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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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   Table of Contents - Current issue
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January-March 2017
Volume 22 | Issue 1
Page Nos. 1-65

Online since Wednesday, November 23, 2016

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PRESIDENTIAL ADDRESS  

Presidential Address at 42 nd Annual Conference of the Indian Association of Pediatric Surgeons (IAPSCON 2016) Agra September 29-October 2, 2016 p. 1
Kishore Panjwani
DOI:10.4103/0971-9261.194605  PMID:28082767
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ORIGINAL ARTICLES Top

Association of levels of serum inhibin b and follicle-stimulating hormone with testicular vascularity, volume, and echotexture in children with undescended testes p. 3
Abhishek Chinya, Simmi K Ratan, Satish K Aggarwal, Anju Garg, TK Mishra
DOI:10.4103/0971-9261.194609  PMID:28082768
Aims: The aim of our study was to assess the association between reproductive hormones (inhibin B [inh B], follicle-stimulating hormone [FSH]) with testicular volume, echogenicity, and blood flow (resistive index [RI]) in children with undescended testis (UDT). Settings and Design: This was a prospective study of 1-year study duration. Materials and Methods: A total of 33 patients (16 unilateral and 17 bilateral) UDTs aged 5-12 years with palpable UDT were included in the study. Morning fasting blood samples were taken for estimation of serum inh B and FSH as well as inh B/FSH ratio. Testicular ultrasound was done to compute testicular volume, testicular echogenicity, and testicular vascularity in terms of RI. Results: The mean age of patients enrolled in the study was 8.29 years for unilateral UDT and 7.97 years in bilateral UDT and it was comparable. The study groups were further subdivided into two age-wise subgroups school goers (5-8 years) and prepubertal (9-12 years). The values of inh B, FSH, and inh B/FSH ratios as well as mean testicular volume were comparable between both groups and subgroups. Overall mean testicular volume had a positive correlation with FSH, inh B, and inh B/FSH, but statistical significance was reached only for inh B (P < 0.001) in children with both unilateral and bilateral UDT. Apart from five patients with hypoechogenicity within the testis, all remaining testes were of homogenous echotexture with no instances of irregular echogenicity or tumor. Children with RI >0.6 were separately studied. The incidence of high RI (>0.6) was also comparable in unilateral or bilateral disease. These subjects had unfavorable biochemical parameters in terms of low inh B levels and high FSH levels. Conclusions: Our findings hint to the fact that palpable UDT forms a homogenous group, whether unilateral or bilateral, whereas impalpable testes may form a separate category and need further studies to substantiate this hypothesis.
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Pediatric penile and glans anthropometry nomograms: An aid in hypospadias management p. 9
Archana Puri, Satyajit Sikdar, Raghu Prakash
DOI:10.4103/0971-9261.194610  PMID:28082769
Objective: To establish pediatric penile and glans anthropometry nomograms. This may be used as a reference model for penile assessment while managing hypospadias. Patients and Methods: Between October 2012 and September 2013, 263 boys of varying ages (0-16 years) were included in the study. Those with genetic, endocrine disorders, having genital anomaly, undescended testis, neonates, and infants with a nonretractile prepuce, with multiple congenital anomalies and refusal to take part in the study were excluded. Evaluated outcome variables were stretched penile length, glans circumference (GC) at coronal sulcus, glans diameter at coronal sulcus (Gdcl), mid glans diameter, and ventral glans length. Glans ratios were generated by dividing Gdcl by GC. Data were expressed as mean, median, and standard deviation. Correlation between age and variables was evaluated using nonparametric Spearman's rank correlation coefficient. Results: The patients were divided in six age groups, namely 0-1 (n = 61), 1-3 (n = 37), 3-5 (n = 36), 5-7 (n = 36), 7-12 (n = 45), and >12 years (n = 48). Gdcl was the maximum transverse glans diameter and based on it small glans size varied widely from 8.9 to 35.04 mm for various age groups. Although glans anthropometry showed age-related changes, glans ratio remained relatively constant between 0.49 and 0.53 (mean: 0.5 ± 0.051, r = 0.29). All the variables except glans ratio showed a significant positive correlation with age (r = 0.954-0.98, P < 0.01). Conclusion: Penile anthropometry nomograms provide a reference model for hypospadias. This may aid in (a) objective preoperative assessment of glans size (b) patient selection for preoperative hormonal stimulation (c) provides a yardstick for postoperative cosmesis.
