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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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Year : 2019  |  Volume : 24  |  Issue : 5  |  Page : 1-89

Abstracts for IAPSCON 2018

Date of Web Publication10-May-2019

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How to cite this article:
. Abstracts for IAPSCON 2018. J Indian Assoc Pediatr Surg 2019;24, Suppl S1:1-89

How to cite this URL:
. Abstracts for IAPSCON 2018. J Indian Assoc Pediatr Surg [serial online] 2019 [cited 2023 Mar 30];24, Suppl S1:1-89. Available from: https://www.jiaps.com/text.asp?2019/24/5/1/257973

   E Poster: Superior Vesical Fissure in a Case of Prune Belly Syndrome with Infravesical Obstruction: Beneficial Pop-Off with a Fatal Congenital Anomaly Category: Urology Top

Tanvir Roshan Khan, Umesh Bahadur Singh, Shrikesh Singh

Department of Pediatric Surgery, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

A wide spectrum of renal, ureteral, and urethral abnormalities has been reported in a patient born with Prune belly syndrome (PBS). The obstruction in the urinary tract can be found anywhere from uppermost (pelviureteral junction) to lowermost (prostatic membranous urethra) urinary tract. The mesenchymal developmental arrest is the main embryological factor responsible for the major features of the syndrome like urethral abnormalities or gastrointestinal abnormalities. PBS patients with urethral obstruction commonly had a patent urachus, because of which such patients survived, early death usually occurred in those patients who did not had a patent urachus. We are reporting an interesting case of prune belly syndrome with superior vesical fissure (an exstrophy variant). To the best of our knowledge this was first reported case of association of two congenital anomalies having common embryological defect process. Presence of superior vesical fissure gives a new insight about the benefits gained by the child for surviving with such fatal congenital anomalies.

   Postnatal Outcomes of Babies Diagnosed with Hydronephrosis In Utero In a Tertiary Care Centre in India Category: Urology Top

Tarun John Jacob, Tarun John Jacob

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Aims: Outcomes and predictors of renal anomalies based on antenatal hydronephrosis at a tertiary health center in South India.

Methods: During October 2012 to June 2017 – all antenatal hydronephropsis detected were followed. IRB cleared. Based in a tertiary care perinatal centre with 14,000 deliveries per year.

Results: Total number of scans was 1,82,214. Two hundred and nine women had foetuses who were diagnosed to have hydronephrosis of which one was a twin pregnancy. The mean gestational age at diagnosis was 25.48 (SD 6.36) with a median gestational age of 22 weeks. One fourth of the foetuses diagnosed with mild hydronephrosis were found to have normal kidneys in their subsequent scans. Among the babies born (n=148), 113 (76.4%) had a follow up ultrasound. 31 (20.9%) of the babies required an operation. Majority (n= 25,80.6%) of the surgeries were pyeloplasties for PUJ obstructions. ROC curve analysis showed that an APD of fetal renal pelvis ≥ 17.5 mm can predict the need for surgery with a sensitivity of 70% and a specificity of 76.6%. List of various other surgical conditions are discussed – PUV, ureterocele, hydrocolpos, duplex, vur and VUJ.

Conclusion: Recognition of KUB anomalies and follow up studies are useful to help with post natal prognostication and counseling of parents.

   A New Variant of Choledochal Cyst Category: GI Surgery Top

Manish Pathak, Manish pathak, TK Jayakumar, Rahul Saxena, Arvind Sinha

Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajastan, India

Introduction: We describe here a case of atretic variant of choledochal cyst in infant that does not fit into any of the present classification of choledochal cyst.

Materials and Methods: The patient demographics were recorded including age, sex, presentation, diagnostic studies, management and outcome. Literature search of electronic database medline was done using the MeSH terms “choledochal cyst”, “cystic biliary atresia”, and 'atretic variant choledochal cyst.”

Case Report: Infantile choledochal cyst was operated at 80 days of age. Intraoperatively, gall bladder was normal in size, cyst was noted in subhepatic region. cystic duct was not opening into the cyst or common hepatic duct but was entering into the duodenum. On further dissection, cyst was found to have a “blind ending”, distally. Right and left hepatic ducts were patent, opening into the cyst. Excision of cyst and hepaticodocho-jejunostomy was done. Distally, ligation and division of cystic duct at the entry into duodenum, and cholecystectomy completed the procedure. Post-operative course was uneventful. Histopathological examination of the cyst was s/o choledochal cyst. Patient was asymptomatic at 6 weeks follow-up.

Conclusion: Atretic variant of Choledochal cyst is a newly described entity with excellent prognosis if timely intervention is done.

   Study of Trichobezoars in Children Category: GI Surgery Top

Nirmal Bhaskar, Bejohn Johnson Kunnath, Sudha Bhanu

Department of Pediatric Surgery, Government Medical College, Thrissur, Kerala, India

Introduction: Trichobezoar is mass found trapped in the gastrointestinal system, formed from the ingestion of hair.

Aim and Objective: To study incidence, presentation, treatment, complication and prognosis of Trichobezoars in children.

Methods: Study includes all the Trichobezoars cases admitted to Paediatric Surgery department for 5 years. Only patients below 12 years who are confirmed Tricobezoars by laparotomy were included. Incidence of disease, presentation, treatment, complication, and prognosis were studied.

Results: Total there was 4 cases. All were females between 8 and 12 years. 2 presented with severe anemia with grade 4 PEM. 2 presented as recurrent vomiting. All cases had epigastric mass. One patient had psychiatric disorder, trichotillomania. Only 2 patients had visible hair loss. CT abdomen was taken. All cases had very big bezoar.(Average size 16 x 15 cm, weight 400 gm.) All cases had laparotomy and removal. Post operative period uneventful. All the patients given psychiatric support. No recurrence.

Conclusion: Trichobezoar is a very rare condition in children. Children may present with severe anemia, Grade 4 PEM, recurrent vomiting and epigastric mass. All patients may not have visible hair loss. In big bezoars, laparotomy is a best option. Post operative complication is rare. Recurrence also not seen.

   Conservative Management of Oesophageal Perforation Post Laparoscopic Cardiomyotomy for Achalasis Cardia Category: GI Surgery Top

Anilkumar Pura Lingegowda, C Ramachandra

Department of Pediatric Surgery, Sakra World Hospital, Bengaluru, Karnataka, India

Aim: To report a complication of Heller's Myotomy which was handled successfully by non operative treatment.

Methods: An 8 year old male child diagnosed to have Achalasia cardia on barium swallow. Laparoscopic Heller's Esophago cardiomyotomy and Dor fundoplication was done. Mucosal perforation occurred while doing cardiomyotomy, which was sutured securely. Dye study under c arm done on POD 5 and confirmed no leak. Started feeds and discharged home on POD 6. He came back with sepsis on POD 10. He had intraperitoneal collection and esophageal leak on CECT chest and abdomen. Pus drained, drain placed under CT guidance and stabilized with IV fluids. Upper GI Endoscopy and covered esophageal stent was placed. Started him on Naso-gastric feeds. Stent removed after 3 weeks. He is feeding well orally.

Results: He had complete resolution of leak and symptoms for which he was operated. He maintained his nutrition during the course of hospitalization through nasogastric tube high calorie enteral feeds.

Conclusion: Early recognition and aggressive non operative treatment will give rise to ideal outcome in the dreaded complication of leak following Heller's Myotomy.

   Post Traumatic Plunging Ranula (Mixed Type) Involving Submandibular Salaivary Gland: An Option to Repair the Duct and Preserve the Gland Category: GI Surgery Top

S Rajah, K Damian, S Sreetharan

Department of Pediatric Surgery, Gleneagles Hospital Kota Kinabalu, Kota Kinabalu, Malaysia

Aim: To illustrates the clinical and imaging findings and surgical management of a mixed ranula involving submandibular gland in a child.

Methods: 14 month old boy was initialy treated for intraoral swelling with bleeding due to fall. The oral swelling persisted beyond a week and ultrasonogram showed a multicystic lesion with enlarged left submandibular gland. Child develpoed neck swelling after a month. MRI showed a multiloculated cyst at left submandibular triangle with intra-oral extension, pushing the submandibular gland. Gradual enlargment of neck and intra-oral swellings caused dysphagia in three months.

Results: Aspiration of brownish mucoid fluid from neck and clear mucus from oral lesions with high amylase confirmed the diagnosis and abscence of communication. Cervical exploration revealed multilocular cyst extending to the floor of the mouth adherent to the dilated submandibular gland duct. Ductoplasty, excison of the psudocyst and repair of the floor of mouth was performed. Partial excision and marsupialization of oral lesion was performed transorally. Child recovered well without reccurrence during 9 months follow up.

Conclusion: Post traumatic mixed ranula involving submandibular gland is uncommon. Combined cervical and transoral approach and meticulous repair of submandibular gland duct can avoid excision of gland in children. Long term follow up and further studies are necessary.

   Bowel Intussusception in Premature Baby: Needs High Degree Suspicion Category: Neonatal Surgery Top

Aboli R Hukeri,Paras Kothari, Abhaya Gupta

Department of Pediatric Surgery, LTMMC, Mumbai, Maharashtra, India

Aims: Intussusception is an extremely rare clinical entity in neonates, especially among premature neonates. This clinical entity is confused with other causes of intestinal obstruction making diagnostic delays in correct diagnosis and hence high degree of suspicion is needed to avoid delay and unnecessary management.

Methods: Intussusception is a rare entity in neonates and its' symptomatology is almost exactly similar to necrotizing enterocolitis. A 30 weeks preterm newborn was initially suspected to have to necrotizing enterocolitis based on clinical conditions and radiological findings, which turned out to be jejuno-jejunal intussusception with bowel gangrene on exploratory laparotomy. An initial diagnosis of necrotizing enterocolitis was made and the neonate was treated with non-surgical management. This led to difficulty in the diagnosis of intussusception. Patient died of sepsis in post-operative period. In preterm newborns, conditions other than necrotizing enterocolitis can have similar pathological abdominal findings and hence suspicion is needed for timely diagnosis and urgent surgical management.

Conclusion: In preterm newborns, conditions other than necrotizing enterocolitis can have similar pathological abdominal findings and hence suspicion is needed for timely diagnosis and urgent surgical management.

   Congenital Prepubic Sinus Category: Miscellaneous Top

Aboli R Hukeri, Paras Kothari, Abhaya Gupta

Department of Pediatric Surgery, LTMMC, Mumbai, Maharashtra, India

Aims: Congenital Prepubic Sinus was suggested as a variation in normal embryological development. Correct diagnosis of the rare entity is needed to provide the curative treatment.

Methods and Results: Congenital prepubic sinus is an extremely rare congenital disorder with uncertain etiology. Also anatomic and pathologic features often differ from each other and hence classification has not been achieved. We report a case of 3 years old girl with congenital prepubic sinus which had histology of 'a dermoid sinus'.

Conclusion: CPS is rare congenital entity for which complete excision is the curative treatment, to prevent recurrence of symptoms and possible complications.

   Case Report of Neonatal Cervical Teratoma Category: Miscellaneous Top

Ritesh Kumar, Amita Sen, Rajasekhar Addagatla, Sandeep Kumar, Pinaki Ranjan Debnath, Vijay Kumar Kundal, Atul Meena, Shalu Shah

Department of Pediatric Surgery, PGIMER and Dr RML Hospital, New Delhi, India

Aims: Case report of rare neonatal cervical teratoma.

