intestinal reminant of 30 The principles were applied to help the obstetrician to close the cm. length improves both peristalsis and absorption. Recently acquired post partum recto vaginal Þ stula in three women. The intestinal lengthening procedures have found favour in the technical details of excision and reconstruction of the vagina management of SBS. In Bianchi procedure two longitudinal and rectum is high lightened. All the above surgeries were tubes are constructed by G.I. Stapler and anastamosed in done without covering colostomy. isoperistalstic manner. However, Serial Transverse Enteroplasty (STEP) procedure by using G.I. Stapler produces a zigzag 141 channel and thus doubling the length of bowel. At present both Short bowel syndrome: Current trends in management Bianchi and STEP procedures are in vogue with 91% to 95% K. K. Maudar survival. Tissue engineering techniques to create neointestine Dept. of G.I. Surgery and Director – Bhopal Memorial Hospital have been described in experimental animals. Small bowel and Research Centre (BMHRC), Bhopal – 462 038 (M.P.), India transplantation is the procedure of choice in the treatment of intestinal failure. 15% – 20% of patients survival rate in one Short Bowel Syndrome (SBS) commonly results from year and 55% survival in 5 years following transplantation is massive resection (> 50%) of small intestine. Intestinal atresia, reported. Today, intestinal transplantation is a viable surgical necrotising enterocolitis, midgut volvulus, volvulus with option in patients on chronic TPN. meconium ileus and gastroschisis in infants and trauma, Intestinal Loop Lengthening: An Experimental Study- The mesenteric ischaemia and Crohn’s disease in older children. aim of the present work was to study the feasibility of loop The immediate eff ects of massive intestinal resection include lengthening procedure in canine model. ß uid and electrolyte loss, malabsorption, diarrhoea, nutritional Materials and Method: The present study was carried out deÞ ciencies, malabsorption of Vitamin A, D, K and E, fats, on 15 adult mongrel dogs weighing 10 – 15 kg and from both carbohydrates, calcium and magnesium. Hypergastrenemia, sexes. The procedure of loop lengthening was done in 2 stages. hyperoxaluria, nephrolithiasis, cholelithiasis, liver failure First Stage: A segment of 10 cm of mid jejunum was isolated and D-lactose acidosis develop. Intestinal adaptation begins by applying two intestinal occlusion clamps up to the level with hyperplasia and hypertrophy of intestinal mucosa with of most distal arterial arcade. The segment of jejunum was elongation of villi, deepening of crypts, thickening of wall of divided including the mesentery up to the point just short of bowel and dilatation of remnant of intestine. Growth factors, distal most arterial arcade. The two halves of the mesentery peptides, long chain fatt y acids, bile, pancreatic secretion were dissected by blunt dissection using long straight artery and humoral factors promote adaptation. Citrulline levels forceps. Thus the 2 leaves of mesentery along with their blood are best marker of adoption. Short chain fatt y acids and long vessels fell apart. The isolated segment of the jejunum was then chain triglycerides, proteins and sugars are essential trophic divided longitudinally. Each half of the bowel was converted nutrients. Glutamine, circulating peptides, enteroglucagon, into a tube using 3 – 0 prolene sutures over a rubber catheter. epidermal growth factors, neurotensin, insulin like growth The two tubes thus formed were joined together by end-to-end factors, interleukin-II and transforming growth factor – anastamosis in isoperistaltic fashion. Intestinal continuity of the alpha are trophic agents. Medical management includes bowel was restored by end-to-end anastamosis of the proximal intravenous ß uids, oral ß uids, total parenteral nutrition (TPN) and distal ends of bowel where the clamps were applied at the and gastrostomy for continuous enteral feeding, growth time of resection of the segment for lengthening. One end of the hormones, glucagon like peptide (GLP-2) derived from L-cells lengthened loop was brought out of the abdomen as mucous of remnant of small intestine, and hypoallergenic formula Þ stula and the other end was closed. (Nutramigen, Pregestimil, Alimentun) and Neocate amino acid Second Stage: Aft er 8 – 10 weeks of Þ rst stage procedure formula. Pharmacologic agents like codeine, diphenoxylate, abdomen was reopened and the lengthened segment was loperamide and octreotide are used to slow intestinal transit. dissected free of the mucous Þ stula. The lengthened loop was Cholestyramine is used for choleretic diarrhoea. Cephalexin, then anastomosed to small bowel by end to side anastomosin by metronidazole, trimethoprim and gentamycine are used to continuous single layer suture with 3 – 0 chromic catgut. Aft er control infection. H2 receptor antagonists and proton pump 2 weeks of second stage procedure, the animals were sacriÞ ced. inhibitors are used to reduce gastric hyper-secretion. Patency of anastamoses, gross appearance of operated small Adjunctive Surgical Procedures: Normal size of small intestine bowel and mesentery were noted. Biopsy specimens were taken of an infant is 200 – 250 cm. and it keeps growing till the size from the lengthened loop for light and electron microscopic of the infant is 100 cm. If the size of the intestinal remnant is studies. 25 cm. TPN dependence develops presence of ileocaecal valve Observations: Post operative recovery was uneventful. The and colon improve survival. Therefore, surgical management stoma of mucous Þ stula was healthy in the Þ rst stage. No as early as feasible off ers good prognosis. Reversed intestinal features of intestinal obstructions or sealed perforations

165 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 were observed following the second stage. There were no under anesthesia. All but one patient had an uneventful ischaemic changes in the lengthened loop. No narrowing due postoperative course and were discharged within 7 to 8 days. to Þ brosis was observed at the sites of anastamoses. Mesentery All patients had excellent cosmetic results with appropriate was thickened and oedematous. Mesenteric vessels of the vaginal length. One patient developed late stenosis of the lengthened loops were normal in appearance. The length of introitus, which responded to dilatations. Mucus discharge lengthened loop was 20 cm. was not a signiÞ cant problem. Results: The procedure of loop lengthening was without Conclusion: Sigmoid colon vaginoplasty is an appropriate morbidy and mortality. The jejunal loop was lengthened from method for the construction of a neovagina in children, 10 cm to 20 cm. It was fully patent and functional. There was meeting all necessary criteria aft er vaginoplasty. Furthermore, no stricture formation. The luminal diameter of the lengthened we believe that colon segments, in particular sigmoid, are loop increased by 1.5 times. Histology of the lengthened loop preferable to small bowel for the creation of a neovagina. They showed normal intestinal mucosa. There was no evidence have the advantage of not requiring prolonged vaginal molding of mucosal disruption, Þ brosis, myonecrosis or autolysis of and self-dilation and Stenosis is unusual. The sigmoid colon is intestinal segments. Electron microscopic examination of thick-walled, large in diameter and does not traumatise easily; lengthened segment showed normal ultrastructure. Normal mucosal secretions, although suffi cient to provide adequate structure of villi and all layers of bowel were present. lubriÞ cation, are not excessive or irritating. Conclusion: All the lengthened loops were viable both macroscopically and light and electron microscopically. Loop 143 lengthening procedure is a feasible procedure to increase the A follow up study of ten cases of solitary kidney length of small bowel. with other urological anomalies Jui Mandke, A. Raut, V. Sarode, S. Jadhav, S. Patil, I. Meisheri 142 SJKC Trust’s Paed. Surg. P.G. Institute, Sangli (Maharashtra), Sigmoid colon neo vaginoplasty in vaginal India agenesis: Experience with 8 cases. Jiledar Rawat, Tanvir Roshan Khan, A Wakhlu, S. N. Kureel Aim: To study the varieties of other urological anomalies, their Department of Pediatric surgery, CSMMU (Upgraded KGMC). investigations and management in ten cases of ‘solitary kidney’. Lucknow, India Method: Other associated urological anomalies in solitary kidney cases pose a challenge in management. Ten cases of Aim: Vaginal agenesis is a challenging problem for the pediatric solitary kidney with associated urological anomalies were surgeon. Outcomes are measured not only by cosmetic and studied and investigated. Blood investigations, MCU, Renal functional results but also by the patient’s psychosocial nuclear scans were obtained. Aft er necessary management development. Congenital syndromes such as mullerian of the other associated anomalies like VUR, obstructive agenesis (Mayer-Rokitansky- Kuster-Hauser syndrome), megaureter and ectopic ureter, the patients were followed up. intersex conditions (congenital adrenal hyperplasia, androgen Results: Although the other urological anomalies were treated insensitivity), and cloacal anomalies are the most frequent on their merits, we had a mixed bag of results. etiologies. Reconstruction has involved the use of skin graft s Conclusion: In cases of solitary kidney, it is important to make and non-operative methods with less than ideal results. an early diagnosis and prompt treatment of other urological Theoretically, a vascularised intestinal transplant would be anomalies to prevent damage to the precious kidney. superior in that there would be a tube of adequate length, lined with mucus membrane with a negligible tendency to 144 stricture. Authors have preference to use sigmoid colon for Tethered Cord syndrome – A follow up of 10 cases creating the neovagina and herein review their experience Jui Mandke, A. Raut, V. Sarode, S. Jadhav, R. Vora, I. Meisheri with this procedure. SJKC Trust’s Paed. Surg. P.G. Institute, Sangli (Maharashtra), Methods: The study was undertaken in the department of India Pediatric surgery, CSMMU (Upgraded KGMC). Over a 5 year interval, from March 2003 to March 2008, ten patients Aim: To follow up 10 cases of Tethered Cord Syndrome (TCS) underwent sigmoid colon neo vaginoplasty. These patients were with spinal dysraphism. retrospectively reviewed and data sheets were evaluated for Method: Ten cases of spinal dysraphism were suspected to etiology, operative procedure and operative and postoperative have TCS on clinical symptomatology and conÞ rmed by MRI complications if any were recorded. spine. All were operated upon and dethethering of spinal cord Results: Age ranged between 11 to 26 years and all patients was done. They were followed up with respect to the degree had vaginal atresia of various etiologies, (MRKH-7, Cloaca-3). of improvement in symptoms, radiological comparisons and A 15-20 cm segment of sigmoid colon was pulled through the recurrence of symptoms if any. retro vesical tunnel. The proximal end was closed in two layers Results: We were successful in detethering the cord without and distal anastomosis was carried out to the opening made on further neural injury. There was signiÞ cant clinical improvement the vaginal plate. The neovagina was examined and calibrated postoperatively.

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Conclusion: In cases of spinal dysraphism where we suspect on further antenatal scans. On postnatal scan left kidney was TCS, specially due to late onset of neurological symptoms, absent. Fourth patient had enteric duplication cyst on postnatal MRI is a must and early exploration for detethering yields scan which was removed during neonatal period. Though the good results. presentations of these cysts are similar antenatally postnatal management and outcome was diff erent. Hence, we propose 145 a classiÞ cation which will aid the sonologist as well as the Our early experience of USG guided aspiration of pediatric surgeon in diff erential diagnosis and planning the liver abscess management. Jui Mandke, N. Mehta, V. Sarode, S. Jadhav, D. Kittur, R.Vora Conclusion: Common causes of antenatal abdominal cystic SJKC Trust’s Paed. Surg. P.G. Institute, Sangli (Maharashtra), lesions are cystic masses of renal origin, ovarian cysts, enteral India duplication cysts, mesenteric cyst, chylolymphatic cysts, and choledochal cysts. These cysts may give similar sonological Aim: Our early experience of USG guided aspiration of liver appearance and pose diffi culty in diagnosis antenatally. Hence abscess. we propose a classiÞ cation of antenatal abdominal cysts based Method: In this study we reviewed 5 cases of liver abscess. All on sonological appearance which will guide the sonologist and patients were in age group of 5 yrs to 15 yrs. They presented the specialist in diff erential diagnosis and planning further with tender hepatomegaly with fever. USG conÞ rmed diagnosis management. of liver abscess in all. In all cases we did USG guided needle aspiration of liver abscess under local anaesthesia along with 147 intravenous antibiotics and amoebicidal drugs. Augmentation colocystoplasty and incontinence Results: Out of 5 cases, 3 cases required repeat USG guided surgery- our ongoing experience needle aspiration at interval of 7 days. All cases were treated Janani Krishnan, Madhavi Thakur, Anant P Bangar, Prashanth successfully with this technique. Kumar, Santosh Karmarkar Conclusion: USG guided needle aspiration is an easy, rapid, Lilavati Hospital and Research Centre, India safe and eff ective method of treatment of all cases of liver abscess, especially in amoebic ones. Surgical intervention is Aim: Successful management of urinary incontinence is a not necessary and can be avoided. cornerstone in endowing patients of neurogenic incontinence with a good quality of life. In recent times introduction of clean 146 intermitt ent catheterization and anticholinergics at an early age Antenatally diagnosed abdominal cysts and is thought to avoid future incontinence surgery. Over the last their proposed postnatal outcome. A proposed few years, we have a growing experience in the management of classifi cation for easier antenatal diagnosis urinary incontinence in spina biÞ da. In this paper we present, Madhavi Thakur, Prashant Kumar, Anant Bangar, Janani a cohort of 9 consecutive cases of colocystoplasty and/or Krishnan, Santosh Karmarkar bladder neck repair and Mitrofanoff and/or MACE procedures. Lilavati Hospital and Research Centre, India A thorough preoperative work up, proper selection of cases, protocol based intraoperative and postoperative management Aim: Intrabdominal fetal cystic lesions are amongst the is required for obtaining good results. These aspects are commonest antenatal malformations seen during fetal anomaly discussed in this paper. scans. A whole myriad of conditions can present as an antenatal Materials and Methods: We present 9 of our patients in the abdominal cyst. Though these cysts may appear similar in the age group of 4yrs-19yrs, out of which 5 were boys and 4 girls. antenatal period their postnatal outcome may be diff erent. Augmentation colocystoplasty was done for all of them,7 Hence a simple classiÞ cation of these cysts is required to aid underwent Mitrofanoff ,5 underwent MACE,4 patients had antenatal diff erential diagnosis. a wide bladder neck and DEFLUX was injected in 2 of these Materials and Methods: We present a series of four cases of patients,1 underwent Young-Dee-LeadBetter repair and fetal abdominal cysts and trace their antenatal, perinatal and a bladder neck ventrisuspension was done for 1 patient. postnatal course, and also their treatment. Preoperative preparation extending over six months to one Results: All four patients had lower abdominal paravesical year included careful evaluation of each patient, thorough cystic lesions which were followed up from second trimester to investigations, CIC training, anticholinergic medication, term and postnatally. Two patients had ovarian cystic lesions. parental counseling and meticulous documentation. Out of these, one patient required bilateral ovarian cystectomy Results: The dry interval of our patients preoperatively due to torsion and hemorrhage. Now the patient is being ranged from <10mins to 120 mins(mean of 45 mins) which followed up for 18 months. In our presentation issues related improved to a mean dry interval of 4 hours(range of 3 to 7 hrs) to hormonal replacement are discussed. The other patient postoperatively.Young-Dee-LeadBett er and bladder neck hitch had bilateral multiseptate ovarian cysts which signiÞ cantly showed good results, whereas results of periurethral injection reduced in size postnatally. Third patient had paravesical of DEFLUX were not encouraging. The Mitrofanoff and MACE cyst in early second trimester which completely disappeared stomas functioned well. There were no major complications in