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Assessment of nutritional status of patients of congenital pouch colon following definitive surgery p. 13
Nand Kishor Shinde, Praveen Kumar, Pradeep Kumar Dabla, Praveen Jhanwar, Rajiv Chadha, Subhasis Roy Choudhury
DOI:10.4103/0971-9261.194613  PMID:28082770
Purpose: To assess the nutritional status in 31 patients of congenital pouch colon (CPC) who had undergone definitive surgery and closure of a protective stoma, if any, at least 1 year earlier and were below 14 years age. Materials and Methods: The clinical history, demographic details, anthropometric measurements, and results of hematological and biochemical tests were recorded. In addition to collective data, analysis was also performed after grouping by age, subtype of CPC (Types I/II and Types III/IV CPC), and in Types I/II CPC patients, by whether the colonic pouch had been completely excised or else a segment preserved by tubular colorraphy (TC). Results: Severe fecal incontinence (FI) was common (64.52%). Anthropometry showed a significant malnutrition in 53.85-95.45% patients, especially "stunting" which was most prevalent in the 0-5 years age-group. Serum Vitamin B 12 , folate, and Vitamin D were lower than normal in 38.71%, 22.58%, and 74.19% patients, respectively, without statistically significant difference among the various groups studied. Patients with Types I/II CPC had a statistically significant higher incidence of anemia, low serum ferritin, and severe FI than patients with Types III/IV CPC. Patients with Types I/II CPC, managed by excision of the colonic pouch, had a higher incidence of severe FI, wasting, and thinness than those undergoing TC. Conclusions: On follow-up of the patients of CPC, anthropometry shows a high incidence of malnutrition, especially stunting in the 0-5 years age-group. There is an adequate adaptation of fluid-electrolyte homeostasis. Although Types I/II CPC patients have a significantly higher incidence of anemia and severe FI than Types III/IV CPC patients, long-term anthropometric parameters are similar. In Types I/II CPC, preservation of the colonic pouch by TC offers long-term benefit.
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Quality of life of indian pediatric surgeons: Results of a survey (of indian association of pediatric surgeons members) p. 19
MM Zameer, Sanjay Rao, C Vinay, Ashley D'Cruz
DOI:10.4103/0971-9261.194615  PMID:28082771
Introduction: Much is debated on the quality of life of pediatric surgeons practicing in India, all based on anecdotal and personal experiences. There is no systematic study on this. This study addresses this and attempts to glean a clearer picture of the life as a pediatric surgeon in India. Methodology: This questionnaire-based study was administered via an online survey to all Indian Association of Pediatric Surgeons members. The responses were anonymous and investigators blinded. Data were collated and analyzed using STAT11.1. Results: A total of 173 pediatric surgeons responded. Eighty-six percent were men. About 73.7% of the surgeons were between 31 and 50 years of age. Almost 63.4% practiced in urban areas, whereas 36% in other smaller towns. About 0.6% reported that their practice was rural. Almost 26.4% were in private/solo practices, whereas 53.4% were in institution-based practice. Almost 80% felt that they were adequately trained while starting their practice. About 78% are professionally satisfied with their work. Only 44.5% of surgeons felt that they were compensated adequately financially. Reading was the favorite pass time. Almost 40% of the surgeons felt that they were either overweight or obese. About 41% of the surgeons exercise more than 3 times a week. Only 11.4% smoke, whereas 36% drink. Fifty-three percent of surgeons felt that their personal savings were adequate. Seventy-six percent use Facebook. Sixty-eight percent were satisfied with their quality of life. Age was significantly associated with professional satisfaction, financial satisfaction, and quality of life and all improve as one's age progresses. None were affected with one's gender, type of practice, and the place of practice. Age, weight, exercise, and one's savings significantly affected ones quality of life. Conclusion: This is the first study which objectively highlights that most surgeons are happy professionally and financially in due course of time and demolishes the common belief that pediatric surgeons are unsatisfied. It also acts as a point of reference and encouragement to newer aspirants in pediatric surgery.