Methods: In march 2018 one rare case of cervical teratoma was reported in our institute which was prospectively analysed as to maternal history, tumour histology, clinical management and neonatal outcome. A 5 days old term female baby presented with left sided neck mass since birth. O/E child is active, afebrile, HR-136, CRT-<3 sec, CTA-Normal, systemic examination within the normal limit. On local examination there was globular firm lump in left cervical region. On USG of neck it showed well defined mass size 4 cm x 3 cm size. On day 2 of admission child got respiratory distress with cyanosis and child was intubated. Excision of mass was done on emergency basis. In post-operative period child was on ventilator for 2 days then discharged on POD-9. Histopathology examination revealed immature teratoma grade 3.

Results: Patient was on ventilator for 2 days then and then post operative period was uneventful. Patient didn't get any other complication. Patient is under our follow up and has not developed recurrence.

Conclusion: Teratomas are rare tumors affecting the neck in 1.5% to 5.5% of all cases. An early diagnosis, airways management and complete surgical approach to congenital cervical teratomas allows good results, with low rates of complication and recurrence.

   Rare Pediatric Gastrointestinal Stromal Tumour Category: Miscellaneous Top

Rajasekhar Addagatla, Amita Sen, Ritesh Kumar, Sandeep Kumar, Pinaki Ranjan Debnath, Vijay Kumar Kundal, Atul Meena, Shalu Shah

Department of Pediatric Surgery, PGIMER and Dr RML Hospital, New Delhi, India

Aim: To discuss the management of rare pediatric tumour, Gastrointestinal Stromal Tumour (GIST).

Methods: We report a case of 1 year old male child with transverse colonic GIST. Child presented with upper abdominal lump of one month duration with no other constitutional symptoms. On examination solitary intraabdominal lump of size 10 cm and 8 cm, non tender, firm, freely mobile in the umbilical region was found. Contrast enhanced CT abdomen revealed 8.3 cm and 6.2 cm heterogenous enhancing mass at root of the mesentery. On exploration an exophytic pedunculated mass was arising from mid transverse colon, tumour excised along with 2 cm colonic margin. Counselling done as chemotherapy was not available in children. Child has been under regular followup for the last 7 months.

Results: Histopathological examination revealed GIST with high mitotic index, immuno-histochemistry (IHC) markers CD117, CD34 and DOG 1 were positive.

Conclusion: Pediatric GIST is very rare and there are no well established therapeutic guidelines for the management of pediatric GIST, so needs close long term followup after surgery and further guidelines need to be established.

   Near Death Aspiration Syndrome: Scarless Resolution Category: Laparoscopic Surgery Top

R Madhu, Apurva Arora, Selvapriya Bharti, Jegadeesh Sundaraman, Prakash Agarwal

Department of Pediatric Surgery, SRMC and RI, Chennai, Tamil Nadu, India

Aim: Subtle GERD is common in infants which mostly resolves spontaneously with growth. Rarely the symptomatic GER which causes significant respiratory morbidity or failure to thrive needs surgical intervention, which nowadays is possible with minimally invasive methods.

Materials: Case 1: One month old baby came with complaints of baby turning blue and unresponsive even after NG feeds. Baby is a known case of GERD, RDS, generalized hypotonia and seizure disorder. Baby underwent Laparoscopic fundoplication with gastrostomy. Intra and post operative period was uneventful. Case 2: One year old child a known case of Pierre Robin sequence and swallowing incordination came with recurrent pneumonia and respiratory distress. Patient had undergone PEG due to failure to thrive in a outside hospital. Baby was diagnosed to have GERD and treated successfully with laparoscopic fundoplication.

Results: Average intraoperative time was 126 minutes, blood loss 15 ml and hospital stay 5 days. There were no major intraoperative or postoperative complications. Both babies showed very good weight gain on follow up.

Conclusion: Fundoplication for GERD is a technically demanding surgery and a challenge to the anaesthetist. It is done in children only for specific indications. We conclude that it can be done by minimally invasive techniques even in pediatric age group with better outcomes.

   Congenital Lumbar Hernia a 5 Case Series Category: Neonatal Surgery Top

Anup B Paliwal

Department of Paediatric Surgery, GMC, Chandrapur, Maharashtra, India

Aim: Congenital lumbar hernias are very rare, with no more than 200 cases reported in the literature so far. This may be the reason why we decided to describe 5 patients with congenital lumbar hernia, along with associated anomalies, and their management.

Methods and Results: One of them had anorecal malformation, two had lumbocosto vertebral syndrome, on had hypospadias,. Out of 5 neonates 3 boys and 2 girl. Out of 5 neonates, two had undergone open repair and are doing well. Third baby with ARM is on colostomy now.other 2 are waiting for repair.

Conclusion: Diagnosis of congenital hernia should alert the surgeon, prompting further investigations for various other congenital anomalies. Open prosthetic repair continues to be the procedure of choice for treating such hernias.

   Virilizing Pediatric Adrenocortical Carcinoma: Does Removal of Tumour Regress All Virilizing Signs? Category: Miscellaneous Top

Shrikesh Singh, Tanveer Roshan Khan, Umesh Bahadur Singh

Department of Pediatric Surgery, Dr RMLIMS, Lucknow, Uttar Pradesh, India

Adrenocortical carcinoma (ACC) in pediatric patients is very rare, and it is associated with various clinical symptoms. ACCs are classified as functioning and non-functioning. The pathogenesis of ACC remains elusive, and diagnosis of ACC is currently based on pathology. We introduce the case of a 5-year-old girl with ACC who presented with virilizing features at his first visit. She displayed clitoral enlargement, facial hairs, pubic hair, and obesity. Her serum adrenal androgen levels were elevated, and abdominal computed tomography revealed a right suprarenal mass. The patient underwent radical adrenalectomy and remained disease-free throughout one year of regular follow-up. After complete surgical resection, the histological diagnosis was ACC. Two months after surgical removal of the mass, she subsequently noticed to halt of virilizing symptoms and reversal to some extent. But clitoromagaly did not regressed anymore so clitoral reduction surgery is now planned for the patient. Gonadotropin-releasing hormone agonist was started to delay further pubertal progression. Radical surgical resection is an efficient therapy for ACC, and hydrocortisone can be used to alleviate symptoms of secondary acute adrenal hypofunction. In patients with functioning ACC after surgical removal, clinical follow-up and hormonal marker examination every 3 monthly, are useful options for the secondary effects of excessive hormone secretion.

   Guide to Beginners for Laparoscopy in Private Practice “do Little Things Matter” Category: Laparoscopic Surgery Top

Anilkumar Pura Lingegowda, C Ramachandra

Department of Pediatric Surgery, Sakra World Hospital, Bengaluru, Karnataka, India

Aims: To guide and give positive confidence to youngsters to take up Laparoscopy.

Methods: My personal journey in learning and furthering my skills in laparoscopic surgery. Different methods of practicing and preparing for surgery. Do you require to gain more surgical experience before embarking on doing major cases, how do you achieve that in private practice. What is the true meaning of a steep learning curve? What are the Phases in training process?

Results: I am doing major reconstructive surgery by laparoscopy.

Conclusion: Surgery is a skill which will be honed by practice. Like open surgery, laparoscopy is the other modality of surgery. Discussion, interaction and practice on model and virtual practice make you perfect.

   Modified Staged Repair and Long Term Followup of an Uncommon Variant of Omphalocele, Extrophy Bladder, Imperforate Anus, Spinal Anomaly Complex with Well Formed Penis and Near Normal Colon Category: Urology Top

S Rajah, S Ramesh, M Choong, S Vinodh

Department of Pediatric Surgery, Gleneagles Kota Kinabalu Hospital, Sabah, Malaysia

Aim: To analyse the advantages of staged repair and long term anatomical and functional out come in two patients with OEIS Comlex varient.

Methods: Records of 8 patients treated in 3 institutions during 1996 - 2018 were reviewed retrospectively.

Results: Two boys had OEIS Complex with well formed penis and adequate colon. The first patient underwent Transverse colostomy on day 2. Osteostomy, reconstruction of bladder neck and Posterior urethra, clossure of Bladder and abominal wall was performed on day 28. Urethroplasty at 18 months and PSARP at 26 months resulted in satisfactory bladder and bowel continence. Unfortunately lost followup after 17 years. Our second patient underwent end colostomy, bladder clossure with reconstruction of bladder neck and posterior urethra which was anastamosed to the hypoblastic penile urethra at 60 hours of life. Abdominal wall defect was repaired using Polypropylene mesh. The urethral anastamosis leaked which was repaired like perineal hypospadias at 38 months. Bladder holds around 100 ml of urine and he is dry over 4 hours and waiting for anorectoplasty later.

Conclussion: Satisfactory anatomical and functional out come is possible in male OEIS patients with adequate colon and penile length. Using mesh can reduce the operating time, avoid osteostomy associated complications.

   Kshar-Sutra – New Operative Technique for Low Anal Fistulae in Infant Category: Miscellaneous Top

Sarita Chowdhary, SP sharma

Department of Pediatric Surgery, Institute of Medical Sciences BHU, Varanasi, Uttar Pradesh, India

Anal fistula in infants is a common disease. Although many are recovered by conventional treatment, there are some patients who are not repaired easily. We performed the Ksharsutra method to an anal fistula and report the good result that we obtained. We are experiencing three cases.

   Posterior Sagittal Anorectal Myectomy for Ultrashort Segment Hirschprung's Disease and Intractable Constipation Category: GI Surgery Top

Aravindan Chandrasekaran

Department of Pediatric Surgery Meenaskhi Mission Hospital and Research Centre, Madurai, Tamil Nadu, India

Aims: This report evaluates effectiveness of posterior sagittal anorectal myectomy for ultrashort segment Hirschsprung's disease and children with intractable constipation.

Methods: The procedure was performed on 21 patients with ultrashort segment Hirschsprung's disease and between 2013 and 2017. The procedure was performed by making a sagittal incision in midline posteriorly from tip of coccyx and rectum approached.4 to 6 cm longitudinal strip of seromuscular layer is removed from the aganglionic portion of the anorectum starting from the internal sphincter. The patients were followed postoperatively to determine the effectiveness of the procedure and its complications.

Results: Operative biopsy showed aganglionosis in 12 of the 21 children in the lower segment of the specimen and for about 3 cms and normal ganglion cell numbers in the upper segment suggestive of ultrashort segment Hirschprung's disease. Five children had hypoganglionosis in the over all specimen and four had normal ganglion cells in the entire length. The posterior sagittal anorectal myectomy was curative for 18 of the 21 patients. Three of the five children who had hypoganglionosis in the biopsy specimen had persisting constipation though with less severity. None of the children Hirschprung's disease requiring pull through operations. Some transient complications included mucosal perforation during surgery (19%) wound infection (23.8%) and transitional increased frequency of stooling and incontinence (33%).

Conclusion: For children with chronic intractable constipation and suspected ultrashort segment Hirschsprung's disease, posterior sagittal anorectal myectomy is a safe and effective method of treatment and diagnostic in most of the cases.