167 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 any of our patients postoperatively. Our surgical techniques Following high dose prednisolone therapy there is signiÞ cant will be discussed. resolution. There is residual lymphangiomatous component. Conclusion: With careful preoperative evaluation and urinary Results: Extensive bladder haemangioma has responded to work up beginning 6months to 1year prior to the proposed date high dose steroid therapy. of surgery, proper CIC training, anticholinergic medication Conclusion: This is a case of extensive Haemangilymphangioama and meticulous augmentation technique, most patients with of bladder and scrotum and has responded to a signiÞ cant neurogenic incontinence stand to benefit significantly by extent to high dose prednisolone therapy. augmentation colocystoplasty. Easy access continent channels such as a Mitrofanoff makes CIC a simpler task. We recommend 150 augmentation colocystoplasty with adjunct procedures Choledocal cysts managed with Lilly’s procedure to achieve social continence in patients with neurogenic and Raffensperger’s conduit: A retrospective incontinence. analysis and long term follow-up Kirthy Promod, Rajiv Padankatti, Namasivayam S 148 Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India BCG adenitis: To treat or not to treat? Narendra Kumar, Nagarjuna, Leela Kumar, Lavanya Kannaiyan, Aim: A retrospective analysis and long term follow-up of Venteshwar, Hasanthi the casse of Choledocal cyst with Lilly’s procedure and Department of Paediatric Surgery, Niloufer Childrens Hospital, Raff ensperger’s conduit is presented in this paper. Osmania Medical College,Hyderabad, Andhra Pradesh, India Methods: Age, sex, investigatory modalities, Types pre and post-op cholangitis,immediate and delayed complications Aim: Suppurative lymphadenitis is the common complication of the choledocal cysts manged with Lilly’s procedure and of BCG vaccination. The optimum treatment for this Raff ensperger’s conduit were analysed. complication is debated. Results: There is no mortality in this series. The incidence Methods: All cases of BCG lymphadenitis presenting to of immediate and long term complications and post-op pediatric surgical service over a 2year study period were cholangitis are not signiÞ cant. reviewed to determine the optimum treatment for this Conclusion: Lilly’s procedure to avoid injury to pancreatic problem. duct and anomalous vessels and Raff ensperger’s conduit to Results: 22 children were referred for the management of reduce post-op cholangitis and peptic ulcer is justiÞ ed for the BCG lymphadenitis during the study period. Children were operative procedure involving more number of anastamosis healthy and received BCG Þ rst 2 months of life. Initially all and prolonged operating time. the patients received medical treatment with anti-tuberculous drugs for one to nine months. 13 children who presented with 151 large (approximately 3cm) ß uctuant lymph nodes, required a Case of congenital chylothorax surgical procedure to avoid spontaneous rapture and sinus Madhavi Thakur, Anant Bangar, Janani Krishnan, Santosh formation, whereas medical treatment ( with antituberculous Karmarkar drugs and aspiration) was eff ective in Þ ve out of the 9 patients Pediatric surgery, Lilavati Hospital & Research Centre, Mumbai, presenting with small (approximately 1 cm) nodes. Maharashtra, India Conclusions: Medical treatment with antituberculous drugs is not eff ective to treat BCG lymphadenitis, when the involved Aim: To depict pictorial course, management and outcome lymph nodes are around 3.0 cm and have developed ß uctuation of child detected to have hydrops fetalis due to congenital and inß ammation of over lying skin. chylothorax (which was diagnosed postnatally). Background: Accumulation of chylous ß uid in pleural space 149 (chylothorax) can be congenital or acquired.Congenital Bladder haemangiolymphangioma: A case report chylothorax may be associated with hydrops and can have a Kirthy Promod, Anoop, Rajiv Padankatti, Amit Gupta, Senthil fatal outcome perinatally. The optimal method of treating this Ganesh, Namasivayam S condition remains controversial. Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India Material and Methods: Herein we present a case of antenatally detected hydrops at 33.3 weeks of gestation, which was due Aim: A case extensive bladder haemangioma was investigated to congenital chylothorax detected postnatally. The treatment and put on high dose steroid therapy. There was good course is discussed and depicted. resolution of the lesion. Results: The child recovered well with our conservative Methods: Twelve year old boy with recurrent H/O haematuria approach over period of one month without any sequelae. since the age of 1 year was found to have a scrotal hamartoama. Presently child is three years old and thriving well. Doppler ultrasound, CT pelvis and cystoscopy showed an Conclusion: We would like to stress the importance of extensive bladder haemangioma and scrotal haemangioma. conservative treatment, close monitoring, multidisciplinary

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 168 IAPSCON 2009 care and patience on the part of treating physician in managing be a classic bladder exstrophy and the condition was not such babies. recognized until the time of surgical exploration when it was diagnosed to be case of duplicate bladder exstrophy. Inability 152 to identify the ureteral oriÞ ce during surgical repair led to Conservative treatment of hemangiomas and the discovery of closed bladder posterior to exstrophied lymphangiomas bladder mucosa and a hypospadiac urethral opening through Rupa Dalmia Singh, Santosh Kumar Singh which even a smallest feeding tube (4fr) couldnot be passed Tulsi Hospitals Ltd., Civil Lines, Kanpur, India in to the bladder. We report a case of duplicate bladder exstrophy in association with hypospadiac urethral opening Aim: To study the effi cacy of various non-operative modalities and to our knowledge this is the Þ rst case report of such an in the treatment of hemangiomas and lymphangiomas. association of hypospadias with duplicate bladder exstrophy. Methods: Patients with these problems were given oral steroids, Postoperatively, the child has normal urinary control with propranolol, intralesional bleomycin, and compression acceptable cosmetic results. Though duplicate bladder bandage in diff erent patients. exstrophy is a rare exstrophy variant it should be ruled out Results: All patients showed good objective response. when the ureteral oriÞ ces are not identiÞ ed at exploration and Conclusion: conservative methods are very eff ective in the the overall prognosis of these patients are far bett er than the management of these lesions. Surgery may be needed when classic bladder exstrophy. these methods have not worked in the occasional patient. 155 153 Early thoracoscopy for empyema thorax: How Contralateral oopheropexy for ovarian torsion: A useful is it? salvage stratergy – our experience Narendra Kumar, Nagarjuna, Leela Kumar, Lavanya Kannaiyan, R. P. Dharmendra, V. Kumaran, G. Rajamani, S. Kannan, N. Venteshwar, Irfan Venkatesa Mohan, V. Muthulingam, R. Rangarajan Department of Paediatric Surgery, Niloufer Childrens Hospital, Coimbatore Medical College, Coimbatore,India Osmania Medical College,Hyderabad, Andhra Pradesh, India

Aim: Paediatric patients with ovarian torsion are at increased Aim: To evaluate the results of thoracoscopy for the treatment risk for a repeat event, and aft er unilateral ovarian loss, the of pleural empyema in pediatric patients. contralateral ovary is at risk for future torsion. Oophoropexy Methods: A prospective study of 15 patients who underwent has not been emphasized enough in contrast with testicular video-assisted thoracoscopy for pleural empyema treatment. torsion in the literature. We present our experiences with General anesthesia and single-lumen oral intubation were laparoscopic oophoropexy in children. used. Surgery was indicated when there was pleural eff usion Methods: The medical records of 12 patients with ovarian and no clinical and radiological response to clinical treatment torsion, who underwent oophorectomy and contralateral (antibiotics, physiotherapy and thoracocentesis) or severe oophoropexy between June 2004 - June 2009, were reviewed sepsis, together with loculated pleural eff usion (conÞ rmed retrospectively and prospectively. through ultrasound or computed tomography of the chest). Results: The ages of patients ranged from 3 years to 12 years, Results: Between August 2008 and June 2009 15 thoracoscopies with a mean age of 10 yearsin our series no torted ovary was were performed in patients ranging in age from 5 months to salvageable. So aft er ipsilateral oopherctomy contralateral 11 years (mean, 4 years). Mean time for thoracic drainage was orchiopexy were carried out. 5 days (range, 2-33 days), and mean period of hospitalization Conclusions: Failure to protect ovaries from subsequent was 7 days (range, 4 to 49 days). One patient underwent open torsions results in infertility, and we performed oophoropexy in decortication due to the nature of the empyema. All patients contralateral ovaries without any postoperative complication. showed good lung expansion on postoperative chest xray. All Oophoropexy is a simple procedure, and should be done in all patients were discharged early with oral antibiotic course. cases of ovarian torsion. Conclusions: Management of pleural empyema in this age bracket is still controversial, and surgical indication is oft en 154 delayed, particularly when there are multiple loculations or Duplicate bladder exstrophy: A rare variant of severe sepsis. We adovocate early thoracoscopy instead of exstrophy bladder primary ICD placement as ityields a bett er clinical outcome Jindal B, Jagdish S, Singh J K, Lalatendu K K for pediatric patients with pleural empyema, with apparent Jawaharlal Institute of Postgraduate Institute of Medical decreased morbidity and mortality, earlier chest tube removal, Education and Research, Pondicherry - 605006, India earlier hospital discharge and improved response to antibiotic therapy. We also suggest the use of Clarithromycin a macrolide A two month male child presented with what appeared to as empirical therapy for empyema

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156 Normoblasts. Extramedullary haemopoiesis was suspected. Foregut duplication cyst masquerading as Haemothorax was managed with ICD and transfusions. loculated empyema Imaging for Extramedullary haemopoiesis was negative. Rupa Dalmia Singh, Santosh Kumar Singh Splenectomy specimen showed foci of Extramedullary Tulsi Hospitals Ltd., Civil Lines, Kanpur Haemopiesis. Results: Child is doing well after the management of Foregut duplication cysts are an important differential Haemothorax and subsequent splenectomy. diagnosis of posterior mediastinal masses apart from Conclusion: Uncommon Extramedullary heamopoiesis neurogenic tumors. Their presentation may be protean and should be kept in mind while dealing with haemothorax therefore these may be overlooked unless a high index of in hamatological conditions so that other possible sites of suspicion is entertained. These may or may not communicate extramedullary haemopoiesis and the complications can be with alimentary tract, and may be found in the neck, thorax investigated. and abdomen, and may manifest accordingly. We present a case of esophageal duplicaton cyst in a child who presented with 159 chronic respiratory symptoms and failure to thrive. An unusual presentation of Hiatus hernia Narendra Kumar, Harish Jayaram1, Nagarjuna, Leela Kumar, 157 Lavanya Kannaiyan, Venteshwar Single stage Fowler-Stephen orchiopexy: Department of Paediatric Surgery, Niloufer Childrens Hospital, Retrospective analysis and follow-up Osmania Medical College,Hyderabad, Andhra Pradesh and 1 Kirthy Pramod, Anoop, Rajiv Padankatti, Namasivayam S Rainbow Childrens Hospital, Hyderabad, India Kanchi Kamakoti Childs Trust Hospital, Chennai, India Two children presented with persistent anemia requiring Aim:Retrospective analysis of the cases of arrested descent of multiple transfusions. On extensive evaluation for the anemia, testis managed by Single stage Fowler-Stephen orchiopexy they were found to have esophageal hiatal hernia. They had during the last 10 years is presented. The results and follow- no previous signs or symptoms of gastroespohageal reß ux. up are shown. Their anemia resolved after correction of hiatus hernia Methods: Single stage Fowler-Stephen orchiopexy was carried and fundoplication. This is associated with Herbst triad of out in these children. These procedures were carried out as GERD with anemia, Þ nger clubbing and hypoproteinemia. Inguinal exploration and open Single stage Fowler-Stephen Association if anemia with GERD and paraesophageal hernia orchiopexy or as Diagnostic laparoscopy and open Single Stage is well established. Hiatal hernia presenting only with severe Fowler-Stephen orchiopexy. Intra-operative measurement of anemia is rare. There are 2 reported cases in literature. testicular size was carried out. Post-op assessment of testicular sensation and status of testicular size were carried out on 160 follow-up. Laparoscopic pyloromyotomy in infants: A study Results: Overall success rate with preservation of testicular Gowri Shankar, Narendra Babu, Ramesh S, Ramchandra C., sensation and maintenance or increase in testicular size is K.R. Srimurthy 88.2%. The rate of post-op atrophy is 11.2% Indira Gandhi Institute of Child Health, Bangalore, India Conclusion:There are few papers on long term follow up and results of one stage Fowler-Stephen orchiopexy. The results Introduction: Laparoscopic Pyloromyotomy (LP) has become of this series are comparable to the results in the other few the standard recommendation in the west, and is being available studies. This study may be useful for comparing the increasingly done in many Indian centers with good results. Lap Fowler Stephen orchiopexy in future. There are not many Indian studies about LP. Aim: To study the feasibility and eff ectiveness of laparoscopic 158 pyloromyotomy (LP). Haemothorax in Beta Thalassemia: An unusual Materials and Methods: This was a prospective study of 39 cause babies who underwent LP over 2 years at our centre. We used Kirthy Pramod, Amit Gupta, Anoop, Rajiv Padakatti, Sarala the standard 3 port technique 1 with an arthrotome knife & Rajajee, Senthil Ganesh, Namasivayam S pyloric spreader. The outcome was evaluated with regard to Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India the total operating time, complications, hospital stay and time to full feeds Aim: A Beta Thalassemic child presented with massive Results: Of the 39 babies, 23 were males and 16 female. The age haemothorax. The cause was investigated to be an uncommon ranged from 16 to 76days ( mean age:28 days). The children Extra-medullary Haemopoiesis. were operated by various surgeons including resident trainees. Methods: A 11 year-old girl with Beta Thalassemia presented In 35 patients, the procedure was uneventful; 2 required with massive haemothorax. Peripheral smear showed conversion due to mucosal breech and 2 had incomplete