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Progressive perineal urethroplasty for pelvic fracture urethral distraction defect in prepubertal children: The outcome p. 23
Bipin Chandra Pal, Pranjal R Modi, Syed Javid Farooq Qadri, Jayesh Modi, Suresh Kumar, Ramya Nagarajan, Yusuf Safee
DOI:10.4103/0971-9261.194616  PMID:28082772
Background: Urethroplasty in pediatric patients is a challenging task. In this study, we have tried to assess the complexity and evaluate the outcome of progressive perineal anastomotic urethroplasty in prepubertal children. Materials and Methods: Retrospective data of all the prepubertal children who underwent progressive perineal urethroplasty between March 2009 and April 2014 were analyzed. Patients were evaluated with history, examination, essential laboratory investigations, retrograde urethrogram, and voiding cystourethrogram. Before subjecting the patients for definitive surgery, antegrade and retrograde endoscopic assessment was done. The surgery was performed by the transperineal route with the help of ×2.5 magnification. Patients were followed up with uroflowmetry for every 3 months in the 1 st year and for every 6 months in the subsequent years. Results: Mean age of the patients was 7.3 (range 5-11) years. Mean urethral distraction defect was 1.7 (range 1-2.5) cm. All the patients were successfully managed by the perineal approach. Crural separation was performed in all the patients while additional inferior pubectomy was required in six patients. Mean operating time was 298 (range 180-400) min. Mean blood loss was 174 (range 100-500) ml. One patient had the left calf hematoma in the immediate postoperative period. Seven out of nine (77.7%) patients had successful urethroplasty. Two patients had failed urethroplasty who were successfully managed by redo-urethroplasty. Transient incontinence was observed in one patient. Erectile function could not be assessed in these patients. Conclusion: This study shows the feasibility of progressive perineal urethroplasty by the perineal route in prepubertal children. An endoscopic assessment should be performed before the definitive surgery. Use of loupe helps in performing better anastomosis and hence yielding a better result.
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Determination of normal anal position index using a modified technique in Turkish neonates p. 29
Nazile Erturk, Omer Kandemir
DOI:10.4103/0971-9261.194617  PMID:28082773
Aim: This study was aimed to determine the normal position of the anus using the anal position index (API) in an attempt to develop a more sensitive method for measuring API. To investigate API in a wide range of neonates, both term and preterm infants were included in the present study. Materials and Methods: API was determined by measuring the anus-fourchette (FA) and anus-coccyx (AC) distance in female neonates and the anus-scrotum and AC distance in male neonates. API is defined as the ratio of the FA (scrotum) distance to the AC distance. A digital caliper was used for all measurements. The FA or scrotum and coccyx-fourchette or -scrotum distances were measured using digital calipers. Results: A total of 267 neonates (females, 143; males 124) were included in this study. Of these, 36 were borderline premature infants (birth at 35-37 weeks gestation) and 231 were term infants (birth at 38-42 weeks gestation). The mean API was 1.06 ± 0.04 in female and 0.90 ± 0.08 in male neonates. When premature infants were analyzed separately, the mean API was 1.12 ± 0.08 in female and 0.99 ± 0.09 in male neonates. No significant difference in API values was observed between term and preterm neonates (P < 0.05). Conclusions: API values that differ from the previous studies were identified in the present study. We believe our modified method allows for more accurate measurements of the API in newborns. According to our method, the anus should be considered as anteriorly located if API is <1 in female and < 0.9 in male neonates. In addition, the present study is the first to measure API using digital calipers. Digital calipers were found to be convenient and are useful in determining the API with high accuracy (to within 0.01 cm).
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Epidemiology of pediatric trauma and its pattern in urban India: A tertiary care hospital-based experience p. 33
Vijay Kumar Kundal, Pinaki Ranjan Debnath, Amita Sen
DOI:10.4103/0971-9261.194618  PMID:28082774
Aim: To assess the epidemiology, pattern, and outcome of trauma in pediatric population. Materials and Methods: A total of 1148 pediatric patients below 15 years of age presenting in the emergency department of our hospital were studied over a period of 3 years. The patients were categorized into four age groups of <1 year, 1-5 years, 6-10 years, and 11-15 years. The data were compared regarding mode of trauma, type of injury, place of injury among different age groups and both sexes. Results: The majority of the pediatric trauma cases were seen in males 69.86%, (n = 802) and females comprised only 30.13% (n = 346). Road traffic accident (RTA) was the most common mode of trauma in male children, i.e. 59.47% (n = 477) followed by fall injuries, i.e. 29.42% (n = 236). In females, fall was the most common mode of trauma, i.e. 52.31% (n = 181) followed by RTA (36.70%, n = 127). Fall injuries occurred mostly at homes. Among RTA, hit by vehicle on road while playing was most common followed by passenger accidents on two wheelers, followed by hit by vehicle while walking to school. Among fall, fall while playing at home was the most common. Out of total 1148 patients, 304 (26.48%) comprised the polytrauma cases (involvement of more than two organ systems), followed by abdominal/pelvic trauma (20.99%, n = 241), followed by head/face trauma (19.86%, n = 228). Out of total 1148 patients admitted over a period of 36 months, 64 died (5.57%). 75 (6.5%) patients had some kind of residual deformity or disability. Conclusion: The high incidence of pediatric trauma on roads and falls indicate the need for more supervision during playing and identification of specific risk factors for these injuries in our setting. This study shows that these epidemiological parameters could be a useful tool to identify burden and research priorities for specific type of injuries. A comprehensive trauma registry in our set up seems to be important for formulating policies to reduce pediatric trauma burden.