   Lipoblastoma of Posterior Base of Skull Causing Iatrogenic Cerebrospinal Fluid Leak Category: Miscellaneous Top

Umesh Bahadur Singh, Tanvir Roshan Khan, Shrikesh Singh

Department of Pediatric Surgery, RMLIMS, Lucknow, Uttar Pradesh, India

Lipoblastomas are rare benign adipocytic usually encapsulated neoplasms of infants and children, more common in males with a tendency for local recurrence, a rare neoplasm of embryonal adipose tissue most often encountered on the trunk and extremities of children. Cervical lipoblastoma is rare, and typically asymptomatic, rarely causing nerve compression or airway obstruction. We diagnosed a 4 years female child with large cervical Lipoblastoma invading into the posterior base of the skull. The tumor was indenting into Atlanto-occipital membrane and after complete surgical excision, we encountered the iatrogenic CSF leak into the suction drain. The CSF leak subsided on itself after removal of drain and compression dressing. The histopathology was consistent with Lipoblastoma and patient free of tumor at 6 months of follow up with no evidence of recurrence. MRI can help to identify the lipomatous nature of the mass, but the findings can be inconsistent due to variable maturity of fat cells and the mesenchymal content of the tumor. Diagnosis is always based on pathological examination. Differential diagnosis is broad and includes sarcoma, vascular tumor, myofibroma, and other fibromatoses. A further chromosomal analysis is useful in differentiating lipoblastoma from liposarcoma. Owing to a high recurrence rate following incomplete resection, a complete resection, preservation of vital organs, is essential. The prognosis is excellent despite large tumor size and local invasion and regular follow up is important for early detection of recurrences.

   Remove the Tumor and Spare the Testis in Paediatric Testicular Tumors: Report of Three Cases and Review of Literature Category: Urology Top

S Rajah, Ahmad Toha, S Chandran

Department of Pediatric Surgery, Gleneagles Kota Kinabalu Hospital, Sabah, Malaysia

Aims: Most paediatric testicular tumors are benign and the treatment has evolved from radical orchidectomy to preserving the testis. This presentation analyse the clinical, imaging and histopathological creteria for testis preserving surgery.

Methods: Records of chilren treated for testicular tumor treated in our institution during 2016 to 2018 reviewed.

Results: Three boys aged 11 months, 6 years, 15 years were referred for painless scrotal swelling of 4 to 6 weeks duration. The 15 years old boy underwent orchiopexy at 6 1/2 years for bilateral cryptorchidism. Clinical examination revealed enlarged right testis and well defined solid heterogenous, hypoechoic, hypovascular, intraparenchymal nodule on ultrasonography. The option for preserving the testis was turned down by the family due to fear of malignency. The histopathology was epidermoid cyst. The 6 years old boy had similar findings with some calcifications underwent enucleation of histopathalogically confirmed teratoma of his left testis. The third patient had solid left testicular tumor with increased vascularity on doppler ultrasonogrphy and high AFP underwent high orchidectomy. Histopathology was endodermal sinus tumor stage I and on servilence.

Conclusion: Careful clinical evoluation, Doppler ultrasonography, serum tumor markers, frozen section biopsy and meticulous surgical clearance can help to spare the testis in most paediatric testicular tumors.

   Clean Intermittent Catheterization Induced Major Lower Urinary Tract Injuries: A Report of Two Cases and Their Management Category: Urology Top

Harish Jayaram, Mainak Deb, Abirami Krithiga

Department of Pediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India

Aims: CIC related complications are rare and generally minor. We report two cases of major complications following CIC and their management.

Methods: Two children aged 16 and 8 years who were on CIC presented with acute symptoms which were evaluated and managed.

Results: Case-1 was a 16 years old boy who was operated for lumbosacral meningomyelocele and on bladder management for neurogenic bladder with CIC and anticholinergic medications. He had sudden onset fecaluria and passing urine through his rectum. Evaluation with RGU confirmed rectourethral fistula and was managed with closure of the same under colostomy cover and adding a Mitroffanoff procedure. Case-2 was 8 years girl with neurogenic bladder with gross bilateral reflux and chronic renal failure managed with CIC, presented with sudden onset suprapubic swelling. Evaluation revealed peri-vesical collection suggestive of bladder perforation. She was managed with bladder catheterization for three weeks, but had a blocked catheter which caused bladder distension and urinary ascites. She was re-catheterized and awaiting bladder augmentation and Mitroffanoff procedure.

Conclusion: CIC is supposedly safe, but unsupervised can result in serious complications. Both cases in our series are rare complications of CIC in children which have not been reported to the best of our knowledge.

   A Case of Tracheoesophageal Fistula without Atresia in an 8 Year Old Category: Miscellaneous Top

Aswathy Ravikumar, GM Asok Kumar

Department of Pediatric Surgery, Sree Avittom Thirunal Hospital, Thiruvananthapuram, Kerala, India

Aim: To demonstrate a case of TEF without atresia in an older child in a tertiary care centre.

Methods: Descriptive study 8 year old boy, one of twins, presented with recurrent chest infections, choking on feeds since infancy. He had multiple hospital admissions and was evaluated for GERD, reactive airway disease and tuberculosis. HRCT chest suggested the presence of congenital H fistula. Bronchoscopy confirmed the diagnosis. Cineesophagogram was inconclusive. Prior to neck exploration, fistula was cannulated with angiocatheter by bronchoscopy. By right cervical incision, neck was explored, fistula identified, looped and divided. The tracheal and esophageal ends were sutured, omohyoid flap was interposed between the two. Postoperative recovery was smooth.

Results: High index of suspicion is required to diagnose a H fistula. HRCT chest was helpful in diagnosis while cineesophagogram was inconclusive. Use of curved angiocatheter for stenting the fistula aided in easy identification and looping of fistula. Hence looping of esophagus and injury to contralateral recurrent laryngeal nerve was avoided, hence postoperative ventilation was avoided.

Conclusion: Repeated aspirations warrant evaluation for H fistula even in an older child. Fistula cannulation aids easier identification and less complications.

   Late Presenting True Hermaphrodite with Acute Abdomen Category: Urology Top

Digamber Chaubey, Sandip Kumar Rahul, Vijayendra Kumar, Ramdhani Yadav, Vinit Kumar Thakur, Zaheer Hasan

Department of Pediatric Surgery, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Background: True hermaphrodites often present late despite having ambiguous genitalia. We present an extremely rare case, with acute abdomen with uterus,  Fallopian tube More Details and ovary on right side and descended testicle on the left side.

Material and Methods: A 25-year-old-supposedly male patient came with difficulty in passage of urine since 3 weeks, pain lower abdomen and fever since 5 days. There was a history of passage of urine from an ectopic opening in perineum since birth, prominence of bilateral breasts since the age of 14 years and female voice. On examination, Perineal hypospadias with chordee and Penoscrotal transposition, left descended testis, hypoplastic right scrotum with absent testis, bilateral breast prominence, feminine distribution of hair were found; a tender boggy swelling anteriorly on per-rectal examination was conspicuous. Sonogram revealed prominent, bulky uterus with right ovary showing haemorrhagic lesion, minimal endometrial and vaginal collection, haematocolpos with left testicular microlithiasis. Karyotyping showed 46 XX/46 XY mosaicism. Surgical management included initial laparotomy for hysterectomy and salpingo-oophrectomy, correction of chordee and penoscrotal transposition, followed by excision of hemivagina on right side through posterior sagittal route and finally urethroplasty for perineal hypospadias over a prolene suture with Suprapubic cystostomy with testicular implant insertion on Right side as the final procedure.

Results: Patient is doing well on regular follow-ups.

Conclusion: Emergency intervention, need for staged surgery to correct the complex abnormalities and issue of sexuality in such True Hermaphrodite cases make their management difficult and challenging.

   A Rare Case of Bilateral Single System Vaginal Ectopic Ureters Category: Urology Top

Shyamendra Pratap Sharma, Sarita Chowdhary, SP Sharma, Pranay Kumar Panigrahi, Arjdeo Upadhyay, Rakesh Kumar

Department of Pediatric Surgery, Institute of Medical Sciences BHU, Varanasi, Uttar Pradesh, India

Aim: To present a rare case of Bilateral Single System Vaginal Ectopic Ureters (BSSVEU).

Methods: A 1 year old female child come to our OPD with chief complaints of dribbling of urine since birth, non passage of urine in stream and no history of high grade fever, chills & rigor, swelling over back, altered bowel habit, with the help of clinical examination, CT IVU (revealed b/l hydro-uretero-nephrosis bilateral Ureters inserted to lateral vaginal wall and contrast collection in vaginal cavity) and Diagnostic Cystoscopy (Bladder neck was developed with Ill-defined trigone was seen, Bladder capacity was approximately < 5 ml and Ureteric orifice could not be visualized in bladder or vagina) Definitive diagnosis of Bilateral Single System Vaginal Ectopic Ureter (BSSVEU) was made. Single stage bilateral ureteric re-implantation was done.

Results: Post operative dry time for patient was 10 min on day 7 which increase up to 1 hour in 1 month and 2-3 hours after 3 month follow up. At 3 month renal function preserved, MCU show increased bladder capacity (30 ml) with B/L VUR, but no contrast retention after micturition.

Conclusion: For ectopic ureters primary ureteral re-implantation is useful option to avoid staged procedure and augmentation surgery complications

   A Surgical Cause for Chronic Intractable Diarrhea in a Child? a Diagnostic Challenge Category: GI Surgery Top

Abirami Krithiga, Harish Jayaram, Mainak Deb

Department of Pediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India

Aims: To report a rare surgical cause for chronic intractable diarrhea in a child and the diagnostic challenges we faced in the evaluation.

Methods: 6 year old boy presented with mucous diarrhea since infancy with no systemic or other GI symptoms. He had blood stained stools from 4 years of age and required blood transfusion for low hemoglobin. He was investigated with USG, CT abdomen, upper and lower GI endoscopy which were all normal. Multiple medical diagnoses were considered and empirical therapy started. After an episode of another lower GI bleed, a Meckel's scan was ordered which showed a large area of uptake suggestive of duplication of bowel. Laparoscopy followed by laparotomy revealed a near total tubular duplication of small bowel which was resected.

Results: Child had an uneventful recovery and the histopathology confirmed duplicated small bowel with ectopic gastric mucosa.

Conclusion: Tubular duplications can have different clinical presentations and a high index of suspicion is required to evaluate and manage these cases. Meckel's scan should be in the armamentarium of diagnostics in complex GI presentations in children.

   Functioning Muscle Transfer for Agenesis of Abdominal Wall Muscle Aponeurotic System: 5 Year Followup Category: Miscellaneous Top

Subhasis Saha, Rajan Tondon

Department of Pediatric Surgery, Advanced Medical Research Institute, Kolkata, West Bengal, India

Aim: Reconstruct a dynamic musculoaponeurotic support for the deficient abdominal wall. Restore “ like with like.”

Materials and Methods: The patient was a 11 year old girl, presenting with a large congenital herniation from a right supraumbillical abdominal wall weakness. She had no associated urinary anomalies. Abdominal CECT revealed lack of musculoaponeurotic structures in the right supraumbillical region, with resultant herniation through the defect. Functioning ipsilateral Latissimus dorsi muscle transfer was performed, with prior pulmonary acclimatization for 6 weeks.

Results: Her postoperative recovery was uneventful and the patient was discharged after 2 weeks. She was taught simulation exercises to enable cortical reorientation associated with functioning muscle transfers. At 5 years follow up, the patient had no herniation and was able to contract the transferred muscle at will.