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 170 IAPSCON 2009 pyloromyotomy, all of them early in the series.. The mean This child had cyanotic episodes associated with feeding, operative time was 25minutes (range: 15 to 75min), the mean inspiratory stridor and recurrent pulmonary infections since time to full feeds was 23 hours (range:36 to 96hrs), the mean birth. As a result child also had tracheostomy and feeding hospital stay was 41hrs (Range: 26 to 130hrs). There were no gastrostomy in Þ rst month of life. She also had undergone operative or post-operative complications. And all the children multiple laser surgeries for suspected web before presenting did well on follow-up (Mean 6 months) to us. We were able to treat this child successfully by open Conclusion: Laparoscopic pyloromyotomy is safe and eff ective surgical anterior approach. in infants, and can be learnt easily even by beginners and Results: Child recovered well aft er this anterior approach open provides bett er cosmesis. surgery and was feeding well orally aft er closing gastrostomy and going to school. 161 Conclusion: We would like to stress the importance careful Laparoscopic gastropexy in infants evaluation before deciding on surgical approach and Janani Krishnan, Prashanth Kumar, Anant P Bangar, Madhavi discourage overjealous use of modern endoscopic and laser Thakur, Santosh Karmarkar approach without giving a thought. A proper planned anterior Lilavati Hospital and Research Centre, India translaryngeal approach gives good exposure for repair of upper laryngotracheoesophageal. Aim: Gastric volvulus in infants is not an uncommon condition. However surgeons are reluctant to undertake a 163 major exploration at this age for a relatively minor procedure. Lymphoma vs intussusception: A retrospective Laparoscopic gastropexy provides simpler alternative in study of related cases such situations. We present our experience of laparoscopic Kirthy Promod, Rajiv Padankatti, Senthil Ganesh, gastropexy as a deÞ nitive treatment for gastric volvulus in Namasivayam S two infants. Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India Material and Methods: We present two cases aged 3 months and 7 months diagnosed to have gastric volvulus clinically Aim: Cases of bowel lymphoma presenting as intussusception and radiologically. Second case had suspected association of or like intussusception and intussusception presenting like Peter Plus syndrome. Both the infants were treated by planned lymphoma causing mismanagement or delay in management. laparoscopic gastropexy. In this paper we will discuss the Retrospective analysis of such cases managed during the last instrumentation, technique, problems encountered during the 10 years to form a treatment protocol. procedure and outcome. Methods: All cases of abdominal lymphomas presented as Results: Both of our patients had uneventful post operative intussuception and cases presented like intussusception and recovery. Both patients have been followed up for 2 years and cases of intussusception presented like lymphoma are analysed. 6 months respectively and are thriving well. Data is presented. Conclusion: We recommend that laparoscopic gastropexy in Results: Analysis of the presentation, age incidence and results infants with gastric volvulus is a safe, simple and eff ective of treatment lead on to a safe protocol of management of such procedure and avoids a major abdominal operation for a cases. relatively minor procedure. Conclusion: This retrospective analysis of bowel lymphomas and intussusception with atypical presentation is used to form 162 a safe management protocol to avoid delay in management and Case of laryngotracheoesophageal cleft mismanagement of such cases. Madhavi Thakur, Anant Bangar, Prashanthkumar M, Santosh Karmarkar 164 Lilavati Hospital and Research Centre, India MACE and Mitrofanoff-techniques and complications Aim: To depict pictorial course, management and outcome of Madhavi Thakur, Prashant Kumar, Anant Bangar, Janani a female child with laryngotracheoesophageal cleft . Krishnan, Santosh Karmarka Background: Congenital laryngotracheoesophageal cleft is Lilavati Hospital and Research Centre, India a rare condition that is charecterised by a posterior midline deÞ ciency in separation of the larynx and trachea from the Aim: Continent abdominal stomas for bowel and bladder hypopharynx and esophagus. Various approaches in the form emptying are being commonly performed the world over. of anterior or anterolateral and open or endoscopic have been The acceptance by patients and familes for such abdominal mentioned. As this is a rare condition, optimal method of wall stomas can be improved by creating cosmetically and treating remains controversial. functionally acceptable stoma. This depends on proper Material and Methods: Here we present a case of female child planning, operative technique and post operative care of with laryngotracheoesophageal cleft treated at our institution. stoma.

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Material and Methods: In 8 patients (cases of spinal bladder. Sinus was extending to the under surface of the dysraphism with bowel and bladder incontinence who also symphysis and was excised. HPE showed the sinus lining to had undergone colocystoplasty) we have performed MACE in be urothelium. 5 patients and Mitrafonoff procedure in 7. Appendix was used Results: Asymptomatic for the last 6 months since excision. for creating cathetrisable channel for Mitrafonoff in 7 patients Conclusion: Literature search revealed it to be Abortive type and for MACE 2. In one patient appendix was divided and of Incomplete dorsal urethral duplication which presents as used for both the stomas. blind ending sinus. Results and Conclusion: In this paper surgical technique of Appendicovesicostomy and MACE along with problems 167 encountered will be presented. Also surgical technique of Two rare cases of perineal exstrophy Caecostomy is discussed. Regimen of regular post operative Narendra Kumar, Nagarjuna, Leela Kumar, Lavanya Kannaiyan, dilatation of stoma (especially of MACE) is necessary to Venteshwar, Hariprasad prevent stomal stenosis. Our patients (and their families) Department of Paediatric Surgery, Niloufer Childrens Hospital, are highly satisfied with the stomas and with simple Osmania Medical College, Hyderabad, Andhra Pradesh, India modiÞ cations, such as indwelling catheter during school or college or working hours, are leading bett er and more We present two rare cases of perineal ectopic intestinal mucosa. independent life styles. 2 new born, male children presented with a large moist red mass between the scrotum and the anterior margin of the anus. 165 These children also had severe penoscrotal hypospadias with Megalourethra: A case report chordee and penoscrotal transposition. They were initially Janani Krishnan, Prashant Kumar, Anant Bangar, Santosh suspected to have perineal exstrophy. To divert the fecal Karmarkar stream they have undergone sigmoid loop colostomy in the Lilavati Hospital and Research Centre, India newborn period. At the age of 6 months they were completely evaluated. MCUG showed normal bladder with good stream Background and Aim: Megalourethra is a rare congenital from the penoscrotal meatus. A barium enema showed noral anomaly characterized by a congenital deficiency of the distal colon, rectum and anus. MRI study done showed no mesodermal tissues of the phallus, leading to enlargement of communication between the perineal mucosal tissue and the the penile urethra. We present a pictorial presentation of a case bowel. They have undergone excision of this ectopic perineal of scaphoid type of megalourethra. bowel mucosa with reconstruction of the perineum. One child Material and Methods: A 3 year old boy presented to us has undergone colostomy closure and is continent for stools. with the isolated scaphoid megalourethra. Other associated Both of the children await hypospadias repair. There have anomalies were ruled out. Reduction urethroplasty was done. been no reports of similar cases in an extensive search of the Results: Post operatively the child started passing urine in good English literature. stream from the tip. Cosmetic outcome too was satisfactory at a follow up of two years post op. 168 Conclusion: Megalourethra has been classiÞ ed into scaphoid Light at the end of the tunnel: Biliary atresia: A and fusiform types and sometimes associated with additional long term follow up of 10 patients after kasai and urinary tract and other system anomalies. In the scaphoid liver transplantation type, there is complete or partial deÞ ciency of the corpus Madhavi Thakur, Anant Bangar, Prashant Kumar, Santosh spongiosum, whereas in the fusiform type, both the corpora Karmarkar cavernosa and the corpus spongiosum are deÞ cient. Meticulous Paediatric Surgery, Lilavati Hospital & Research Centre, surgical correction as described and depicted will provide a Mumbai, Maharashtra, India good functional and cosmetic result, as in our case. Aim: Biliary Atresia and Kasai Portoenterostomy are 166 increasingly seen as entities with an eventually poor outcome. Penopubic sinus: A case report However our experience has been otherwise – a careful long Kirthy Promod, Anoop, Senthil Ganesh, Vrindu, term follow-up, endoscopic management of varices and timely Namasivayam S organization and performance of Liver transplantation in these Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India patients has shown us the bright “light at the end of the tunnel”. We present this long term follow up of upto 12 years. Aim: A case of Penopubic sinus since birth was investigated Materials and Methods and Results: In this paper we present for Dermoid Urethral duplication and was excised. HPE shoed the long term outcome in a cohort of 10 patients, who were it to be dorsal urethral duplication. diagnosed to have Biliary Atresia in Infancy and underwent Methods: Two year boy presented with a penopubic sinus. the Kasai Operation between the ages of 2 -7mths. They are Sinogram did not reveal any communication to urethra or under our regular follow up since their portoenterostomies for

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 172 IAPSCON 2009 the past 3 to 12 years. All 10 patients are presently anicteric and laparotomy derooÞ ng and marsupialisation. HPE showed it with normal Liver functions and are thriving well ( doing well it be an epithelial cyst. in school). Of these, 7 are normal without requiring a LT while Methods: Eight year-old boy presented with a Rt upper 3 patients who gradually deteriorated over the years underwent abdominal mass. Imaging showed it to be a large splenic successful live related Liver transplants at three diff erent centres cyst with sediments and a rind of splenic tissue all around. and are now normal. The follow up and monitoring aft er a Kasai Laparotomy, excision of large area of the cyst wall where operation and the interim management including the role of the thinning of splenic tisuue was more prominent and OGD scopy (done in two patients) is discussed in the paper. marsupialisation with omental plugging was carried out. Conclusions: BA is not a disease with a bleak outcome. The Results: Child is recurrence free 8 months aft er the surgery. tunnel through which the patient, the family and the surgeon Concusion: Laparotomy, patial excision of the cyst wall and has to pass, is long and dark, but there is light at the end of the marsupialisation was opted as 1. more common hydatid cyst tunnel. We recommend active follow up of Post Kasai patients could not be ruled out, 2. splenic salvage is preferred and 3. and active counseling for timely LT wherever necessary. recurrence is common.

169 171 Primary pull-through for Hirschsprung’s disease Sternal cleft: A case report in newborn and early infancy Kirthy Promod, Rajiv Padankatti, Rahul Yadav, Muralidharan Gowri Shankar, Narendra Babu, Ramesh S, Ramchandra C, K V, Namasivayam S K. R. Srimurthy Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India Indira Gandhi Institute of Child Health, Bangalore, India Aim: A rare case of Sternal cleft in a neonate is presented. Introduction: Primary endorectal pull-through (ERPT) for Methods: A male neonate presented with sternal cleft with Hirschsprung’s disease has become immensely popular due the thinned out skin at the summit of the swelling exposing to the simpliÞ ed approach and reduction in number of stages. pericardium and was associated with ASD. Repair was carried However there are limited studies evaluating functional out at the age of 9 days successfully. outcome of EPRT done in early infancy. Results: Doing well 1 year postoperatively. Objective: To study the safety and eff ectiveness of primary Conclusion: Presented for rarity, uncommon exposure of ERPT in early infancy. pericardium, association of ASD and to advise surgery as early Material and Methods: We retrospectively analyzed 30 infants as possible during neonatal period so as to do a simple repair (age < 3months) who underwent primary EPRT between 2004 rather than doing late complicated orthopaedic procedures -2009 at a single centre. Patient data, intra-operative events, and their long term complications. early and late complications were recorded. The stooling record examined the frequency of stooling, the incidence of 172 enterocolitis, and the functional outcome was analyzed. Anterior urethral valve / Diverticulum: A case Results: Mean age at operation was 42 days. Operative time report varied between 90 minutes to 150 minutes. There were no Kirthy Promod, Anoop, Rajiv Padankatti, Amit Gupta, Senthil complications, except for one neonate who had intra-abdominal Ganesh, Namasivayam S serous collection. Though an increased frequency of stooling was Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India seen in the early postoperative period in most of the infants, the stool frequency sett led down to 3-6/day over the next 3 months Aim: Child with anterior urethral valve / Diverticulum was in all. During the follow-up of 2-4 years the functional outcome investigated and treated like valve. Latt er repeat cystoscopy assessed was encouraging with a stool frequency of 2-4 per day. showed it to be a diverticulum. Conclusion: ERPT can be safely performed in neonatal period. Methods: Eleven months male child with dribbling showed Early functional outcome is encouraging except for increased anterior urethral valve in MCU. Cystoscopy and fulguration frequency of stools. Long term functional outcome needs of anterior urethral valve was carried out. Repeat cystoscopy further evaluation. for persistent symptoms showed a posterior lip of a posteriorly projecting anterior urethral diverticulum. 170 Results: Following fulguration of both anterior and posterior Splenic cyst: A case report lips of the diverticulum child is asymptomatic for the last 3 Kirthi Promod, Anoop, Rajiv Padankatti, Senthil Ganesh, months. Namasivayam S Conclusion: Common diagnosis of anterior urethral valve Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India and att empted fulguration of anterior lip of the diverticular opening resulted in persistent symptoms. Repeat scopy reveals Aim: A case of large splenic cyst which was managed by the diagnosis of diverticulum.

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173 There were no recurrences of blockage of the peritoneal end. Video-bronchoscopy in H-tracheo-oesophageal Conclusion: In such situations where we Þ nd the abdominal fi stula: Our experience cavity inaccessible for shunt placement, many surgeons would Amit Raut, J. Mandke, V. Sarode, S. Patil, S. Jadhav, R. Vora, consider a ventriculopleural or ventriculoatrial shunt, which Ila Meisheri can have their own additional complications. In our experience S.J.K.C.Trust’s,Paed-Surgery, P.G. Institute, Sangli of these three cases suprahepatic placement of the shunt in such (Maharashtra), India cases has shown encouraging results. We suggest, suprahepatic space can be a safe haven for the placement of peritoneal end Aim: Role of video-bronchoscopy in diagnosing H-TOF, of the shunt, in cases with peritoneal end blockage. otherwise undetected. Methods: Three cases who had recurrent lower respiratory tract 175 infections were investigated by routine methods. Although Stage-IV Burkit’s Lymphoma H-TOF was suspected in these cases, it was not detected on Usha Gajbhiye Ba-swallow, however video-bronchoscopy demonstrated Superspeciality Hospital, Amravati, Maharashtra, India H-TOF conclusively. One of the three cases was a complication of operated tracheo-oesophagel Þ stula. repair done elsewhere. 12 yr old male referred as acute abdomen followed by history of Here Cystoscope was used as a tool for video-bronchoscopy acute gastroenteritis. He was well before this episode, but in all three cases and it has given excellent view of H-TOF,and started to have recurrent vomiting and abdominal distension. it could be cannulated easily before surgery. Videos att ached Admitt ed and initially managed as sub acute obstruction and herewith. investigated. Clinically greenish aspirates form NG, afebrile, RR Results: Following Video-Bronchoscopic diagnosis usual 38/Min, distended abdomen with visible veins with ß ow below surgical management of H-TOF was carried out successfully. upwards. Abdomen was nontender, with present bowel sounds. All patients had uneventful recovery. Basic investigations were normal. USG abdomen single loop Conclusion: Video-bronchoscopy is the important diagnostic in epigastrium and right hypochondria showed edematous,? tool for diagnosis of H-TOF which is not detected by usual Gangrenous with low blood ß ow in that loop. Mesentery of radiological investigations. bowel and colon was edematous and thickened (12 and 20mm). There was minimal Ascitis in pelvis Either suprarenal area 174 had echogenic lesions. CT abdomen had correlative Þ ndings Suprahepatic placement of ventriculoperitoneal as in USG. He did not sett le with conservative management, shunt: A safe haven in cases of recurrent Underwent laparoscopy Þ ndings were mass obliterating whole abdominal end blockage lumen in jejunum, thickened, shortened, mass at base of small Janani Krishnan, Madhavi Thakur, Anant P Bangar, Prashanth and large bowel mesentery. Omentum studded with mass and Kumar, Santosh Karmarkar friable. Milky ascitis. The epiloiecae were nodular throughout Lilavati Hospital and Research Centre, India the colon. Mass in pelvis. Pleural eff usion left chest. Mass could not be resected so side to side jejunal anastomosis was done. Aim: Hydrocephalus is a common problem encountered in the Biopsy sent from jejunal mass and omentum, along with ß uid pediatric age group and in most cases, requires the placement of for cytology. Biopsy was suggestive of Burkit’ Lymphoma. a ventriculoperitoneal shunt for its treatment. These shunts are Bone marrow biopsy and trephine bone Biopsy had evidence associated with its own complications; out of which blockage of of non Hodgkin’s lymphoma. Child receiving chemotherapy the abdominal end of the shunt is a worrisome problem, owing for stage 4 Burkit’s lymphoma. This case presented for acute to multiple adhesions and pseudocyst formation. presentation of disease without any other symptoms. This child Materials and Methods: We present three cases of had very typical Þ ndings of colonic involvement. hydrocephalus with VP shunt in situ, two years, six years and fourteen years of age. All three of them had recurrent blockage 176 of the peritoneal end of the shunt due to multiple adhesions Acute abdomen due to volvulus and gangrene of in one and pseudocyst formation in the other two. In the Þ rst a huge tubular colonic duplication of the hepatic patient who presented with adhesio-obstruction, the peritoneal fl exure: A case report end was placed in the suprahepatic space on Þ nding a plastered Anurag Rastogi, Dhananjaya Sharma, Anil Khanna general peritoneal cavity on exploration. In the other two Ajanta Hospital, Lucknow, India patients, two att empts were made at repositioning the shunt at diff erent sites in the general peritoneal cavity, which were Introduction: Colon is the second most common site of enteric unsuccessful. The third time, we repositioned the shunts in the duplications and about 15-20% of all duplications of the suprahepatic space. alimentary tract involve the colon. Results: In all the three patients the shunts functioned well Case Report: A 3- year- old, male child presented with acute postoperatively aft er placement in the suprahepatic space. abdominal pain, massive abdominal distension, fever and