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Male gender assignment of a child with aphallia and associated complex urological anomaly p. 38
Satish Kumar Kolar Venkatesh, PR Babu, TP Joseph, Karthikeya K Varma
DOI:10.4103/0971-9261.194619  PMID:28082775
A 2-year-old male child presented to us with aphallia. At birth, he was passing urine from the anus and had undergone emergency colostomy and pyelostomy for urinary sepsis at 1 week of life. After a complete evaluation, the child underwent perineal urethrostomy and scrotal phalloplasty followed by buccal mucosal tube urethroplasty in the second stage, which was completed before the child started schooling.
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CASE REPORTS Top

Protean presentations of parathyroid adenoma in childhood p. 40
Subrata Dey, Aziz Beawarwala, Saikat Gupta
DOI:10.4103/0971-9261.194620  PMID:28082776
Parathyroid adenoma is a rare disease which is known to present with protean manifestations, leading to misdiagnosis in the initial stage of the disease. It is known to pose a diagnostic dilemma to the clinician, in which a high index of suspicion alone often leads to a proper diagnosis and timely management. We encountered two such cases who presented to us with varied presentation, in which nuclear scintigraphy along with intraoperative parathyroid hormone assay played a major role in diagnosis and management.
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Extensive chest wall tissue loss and its management by vertical rectus abdominis myocutaneous flap p. 43
Sandip Kanti Basu, Jayanta Bain, Debarati Chattopadhyay, Bijay Kumar Majumdar
DOI:10.4103/0971-9261.194621  PMID:28082777
Extensive electric burn around the chest in children is rare and this type of injury always poses a great challenge for its management. A 12-year-old male child with extensive electric burn of the chest wall was admitted to hospital. It was a neglected case of 9 days old burn; the young boy was in critical condition having systemic features of toxemia with widespread necrosis of the skin, subcutaneous tissues, and muscles along with exposed bones (ribs and sternum) with the risk of impending rupture of pleura through the exposed intercostal spaces. After initial resuscitation, a thorough debridement of all necrotic tissues was done. Thereafter, a superiorly based vertical rectus abdominis myocutaneous flap was harvested to cover the exposed bones and intercostal spaces. The remaining raw areas were skin grafted. The child made an excellent recovery with good outcome.
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Tessier 30 facial cleft with duplication of tongue p. 46
Jayanta Kumar Goswami
DOI:10.4103/0971-9261.194622  PMID:28082778
A case of midline cleft of the lower lip, mandible, and the neck with complete duplication of the tongue repaired at neonatal period is reported here. Median cleft of the lower lip, mandible, and bifid tongue with ankyloglossia is reported in the literature, but cleft of the neck with complete duplication of the tongue as a part of the Tessier 30 cleft is very rare. We could not find such report in the available English literature.
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Laparoscopic treatment of median arcuate ligament syndrome: A rare cause of chronic severe abdominal pain p. 48
Emre Divarci, Ulgen Celtik, Zafer Dokumcu, Ahmet Celik, Orkan Ergun
DOI:10.4103/0971-9261.194624  PMID:28082779
Median arcuate ligament syndrome is a rare disorder characterized by chronic postprandial abdominal pain and weight loss caused by compression on celiac artery. A 17-year-old girl with chronic severe abdominal pain and weight loss was referred to our clinic. Other causes of chronic abdominal pain were investigated and excluded. The compression on celiac artery was detected on Doppler ultrasound and diagnosis was confirmed by computed tomography angiography. The patient underwent laparoscopic release of median arcuate ligament. There were no intraoperative complications; however, partial pain response was observed postoperatively that necessitated para-spinal ganglion blockage. The patient is symptom-free in 1-year follow-up period.