Conclusion: Functioning muscle transfer is the best way to replace deficiency of muscle. Proper training can help in the patient utilising the functioning transferred muscle. The girl who had missed school for 4 years being ridiculed day in and day out is now a regular at school and a topper at that too.

   Complicated Case of Urethral Duplication with Dilated Posterior Urethra and Renal Failure Category: Urology Top

Ruchira Nandan, Shilpa Sharma, Devendra Yadav, Devendra K Gupta

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Aim: To report a complicated case of urethral duplication.

Case Report: A six year male presented with urinary retention. He passed urine in two streams since birth, dorsal stream being much thinner than ventral. Bladder was palpable. There were two urinary meatus on glans. Catherization with 8 Fr Foleys was possible only through ventral meatus. Urine was turbid. Urea; Creatinine were 119 mg/dl; 3.6 mg/dl. Ultrasonography showed right gross hydroureteronephrosis, small left kidney with dilated tortuous ureter and bladder wall thickening with diverticulum. MCU showed urethral duplication type II A2 (Effman classification), dilated posterior urethra in dorsal urethra, right grade V vesicoureteric reflux and urinary bladder with diverticulae. On DMSA, left kidney was not visualized and right kidney had impaired function. GFR was 19 ml/min/1.73 m^2 BSA. Cystoscopy through ventral urethra showed normal urethra, trabeculated bladder with multiple sacculations and diverticulae. Left golf-hole shaped ureteric orifice was visualized. Right ureteric orifice was not visualized. Smallest available cystoscope 6.5 Fr could not be negotiated through dorsal meatus. Right loop ureterostomy was done to save the only functioning renal unit. Urea; Creatinine reduced to 85 mg/dl;1.6 mg/dl on postoperative day 7.

Conclusion: Urethral duplications can present with obstructive uropathy and should be tackled early to prevent renal failure.

   An Unusual Case of Partial Prune Belly Syndrome Category: Urology Top

Jujju Jacob Kurian, Arun Kumar

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Introduction: Prune Belly Syndrome comprises of congenital deficiency of anterior abdominal wall musculature, complex urinary tract anomalies and bilateral crytorchidism. We report a case of partial prune belly where the above mentioned defects were confined to the left side of the abdomen.

Case Report: An 11 month old boy presented with a swelling of the left abdomen since birth and left sided cryptorchidism palpable in the inguinal canal. He has had 2 episodes of urinary tract infections in the past four months. Investigations revealed that the left kidney was poorly functioning with mild hydronephrosis and a non obstructed refluxing megaureter. No obvious cause could be made out for the left sided abdominal swelling other than muscle weakness. Cystoscopy revealed a comparatively small bladder with wide and gaping left ureteric orifice and a normal right side. An end ureterostomy on the left with left orchidopexy was done.

Conclusion: Partial prune belly is a rare entity. The fact that partial prune belly exists, maybe a pointer that abnormal development of the lateral plate mesoderm is the true reason for Prune Belly Syndrome.

   Hypospadiac Urethral Duplication: A Rare Variant and Novel Technique of Repair Category: Urology Top

Rahul Saxena, Manish Pathak, Arvind Sinha, Tanmay Motiwala, TK Jayakumar

Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajastan, India

Background: Urethral duplication is a spectrum of congenital anomalies that is more common in males, but very little is known about the possible reconstruction methods and their outcome. The various sagittal duplications identified are prepubic sinuses, epispadiac, hypospadiac, spindle urethra and Y duplications. The management of these cases has to be individualised according to the anomaly and the prognosis is usually good but depends on a successful reconstruction. Hypospadiac urethral duplication is a variety which is usually treated with onlay preputial flap.

Case Report: We report a 3-year-old patient of hypospadiac duplication who was treated with single stage urethroplasty. An excellent cosmetic and functional outcome was achieved by dorsal to ventral urethra-urethrostomy and novel application of tubularised incised plate technique for urethroplasty.

Conclusion: Urethral duplication is a rare entity with wide anatomical spectrum. Novel application of tubularized incised plate technique in hypospadiac duplication can simplify its management with excellent results.

   The Role of Laparoscopic Suture Rectopexy and Utility of the Lift Sign in Children with Rectal Prolapse Category: Laparoscopic Surgery Top

Vaibhav Pandey, Ajay Narayan Gangopadhyay, Saroj C Gopal, Shiv Prasad Sharma

Department of Pediatric Surgery, I.M.S. B.H.U., Varanasi, Uttar Pradesh, India

Aim: Different surgical repair techniques have been described for the repair of rectal prolapse in children with no response to the conservative management. We performed this study with an aim to assess the role of laparoscopic rectopexy and assess the utility of lift sign for the achievement of adequate anchorage of the rectum.

Methods: All the children with complete rectal prolapse who were either non responder to the conservative treatment or with recurrence were included in the study. Children with associated neuromuscular disorders were excluded from the study. Patients underwent laparoscopic suture rectopexy. The “lift sign” was utilised for the achieving for adequate anchorage.

Results: There recurrence rate in the laparoscopic suture rectopexy was similar to the open group ((p value= 0.08).). The mean hospital stay and the cost were less in the laparoscopic group compared to the open group. The rate of recurrence was more in laparoscopic group without use of lift sign compared to the use of lit sign (p value= 0.04). Conclusion: Laparoscopic suture rectopexy has got shorter hospital stay and is more cost effective compared to open rectopexy. The lift sign was extremely useful in demonstrating the adequacy of anchorage.

   A Case of Congenital Megaprepuce Category: Urology Top

Lydia Mary, GM Asok Kumar

Department of Pediatric Surgery, SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala, India

Aims: To highlight the clinical presentation and surgical management of Congenital Megaprepuce.

Methods: Case record of a patient managed for congenital megaprepuce was retrospectively evaluated.

Results: After a follow up of 3 months, the functional and cosmetic outcome was satisfactory. Short term complication was a minimal skin dehiscence at penoscrotal junction.

Conclusion: Congenital Megaprepuce is a striking condition and is diagnosed by physical examination. It can be confused with anterior urethral diverticula. Excision of inner preputial mucosa with usage of external skin for penile coverage will provide good results.

   Anorectal Malformation with Tubular Hindgut Duplication Category: GI Surgery Top

Arj Deo Upadhyay, Vaibhav Pandey, Ajay Narayan Gangopadhyay, Saroj C Gopal, Shiv Prasad Sharma

Department of Pediatric Surgery, I.M.S. B.H.U., Varanasi, Uttar Pradesh, India

Aim: Anorectal malformation with tubular hindgut duplication is extremely rare. We herein present one such case with diagnostic dilemma and complicated management.

Case Report: A 4 Year male presented to us in obstruction with past history of anolpasty for low ARM on 2nd day of life. On examination the anus was pliable with easily incorporating the index finger with a bulge on the posterior rectal wall. There was also history of chronic constipation. Ultrasound of the abdomen was showing cystic mass in the presacral region. An MRI of the abdomen revealed complete duplication of the hindgut. A laparotomy and colostomy at hepatic flexure was performed. Six week later rectal mobilisation was performed through PSARP and the incision was closed over a large tube after which abdomen was opened. The distal blind end of duplicated colon was opened and the common wall of duplicated gut was divided with stapler. Pull through was performed along the tube placed by PSARP approach. The colostomy closure was performed after six weeks. The child is doing well at 3 month follow up.

Conclusion: Our case is unique as it is first case with perineal fistula in male child and complete hindgut duplication. This led to missing of duplicated segment in the first place. Further, the use of stapler helped to us preserve long segment of hindgut.

   Pediatric Robotic Pyeloplasty: Our Initial Experience Category: Urology Top

Cherian Jerin Oommen, Vivek BR, Pavithra V, MM Zameer, C Vinay, Sanjay Rao, Ashley D'Cruz

Department of Pediatric Surgery, Narayana Health, Bengaluru, Karnataka, India

Aim: To review the experience of robotic pyeloplasty at our institute.

Introduction: The availability of robotic device has now increased its use in performing pyeloplasty which was initially done as open or laparoscopically. Robotic pyeloplasty has proven benefits like smaller incision, minimal blood loss and shorter hospital stay. We are sharing our experience with Robotic Pyeloplasty. Da Vinci SI system was installed in our institute from 2016. Methodology: This is a retrospective and descriptive study of all robotic pyeloplasties done from January 2017 till date. Data was collected from MRD and analysed.

Results: Eleven children have undergone robotic pyeloplasty for PUJO. Ten were boys. All had left PUJO. Mean weight was 26.5 kg (range 10- 50 kg). Mean age was 5.6 years (range 2 - 15 years). Crossing vessels were found in 2 children and rest had classical PUJO. Retrocolic approach was done in 3 and transmesocolic approach in 8. Average console time was 3 hours. All had uneventful recovery except one who had re-exploration for anastomotic leak. Follow up DTPA in 9 children showed unobstructed drainage and 2 children haven't completed followup.

Conclusion: Our initial experience on robotic pyeloplasty seems to be favourable and safe.

   Scrotal Migration of a Ventriculoperitoneal Shunt in Child with Hydrocephalus: A Case Report Category: Miscellaneous Top

B Viswanath, P Sreenivas Reddy, C Babu Rao, M Rajesh

Department of Pediatric Surgery, Niloufer Hospital for Women And Children, Hyderabad, Telangana, India

Ventriculoperitoneal shunt implantation is commonly used in the treatment of hydrocephalus and there have been many reports on the migration of the distal catheter since this phenomenon was recognized 50 years ago. However scrotal migration of peritoneal end of ventriculo-peritoneal (VP) shunt into the patent processus vaginalis (PPV) is a rare complication. We present a rare case of a 13 month child presenting with a right-sided scrotal swelling with the distal end of the shunt migrating through the patent processus vaginalis into the scrotal sac following a VP shunt placement for congenital hydrocephalus. Its exact incidence is not mentioned in the literature to date. The appropriate management of our case included exploration of the inguinal canal and repositioning of the distal catheter back into the peritoneal cavity followed by Gross – Ferguson's herniotomy.

   Appendicular Interposition as Ureteric Substitute Category: Urology Top

Siva Satya Prasun, N Bhuvaneswar Rao, KVS Narayana, KT Mandakini

Department of Pediatric Surgery, Niloufer Hospital for Women and Children, Hyderabad, Telangana, India

Ureteral diverticula is a rare urological condition Only 45 cases have been reported to date Classification: (1) true congenital diverticulum (2) acquired diverticulum Diverticulectomy with segmental resection and end to end anastomoses is the treatment of choice. A variety of surgical techniques have been described for substitution of long ureteral segments. The first choice procedures make use of urinary tract tissues as seen in psoas- hitch procedure, boari - flap procedure and trans ureteroureterostomy. If ureteral loss cannot be repaired by intrinsic urinary tract tissue partial or total replacement by gastrointestinal tissue used Bowel substitutes includes colon, ileum and appendix. We present a rare case of large ureteric diverticulum with solitary kidney for which ureteric diverticulum excision was done and appendix was interposed as a ureteric substitute.

   Heteropagus: A Complex Anomaly with Complex Management Needs Category: Miscellaneous Top

Rohith Srinivas, Harshjeet Bal

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Aims: Presenting two cases of Heteropagus or 'parasitic twins', their clinical profile, evaluation, surgical management and outcomes.