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 174 IAPSCON 2009 constipation for one and a half days. There was history of two Materials and Methods: A prospective study was conducted in episodes of bilious vomitings initially. There was past history Department of Pediatric Surgery between Nov 2006 and June of intermitt ent colicky pain associated with appearance of 2009. Indications of treatment were deÞ ned, all age groups visible peristalsis. The patient was taking antitubercular were included. Bleomycin was chosen as sclerosant and injected treatment for the above symptoms for the past three months. intralesionally when indicated in the dose of 0.66 to 1units /kg/ On examination the patient was critically ill, febrile, had dose diluted in 1:1 normal saline. Complications, if any and a feeble pulse and had a hugely distended and diff usely response following each session were recorded. The data was tender abdomen. Aft er a plain X Ray of the abdomen and analysed in terms of age, sex, site, size of lesion, number of initial resuscitation, the patient was explored. A huge tubular sessions and response following sclerotherapy. Response was duplication of the hepatic ß exure of the Colon measuring categorised as complete, signiÞ cant, partial and no response. more than 18 inches was found which undergone complete Results: 9 patients, with 10 lesions of cystic hygromas were volvulus and gangrene. Aft er derotation, the duplication was included in the study ranging from 10 days to 10 years of which excised and the colon repaired primarily. The postoperative 33% were females. Most common site of the lesion was found recovery was uneventful. This case is being reported for its to be on the face and neck (80%). Other sites included axilla rarity. It also highlights the importance of early diagnosis and and extremity. Number of sessions ranged from 1-6. Outcome treatment of enteric duplications since they can have varied was assessed and we found that 60% had complete response, clinical presentations that may oft en be misleading. 10% had signiÞ cant response and 10% had poor response and 20% had no response, of which one patient underwent 177 surgical excision. Minor, coorectible local complications were Complicated duodenal ulcer in an infant: A case encountered in 3 patients. Surgical excision following a course report of sclerotherapy provided easier dissection, less bleeding and Anoop, K. Senthil Ganesh, S. Namasivayam, Malathy more complete excision. Sathyasekaran Conclusions: Although surgical excision was one of the Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India mainstays of treatment of lymphatic malformation, but with high chances of recurrence and increased morbidity Duodenal ulcer disease is a rare clinical condition managed following surgical excision, sclerotherapy has emerged as an by clinicians in infancy and childhood. Because of its rarity eff ective and safer alternative. Many drugs have been used as and low index of suspicion on part of the physicians, it sclerosant, of which Bleomycin is the one used in our study. usually presents with serious complications like perforation or This study proves the effi cacy and eff ectiveness of Bleomycin gastrointestinal hemorrhage. In earlier times, the mortality for as a primary modality of treatment in lymphatic malformations duonenal ulcer hemorrhage and perforation in childhood was with excellent cosmetic results and absence of any untoward very high. However in recent years improvement in pre complications. and postoperative care of children, reÞ nement of parenteral nutrition and advancement in life support systems an improved 179 outcome has been noted worldwide. There are isolated reports Cystoscopic incision of ureterocele: Our of successful management of serious sequelae of duodenal experience ulcer in children. The present report adds a case of successful Himanshu Acharya, S B Mane, Nitin Dhende, Ashokanand surgical management of bleeding duodenal ulcer in a 10 Thakur, Abu Obaidah, Suyodhana Reddy, Pankaj Shastri, month old girl who developed the same following surgery Jamir Arlikar, Nitin Goel for a cerebral astrocytoma. In the postoperative period she Grant Medical College and Sir J J Group of Hospitals, Mumbai, developed primary peritonitis, which was managed along India side the bleeding ulcer. The successful management of the child along with review of literature about the incidence and Introduction: Ureterocele is dilatation of terminal part of ureter. management of complicated duodenal lucer disease in children It may be associated with single or duplex renal system. It discussed. can be diagnosed antenatally. It may present as urinary tract infection or urinary retension. We are presenting our experience 178 of 4 cases of ureterocele of diff erent clinical presentation. One Conservative management of lymphatic case was diagnosed antenatally, one case presented to us with malformations urinary retension another case as urinary tract infection and S N Bhatnagar, P. Darveshi, Pradeep Shenoy, Praveen Gadsing in one case it was as incidental Þ nding. Bai Jerbai Wadia Hospital For Children, Parel, Mumbai, India Materials and Method: The age group of child was between 7 months to 7 years. sonography was done in all cases. Aims: 1)To study the role of non-operative treatment modality Micturating cystourethrogram under IITV was done in 3 (sclerotherapy) in the management of lymphatic malformation. cases. Filling defect was clearly seen in early Þ lling phase 2)To establish the effi cacy of bleomycin as a sclerosant and its of Micturating cystourethrogram in all cases. In one case safety and eff ectiveness. intravenous pyelogram was done. Cystoscopic incision was

175 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 done at the base of ureterocele and above the bladder neck. occurred in few cases. 3 Fr bug bee electrodes with cutt ing current were used. All Conclusion: Thoracotomy with primary repair of the patients were kept on antibiotic prophylaxis and repeat esophagus by single layer anastomosis aft er ligation of the sonography and Micturating cystourethrogram was done Þ stula is the standard approach. This has a good postoperative aft er 3 months. result with regard to morbidity and mortality. Results: There was no reß ux or persistent Þ lling defect in two cases. Reß ux was present in one case and persistent Þ lling 182 defect was present in one cases. We are presenting the technical H-type of tracheo esophageal fistula: Our details of diagnosis and Cystoscopic incision of ureterocele. experience Himanshu Acharya, S B Mane, Nitin Dhende, Suyodhana 180 Reddy, Pankaj Shastri, Jamir Arlikar, Abu Obaidah, Nitin Goel Duplication of urethra Grant Medical College and Sir J J Group of Hospitals, Mumbai, A. S. Vaidya, P. Gadsing, P. Dharvesi India Bai Jerbai Wadia Hospital For Children, Parel, Mumbai, India. Aim: H type of tracheoesophageal Þ stula is a very rare anomaly. Background: Duplication of urethra is a rare congenital Aim of this presentation is to highlight the diffi culties in anomaly in children. Saggital duplications are commoner diagnosis of H Fistula and reÞ stula in operated case of TOF. among them. Our aim is to highlight unusual association of Material And Methods: We present three cases of Primary duplication of urethra with ectopic ureters. H-type of tracheoesophageal fistula and two patients of Case Report: 1 year male child presented with history of operated TOF with re-Þ stula. Age of patients was ranging from passing urine from perineal opening, was also passing drop 30 days to 2 months. We describe the presentation; diagnosis of urine from tip of penis. Child didn’t have incontinence. On and surgical treatment.We describe a novel approach of doing investigation child was found to have bilateral ectopic ureters bronchoscopy by using 10 french pediatric cystoscope with with left sided vesico-ureteric reß ux. child initially underwent 30 degree telescope for the visualization of Þ stula and its bilateral extravesical ureteric reimplantation followed by cannulation. Urethroplasty 3 months later. Results: All Five patients did well in postoperative period and Result: Child is now passing urine with good stream from are on regular follow up. tip of penis. Conclusion: High index of suspicion of H Þ stula is needed for Conclusion: Although duplication is a well deÞ ned entity in the timely diagnosis. Bronchoscopy is mainstay of diagnosis pediatric urology, its association with bilateral ectopic ureter for primary cases while in cases of redo H Type of Þ stula use of is unique one. betadine solution through gastric tube and compression over stomach with subsequent visualization on bronchoscopy gives 181 bett er delineation of Þ stula. Our experience with management of esophageal atresia with tracheo esophageal fi stula from 2007 183 to 2009 Unusual presentation of hemolymphoid Arun Dash, H K Mohanty, P C Subudhi, R N Dash, P K Mohanty, malignancies R K Mohapatra, Akash Pati Anoop, K. Senthil Ganesh, S. Sridaran S V P Post Graduate Institute of Pediatrics, S C B Medical Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India College, Cuttack, India. The typical presentation of hemolymphoid. Malignancies is Aim: To study the short term outcome of surgery for commonly painless. Lymphadenopathy as in lymphomas or Esophageal atresia with Tracheo esophageal Þ stula (EATEF) with clinical picture pertaining to bone marrow changes as in operated during 2007 -2009 in our institution. hematoid malignancies. Herewith presenting three children Methods: Repair of EAlTEF using a thoracotomy incision is the with unusual clincal presentations causing diffi culty and delay standard approach in our institution. P.cri-operative mortality in diagnosis of the disease. 1) 1.5 Yrs of age presenting with though very uncommon it is associated with significant a suspected abcess cheek, drained elsewhere, subsequently morbidity in some cases. developed a second swelling in the inguinal region, suspected Results: With approximately 20% mortality the signiÞ cant To be an obstructed hernia, finally diagnosed to suffer associated morbidities are anastomotic stricture requiring from granulocytic sarcoma 2)8 month old infant initially dilatation are approximately 40%. Gastroesophageal reß ux managed as empyema thoracis/purulant pericarditis and requiring anti reß ux procedure was quite low at about 5%. later diagnosed to have T cell lymphoblastic lymphoma with Anastomotic leak was present in approximately 25% of cases pericardial secondaries 3)single cystic neck swelling in a 2.5 which was associated with mortality in 50% of cases. Few Year old, initially suspected to be a cystic hygroma/mixed complications like winging of scapula and scoliosis also malformation and diagnosed to have a large cell lymphoma

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 176 IAPSCON 2009 above presentation done to highlight unusual presentations of NADPH diaphorase reaction was less than in controls and and need for high degree of clinical suspicion when evaluating some abnormal ganglia were present. On statistical analysis unusual lesions and symptoms especially in a smaller child. (Pearson’s correlation) the bowel circumference correlated signiÞ cantly with plexus width in circular and longitudinal 184 axis both in distal and control bowel. There was no reduction Rare association of idiopathic hypertrophic pyloric in the number of myenteric or muscular ICCs. stenosis in a case of tracheoesophageal fi stula: Conclusions: The distal bowel has near normal plexus A case report architecture and dimensions with no reduction in ICCs. This Anurag Rastogi segment of bowel does not seem to be signiÞ cantly aff ected Fatima Hospital, Lucknow, India by in-utero vascular accidents that cause small bowel atresia.

Introduction: Patients with Tracheoesophageal Þ stula (TEF) 186 are known to have other associated anomalies. Laparoscopically assisted anorectoplasty for high Case Report: Association of TEF with hypertrophic pyloric and intermediate imperforate anus stenosis (HPS) is rare; and adequate management requires Rasik Shah, Ashokanand Thakur, Jamir D Arlikar, Nitin P timely clinical suspicion since the cardinal symptom of HPS Dhende, Suyodhan Reddy, Pankaj Shastri, Abu Obaidah, viz. nonbilious vomiting mimicks the common complications Himanshu Acharya, Nitin Goel associated with TEF repair viz. gastroesophageal reß ux Grant Medical College and Sir JJ Group of Hospitals, Mumbai, (GER) and stricture of the anastomotic site. We report an India infant who underwent primary repair of TEF on day 2 of life, was discharged on the 8th postoperative day and Aim: We would like to report our experience of Laparoscopic subsequently developed nonbilious vomitings on day Anorectoplasty for high and intermediate variety of imperforate 28 of life. Aft er ruling out the possibility of anastomotic anus. This is the retrospective review of laparoscopic stricture and GER; and thoroughly examining the patient, anorectoplasty performed over last 5 years. a provisional clinical diagnosis of hypertrophic pyloric Material and Methods: Fifteen patients underwent stenosis was made which was conÞ rmed by radiological laparoscopic anorectoplasty with the age range from 5 months investigations. The patient subsequently underwent to 7 years. Nine patients had transverse colostomy and six pyloromyotomy for the same and is presently thriving well patients sigmoid. The laparoscopic repair was performed at 14 months of follow up. using three ports. The rectum was mobilized using monopolar diathermy or Harmonic scalpel. The Þ stula was ligated only 185 in Þ rst the four patients in our series and aft er that the Þ stula Innervation of the distal bowel in Jejunoileal is divided without ligation. Sphincter muscle complex was atresia identified using muscle stimulator on perineal side and Priya Ramachandran, Rajiv P, Kirthy Pramod R tunnel was created by laparoscopic assistance using Veress Kanchi Kamakoti CHILDS Trust Hospital, Chinnai: India Needle, guide wire, PCNL dilators and Hegar’s dilators. The maximum Hegar’s dilator size used was 14 or 15 number, Background: Small bowel atresia is a common cause of neonatal so that the mobilized rectum could be easily accommodated bowel obstruction. In-utero ischemic vascular accidents are in the tunnel. There was no conversion and blood loss was believed to be the cause of type III A atresias. Our study minimum during the procedure. aimed at examining the changes in cholinergic and nitrigenic Results: Postoperatively mucosal prolapse was seen in 3 innervation in myenteric plexus of the distal bowel as well as patients and was excised under general anesthesia. Rectal C-kit positive interstitial cells of Cajal (ICCs) that may have retraction was seen in one patient and required revision on D 10 occurred due to in-utero ischemia. postoperatively. On follow up clinically all patients have good Methods: Whole mount preparations made from the distal sphincter tone and anal sensation. However long term follow bowel of three neonates with type III A atresia were stained up is awaited to comment upon continence in these patients. with Acetylcholine esterase and NADPH diaphorase. Conclusion: Laparoscopic repair of ARM is feasible in high The myenteric plexus was examined for morphological and intermediate variety. Long term results are awaited for abnormalities. A morphometric analysis of width of plexuses in continence. the circular and longitudinal axis was also done. Full thickness specimens from the same points were stained for enzyme 187 immunohistochemistry using anti-S 100 and anti C-kit receptor Our experience in laparoscopic correction of (CD 117) antibodies in conventional paraffi n sections. Control malrotation bowel from two neonates was also studied. Rasik Shah, Pankaj Shastri, S. B. Mane, Nitin P. Dhende, Abu Results: The polygonal architecture of the myenteric plexus Obaidah, Suyodhan Reddy, Jamir Arlikar, Himanshu Acharya, of distal bowel was similar to controls. However the intensity Nitin Goel