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Intrauterine arrow injury p. 51
Jayanta Kumar Goswami, Kaushik Lahiri
DOI:10.4103/0971-9261.194625  PMID:28082780
Injury of a pregnant lady risks both mother and fetus. Various modes of injuries are possible. But arrow injury is not usually heard of in today's world. We have reported a male child delivered with a cut injury on the face. It was caused by a penetrating arrow hitting his mother in her lower abdomen at term. The injury of the baby was repaired successfully.
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Obstructive jaundice caused by hepatic torsion in an infant with congenital diaphragmatic hernia p. 53
Iftikhar Ahmad Jan, Basmah Al Hamoudi, Abdulla AlJunaibi, Abdelmatlub Ben Mussa
DOI:10.4103/0971-9261.194627  PMID:28082781
Right sided congenital diaphragmatic hernia may cause biliary obstruction. We present a 2 months female infant who had respiratory distress and persistent jaundice since birth. Investigations suggested direct hyperbilirubinemia, right-sided diaphragmatic hernia with liver herniation in the thorax, and intra- and extrahepatic biliary dilatation. Laparotomy showed herniation of liver in the chest with hepatic torsion of about 180΀ causing obstruction of bile ducts. Liver torsion was corrected and liver relocated in the abdomen. An operative cholangiogram confirmed free passage of contrast to the intestine after correction of hepatic torsion. Repair of the diaphragmatic hernia was performed. Only skin closure was performed leaving a ventral hernia to avoid abdominal compartment syndrome. Postoperatively, the baby was kept on ventilator for 2 days and then extubated. She showed rapid recovery and was discharged in a stable condition. The ventral hernia was repaired at the age of 6 months. Her total bilirubin levels dropped gradually from 12.50 mg/dl into its normal values within 3 months.
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Torsion of accessory hepatic lobe p. 55
Saravanan Natarajan, Jayasudha , Manikandhan Periasamy, Saminathan Rangasamy
DOI:10.4103/0971-9261.194628  PMID:28082782
An accessory hepatic lobe is a rare congenital anomaly that can undergo torsion and present as an acute surgical emergency. A 5-year-old child admitted as acute abdomen, on laparotomy found to have torsion of accessory lobe of liver, is being reported.
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Primary pulmonary rhabdomyosarcoma in a child p. 57
Raghunandan Balaji, Prasanna Kumar, Isha Garg, Kanishka Das
DOI:10.4103/0971-9261.194629  PMID:28082783
A 9-year-old female presented with fever, cough, and hemoptysis for a week. The chest skiagram and contrast-enhanced computerized tomography delineated a well-defined solid lesion localized to the superior segment of the right lower lobe with features of a congenital pulmonary airway malformation. The lesion was surgically managed with a segmentectomy and histopathology confirmed a contained pulmonary rhabdomyosarcoma (RMS). No other primary site of origin was evident, and a final diagnosis of "primary" pulmonary RMS was made. She received adjuvant chemotherapy and was disease free after 6 years of surveillance. The unique clinicoradiological features of the case are discussed and the sparse literature is reviewed.
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Fetal cyst reveling retroperitoneal enteric duplication p. 60
Imene Dahmane Ayadi, Ahlem Bezzine, Emira Ben Hamida, Zahra Marrakchi
DOI:10.4103/0971-9261.194630  PMID:28082784
Retroperitoneum is a very uncommon site of enteric duplication (ED). We report a new case of retroperitoneal ED cyst suspected in utero. Prenatal ultrasound showed an abdominal cystic mass. Noncommunicating retroperitoneal ED cyst measuring 70 mm × 30 mm was resected. Histopathologic examination confirmed the diagnosis.
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LETTER TO THE EDITOR Top

Laparoscopic pyloromyotomy p. 62
Dinesh Kittur
DOI:10.4103/0971-9261.194631  PMID:28082785
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Use of whatsapp in pediatric surgery division of general surgery department: Is it worthwhile? p. 62
Anand Pandey, Shailendra Pal Singh, Jigyasa Pandey, Vipin Gupta, Rajesh Verma
DOI:10.4103/0971-9261.194632  PMID:28082786
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Pancreatoblastoma masquerading as a retroperitoneal germ cell tumor p. 64
Muffazzal Rassiwala, Jigar N Patel, Partap Singh Yadav, Praveen Jhanwar
DOI:10.4103/0971-9261.194633  PMID:28082787
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