Methods: Two children born with Heteropagus were studied; their clinical and management details were recorded. Results: Heteropagus is a complex, rare form of conjoined monochorial monoamniotic twins with an incidence of less than one per million live births. We present a male child and a girl with similar set of anomalies including anorectal malformation, additional/rudimentary limb, duplication of genitalia and spinal dysraphism. The boy presented with rectobulbar fistula and the girl with rectovestibular fistula. Both children (autosites) had rudimentary limbs of the parasitic twin with preserved pelvic/limb bones attached to the autosite pelvis. An MRI, contrast study and Ultrasound was performed to study the extent of anomalies. The boy underwent colostomy, followed by excision of rudimentary limb with sacroperineal pull through and closure colostomy. The girl underwent excision of the additional limb followed by single stage ASARP. Although the reconstruction was excellent, poor pelvic floor development and neurological impairment due to spinal dysraphism have led to poor functional outcomes.

Conclusions: Careful preoperative planning and a multidisciplinary approach involving Paediatricians, Paediatric orthopaedicians and Neurosurgeons helped provide the best possible outcome for this rare anomaly.

   Use of Negative Pressure Wound Therapy Device (Pico Device) in Paediatric Surgery Practice Category: Miscellaneous Top

Santanu Singha, Sanat Kuamr Khanna

Department of Pediatric Surgery, Command Hospital, Panchkula, Haryana, India

Aims: To assess the effectiveness of NPWT (PICO) in management of complex post- operative wound in Paediatric surgery practice.

Methods: The management of postoperative non healing chest wound in cases like Absent sternum (optd), Pectus excavatum (optd) cases or other non healing low exudate wound can be at time challenging to the treating surgeon by conventional dressing due the the presence of underlying prosthesis used during corrective surgery. The use conventional dressing in these complex wounds usually increase the healing time, hospital stay & extra load on dressing changes. Therefore in these cases NPWT device (PICO device) for min 7 days is very helpful in management of these type of wound which hasten the wound healing in such cases by reducing oedema, increasing perfusion, removing infectious materials, splinting of incision in a close environment & thus optimize the patient care. Many young paediatric surgeons are not aware of this PICO (NPWT) device, which is very helpful in tissue healing.

Results: The PICO device was used three cases of post op wound dehiscence with excellent outcome (Absent sternum-1, Pectus excavatum-1, MMC -1 & others-01) in our centre. The device is small & can be used on OPD basis.

Conclusion: These device can be used in wide ranges of low exudative non-healing post op wounds in our speciality as it is helpful in reducing risk of infection, hematoma, dehiscence & seroma.

   An Enigmatic Case of Swelling of Upper Limb and Thorax in 5 Year Old Child Category: Miscellaneous Top

Advait Prakash, Advait Prakash, Sangram Singh

Department of Pediatric Surgery, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Mathya Pradesh, India

Aim: Swelling involving the upper limb and thorax can be due to various disorders such as lymphatic disorders, tumors, venous malformations, infections, hematological disorders etc. Owing to multiple sites of origin and involvement reaching the correct diagnosis becomes an arduous task.

Patients and Methods: A 5 yrs old male child presented with a swelling involving the right upper limb, right side of neck, anterior chest wall of the same side and extending up to inferior border of the right scapula on the back. It originated one and half years back at the right forearm and dorsal aspect of right hand and progressed gradually. The patient was investigated and treated at various centers without any improvement. At our institution the ultra sonography of showed swelling in the subcutaneous plane only and not involving the muscle or underlying structures. Incision biopsy was performed which revealed Subcutaneous Zygomycosis. On retrospective analysis there was history of thorn prick which was not attended. The patient was then put on oral Fluconazole 150 mg for 4 weeks.

Results: Drastic improvement and the swelling completely resolved in two months' time with excellent functional and cosmetic outcome.

Conclusion: Zygomycetes affect the immune competent individual, causing principally chronic infection of the subcutaneous tissue. The disease is usually misdiagnosed due to lack of awareness owing to paucity of literature. High index of suspicion and biopsy are required to reach the correct diagnosis. Proper and timely intervention yields rewarding results.

   An Extremely Rare Co-Infection of Hydatid Cyst with Aspergillus In an Immuno-Competent Host: Diagnostic and Management Challenges Category: Thoracic Surgery Top

Advait Prakash, Advait Prakash, Sangram Singh

Department of Pediatric Surgery, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Mathya Pradesh, India

Aim: Hydatid disease is a parasitic infection caused by the larval stage of Echinococcus granulosus. The co-infection of hydatid cyst with Aspergillus which is a saprophytic fungus is extremely rare. Such occurrence is usually observed in immuno-compromised patients. We hereby describe an adolescent immuno-competent patient who suffered from such co-infection.

Patients and Methods: A fifteen-year-old young male child presented with dry cough, dyspnea and non-specific chest pain since three months. There was no history of pulmonary tuberculosis, hemoptysis, fever, loss of weight. He was recieving treatment and advised surgery for suspected hydatid cyst. Ultrasound of chest revealed cystic lesion in the right hemithorax, encysted collection with consolidation of adjacent lung. High resolution CT scan of thorax was suggestive of cyst in right lower lobe of lung with intact pericyst, ruptured endocyst and air fluid levels. Patient underwent right postero-lateral thoracotomy. Surgical Specimen showed Hydatid membrane/cyst present along with pus. Histological examination of cyst wall showed intense inflammation and several septate hyphae of Aspergillus species.

Results: The patient had a stormy post-operative course initially and once the anti-fungal was added improved significantly.

Conclusion: The rare occurrence of such a condition can lead to a delay in diagnosis and treatment. In patients having hydatid disease with prolonged illness and little response to treatment, a co-infection with aspergillus should always be considered.

   Empyema Chest: A Rare Cause Category: Thoracic Surgery Top

Aamer Iqbal, Sudhakar Jadhav, Dinesh Kittur, Santosh Patil, Yogesh Tiwari

Department of Pediatric Surgery, SJKCT Paediatric Surgery Centre and P.G Institute, Sangli, Maharashtra, India

Aim: To study a rare cause of empyema chest.

Materials and Methods: 2 months male child presented with swelling in right chest wall. Swelling was warm and tender. There was history of incision drainage at the same site 1 month back. Investigations revealed osteomyelitis of right 7th rib with empyema chest. Segment of rib was excised alongwith thoracotomy and debridement/decortication. Baby had uneventful recovery and right lung expanded well.

Results: Post operatively patient had an uneventful recovery and is on regular follow up.

Conclusion: osteomyelistis of the rib is very rare.

   Solitary Kidney with Ectopic Ureter Category: Urology Top

Tarun Gupta, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur

Department of Pediatric Surgery, SJKCT's Paediatric Surgery Centre and P.G. Institute, Sangli, Maharashtra, India

Aim: To study a case of solitary kidney with ectopic ureter.

Materials and Methods: 14 years old girl presented with abdominal pain and hematuria at the time of 1st menses. Onperineal examination patient had a single opening. USG had revealed righthydroureteronephrosis, left renal agenesis. Examination under anaesthesia didn't reveal ectopic ureteric orifice. CT scan revealed high residing urethra opening on right side of vagina. Creatinine was 1.74. Right sided ureteric reimplantation was done.

Results: Patient did well post operatively and is on regular follow up.

Conclusion: Solitary kidney with ectopic ureter is rare.

   Giant Rectal Polyp in Pediatric Age Group- an Uncommon Clinical Entity Category: GI Surgery Top

Vipul Prakash Bothara, Vipul Prakash Bothara, Anand Pandey, Archika Gupta, Abhishek Kumar Singh, Gurmeet Singh

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aims: A rectal polyp of more than 3 cm is extremely rare in pediatric age group. Juvenile rectal polyp of more than 4 cm size has not been reported in the literature. We treated two children having juvenile rectal polyp of this type.

Methods: Two patients presented with bleeding per rectum were evaluated at our center. They were 11 and 10-year-old respectively. Digital rectal examination revealed rectal polyp. After anesthetic fitness, digital rectal polypectomy was performed.

Results: Both the patients had a solitary rectal polyp (size 4 cm X 4.5 cm in the 1st child and 5 cm X 5 cm in the second child). Histopathology revealed the diagnosis of juvenile rectal polyp. There was no problem in the follow up of 6 months.

Conclusion: To the best of our knowledge, this is the first description of giant rectal polyp in pediatric population. High index of suspicion is needed for diagnosing it. Care during intra-operative and post-operative period is essential due to the size. If properly taken care of, results are good. Histopathological confirmation is important to rule out any possibility of malignant potential.

   Complications of Ureterosigmoidostomy in a Bladder Exstrophy Patient: A Long Tale Category: Urology Top

Harshjeet Singh Bal, Harshjeet Singh Bal, Sudipta Sen, Dipti Masih

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Introduction: The bladder exstrophy is a rare congenital anomaly. The uretero-colic anastomosis has been in practice since more than a century ago as ureteral diversion for achieving urinary continence in bladder exstrophy. The ureterosigmoidostomy has multiple long-term complications including ascending urinary infection, hyperchloremic metabolic acidosis, electrolyte imbalance, urinary stone and anastomotic colon cancer. Herein we present a case of bladder exstrophy, who initially underwent ureterosigmoidostomy and faced major late complications due to this.

Case Report: A 21-year-old male, who underwent bladder excision and ureterosigmoidostomy for bladder exstrophy at 18 years of age in another center, presented to us with complaints of recurrent febrile episodes with bilateral flank pain. He was evaluated and found to have left non-functioning kidney with pyonephrosis. He underwent left nephrectomy and bladder substitution with Mitrofanoff stoma using ileocecal segment of bowel. During regular follow-up, 7 years later, he was found to have anemia due to occult bleeding per rectum. Evaluation revealed a sigmoid mass at ureteric reimplantation site, which was excised and reported as an unusual polypoid tumor.

Conclusion: This case is being presented as our patient uniquely suffered two major complications of ureterosigmoidostomy – ascending urinary infection leading to renal loss and bowel neoplasm.

   Foreign Body Acute Appendicitis in a Child Due to Ingested Pin: A Rare Case Category: GI Surgery Top

Gurmeet Singh, Jiledar Rawat, Sudhir Singh

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aim: To report a very rare case of acute appendicitis due to ingested metallic pin.

Materials and Methods: A 4-year-old girl child presented with lower abdominal pain, vomiting, fever, and abdominal distension for five days. On abdominal radiograph, a radiopaque foreign body was identified in a right lower abdomen along with multiple air-fluid levels. Exploratory Laparotomy revealed acutely inflamed appendix with adherent omentum, perforated at its tip by a metallic needle which had penetrated both walls of appendix. Appendicectomy was performed.

Results: Patient had an uneventful postoperative course. Histopathology revealed acute foreign body appendicitis.

Conclusion: Foreign body appendicitis is a rare condition. The condition should be suspected in a child with features of appendicitis and on radiography findings of foreign body opacity in right iliac fossa.

   H-Type Tracheoesophageal Fistula with Isolated Left Lung Bronchiectasis: A Very Rare Presentation Category: Thoracic Surgery Top

Gurmeet Singh, Jiledar Rawat, Sudhir Singh, Gaurav Shandilya

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aims: To highlight a rare case of H Type Tracheoesophageal fistula (TEF) with isolated left lung bronchiectasis.