177 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009

Grant Medical College and Sir J J Group of Hospitals, Mumbai, with full feeds on second day and patient was discharge. India Patient is following up regulary and have not developed any complains. Aim: To present our experience of correction of malrotation of Conclusion: Chronic abdominal pain can be caused by rare bowel using laparoscopic techniques. internal hernia. One may not Þ nd any defect for the closure. Material and Methods: This is a retrospective analysis of 5 cases of malrotation corrected laparoscopically. All cases 189 presented with chronic abdominal pain and were referred with Laparoscopic repair of achalasia cardia: Our the barium study suggestive of malrotation. Three patients experiences were referred with the CT scan of abdomen. One patient had Rasik Shah, Jamir Arlikar, Nitin P Dhende, Ashokanand Thakur, appendicectomy for chronic abdominal pain and one patient Suyodhan Reddy, Pankaj Shastri, Abu Obaidah, Himanshu had exploratory laparotomy with jejunal stricturoplasty before Acharya, Nitin Goel referral. Four ports were used; one camera port, two working Grant Medical College and Sir JJ Group of Hospitals, Mumbai, ports and one port for retraction of colon. Thirty degree camera, India either 5 mm or 10 mm was used in all cases. Standard steps of the open surgery were performed in laparoscopic correction Aim: This is a report of patients who have undergone of malrotation, i.e., division of Ladd’s band on duodenal wall, laparoscopic repair of Achalasia cardia over last 5 years. widening of base of mesentery, straightening of the DJ ß exure Material and Methods: The age range was 3 years to 14 years. and appendicectomy. Diagnosis was based on clinical symptoms and it was conÞ rmed Results: Age ranged from 3 year to 18 year. All patients had with Ba swallow. In one patient esophageal manometry was excellent post operative recovery and were on full feeds by also performed to confirm the diagnosis. Laparoscopic third day and discharged from the hospital. One patient esophagomyotomy with anterior Dorr’s Fundoplication was came back with bilious vomiting and underwent exploratory performed. Operative time was 150 mins to 200 mins. Blood laparotomy with possible diagnosis of adhesive obstruction. loss was minimal. The orals were started on the Þ rst or second However, he was found to have duodenal obstruction due to post operative day and patients were discharged on 3rd or 4th duodenal stenosis and underwent gastro-jejunostomy with post operative day. uneventful recovery. Results: Clinically there was immediate and long term Conclusion: Laparoscopic correction of malrotation is feasible resolution of the symptoms. Post operative barium swallow with excellent outcome. In older patient upper gastrointestinal showed disappearance of rat tail appearance of the lower endoscopy should be performed preoperatively to rule out associated intra-luminal obstruction so that it can be tackled esophagus. On follow up of 1 to 60 months all patients are in the same surgery. doing well. Conclusion: Laparoscopic repair of Achalasia cardia is feasible 188 in children with excellent results and long term outcome. Paraduodenal hernia: Laparoscopic management 190 Himanshu Acharya, Rasik Shah, S. B. Mane, Nitin P. Dhende, Abu Obaidah, Jamir Arlikar, Suyodhan Reddy, Pankaj Shastri, Our experience with laparoscopic Spleenectomy Nitin Goel in children Grant Medical College and Sir J J Group of Hospitals, Mumbai, Rasik Shah, Suyodhan Reddy, S. B. Mane, Nitin P. Dhende, India Abu Obaidah, Pankaj Shastri, Jamir Arlikar, Himanshu Acharya, Nitin Goel Internal abdominal hernias are rare conditions, accounting Grant Medical College and Sir J J Group of Hospitals, Mumbai, for 0.9% of all intestinal obstructions. Paraduodenal hernias India constitute half of all internal abdominal hernias. Case Report: A 10 Year old girl with complains of chronic Aim: Splenectomy is frequently required in children for various abdominal pain without any associate fever or vomiting was haematological conditions. With advances in the minimally referred for further management. The barium meal follow invasive surgery, laparoscopic splenectomy (LS) is becoming through and sonography of abdomen was performed and were the standard of care. Herewith we present our experience with reported to be normal. Patient was taken up for diagnostic laparoscopic spleenectomy. laparoscopy, which revealed large right paraduodenal hernia. Materials and Methods: This is the retrospective review of the Almost entire small bowel, caecum, appendix and part of the patients who underwent laparoscopic spleenectomy (n=21). ascending colon were in the hernial sac. The anterior boundary Age of patient ranged from Þ ve to nine years. The indication of the hernial sac was formed by the superior mesenteric for LS were Thalessemia Major in 13 patients, 5 patients were vessels. Aft er reduction of the content there was no defect in of Hereditary Spherocytosis and 4 patients with ITP. Four ports the mesentery which could be closed. The operative time was were inserted in the arch fashion 3-4 cm away from the palpable 60 mins and there was no blood loss. The recovery was excellent edge of the spleen. Ten mm 30 degree telescope, two working

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 178 IAPSCON 2009 ports and one port for retraction of the spleen was used. In repair and release of buried penis with urethroplasty did well our technique we open the lesser sac and control the splenic in postoperative period. artery Þ rst and then mobilise the spleen from its att achments. Conclusion: Judicious use of local skin ß ap is very useful in The splenic artery was clipped in four patients, ligated in 14 Redourethroplasty. When there is scar over penile skin that patients and staplers were Þ red in 3 patients. The harmonic can’t be used as neourethra then free graft should be used. scalpel was used in 14 patients and in two patients’ combination BEAM should not be done in previously operated Snodgrass of bipolar and monopolar diathermy was used for mobilisation urethroplasty as urethra was incised dorsally is relatively of the spleen. The specimen was extracted by inserting it in weak when it heals hence not advisable to mobilize it. Re do the everted Ziplock plastic bag successfully in 13 patients. Snodgrass urethroplasty for previously failed Snodgrass may In remaining patients they were removed by extending the not do well in all cases, depending upon pliability of urethral incision of camera port, subcostal or Pfennesteil incision. plate one should plan. Mathieu`s Flip ß ap is very good repair Result: The operative time was 90 min to 200 min. There were for distal cases with open glans wings. two conversions to open procedure due to excessive bleeding. In all other patient was blood loss was less than 30 ml. One 192 patient developed epigastric pain aft er 3 weeks of surgery Miliary abscesses in MDR tuberculosis and investigation revealed presence of portal vein thrombosis. P. Darveshi, S. N. Bhatnagar, P. Gadsing, P. Shenoy There was no mortality in our series. Bai Jerbai Wadia Hospital For Children, Parel, Mumbai, India Conclusion: Laparoscopic splenectomy is safe and eff ective procedures in children. Aim: To highlight the uncommon presentation and multiple sites of abcesses in MDR Tuberculosis. 191 Case Report: A 10 years female presented to us with cervical, Use of local skin fl ap in Redourethroplasty in axillary swellings and pain in the abdomen since 15 days. hypospadias Swellings were soft , cystic & nontender. Patient had a prior Ashokanand Thakur, S B Mane, Nitin Dhende, Himanshu history of abcess at the Left shoulder joint for which she had Acharya, Abu Obaidah, Suyodhana Reddy, Pankaj Shastri, undergone debridement twice and on investigation was found Jamir Arlikar, Nitin Goel to be tuberculous in origin so was started on Þ rst line AKT, Grant Medical College and Sir J J Group of Hospitals, Mumbai, which patient was taking since about 1 year elsewhere. For India abdominal pain ultrasonography of abdomen done which showed multiple mesenteric abcesses, conÞ rmed by CT-scan Introduction: The goal of redourtehroplasty is to achieve Abdomen. Patient was treated with non dependent aspiration functional penis with meatus at tip and normal cosmetic of Cervical Abscess and open drainage of the abdominal and appearance. We have done redourethroplasty in 13 cases in axillary abcesses, was continued on Þ rst line AKT awaiting last 2 years. We have use local skin ß ap in majority of cases culture and histopathological reports. and end result was good. Result: Despite Þ rst line AKT therapy patient had reÞ lling Material and Method: We have done redourethroplasty in of the cervical abscess which required reaspiration twice. 13 cases in last 2 years. The primary surgery was Snodgrass meanwhile the culture showed growth of Mycobacterium urethroplasty in 4 cases, with prepucioplasty in 2 case. Duckett ’s tuberculosis resistance to the Þ rst line antituberculous drugs, tube urethroplasty was done in 2 cases and in one cases BEAM sensitive to 2nd line drugs- Ethionamide, Moxiß oxacin & procedure was done. Primary surgery was not known in 6 Amikacin. Patient is currently started on these drugs with cases as they were operated outside. Out of 13 cases 10 cases good response. presented with open glans wing with sub coronal meatus. Conclusion: The modern era of tuberculosis recently has been In one case there was associated buried penis. Two patients characterized by a rise in the number of cases of multi-drug had penoscrotal meatus and one case presented with two resistant tuberculosis leading to increased morbidity. Drug diverticulum. We used local skin ß ap (Mathieu’s Flip- ß ap) in 6 resistance should be suspected whenever therapeutic progress cases. In one case we used two split onlay skin ß aps. Snodgrass is not maintained and relapse occurs. Close follow up with early urethroplasty was done in 3 cases and BEAM was done in 1 suspicion is mandatory to reduce morbidity. cases. Diverticulum repair with urethroplasty was done in one case and release of buried penis with urethroplasty was 193 done in one case. Neonatal intestinal obstruction – peculiar Result: Total seven patients were operated with the use of challenges local skin ß ap. 6 patients passed single good in postoperative P. Gadsing, P. Shenoy, P. Darveshi, S. N. Bhatnagar. period. Two patients of Snodgrass urethroplasty developed Bai Jerbai Wadia Hospital For Children, Parel, Mumbai, India fistula. The patient operated with BEAM procedure had complete breakdown of glans. The primary surgery in this Aims: To highlight peculiar diagnostic challenges while case was Snodgrass urethroplasty. Patients of diverticulum managing neonatal intestinal obstruction.

179 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009

Methods and Materials: A prospective study was conducted CT scan chest & Barium swallow showed a linear tear in the in Department of Paediatric Surgery between Feb 2009 to lower third of oesophagus, Feeding gastrostomy was done June 2009 of neonates who presented to us with unusual form and child was kept nil per oral for one month. He was also of intestinal obstruction. Patients were worked up in detail. kept on I V antibiotics and gastrostomy feeds. A repeat Barium Indications of operative treatment deÞ ned. Their investigations swallow done aft er 5 weeks of injury did not show any tear in. and management are described. oesophagus. The child was started oral feeds and gastrostomy Results: 3 neonates, of which 2 were male & 1 female, all removed and was discharged home in good condition. In this FTNVD, with age range of 7 to 10 days were included in the presentation the diagramatic picture of mode of injury as study. The peculiar symptomatic challenges were sudden well as CT scan & Barium Swallow Þ lm photographs will be onset absolute constipation aft er having passed meconium illustrated along with a brief discussion of relevant literature. for Þ rst 4-5 days and presenting with features of intestinal obstruction. Investigations with radiographs, dye studies 195 and blood investigations were not very conclusive. An initial Preputioplasty conservative management with bowel washes, drip and suck Shivaji B Mane, Jamir D Arlikar, Nitin P Dhende, Suyodhan and antibiotics for 48 hours did not show any changes in the Reddy, Dr. Pankaj Shastri, Dr. Ashokanand Thakur, Dr. Abu obstructive patt ern. Surgical exploration did not reveal any Obaidah, Dr. Himanshu Acharya, Dr. Nitin Goel. obvious pathology as the cause of obstruction, in spite of which Grant Medical College and Sir JJ Group of Hospitals, Mumbai, an ileostomy with multiple biopsies was performed in all of the India three patients. Histopathological reports were inconclusive. In one baby, ileostomy was closed aft er conÞ rming distal patency Aim: This is report of patients who have undergone a month aft er stoma creation, but child expired aft er 2 months hypospadias repair with preputioplasty. Main purpose was at home. 2nd child developed generalised sepsis soon aft er to get an uncircumcised penis aft er the repair on demand of surgery, and succumbed 10 days post-operatively. The 3rd parents. neonate is awaiting closure of ileostomy. Materials and Methods: Hundred and twenty Þ ve patients Conclusion: Intestinal obstruction remains one of the most underwent preputioplasty along with the hypospadias repair. common conditions seen in the neonatal period. Early Age range was 9 months to 7 years. All patients had distal diagnosis depends largely on the prompt detection of hypospadias without chordee and torsion. Depending upon obstructive manifestations by the clinician and the subsequent the site of meatus, urethral plate and glans various repairs done accurate interpretation of radiographic Þ ndings and other were MAGPI, GRAP, Snodgrass urethroplasty and Snodgraft investigations. Although relatively straightforward at times, along with preputioplasty. Preputioplasty was done in twenty sometimes it may be very diffi cult to diagnose and even more patients who underwent MAGPI, hundred patients with diffi cult to treat as seen in our series. Snodgrass, three with GRAP and two with Snodgraft . Dorsal vertical slit was given when the prepuce is tight and sutured 194 transversely. Oesophageal rupture by compressed air (Tyre Results: Immediately in postoperative period there is increase tube): A case report in edema which starts subsiding by second week. Steroid Yogender Singh Kadian, K. N. Rattan, Pradeep Kajal, Nityasha, ointment helps in retraction of prepuce. One patient had Shalini Aggatrwal complete preputial dehiscence. Three patients had phimosis but Pt.B.D. Sharma PGIMS Rohtak, India that was in earlier part of our experience, when we resorted to dorsal slit there was no incidence of phimosis. Seven patients Compressed air is a rare cause of rupture of the oesophagus. with Snodgrass repair had Þ stula. Rest all patients have good These types of injuries commonly occur in factories where cosmetic appearance and uncircumcised penis as desired by compressed air hoses are employed. However, such accidents parents. are also reported in children following accidental biting of the Conclusion: Preputioplasty eff ectively gives good cosmetic inner tube of the tyre of tractor or cars. We have successfully appearance with uncircumcised penis as desired by parents. managed an 8 years old child with oesophageal rupture following accidental bursting of a tyre tube into his mouth 196 when he was playing with the same. The child was admitt ed in Variable presentation of mullerian anomalies with Paediatric Surgery ward with severe chest pain & respiratory hematometra and its management distress following the injury. On examination there was surgical Pankaj Shastri, S. B. Mane, Nitin P. Dhende, Suyodhan Reddy, emphysema on left side of chest extending into neck and there Jamir Arlikar, Himanshu Acharya, Abu Obaidah, Nitin Goel was decreased air entry on left side. X-ray chest revealed left Grant Medical College and Sir J J Group of Hospitals, Mumbai, side pneumothorax and left intercostals tube was put in. The India child was put on ventilator for 48 hours and also started on intravenous ß uids and antibiotics. When he was given oral Aim: Though the Mullerian duct anomalies are rare in feeds, saliva and milk started coming from left chest drain. incidence but their variable age, and mode of presentation