Methods: A 4-years-old female child presented with recurrent pneumonia nasal and oral regurgitation of feeds since birth. She required recurrent admission for pneumonia and also required recurrent ventilatory support. On radiography isolated left lung bronchiectasis was present. Bronchoscopy confirmed the diagnosis of H type TEF. Per op bronchoscopy was performed and the fistula tract was cannulated with 10 Fr IFT. Ligation and repair of fistula by right trans cervical approach was planned but fistula could not be isolated by cervical approach. Thoracotomy was performed and fistula was ligated with repair of trachea and esophagus.

Results: Patient is asymptomatic in 6 month follow up.

Conclusions: Congenital TEF (H-type) is a rare disorder and this condition should be ruled out in cases of repeated pneumonitis.

   Case of Complete Duplication of Colon and Terminal Ileum Category: GI Surgery Top

Abhishek Anand, Tapanjyoti Banerjee, Ashok Kumar Basu

Institute of Child Health, Kolkata, West Bengal, India

Aims: To make surgeon aware of such complicated condition and to demonstrate the novelty of surgery.

Methods: 7 years old girl was admitted with complaints of high grade fever associated with discharge of pus from vagina. She also gave history of passing stool from anus and vagina since birth. On physical examination abdomen was tense and tender with decreasd bowel sounds. A provisional diagnosis of peritonitis was made. At laparotomy a complete tubular duplication of colon, terminal ileum and appendix was detected. A pelvic colostomy was done of the duplicated colon. Passage of red rubber catheters through two distal openings of colostomy was done. One came out through the normal anus and the other came out through the vagina. Thus diagnosis of complete duplication of the colorectum was confirmed with one end opening into the vagina and the other end into the normal anus. At second operation, mucocectomy of vaginal part of distal end of duplicate colon was done and end to end anastomosis of upper duplicated colon with distal rectal end of colon done. Post operative period was uneventful and patient was discharged is charged.

Results: Near normal anatomy can be achieved even in patient with complicated colonic duplication.

Coclusion: Complete colonic duplication is a rare anamoly and successful repair can be done to give patient normal healthy life.

   Annular Pancreas in an Older Child: A Case Report Category: GI Surgery Top

T Vidhya, S Namasivayam

Department of Pediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India

Aim: Annular pancreas is rare in older children. Presents with recurrent cholangitis unlike the neonatal presentation which is of duodenal obstruction. Relief of obstruction relieves cholangitis.

Methods: Two-year old boy presented with recurrent cholangitis. USG showed Annular pancreas. Recurrent episodes of cholangitis with short intervals caused a delay in carrying out MRCP and contrast study. It was difficult to establish evidence of duodenal obstruction. Duodeno-duodenostomy was carried out.

Results: Duodeno-duodenostomy has relieved obstruction and cholangitis during short term follow up.

Conclusion: Annular pancreas in a older child presented with recurrent pancreatitis. There was difficulty in establishing evidence for obstruction in the early coarse of hospitalisation. Duodeno-duodenostomy relieves obstruction and cholangitis.

   Gastric Teratoma: A Case Report Category: Surgical Oncology Top

Uday Bhaskar, S Namasivayam

Department of Pediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India

Aim: A case report of Gastric Teratoma is presented for it's rarity. Contrary to the common statement that Gastric Teratoma is always benign this case has uncommon tendency towards malignancy like few recent reports.

Methods: Three months old baby presented with large mass abdomen and history of melena. X- ray abdomen and Ultrasound suggested a retroperitoneal teratoma. CT and MRI suggested a large intraperitoneal teratoma. AFP was more for the age. Laparotomy showed a gastric teratoma. The teratoma was excised and sent for HPE. AFP became normal post operatively.

Results: Gastric teratoma with raised AFP which came to normal after excision. HPE showed immature elements.

Conclusion: The case require careful follow up for recurrence or malignancy contrary to the common statement that Gastric teratoma is always benign in accordance with the few recent reports.

   Secondary Intussusception-Rare Cause Category: GI Surgery Top

Yogesh Amarnath Tiwari, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur

Department of Pediatric Surgery, Sudhakar Jadhav Institute, Sangli, Maharashtra, India

Aim: To study a case of Ileocaecal Intussusception secondary to Duplication Cyst.

Methods: This is a study of 3 cases who presented with h/o intermittent abdominal pain, bilious vomiting. On examination, patients were dehydrated, lethargic and had abdominal distension. USG abdomen revealed ileocolic intussusception. Hydrostatic reduction was done but failed. Then exploratory laparotomy revealed pathological lead points such as Duplication cyst, double meckel's. Manual reduction followed by resection & anastomosis was done.

Results: The patients did well post operatively and are on regular follow up.

Conclusion: Secondary intussusception, rare cause.

   Bilateral Congenital Obstructive Megaureter Category: Urology Top

Yogesh Tiwari, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur

Department of Pediatric Surgery, Sudhakar Jadhav Institute, Sangli, Maharashtra, India

Aim: To study a case of Bilateral Congenital Obstructive Megaureter.

Methods: Two and a half years female child presented with h/o UTI and loss of appetite x 1 month. Examination was normal. USG abdomen revealed fullness and dilatation of B/L PC systems and ureters. On IVP, B/L obstructive megaureters were found. MCU revealed smooth walled urinary bladder with no v.u. reflux. B/L ureteric reimplantation was done followed by cystoscopic stent removal after 1 month.

Results: The patient recovered well and is on regular follow up.

Conclusion: b/l obstructive megaureter can be managed by reimplantation.

   Testicular Acute Lymphoblastic Lymphoma Category: Miscellaneous Top

Yogesh Tiwari, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur

Department of Pediatric Surgery, Sudhakar Jadhav Institute, Sangli, Maharashtra, India

Aim: To study a case of testicular lymphoblastic lymphoma.

Materials and Methods: 5 years male presented with right testicular swelling since 15 days. The swelling started suddenly and progressively increased in size. On examination there was a swelling in both the testis right>left. Right sided testicular swelling was firm, red and non tender. LDH – raised, HCG - <1.2, AFP – 2.09. USG revealed enlarged, hypoechoic right testis with altered echotexture. Left testis is normal. Right orchidectomy and left testicular biopsy was done. Histopathology revealed acute lymphoblastic lymphoma.

Results: Post operatively patient had an uneventful recovery and is receiving chemotherapy at a cancer institute.

Conclusion: Testicular acute lymphoblastic lymphoma is rare.

   Thoracoscopic Thymectomy-Our Initial Experience Category: Thoracic Surgery Top

Raghu Shankar, B Sandeep Rai

Department of Pediatric Surgery, K. S. Hegde Medical Academy, Mangalore, Karnataka, India

Aim: To report our initial experience with thoracoscopic thymectomy.

Methods: Two patients, aged 8 and 14 years underwent complete thoracoscopic thymectomy in the year 2015 for Myesthenia Gravis.

Results: Total thymectomy could be accomplished through thoracoscopy causing minimal morbidity to the children as compared to sternotomy. No evidence of any thymoma noted in the Histopathology examination. Both the children are doing well on follow up and their dose of immunospressive drugs has reduced since.

Conclusion: Some series have shown comparable benefits of open versus thoracoscopic thymectomy in terms of disease remission or decreasing the need for immunosupression. However, the benefit in terms of reduced morbidity to the child is definitely much more with thoracoscopic thymectomy. We found early recovery due to reduced postoperative pain and better respiratory efforts leading to reduced incidence of pulmonary conmplications, not to mention the cosmetic benefit. Total thymectomy can be achieved thoracoscopically with better visualisation of the anatomy of entire mediastinum and better differentiation of the thymic tissue from mediastinal fat.

   Esophageal Duplication Cyst: A Rare Congenital Anomaly Category: Thoracic Surgery Top

Vipul Prakash Bothara, Anand Pandey, Abhishek Kumar Singh

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aims: Esophageal duplication cyst (EDC) is a rare congenital anomaly in which the cyst is usually present in the mediastinum close to esophagus and may or may not communicate with the esophagus. We present a case of an esophageal duplication cyst located in right thoracic cavity away from the esophagus.

Methods: A 10-year-old male child presented with recurrent right chest pain for 1 year. He was initially managed as a case of right pyothorax. On investigations a cystic space occupying lesion was noted in right thoracic cavity.

Results: Thoracotomy revealed a large cystic swelling in right pleural cavity. On histopathological examination, it was an esophageal duplication cyst. Patient recovered completely with full expansion of lung on subsequent X-ray. He was asymptomatic at 3 months follow up.

Conclusion: Being a rare congenital anomaly, the diagnosis of EDC may be difficult. Misdiagnosis may result in incorrect treatment. High index of suspicion is important. Proper diagnosis, followed by thoracotomy and complete excision of cyst may result in good outcome.

   Ulcerated Peno-Scrotal Hemangioma: A Rare Case Report Category: Miscellaneous Top

Gaurav Shandiya, Archika Gupta, Gurmeet Singh, SN Kureel

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aim: Penoscrotal Hemangioma is a very rare entity with only 45 cases reported in literature of which only six had ulcers. Aim of the paper is to report a rare case of ulcerated penoscrotal hemangioma.

Materials and Methods: An 8-year-old boy presented with bleeding from the ulcerated right-sided penoscrotal swelling. The swelling involved scrotum, base and shaft of penis with an overlying ulcer of 2 x 2 cm size. Patient was initially resuscitated with iv fluids, blood transfusion and pressure dressing to control bleeding. After control of bleeding, CT Angiography of penoscrotal region was performed that revealed a large hemangioma involving penis, right hemiscrotum and medial aspect of left hemiscrotum. After required evaluation, propranolol was started in doses of 2 mg/kg.

Results: After propranolol therapy for 8 months, there was decrease in size and healing of ulceration of hemangioma.

Conclusion: Ulcerated penoscrotal hemangioma is very unusual entity. Propranolol therapy has a definite role as first-line therapy that can even secure bleeding in acute condition and in addition decreasing the size of hemangioma.

   Mesocolic Hernia: A Rare Cause of Intestinal Obstruction Category: GI Surgery Top

Jaya Prakash, G Rajamani, R Rengarajan, N Venkatesa Mohan, V Muthulingam, RP Dharmendra

Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Congenital mesocolic hernia is an extremely rare, but causes intestinal obstruction in children. Given the rarity of this condition, delays in diagnosis and management can have catastrophic consequences. We present a 4 year old child who underwent emergency laparotomy for intestinal obstruction. Intra operatively, a large sac with gangrenous ileum was seen on one side of the abdomen and was diagnosed to have left mesocolic hernia. The clinical features in relation to a mesocolic hernia can be quite dramatic. Similar to malrotation, prompt surgical intervention is advocated.

   Wandering Spleen: Laparoscopic Approach Category: Laparoscopic Surgery Top

Jaya Prakash, G Rajamani, R Rengarajan, V Muthulingam, RP Dharmendra

Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Wandering spleen, also referred to as 'ptotic spleen', is a rare clinical condition characterized by splenic migration form its normal hypochondrial position to any other abdominal or pelvic position. Among the multifactorial etiologies proposed, laxity of the spleen's primary supporting ligaments is the most agreed-upon hypothesis. We present two rare cases of wandering spleen in an 6 year-old girl and who presented with abdominal pain with no localizing features. Their abdominal examination revealed severe tenderness over left hypochondrium, which was confirmed as wandering spleen by abdominal sonography and contrast-enhanced computed tomography. Intraoperatively, infarcted spleen was encountered with tortuous, elongated, torsional splenic pedicle. Laparoscopic splenectomy was offered to the patientsAnother 8 months old child presented with features of intestinal obstruction and dextrocardia with an incidentally diagnosed Wandering spleen. The clinical diagnosis of this condition, particularly in the paediatric age-group, makes it an enigma for the surgical world.

   Left Paraduodenal Hernia with Malrotation in an Infant: Rare Entity Category: GI Surgery Top

Ashutosh Kumar Sharma, Kedar mukhedakar, Deepa Peswani, kamal Kant sharma

Department of Pediatric Surgery, KEM Hospital, Mumbai, Maharashtra, India

Aim: To study mesocolic hernia as possible entity in neonatal malrotion.

Methods: One and half month old male child presented with complaints of abdominal distention and bilious vomiting. Ultrasonography suggested Malrotation with inversion on SMA and SMV. on exploratory laprotomy there was left paraduodenal hernia with one and half turns twist in the mesentry.patient underwent Ladds procedure with closure of the defect of the hernia.

Conclusion: Although rare Mesocolic hernia is a possible differential diagnosis with suspected malrotation.as preoperative diagnosis is difficult, a high index of suspicion need to be kept in such cases.

   Congenital Midline Cervical Cleft: An Extremely Rare Branchial Fusion Anomaly Category: Miscellaneous Top

Murali Krishna Nagendla, VK Singh, Shilpa Sharma, DK Yadav, DK Gupta

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Background: Congenital midline cervical cleft (CMCC) also known as mento-sternal dysraphism is a very rare congenital anomaly of the anterior neck. It may sometimes be misdiagnosed as thyroglossal duct or branchial cleft anomaly.

Aim: To describe the features of an adolescent girl with CMCC.

Methods: A clinical case of CMCC is described. The literature was reviewed.

Results: A 12 year old presented with complains of poor cosmesis due to an ulcerated lesion in the midline of the neck from the chin to the suprasternal notch. Complete surgical removal and Z- plasty is planned. On literature review, less than 100 cases are reported. The anomaly can be diagnosed and treated in the newborn age. Most cases are sporadic and it is more common in Caucasian girls. Embryopathogeny remains unclear and several hypotheses are proposed. The characteristic features are a defect at the ventral area of the neck with subcutaneous fibrous cord and a nipple like projection at the upper part and a sinus or fistulous tract at the lower end of the defect. CMCC may have a variable length and width. Z plasty gives a better cosmesis as well as prevents the complications of cicatricial neck contracture and thus neck extension disabilities.

Conclusion: CMCC is a rare anomaly. The treatment is surgical excision and closure of the defect. Linear scars are much more noticeable than broken line, so closure with Z-plasty is done to prevent neck contracture. There is no agreement on the appropriate age for surgical correction of this anomaly.

   Staged Ventral Hernia Repair Using “foker” Type Traction Sutures: A Simplified Technique Category: Miscellaneous Top

Rupa Banerjee, Gaurav Singh, Muni Varma, Aparajita Mitra, Satish K Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aims and Objective: Ventral hernia after Gastroschisis is often repaired in stages by a mesh. We report a simple technique using Foker principle of traction sutures.

Case Report: A four year old girl presented with a large ventral hernia secondary to repair of gastroschisis at birth. She had also undergone a mesh repair at 1 year of age but the mesh had to be removed due to multiple infections and sinus tract formation. At presentation she had a large defect, covered with skin.

Surgical Procedure: Redundant skin was excised. The skin flaps were raised. The edges of recti muscles were identified and multiple # 1 Prolene sutures were applied for cross traction. Lateral relaxing incision in the muscle sheath was made on both sides. A sheet of mesh was placed on the exposed bowel to prevent direct injury to the bowel and the traction sutures were tightened over a gauge piece. The traction sutures were re-tied on POD 2 and 5 under sedation. Complete closure was obtained on POD7. She remains well after two month follow-up.

Conclusion: Standard practice for such closure is mesh closure initially followed by tightening of the mesh. However, our patient was older and also previous mesh repair had failed. “Foker” style contraction is an alternate way to achieve primary closure of ventral abdominal wall.

   Beaded Foreign Body Bronchus: A Surgical Challenge in Removal Category: Miscellaneous Top

Murali Krishna Nagendla,M Bajpai, Prabudh Goel

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Introduction: Foreign body bronchus are common in children. Beaded foreign bodies are difficult to diagnosis and removal.

Aim: Retrieval of beaded foreign bodies with fogarty catheter.

Methods: A clinical case of beaded foreign body bronchus described.

Results: A 31 months old male child presented to emergency with history of accidental inhalation of plastic bead. Underwent evaluation by flexible bronchoscopy shown plastic bead in left main bronchus. Child underwent rigid bronchoscopy, shown hole of bead in alignment with main bronchus. Difficulty in retrieval of foreign body with conventional forceps, a fogarty catheter passed through hole of bead and plastic bead retrieved.

Conclusion: Beaded foreign bodies poses surgical challenge in removal. Even diagnosis of foreign bodies becomes difficult when holes align with lumen of bronchus. Removal may be difficult with conventional forceps in view of difficulty in grasping further accentuates distal dislodgement. Use of fogarty catheter for removal is secure and helps in easy retrieval especially beaded foreign bodies with central hole.

   Clinicopathological Correlation of Rare Adrenal Tumour Category: Urology Top

Murali Krishna Nagendla, Shilpa Sharma, Vivek Singh, Aanchal Kakkar, Nishu Bhardwaj, Devendra Yadav, Devendra K Gupta

All India Institute of Medical Sciences, New Delhi, India

Introduction: Adrenocortical tumors are very rare in children. In those functional tumors are very rare. Most common functional tumors involve catecholamine secretion. Sex hormone secreting tumors very rare and needs proper evaluation and management.

Aim: To describe a female adolescent with functional adrenocortical tumor presented with hirsutism.

Methods: A case of functional adrenocortical tumor described.

Results: A 13-year female child presented with complaints of excessive hair growth all over body, low pitch voice, abnormal stature. Underwent hormonal evaluation shown raised serum testosterone. Radiological evaluation shown calcified lesion in right adrenal, and diagnosed as testosterone secreting tumor. Underwent right adrenalectomy and follow up hormonal evaluation shown declining serum testosterone levels. Histopathology of tumor confirms adrenal adenoma, oncocytic variant.

Conclusion: Functioning adrenocortical tumors are very rare in children. Presenting with hormonal secretion and virilization needs timely evaluation and management. Premature epiphysial fusion leads to abnormal growth and stature especially at puberty.

   Series of Patients of Infantile Hemangioma Treated by Low Dose Oral Propranolol Category: Experimental/Basic Sciences Top

Kamal Kant Sharma, SV parelkar, Beejal Sanghvi, Rahul K Gupta, Kedar P Mudhkhedkar, Deepa Makhija, Rujuta Shah, Pooja Tiwari, Kavimozhy Illakya, Manish Kumar, Ashutosh, S Soundharya

Department of Pediatric Surgery, GSMC and KEM Hospital, Mumbai, Maharashtra, India

Aims: To assess short-term results of treatment of infantile hemangiomaswith oral propranolol.

Methods: All 23 patients (M:F= 15:8) of age group one month to 7 years with variety of hemangioma at different sitesseen between june 2017 and june 2018 underwent diagnostic colour Doppler with screening 2 D Echo, Blood pressure, heart rate and blood sugar before starting treatment. After clinically excluding patients with asthma these patients were given low dose oral propranolol 0.2 mg /kg (pulverized 10 mgtablet) and first doses were monitored with measurements of heart rate, blood sugar and blood pressure on admission. Serial monthly follow up was done and results were assessed with the help of comparisons with (serial) previous pictures and history given by mother in the form of change in colour, size and texture of lesion.

Results: Significant improvement was noted in all patients in the first 2 months of therapy with slow and continuous effect throughout the follow-up period. No serious complications were observed.

Conclusion: Low dose propranolol can be safely used as a primary modality of treatment for treatment of infantile haemangioma.

   Tubularised Incised Plate with Buck's Fascia Repair for Distal Penile Hypospadias: Our Initial Experience Category: Urology Top

C Sridhar, Vinay Jadhav, Narendra Babu, GS Murali, S Ramesh, J Deepak

Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Introduction: Even though Tubularised Incised Plate (TIP) Urethroplasty repair is a popular choice for Distal Penile Hypospadias (DPH), it is not without complications. Many alternatives have been proposed of which TIP with Buck's fascia repair is recently recommended. We here with report our initial experience with this technique.

Materials and Methods: This is a prospective study of 26 cases of DPH with defined inclusion criteria. The outcome of these cases were analyzed with regard to the cosmesis & complications like urethrocutaneous fistula (UCF), Glans dehiscence & meatal stenosis.

Results: Of these 26 cases, 16 out of 26 (61 %) had good outcomes with no complications and good cosmesis. The other 10 cases had some complications like UCF 6 out of 26, Glans dehiscence 2 out of 26, Meatal stenosis 6 out of 26, Dehiscence requiring repeat surgery 1 out of 26. The results were comparable to the conventional TIP repair.

Conclusion: TIP with Buck's fascia repair is a good technique requiring minimal glans dissection& good cosmesis with acceptable complication rate. This technique need to be considered as an alternative when prerequisites are met. The results are likely to get better with more experience.

   Choledochal Cyst Arising in Intra-Hepatic Bile Duct: A Rarity Category: Hepatobiliary Top

Rupa Banerjee, Gaurav Singh, Aparajita Mitra, Satish K Aggarwal

Department of Pediatric Surgery, Sir Gangaram Hospital, New Delhi, India

Aims: We report a rare case of choledochal cyst arising in an intra-hepatic bile duct masquerading as simple hepatic cyst. Only 20 such cases have been reported till date.

Case Report: An eleven year old boy presented with intermittent right upper quadrant pain of several year's duration. USG and CT revealed a septated cyst (9.3 x 6.8 x 7.6 cm) in the right lobe of liver. The lesion was compressing the gall bladder, abutting the portal vein at its division. CBD was normal. Hydatid serology was negative and LFT was normal. Intra-operative findings: multi-loculated cystic mass with arborizing vessels over the surface. Gall bladder was inseparable from the cyst. Right anterior sectoral duct was communicating with the cyst through an elongated thinned out duct. However the cyst had no bile. The gall bladder and the cyst was completely excised, using Lily's technique at the portal vein division. Histopathology revealed biliary lining of the cyst.

Discussion: The diagnosis in our case was made only during surgery as the bile duct was seen entering the cyst. Anatomical details must be made out on imaging to prevent injury to portal structures. Procedure similar to “Lily's” technique was a useful adjunct to save the portal vein confluence.

   Neonatal Gastric Perforation: Laparoscopic Management Category: Neonatal Surgery Top

P Balamourougane

Department of Pediatric Surgery, Cloudnine Hospitals, Chennai, Tamil Nadu, India

Aims: To report on the application of laparoscopy in gastric perforation in neonates.

Methods: 4 neonates who developed pneumoperitoneum were initially managed with a flank glove drain to decompress the abdomen and stabilize. They were taken up for Surgery after 48 hours due to persistent air leak. Laparoscopy was attempted in 3, with 3 port technique. Conversion was done in one due to large perforation visualised.