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 180 IAPSCON 2009 makes the management diffi cult. The treatment depends upon Superspeciality Hospital, Amravati, Maharashtra, India the type of anomaly. Material and Methods: We have managed 3 patients of 15 mth male child att ended hospital with ulcerated fungated hematometra with diff erent types of mullerian anomalies. mass over scalp. Mass initially appered as small nodule, They have presented to us with lower abdominal pain and grown rapidly over 6 mth period and got ulcerated one month lump in lower abdomen. Patients of uterine didelphys had before child was reff ered to us. Was treated locally as infected normal menstruation.These two patients of uterus didelphys, sebacious cyst. Clinically he had above mentioned lesion one patient had vertical septum separating the vagina into two of size 8-9 cm at ulcerated area and base was 6-7 cmin left halves and a transverse vaginal septum on left side, another parietooccipital region. There was another nodule measuring had cervical agenesis on the right side with normal opening 3-4 cm below above mass with puckered skin. He also had in normal vagina. Third case is agenesis of lower 2/3 vagina. half of his scalp on same side was black discoloured, multiple Patient of uterine didelphys one with the transverse septum cafe au lait spots seen over the both lower limbs, back and underwent excision and in another with cervical agenesis, abdomen. Lymph nodes developed in the right neck very hematometra drain through the vagina and drain kept across rapidly over a period of 15 days. Child underwent wide the opening. Patients of vaginal agenesis underwent sigmoid local excision of mass along with nodule and primary skin colon vaginoplasty. graft . Healed well within a period of 10 days. Biopsy from Results: The patients of vaginal agenesis who underwent specimen revealed highly malignant blue round cell tumour. sigmoid colon vaginoplasty is on regular average follow up Immunohistochemestry studies were advised and child was with normal menstruation for last two year, without any sent for further management to higher center. Rarity of scalp complaint.The per vaginal examination showed that the malignancy in such small child. Delayed diagnosis due to its neovagina was of adequate caliber. Both the uterine didelphys rarity and association with skin lesions. patient is on regular follow up of six month to two year and non have any complaint. 199 Conclusions: Mullerian duct anomalies can be presented in Solid tumors in infancy: An audit any age group and with variable symptoms. At peri- pubertal P. Darveshi, S N Bhatnagar, P. Gadsing, P. Darveshi, A. Swami, age, girls presenting with lower abdominal pain with normal B. Agarwal menstruations does not rule out Mullerian anomalies and Bai Jerbai Wadia Hospital For Children, Parel, Mumbai, India hematometra. Correct evaluation of this patients and proper management is a challenge. Sigmoid colon vaginoplasty is an Aim: To audit the demographics and outcome in infants with excellent procedure for complete or partial vaginal agenesis. solid tumors treated in a tertiary care pediatric hospital in India and to analyse the factors aff ecting their poor outcome in an 197 att empt to improve the current status. A rare case of benign multilocular cystic nephroma Methods: Retrospective case cohort study was performed in Gogoi M, Bhattacharvva NC the department of pediatric surgery at B.J.Wadia hospital for Gauhati Medical College and Hospital, India children, Mumbai by retrieving data from Þ les between January 1996 to December 2008. Demographic details, surgical details, Multilocular cystic nephroma is an uncommon, usually treatment protocols and outcome were reviewed. benign, renal neoplasm characterized by a well-encapsulated Results: 55 infants( M:F 1.2:1) with the ages ranging from mass of noncommunicating, ß uid-Þ lled locules separated by day 1 of life to 12 months of age, mean age of 5.18months thin septations. It has a bimodal age and sex distribution, over a period of 12 years were managed in the departments aff ecting boys from 3 months to 4 years of age, and women of Pediatric Hematology Oncology and Pediatric Surgery at over 30 years of age. The tumor usually presents as a BJ Wadia hospital for children. Of the 7 neonates, 4 had been non-painful abdominal mass in children. We present our antenatally diagnosed to have an abdominal mass, which was experience with a rare case of benign MLCN of the right conÞ rmed postnatally. 51 of the infants had tumors which were kidney in a 7 yrs old male child who presented with a > 5 cms. in size and none of these were diagnosed antenataly. painless huge abdominal swelling. Patient was treated by of SpeciÞ c diagnostic workup included tumors markers(69%) surgical excision (right nephrectomy) of the tumor. The tumor and pre-operative biopsy(25%). Neuroblastoma was found weighed 8kg while the weight of the patient aft er removal of to be the commonest tumor(22%), Hepatoblastoma(18%), the tumor was 12kg. The patient had an uneventful recovery Malignant germ cell tumor(16%), soft tissue sarcomas(13%), aft er undergoing complete resection of the cystic nephroma and others(11%). 17(31%) babies received neoadjuvant and is doing well in follow up. chemotherapy and about an equal number received adjuvant therapy. 45% of the children underwent surgical removal of 198 the tumor of which gross total resection could be achieved Mischievous round cell tumor of scalp in just 34.5%. Of the overall mortality of 31%, chemotherapy Usha Gajbhiye, B Shah related deaths occurred in 25%. A high incidence(34.5%) of

181 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 non-compliance left behind just an equal number of patients well accepted. Most TIVAD have been advocated for solid who are alive and well, TFS from 2 to 12 years. malignancies requiring long term chemotherapy. We present Conclusions: Treatment failures from deaths or non-compliance our experience with the use of TIVAD in children with both to therapy amounted to 65.5%. These are the two major issues hematological and solid malignancies which need to be addressed in the future management of Material and Methods: We retrospectively analyzed 23 infantile tumors in our institution. Large tumors with delayed children referred to us from regional cancer centre for insertion presentations led to unfavourable outcomes, hence we of venous access from 2004-2009. The age ranged from 8 months recommend eff orts for early detection of the tumors in lower to 4 years. Internal jugular vein using Seldinger’s technique stages of the disease and increased surgical interventions to was used for venous access. improve long-term tumor free survival in infants. Results: The duration of venous access ranged from 3 months to four years. There was one intra-operative complication and 200 one early complication in the from of migration. There where Preliminary experience of thoracoscopic three minor late complications on follow up. There were no thymectomy in pediatric myasthenia gravis mechanical complications in the follow-up period. Rajesh Jain, Ketan Parikh1, Amrish Vaidya1, Anaita Hegde2 Conclusion: TIVAD can be safely utilized in the delivery of Clinical Associate Dept. of Pediatric Surgery, 1Consultant long term chemotherapy with minimal morbidity. Pediatric Surgeon, Kokilaben Dhirubhai Ambani Hospital Mumbai, 2Pediatric Neurologist, Jaslok Hospital, Mumbai, India 202 Role of thoracoscopic decortication in advanced Conservative medical management has been the main stay empyema: A study in the treatment of myasthenia gravis. Thymectomy, as a Dhiraj Parihar, Gowrishankar, Narendra Babu, S. Ramesh, surgical treatment, is being off erd to an increasing number of C. Ramachandra patients in recent times. Various approaches have been used Indira Gandhi Institute of Child Health, Bangalore, India for thymectomy of which sternotomy is the most commonly used.Thoracoscopic thymectomy represents a minimally Introduction: Video Assisted Thoracic Surgery (VATS) has invasive alternative to traditional thymectomy via sternotomy. Þ rmly established its utility in early empyema. But, its role in We present our preliminary experience with Thoracoscopic late stages of empyema is not well established and needs to thymectomy as a deÞ nitive treatment for myasthenia gravis. be considered Three children ages ranging from 3-18years underwent Aim: To study the feasibility, safety and effi cacy of VATS in Thoracoscopic thymectomy for myasthenia gravis have been advanced empyema in children reviewed retrospectively. Thoracoscopic thymectomy was Materials and Methods: A total of 66 children presented to our typically performed via the right thoracoscopy using three institute in the last 2 years with empyema. Of these, 18 were or four ports. A complete gland resection was possible in all advanced empyema with thick peel and entrapped lung. Pre- cases and the procedure could be completed thoracoscopically operative imaging included chest ultrasound and C T scan. VATS in all cases. Mean operating time was 2 hours and 45 minutes. was att empted in this group. The results were analyzed with There were no intra or post-operative complication. Length respect to the total operative time, blood loss, any intra-operative of hospital stay averaged 2 days. Minimum post thymectomy problem, necessity for conversion and the post operative out com duration of follow-up in the VATS patients is six months Results: The age range was 11 months to 4 years (mean age - with all patients clinically improving over their base line 2.5 yr). Of the 18 cases taken for VATS, we could successfully status. Complete thymectomy, the goal of traditional surgical complete in 10 without any signiÞ cant intra-operative events.. treatment for myasthenia gravis can be eff ectively achieved via 8 children required conversion due to underlying signiÞ cant this minimally invasive technique. It signiÞ cantly shortens the parenchymal lesions &/or very adherent peel. The average post operative hospital stay, decreases blood loss and off ers operative time in VATS group was 96 min; the average post superior cosmetic results. operative stay was 5 days. 201 Conclusion: There is a deÞ nite role for VATS in advanced empyema due to the obvious advantages. Good preoperative Totally implantable venous access devices for long imaging and planning is vital for a successful out come. term chemotherapy in children: An institutional experience Gowri Shankar, Narendra Babu, Ramesh S, Ramchandra C., 203 K.R. Srimurthy Our experience of ureteric substitution in pediatric Indira Gandhi Institute of Child Health, Bangalore, India age group Abu Obaiadah, S B Mane, N P Dhende, Suyodhan Reddy, Introduction: Totally implantable venous access devices allow Jamir Arlikar, Himanshu Acharya, Nitin Goel, Pankaj Sashtri, for bett er treatment of children with malignancies, and are Grant Medical College and Sir J J Hospital, Mumbai, India

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Aim: Present objective of this study is to look for suitable 205 ureteric substitute in the paediatric age group. Two cases of Aphallia Material and Method: Retrospective analysis was done from Parag J. Karkera, Paras Kothari, Abhaya Gupta, Gursev 2003 to 2008 of all cases operated in our hospital that had Sandlas, Prashant Joshi underwent ureteric replacement. All cases were followed up LTMG hospital, Sion, Mumbai, India to look for conduit patency, renal function and any related complication. Case 1: 6months child reared as male came with a small Result: In five cases ureteric replacement was done. Age rudimentary phallus since birth and passing urine & ranged from 6 month to 9 year. Three cases were of obstructive stools from normally situated anal opening since birth. megaureter; one was of redo-pyeloplasty and one case was of On investigations, serum testosterone was raised and iatrogenic injury of ureter. Three patients underwent partial b-hcg, Ldh levels were normal. On clinical examination of ureteric substitution of right ureter and in one patient complete external genitalia, a small rudimentary phallus was palpable replacement of left ureter with appendix was done. In one case (hypoplastic corpora). Scrotum was well developed with small bowel as Monti tube was used to substitute ureter. At both testis descended. There was no identiÞ able urethral median follow up of 23 month (14-66 month) all the patients opening. Anal opening was very small and skin lined soft were well except in one case who had slight decrease in renal tissue of 3x2cm-pyramid shaped seen at anterior anal verge. function. On examination under anaesthesia, rudimentary glans Conclusion: We believe that our small series supports that & prepuce with hypoplastic corpora seen aft er releasing either appendix or small bowel as Monti’s tube should be preputial adhesions present at the site of phallus-no urethral considered as ureteric replacement when confronting with meatus or plate seen. Urethral opening was seen on anterior short ureter in paediatric age group. wall of rectum 2-3cm from anal margin. Anus was small and stenotic. Y-V cutback Anoplasty was done. MCU showed right 204 grade II VUR and good capacity bladder. Urethroplasty & Post-operative evaluation by MRI and manometry Phalloplasty is planned later. in 9 cases of Intermediate ARM after Sacro- Case 2: 6yr old child reared as male with perineal urethroplasty perineal pull through using muscle stimulation done in infancy. Clinical examination revealed aphallia and Saji Vargheese, Jacob Chacko, Sudipta Sen, Sampath Karl, left undescended testis. Plan:Orchiopexy, phalloplasty later. John Mathai, Reju Joseph Thomas Aphallia is seen in 1 in 30 million births and is due to complete Christian Medical College and Hospital, Vellore, Tamil Nadu- or partial failure of genital tubercle to develop. Genitourinary 632004, India anomalies are reported in 54% of aphallia patients and more proximal the meatal opening, more severe the associated Aim: 1. To determine surgical and functional outcome in anomalies & higher the mortality. children with Intermediate anorectal malformation who have undergone sacro-perineal pull through aft er accurate localization of sphincter complex during surgery using a 206 muscle stimulator. 2. To study the relationship of the pull High anorectal malformation with sigmoid through rectum to the anorectal sphincter complex post- perforation operatively by pelvic MRI. Parag J. Karkera, Paras Kothari, Abhaya Gupta, Gursev Materials and Methods: 9 children with aged ranging from Sandlas, Prashant Joshi 5months to 13 months (Mean age 9mths) between 2006-9 LTMG hospital, Sion, Mumbai, India underwent sacro-perineal pull through in our department. All had accurate localization of the sphincter complex using muscle A DAY 1 male child, presented with imperforate anus at stimulator at the time of surgery and anorectal manometry and birth with distension of abdomen..Clinically, there was gross MRI evaluation of the pelvis post operatively. abdominal distension, with tenderness all over and absent Results: The position of the neo anus was in normal position bowel sounds.. X ray abdomens erect revealed free gas under in all nine children. Anal manometry showed average anal diaphragm. In view of poor general condition and abdominal resting pressure of 63.3 cm of H2O which indicates that the distension causing respiratory distress,abdominal drain was bowel is within the sphincter complex. Recto-anal inhibitory inserted under LA. Meconium and air was released, which reß ex was present in 4/9 children. Pelvic MRI showed that the decreased the abdominal distension. I.V. ß uids and antibiotics rectum was in the centre of pubo-rectalis in all nine children. were started. Next day, exploratory laparotomy was donewhich Conclusions: With intraoperative localization of the sphincter revealed meconium peritonitis and rectum ending above the complex with muscle stimulator, the bowel can be placed levator ani complex suggestive of high Anorectal malformation. in the centre of the puborectalis sling with out dividing the Longitudinal perforation in the sigmoidwas found and right sphincter complex (divided in PSARP), thus avoiding Þ brosis transverse colostomy, perforation closure and peritoneal and damage to the sphincter muscle complex. This may results lavage was done. Post operatively patient required prolonged in bett er functional outcome in the long term. ventilator support and was discharged by post-op day 24 on

183 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 full orals and healthy functioning stoma. Conclusion: Sternal cleft is a rare anomaly. Fracturing the clavicle helps in easy closure of the defect at its widest point 207 without any cardiac embarrassment. “Buried strip” urethroplasty with tunica vaginalis pedicled fl ap for re-do hypospadias 209 Uday Sankar Chatterjee Cloacal exstrophy: Putting the gut to use Park Medical Research & Welfare Society, Kolkata, India John Mathai, J Chacko, S Sen, Sampath Karl, Reju Thomas Dept of Paediatric Surgery, Christian Medical College & Hospital Introduction: Vascularity of the neourethra determines the Vellore, Vellore, Tamilnadu 32004, India outcome of urethroplasty. In re-do urethroplasty the residual urethral plate or the skin (intended to be neourethra) are Cloacal exstrophy represents one of the most severe congenital usually less vascular than the native plate and during creation anomalies compatible with life. None of the organ systems of tube in urethroplasty, vascular supply may be diminished are exempt, especially those developing from the caudal further due to the gradual tangential separation of ‘plate’ from pole of the fetus. There is marked variation amongst aff ected subcutaneous tissue. Author reports the experience of “Denis individuals, with respect to the external appearance and the Browne’s buried strip” principle in re-do urethroplasty. internal anatomical arrangement. Our case was unique in that Patients and Method: Since December 2005 to Jan 2009, in there was an isolated type IIIa ileal atresia. We summarize our 28 patients had the failure of previous urethroplasty and the 5yr experience of managing one such patient, using staged previous att empt of urethroplasty were in the range (mean)of repair. At the Þ rst stage the exstrophic central bowel plate was 2-6(2.5) times. Buried strip urethroplasy and wrapping with separated from the exstophic hemibladders. This was, followed Tunica Vaginalis Pedicled Flap (TVPF) were done in all cases. by bladder closure with Rectus abdominis onlay ß ap six months Supra pubic cystostomies were done in eight patients to avoid later. The urinary tract was Þ nally reconstructed by fashioning the bad eff ects of post op penile erection. an ileal neobladder, with bilateral ureteric reimplantation Results: Post-op uroß owmetry was satisfactory in 26 patients. and a Monti Mitt roanoff catheterisable stoma. 1year later she Fistula in one patient. No stenosis. In two patients neo-meatus manages with an end colostomy and daily bowel wash outs. receded to corona and disruption of reconstruction in another Att empts to preserve the gut length and function is essential patient. Vertical meatus was possible in 20 patients. for a promising future in these individuals. Conclusion: Successful repair with preservation of renal function and social continence for urine and faeces is possible 208 in these individuals. Needless to say these individuals are best Three cases of cleft sternum closed successfully delivered and managed in multidisciplinary centres. Att ention Sundeep K, Reju Thomas, John Mathai, Jacob C, S Sen to the gut related issues that contribute to morbidity can result Dept. of Paediatric Surgery, Christian Medical College Vellore, in an acceptable quality of life. Tamil Nadu - 632004, India 210 Aim: To highlight our experience with three cases of sternal Congenital hepatoblastoma cleft and the surgical technique of closure. Parag J. Karkera,Paras Kothari, Abhay Gupta, Gursev Sandlas, Materials and Method: Three infants born with sternal cleft Prashant Joshi without any other congenital anomalies underwent primary LTMG Hospital, Sion, Mumbai, India closure of the cleft sternum. The defect was widest between the two sternoclavicular joints. Mid-saggital incision was Congenital hepatoblastomas are more common at the age made; skin flaps raised and reflected laterally until the of 1 – 3year. Less than 10% cases are diagnosed in neonatal appearance of pectoralis major fibres, without injuring period. They are commonly associated with Beckwith – the pericardium. The endothoracic fascia was entered, the Wiedemann syndrome and FAP. A full term child presented periostium over the Þ rst Þ ve ribs were opened on both sides with hepatomegaly and jaundice since birth. Antenatal and and a sliding chondrotomy was made at the costochondral post natal ultrasounds and CT abdomen were suggestive of junction. Att empts to approximate the sternal bars may be an echogenic mass in the right lobe of liver. CT guided biopsy unsuccessful due to the strut like clavicles and may result in revealed congenital hepatoblastoma. Tumour markers (LDH, cardiac tamponade. This may be overcome by fracturing the AFP) and bilirubin were increased but showed a downward clavicle at the junction of the medial and lateral two thirds. trend over the 1st month. Patient was started on chemotherapy Post-operatively, the infants were electively ventilated and (Cyclophosphamide, 5FU, Vincristine, Adriamycin).Surgery is recovery was uneventful. planned aft er 4 cycles. Results: Fracturing the clavicle during surgery helped in easy closure of the sternal cleft in all three cases. This is a new 211 technique and we report our experience in three cases. A rare case of epigastric heterophagus twin

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 184 IAPSCON 2009 Gogoi M, Bhattacharyya NC 214 Gauhati Medical College and Hospital, India Ovarian fi broma: A rare entity in children Parag J. Karkera, Paras Kothari, Abhaya Gupta, Gursev Conjoined twins are one of the rarest congenital anomalies (1 in Sandlas, Prashant Joshi 50,000 to 100,000 life births) and are classiÞ ed into symmetric LTMG Hospital, Sion, Mumbai, India & asymmetric types. The asymmetric form is known as heterophagus. Asymmetrical conjoined twining constitutes Fibromas are benign tumours arising from the mesenchyme only 1¬2% of all the conjoined twins. In parasitic (heterophagus) composed of Þ brous and connective tissue, commonest ovarian twins the dependent portion (the parasite) is smaller than tumour of stromal origin and commonest solid tumour of the host (autosite). The embryopathy is related to incomplete the ovary but very rare in children. A 6 year old female had cleavage of the embryo at 2 weeks of gestation. However, some presented with pain in the left lower abdomen and lump form of ischemic atrophy at an early age of gestation is also in the abdomen since 2 months. Clinically it was a hard, hypothesized. We report our experience with one rare case non tender, mobile mass and on CT scan of the abdomen it of epigastric heterophagus twin in which the parasite had an revealed a heterogeneously enhancing mass in the pelvis upper limb with shoulder girdle, a trunk, pelvis and both well with calciÞ cations within, likely to be an ovarian teratoma. developed lower limbs. Surgical excision of the parasite and Exploratory laparotomy was done and well encapsulated repair of the abdominal wall defect was successfully done. The left ovarian mass found and left oophorectomy was done. patient is doing well in follow up. Histopathological examination revealed ovarian Þ broma. Pre- and post-op tumour markers were found normal. 212 A rare case of hepatic mesenchymal hamartoma 215 Deuri PK, Bhattacharyya NC Management of near amputation of glans and Gauhati Medical College and Hospital, India transection of the urethra after circumcision with a partial de-epithelialisation technique: Experience Hepatic Mesenchymal Hamartoma is a rare benign lesion with two children arising from the mesenchymal tissue in and around the porta Ravi Kishore, Reju Thomas, Sampath Karl, Sudipta Sen with associated cystic changes. It is seen predominantly in Christian Medical College, Vellore, Tamilnadu, India children within 2 - 3 yrs of age. It usually presents as a painless right upper abdominal mass. The tumor is usually solitary and Aim: To highlight the danger of constrictive dressing or suture located in the right lobe of the liver. Edmonsons proposed that aft er circumcision and its surgical management. Mesenchymal Hamartoma arises from mesenchymal rest that Materials and Methods: Two boys presented with near becomes isolated from the normal portal triad architecture and amputation of the glans penis and complete transection of the diff erentiates independently. We report our experience with one urethra at the coronal level aft er circumcision done elsewhere. rare case of Mesenchymal Hamartoma that involved segment They were managed surgically by de-epithelialisation v,vi,vii and viii of the liver in a 4yrs old male child. In the technique, carefully preserving the tenuous soft tissue pedicle present case complete surgical excision of tumor was done and to the glans. no tumor recurrence was noted during the follow-up period. Results: Both boys had a satisfactory cosmetic result with a normal appearing penis, good glans vascularity and normal 213 voiding. Lump in abdomen in a neonate: Enteric duplication Conclusions: The partial de-epithelialisation technique is cyst very eff ective treatment for the dangerous complication of Parag J. Karkera, Paras Kothari, Abhaya Gupta, Gursev circumcision. Sandlas, Prashant Joshi LTMG Hospital, Sion, Mumbai, India 216 Case presentation of a case of pouch colon with A 3 day old male child presented with lump in the right lumbar uterine fi stula region since birth. Clinically, a cystic, non-ballotable lump in Arun Dash, H K Mohanty, PC Subudhi, R N Dash, P K Mohanty, right lumbar region was noted and radiological investigations R K Mohapatra, Akash Pati suggested a mesenteric cyst or an enteric duplication S V P Post Graduate Institute of Pediatrics, S C B Medical cyst. Exploratory laparotomy and cystectomy was done. College, Cuttack, India Histopathological examination revealed enteric duplication cyst. Post operative course and follow up was uneventful. Aim: Presentation of a case of uterine Þ stula associated with Enteric duplication cyst was Þ rst reported by Calder in 1733. It type 2 pouch colon. may be tubular or cystic and duplication of the colon & rectum Methods: A 12 day old female child with anorectal malformation constitute about 17% of all enteric duplications. presented to our department. On exploration it was found that

185 J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 IAPSCON 2009 the patient was having a type 2 pouch colon which was having Materials and Methods: five boys underwent ureteric a Þ stulous communication to the uterus. Fistula ligation with reimplant for major VUR. Indications for reimplantation were tuboplasty of the colonic pouch done which was opened as an Grade IV / V VUR, Renal scars and recurrent UTIs. In each case, end colostomy pending future pull through surgery. a trabeculated bladder wall was noted at surgery, along with Conclusion: Association of uterine Þ stula being rarely reported widely gaping ureteric oriÞ ces. Evidence of abnormal bladder in literature prompted us for presenting the case. function was also noted in preoperative radiology by one or more of the following: 217 1. Trabeculations Management of the troublesome prostatic utricle/ 2. Thick bladder wall uterus masculinus in 4 boys 3. Very large bladder Sampath Karl, Reju J Thomas, Sudipta Sen 4. Dilatatiom of posterior urethra Christian Medical College, Vellore, Tamilnadu, India 5. Hydroureteronephrosis in a contralateral nonreß uxing unit The operative strategy included the antireß ux surgery with Aim: To highlight the clinical presentation and management concomitant addition of an appendicular Mitrofanoff port. Post of the symptomatic Prostatic Utricle in 4 boys. operatively the children were advised anticholinergic therapy, Materials and Methods: 4 boys, 2 with major hypospadias CIC and night drainage. and 2 with a normal penis presented with either retention Results: All boys are complying with the regimen. VUR of urine or recurrent epididymoorchitis. Initially they were has sett led in 6 units but persists in one operated and one managed with daily rectal massage to empty the utricle, which nonoperated unit. Signs of bladder dysfunction persist in 4 partly succeeded for about a year. However due to persistent patients but are stable. No case has shown worsening of the symptoms they were operatively managed. The utricle was hydroureteronephrosis and improvement was noted in 6 out removed via a posterior approach, by retracting the rectum. of 8 reß uxing units. Results: 3 children were relieved of there symptoms while 1 Conclusion: VUR and bladder dysfunction are related child had another episode of epididymoorchitis for which a pathology. Since the literature is unclear as to whether vasectomy was done. treatment of one entity will resolve the other, we have elected Conclusion: The enlarged prostatic utricle can cause to treat both in the same operative procedure. troublesome symptoms in hypospadias and non-hypospadiac boys. The various surgical approaches will be discussed. 220 Selective nonoperative management of blunt liver 218 injury: Where do we stand ? Rib osteomyelitis Gayathri, Sampath Kumar, Sibasis, B Patil, Dinesh Parag J. Karkera, Paras Kothari, Abhaya Gupta, Gursev Dept of Surgery, Kasturba Medical College, Manipal University, Sandlas, Prashant Joshi Manipal, Karnataka-5876104, India LTMG Hospital, Sion, Mumbai, India Background: Despite advances in the management of liver Osteomyelitis of the ribs is a rare entity due to bacteria(45%),t trauma during the past 40 years, hemorrhage has remained uberculous(45%),fungal(8-10%),parasitic(1%) causes. Pediatric the commonest cause of death. Liver trauma, especially that osteomyelitis often masquerades as skeletal neoplasia, as as result of road traffi c accidents; still remains a complicated illustrated in our case. A 2 year old boy had a swelling over problem Modern treatment of liver trauma is increasingly the posterior chest wall, since 5 months. This hard, immobile non-operative. paraspinal mass on radiological investigations revealed 12th Aim of the study: We retrospectively reviewed the severity rib osteolytic lesion suggestive of infective pathology with a of liver injury, associated injuries, treatment, and outcome. possibility of malignancy.12th rib excision was done, histopath To determine the contrast material-enhanced computed examination revealed osteomyelitis. Post operative recovery tomographic (CT) criteria for selection of hemodynamically was uneventful but for wound infection. stable patients with blunt hepatic injury for angiographic evaluation. We reviewed our liver trauma to assess the success 219 of non-operative management protocols Surgical management of boys with major refl ux Materials and Methods: 40 patients with blunt liver injury from and suspected bladder dysfunction jan 2008 to june 2009 underwent CECT. Hepatic injuries were Kshama Kulkarni, Arindam Dastidar, Reju Thomas, Sampath graded with CT-based classiÞ cation. Scans were assessed for Karl, Sudipta Sen evidence of contrast extravasation and laceration or contusion Christian Medical College, Vellore, Tamilnadu, India extending into the hepatic vein(s), inferior vena cava, porta hepatis, or gallbladder fossa. Medical, CECT PACS, and Aim: To highlight the importance of recognising the surgical records were reviewed to determine angiographic dysfunctional bladder during operating on a major VUR. Þ ndings, surgical indications and Þ ndings, and outcomes.

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Findings and Conclusion: Our data indicate that CT-based M. Y. Wani, Nisar A. Wani, Shafi , Sheikh Sajjad, lshfaq, Majid, criteria can be used to guide the diagnostic management of Firdoos blunt hepatic trauma in hemodynamically stable patients. Out Pediatric Surgery Division, Dept of Surgery Govt. Medical of the 40 patients around 90% of the patients were managaed College, Srinagar - 190010, India conservatively It seems that patients with limited liver injury diagnosed by CT scan and selected by strictly applied criteria Aim: To study the clinical proÞ le of Anorectal malformation can be managed safely without laparotomy in a sett ing where (ARM’S) in Kashmir valley and its Surgical management and rapid evaluation and treatment of any potential complication post operative rehabilitation of the aff ected children. is available. Methods: This post operative study extends over a period of 5 yrs. and involved a total of 96 patients.Patients were thoroughly 221 evaluated for the nature and type of ARM ‘S and any associated Evaluation of focused assessment with sonography anomalies using proper investigation including prone cross for trauma in blunt abdominal trauma: A 26 months table lateral view X-ray, X-ray lumbosacral spine, USG, prospective study MCU, IVU, Echocardiography,distal cologram, cystoscopy Sibasis Bisoi, Annappa kudva and vaginoscopy. ClassiÞ cation of the defect was made by Dept of Surgery, Kasturba Medical College, Manipal University, Wingspreads method. Patients were managed according to the Manipal, Karnataka-5876104, India type of the defect. All rectoperineal Þ stulae in both the sexes were managed without a colostomy. A protective colostomy Background: The use of focused ultrasonography has now was fashioned in all male babies with rectovesical Þ stulae, become an extension of the physical examination of the trauma rectourethral Þ stula, imperforate anus without Þ stula and rectal patient. Performed in the trauma room by properly trained and atresia. In female babies a prior colostomy was made in all credentialed staff , it allows the timely diagnosis of potentially cases of Rectovaginal Þ stula, imperforate anus without Þ stula, life-threatening hemorrhage and is a decision-making tool to rectal atresia and persistent cloaca. Colostomy was required in help determine the need for transfer to the operating room. CT all cases of H-type Þ stulae. We always preferred a descending scanner or angiography suite. colostomy with separate stomas. Anal dilatations and bowel Aim of the study: To study the diagnostic accuracy and clinical training formed an important part of the postoperative effi cacy of Focused Assessment With Sonography For Trauma management. (FAST) in blunt abdominal trauma. Results: Out of the 96 patients, 90 were assessed for the results Objective: To evaluate abdominal ultrasonography (FAST of surgery. Male babies were aff ected more commonly than scan with free ß uid analysis) for indirect detection of organ females. High and low anomalies were commoner in male injury in patients with blunt abdominal trauma, with babies. Intermediate anomalies were more common in female Þ ndings at computed tomography (CT) and/or surgery as sex. All cases of H-type Þ stula in our series were of female the standard of diagnosis. To analyze whether the quantity of sex. Among the associated anomalies genitourinary were free intraperitoneal ß uid on the FAST examination, alone or in commonest followed by sacral anomalies, sacral anomalies combination with unstable vital signs, is sensitive in predicting signiÞ cantly aff ected the functional outcome of the ARM’s. the need for exploratory laparotomy in patients presenting with PSARP was the most common deÞ nitive surgery performed. blunt abdominal trauma. Bowel continence was the main aim of the correction and Findings and Conclusions: focused assessment with sonography the most important factor assessed in the follow up. All for trauma {FAST}/trauma ultrasound, for free ß uid analysis cases of low defect were totally continent. Voluntary bowel for indirect detection of organ injury in patients with blunt movements were achieved in 77.77% cases. The highest abdominal trauma, is readily available, rapid, safe, relatively incidence of soiling was seen in bladder neck Þ stula and inexpensive, minimally invasive. It can be performed at the persistent cloaca. bedside and can predict organ injury from Blunt Abdominal Conclusion: ARM’s are the frequently occurring birth defects Trauma fairly accurately. FAST provides an early extension of in our region. The incidence and clinical spectrum of these the physical examination A negative FAST scan reduces the anomalies is similar to those reported in other parts of the number of emergency CT scan performed, increases the rate of country and rest of the world. The exception to this fact is the H- conservative management and probably eliminates altogether type Þ stula which has been reported very frequently by other the need of DPL in blunt abdominal trauma The high sensitivity authors. In general, the main purpose of surgical management and negative predictive value of FAST makes it a excellent test of a baby with ARM is not only to restore the continuity of the for blunt abdominal injury and it can be can be put to good use alimentary canal but also the physiology of the canal mainly as screening tools for surgical triage of patients with suspected bowel control, urinary control, and future sexual functions. solid visceral injury from blunt abdominal trauma. 223 222 Renal function, metabolic and acid-base status in Management of anorectal malformation our exstrophy bladder patients following augmentation experience colocystoplasty

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M. Ragavan, V. Bhatnagar bladder plate. The urodynamic study (UDS)was done by a All India Institute of Medical Science, New Delhi, India computer based standard ß uid cystometry using a 7 Fr double lumen catheter, saline infused @ 10 % of the expected capacity Aim: To study the eff ect of augmentation colocystoplasty for the age per minute. Cystometric bladder capacity (MCC), on renal function, metabolic & acid-base status in exstrophy bladder compliance, leak point pressure, volume at detrusor bladder patients. Methods: A retrospective study on 47 pressure of 20 cm H20, post void residue and external sphincter exstrophy bladder patients who ! underwent augmentation electrical activity were measured. Any uninhibited detrusor with detabularised sigmoid colon during Jan.’85-May’07. contractions during Þ lling were recorded. If the patient was able The patient details were obtained from the pediatric urology to void per urethra, uroß owmetry was also done. Mean +SD of clinic records; the parameters included blood urea, serum pre & post augmentation values were compared by student’s creatinine, Na+, K+, Ca+, PO4-, alkaline phosphatase & arterial paired t test and p value <0.05 was considered signiÞ cant. blood gas (ABG) analysis. Glomerular Þ ltration rate (GFR) was Results: The interval between bladder closure & UDS ranged calculated with DTPA, during Þ ltration phase of renal dynamic from 3¬84 months (mean 27 months). There was 7x increase scan in ml/min/1.73m2 BSA. Mean+SD were computed for all in bladder capacity; MCC pre & post augmentation was 57 the measurable variables & the corresponding pre & post- ml & 402 ml resp. The improvement in compliance was 6.6x; augmentation values were compared by applying student’s the pre & post augmentation mean compliance was 2.72 & paired t test; p value <0.05 was considered signiÞ cant. 18 ml/cmH2O resp. There was 13x increase in the residual Results: The mean urea & creatinine values were within the volume, suggestive of poor emptying aft er augmentation. normal range both pre and post augmentation. A rise of 6m1/ The pre & post augmentation 20 below capacity was 32 & 252 min/1.73m2 body surface area in the mean GFR was observed ml respectively. Hyper-reß exia was present in 16% patients in the post-augmentation period. The mean serum Ca+ and before augmentation and in 37% patients aft er augmentation. PO4- levels were within normal limits’ before augmentation Regular phasic activity was observed in 6.3% patients aft er & slightly higher in the post augmentation period (p=0.053). augmentation. Mean alkaline phosphatase level was 217 & 458 IU pre & post- Conclusion: The UDS show that changes in the bladder augmentation respectively (p=0.0005); although statistically dynamics aft er augmentation are favorable and prevent renal significant, the mean value was within the normal range damage. The augmented bladder functions as a continent low for children. ABG reports, available for 34 patients, showed pressure reservoir. The ill eff ects of increased post void residual mean pH of 7.37 & 7.28 pre & post-augmentation respectively urine can be annulled by CIC, supra pubic pressure during (p=0.217). Severe acidosis with al pH of <7.2 was seen in 3 voiding, double voiding and continuous catheter drainage patients only. The pre & post-augmentation mean HCO3 during the night. levels were 25.31 & 18.36mmol/dl resp. (p=0.0001). The mean pre-augmentation PaCO2 & base excess were 47mmHg and 225 -1.11 respectively, while the post-augmentation values were Effect of augmentation colocystoplasty on 34.26mmHg and, -6.20 respectively. The diff erence in base physical growth and bone mineral density in excess was statistically significant (p=0.0001) & suggests exstrophy bladder patients compensated metabolic acidosis. M. Ragavan, N.Tandon, V. Bhatnagar Conclusion: Colocystoplasty for children with normal renal All India Institute of Medical Science, New Delhi, India function is not associated with signiÞ cant metabolic changes, renal function or l ABG. The low level of PaCO2 probably Aim: To study the eff ect of augmentation colocystoplasty on implies CO2 washout from the lungs as a compensatory physical growth & bone mineral density in exstrophy bladder mechanism for the metabolic acidosis. patients. Methods: A retrospective evaluation of 54 classical exstrophy 224 bladder patients who had undergone augmentation sigmoid Urodynamic behavior of sigmoid augmented colocystoplasty from Jan.’85 to May’07. The details of bladder in classical bladder exstrophy patients anthropometry (height and weight) were obtained from the M. Ragavan, V. P. Grover, V. Bhatnagar pediatric urology follow-up clinic records. The percentile All India Institute of Medical Science, New Delhi, India height and weight were calculated using CDC 2000 Indian reference charts and categorized into three subgroups (<50th, Aim: To study the urodynamic behavior of augmented neo- 50th-75th, >75th percentiles). Following colocystoplasty the bladder aft er sigmoid colocystoplasty for exstrophy bladder. patients were submitt ed for bone densitometry (BMD) scan Methods: Urodynamic changes were studied in the bladder of upper end of femur using QDR 4500A model dual energy of 54 classical exstrophy bladder patients who underwent X-ray absorptiometry (DEXA), Hologic, USA. The BMD values augmentation with detubularised segment of sigmoid colon were compared with the age and sex matched normal children during Jan.’85-May’07. The augmentation was done either and exstrophy bladder patient who were not augmented. In following staged bladder reconstruction, during bladder neck augmented group BMD scan was also repeated 6 months aft er repair or as primary augmentation in cases with very small the Þ rst study to note any change. Pre and post¬augmentation

J Indian Assoc Pediatr Surg / Jul-Sep 2009 / Vol 14 / Issue 3 188 IAPSCON 2009 values were compared by applying student’s paired t test and Conclusions: There is a signiÞ cant increase in the retention p value <0.05 was considered signiÞ cant. rate, pyuria and fistula formation after augmentation Results: The median percentile of height and weight was 50. necessitating follow-up and timely intervention to preserve the The percentile height and weights were nearly the same in the renal function. Stone formation and mucus production was a pre & post augmentation period. The anthropometric values problem in the initial postoperative period, but decreased over of 60-80% of cases remained in the 50th-75th percentile group. time and none of our patients had considered it a signiÞ cant A total of 34 augmented children were evaluated for BMD at a problem aft er 2 years. Plenty of hydration and regular CIC has mean of 15±4.5 months aft er augmentation. The mean BMD of helped to reduce the problems. Indian normal child matched for age and sex of the study group was 0.665±0.06 g/cm2. The BMD of exstrophy bladder patients 227 was 0.612±0.10) g/cm2 and post augmentation study group Voiding pattern and continence status of was 0.645±0.17) g/cm2. There was no statistically signiÞ cant exstrophy bladder patients after augmentation diff erence among the 3 groups. The mean of BMD repeated colocystoplasty at 6 months in the augmented group was 0.657±0.158 and is V. Bhatnagar, M. Ragavan, D. Kumar on uptrend. All India Institute of Medical Sciences, New Delhi, India Conclusion: The results of our study shows no reduction in linear growth & bone mineral density aft er augmentation with Aim: To study the voiding patt ern and continence status of sigmoid colon in exstrophy children. exstrophy bladder patients aft er augmentation colocystoplasty. Methods: The study group includes 54 classical exstrophy 226 bladder patients who underwent augmentation colocystoplasty Complications following augmentation sigmoid with detubularised sigmoid colon during Jan.’85-May’07. colocystoplasty for bladder exstrophy Detailed history on voiding patt ern, frequency, duration of V. Bhatnagar, M. Ragavan dry period, stress incontinence and number of pads used per All India Institute of Medical Science, New Delhi, India day were enquired. The degree of continence was deÞ ned as `dry’ if completely dry or dry interval >3 hours; `acceptable’ if Aim: To study the complications following augmentation dry interval >2 hours or usage of <3 pads per day and as `wet’ sigmoid colocystoplasty for bladder exstrophy. for all other cases. Pre and post augmentation changes in the Methods: A retrospective study of complications in 54 patients degree of continence were tested for statistical signiÞ cance of bladder exstrophy who underwent augmentation cystoplasty by applying student’s t test and p value <0.05 was considered with detubularised sigmoid colon during Jan.’85-May’07. The statistically signiÞ cant. details of the patients were obtained from the pediatric urology Results: The mean age at colocystoplasty was 4.3 years and clinic records. Mean and standard deviation were computed follow up ranged from 3 months-19 years (mean 4.5 years). for all the measurable variables and the corresponding pre- The mean age at analysis of data was 9.5 years. The pre and ¬augmentation and post-augmentation values were compared post augmentation continence status was available in 44 by applying student’s paired t test and p value < 0.05 was patients; ‘dry’ in 6 (13.6%) and 28 (63.6%) patients (p=0.0001), considered signiÞ cant. ‘acceptable’ in 5 (11.3%) and 10 (22.7%) patients and `wet’ in Results: The mean age at colocystoplasty was 4.3 years 33 (75%) and 6 (13.6%) patients (p=0.0001) before and aft er and follow up ranged from 3 months - 19 years (mean 4.5 augmentation respectively. Three patients were able to void years). The mean age at analysis of data was 9.5 years. Three normally per urethra and remain dry pre augmentation and patients were above 20 years of age. The complications 2 more patients could achieve this status post augmentation; included stone formation, ‘pyuria’, Þ stula, urine retention, this was statistically not signiÞ cant. Before augmentation only and intestinal complications. Sixty six percentage (31 cases) 4 (9%) patients required CIC per urethra but this increased to of cases had at least one episode of retention of urine aft er 68 (native urethra 59%, Mitrofanoff 9%) aft er augmentation augmentation either due to thick mucus or bladder outß ow due to increase in post void residue. obstruction; 12 patients required urethral dilation under Conclusions: A significant number of cases become dry anesthesia. Though 16 patients had 20 instances of bladder and continent aft er augmentation as the bladder becomes a calculi it is not statistically signiÞ cant when compared with capacious reservoir. They should be counselled for performing pre augmentation status. CIC prior to the augmentation.

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