Results: There was no mortality in our series. 2 babies made a smooth recovery while one had a small contained leak, which was managed conservatively. 2 babies had a small capacity stomach and needed prolonged period of stay for building up full feeds. The predisposing risk factors, investigations, port placements, operative technique and the post operative course are discussed.

Conclusions: Laparoscopy is feasible though challenging in neonatal gastric perforation, even in preterm babies.

   Neonatal Intussusception: A Rare Clinical Entity Category: Neonatal Surgery Top

Gaurav Shandilya, Anand Pandey, Gurmeet Singh, JD Rawat, Ashish Wakhlu, SN Kureel

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aim: To report a rare case of neonatal intussusception.

Materials and Methods: In neonates and premature infants, intussusception accounts for only 3% of intestinal obstruction and 0.3% (0%–2.7%) of all cases of intussusception. A 15-days-old neonate presented with bilious vomiting, abdominal distension and inability to pass flatus and faeces for 3 days. Exploratory Laparotomy revealed jejunojejunal intussusception with a intraluminal jejunal cyst as a lead point.

Results: Cyst was excised and jejuno-jejunal anastomosis was performed. Patient was discharged after an uneventful postoperative period.

Conclusion: Intussusception is an extremely rare cause of intestinal obstruction in neonatal age group and coupled with its presentation similar to NEC, the diagnosis of Neonatal intussusception is easily missed. Since the initial treatment protocol for intussusception (Surgical intervention) and that of NEC (Conservative management) are diametrically opposite, it becomes important to accurately diagnose and differentiate these conditions.

   Evalution of Low Ano-Rectal Malformation in Male Children Category: GI Surgery Top

Gaurav Shandilya, Anand Pandey, Gurmeet Singh, Akhilesh Kumar

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Introduction: Low anorectal malformation (ARM) is an important presentation of ARM. Because of its varied clinical presentations, patient may develop various problems and complications. This study deals with evaluation and management of low ARM at our centre.

Methods: It was a retrospective study from 2010 to Dec 2017. All patients of male low ARM patients were evaluated for age at presentation, clinical type, any prior intervention, and outcome.

Results: During the study period, 220 patients of low ARM were admitted. Age at presentation was 1 day to 13 years. Clinical presentations were anal stenosis, imperforate anus, operated elsewhere with colostomy, constipation. Total number of cases subjected to redo surgery because of previous mismanagement amounted to 27. Management included anoplasty where it was possible. Limited PSARP was performed for acquired anal stenosis. Misdiagnosis at other centres without pediatric surgical facilities resulted in unnecessary colostomy, urethral injury, ectopic anus, and acquired anal stenosis.

Conclusion: Low ARM needs careful diagnosis & precise management. Inadvertent procedure may complicate the future perspective. Follow up is necessary to avoid anal stenosis and other problems.

   Neuroblastoma: Is There a Role for Laparoscopy? Category: Laparoscopic Surgery Top

P Balamourougane

Department of Pediatric Surgery, Mehta Children's Hospitals, Chennai, Tamil Nadu, India

Aims: to report on the utility of Laparoscopy in the management of select children with Neuroblastoma.

Methods and Results: Patient 1- 10 month old female was incidentally detected to have left upper abdominal mass on evaluation for fever. Had no other symptoms and thriving well. There was a 5 X 4 cm mass left upper abdmen disappearing under the costal margin. USG/ MRI/ Bone scan done. Left Suprarenal mass with no spread/ nodes. Laparoscopic excision done. Patient 2- Antenatally detected mass in right Suprarenal region. At birth was found to have hepatomegaly extending for 3 cm below costal margin. USG showed right suprarenal mass. Sudden increase in Hepatomegaly by 1 month with respiratory distress- extending till iliac region. Laparoscopy done- Liver studded with multiple secondaries but right adrenal could not be accessed in view of huge liver. Liver biopsy s/o Neuroblastoma. Started on chemotherapy. Patient 3- Antenatally detected mass in right Suprarenal- localised to adrenal on post natal evaluation- Excised by 3 port technique. Received chemotherapy based on N myc status and was well till 2 years follow up. Recurrence of mass was noted in the right Suprarenal region. Received additional chemotherapy and then PET scan done-activity localised to adrenal region- Attempted Laparoscopy through previous ports and all adhesions freed, mass separated from IVC and excised. Patient 4- 2 months old female child thriving well was found to have right abdominal fullness with minimal distress. Evaluated with USG/ MRI-Rt Adrenal Neuroblastoma with Liver secondaries- Laparoscopic Liver biopsy done and patient put on chemotherapy. There was regression of Hepatomegaly but residual mass noted post completion of chemo. Laparoscopic excision of the residual mass was done.

Conclusions: Minimal access Surgery has a role in carefully selected patients with Neuroblastoma and avoids the morbidity associated with open Surgery - long incision. more pain, post operative adhesions etc., and facilitates quicker recovery in these debilitated patients.

   Laparoscopic Pyeloplasty: Our Experience Category: Laparoscopic Surgery Top

P Praveen, R Senthilnathan, Mohanavel, Karpaga Vinayagam, S Vivek

Department of Pediatric Surgery, Institute of Child Health, Madras Medical College, Chennai, Tamil Nadu, India

Aim: We are managing an average 60 cases of pyeloplasty per year. After we started using minimal access surgery widely, we have done 15 cases of laparoscopic pyeloplasty in last 1 year at Dept. of Paediatric surgery, ICH & HC, MMC, Chennai.

Methods of Study: Since we are in the beginning of reconstructive procedure in minimal access surgery, we have chosen, children more than 5 yrs of age who presents with hydronephrosis with pelviureteric junction obstruction. All patients had radiographic evidence of obstruction with signs, symptoms or deterioration of renal function. We performed Anderson-Hynes dismembered pyeloplasty in all these 7 cases.

Results: Average operative time was 4.5 hrs. Average hospital stay was 3.5 days. There were no intraoperative complications. There was no postoperative complication like anastomotic leak, pneumonia, fever. These children are on follow-up. This paper discusses the technical aspect of laparoscopic pyeloplasty and gratifying results we have obtained.

Conclusions: Laparoscopic pyeloplasty is an effective alternative treatment for symptomatic ureteropelvic junction obstruction. The results appear durable and comparable to open pyeloplasty with decreased postoperative morbidity.

   The Role of Cortical Transit Time as an Early Predictor for Need of Surgery in Children with Hydronephrosis Due to Pelvi-Ureteric Junction Obstruction Category: Urology Top

Goutam Chakraborty, Nidhi Sugandhi

Department of Pediatric Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Aims: (1) To compare CTT in between patients requiring immediate surgery (based on existing criteria) vs patients earmarked for conservative management of HDN (based on existing criteria). (2) To assess the proportion of patients with deranged CTT on initial study who ultimately required operative intervention on follow up.

Methods: (1) Prospective and Retrospective observational. (2) HDN assessed by USG and RDS. (3) Prospective patients divided in 2 groups - Group I (requiring immediate surgery) and Group II (conservative).

Results: Patients undergoing immediate surgery had prolonged CTT.15 patients were managed conservatively had normal CTT. The difference of CTT between Group I and Group II was found significant. Also, Group I patients who underwent surgery due to low Differential Renal Function (<40%) were found to have deranged CTT (>3 minutes). All retrospective patients had low DRF and deranged CTT. All patients conserved on basis of preserved DRF (>40%) had normal CTT. Thus, the correlation between DRF and CTT as well as between CTT and need of surgery were found significant.

Conclusion: CTT can be used as an adjunct to standard criteria for surgery as it serves the role of a reliable predictor quite well. More studies with longer duration should however be encouraged.

   Effect of Medical Therapy on Clitoral Length in Patients with Congenital Adrenal Hyperplasia Category: Urology Top

Kashish Khanna, M Bajpai, Kashish Khanna, SS Panda

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Background: 17OHP levels are usually high in patients with congenital adrenal hyperplasia (CAH) with variable degrees of clitoral enlargement at the time of presentation. In this study the effect of steroid therapy on clitoral length was studied.

Methods: Medical records of patients of CAH treated in our institute between January 1990 and December 2011 were searched. 17OHP levels and length of clitoris were assessed and compared before and under steroid therapy.

Results: This study includes a total of 82 patients with CAH aged 3 months to 12 years old whose 17OHP levels and clitoral length were present both before and under therapy. The 17OHP levels significantly decreased to normal level after treatment (p < 0.001) but there was no significant change in clitoral length under therapy. The mean clitoral length of patients presented with high 17OHP levels (> 100 ng/ml) after treatment was less than the patients with > 7 years of age before therapy.

Conclusion: While the length of clitoris at presentation does not reduce, its further growth is arrested. Hence, when indicated, option of surgery should be offered as soon as the endocrine axis is stabilized.

   Aplasia Cutis Congenita: A Rare Condition with Lessons Learnt from 3 Cases Category: Neonatal Surgery Top

Rishi Dwivedi, Monika Bawa, Ravi Prakash Kanojia, Sunil Gaba, Rajesh Chhabra, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim: Aplasia cutis congenital (ACC) is characterized by focal deficiency of cutaneous tissues of varying extent and depth, ranging from absence of skin to full thickness defects involving even bone and dura. We present 3 neonates of ACC who were treated successfully.

Patients and Methods: we describe 3 cases with ACC, treated at our institute. They were managed by individual merits of the symptoms at initial presentation.

Results: First case, the only live baby, of triplets with symmetrical full thickness lesions on both knees and bilateral flanks connected by a thick fibrous band. Second case, a 2 day old neonate, with absence of skin, bone and exposed dura without any CSF leakage. The two, were managed conservatively. Third neonate had a defect of 3 x 2 cms in the midline just above the sagittal sinus with CSF leak. A peri-cranial graft and a skin flap were used to cover the defect. All three children are surviving.

Conclusion: By virtue of its rarity, management of ACC can be perplexing for the unknown. Treating pediatric surgeons need to be aware of this entity. Majority do not require any treatment and the skin lesions heal spontaneously. However some might need surgical intervention to prevent complications.

   Adrenal Tumors in Children: Diagnosis and Outcome Category: Surgical Oncology Top

Swapnil Pattanshetti, Jai Kumar Mahajan, Enono Yhoshu, Muneer Malik

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aims: Adrenal tumors are rare in children. We analyzed the incidence, presenting features and outcome of of adrenal tumors.

Methods: The cases records of the patients operated for adrenal tumors were retrospectively analyzed.

Results: Five cases of adrenal tumors were seen over a period of 1.5 years. There were 4 males and 1 female and age of the patients ranged from 2 -12 years. Three patients presented with features of hypertension, one patient had poor feeding and lethargy while the female baby presented with weight gain, hyperactivity, hypertension and virilisation. The VMA levels were raised in 4 patients and female child showed raised cortisol and low ACTH levels. Imaging studies revealed a suprarenal mass lesion. PET scan was performed in 4 patients. All the patients underwent excision. The size of the lesion varied from 2.5 to 6.8 cms. Histopathology did not show features of malignancy in the excised specimens. Hypertension normalized in 3 patients in immediate postoperative period and 2 patients needed antihypertensive medication for up to 3 months. All are doing well in the follow up.

Conclusions: Hypertension is common mode of presentation of tumors of adrenal medulla and cortex in children. Biochemical studies help to pinpoint the diagnosis. Resection is curative and malignancy is uncommon.

   Pleuropulmonary Blastoma in Children Category: Thoracic Surgery Top

Swapnil Pattanshetti, Jai kumar Mahajan, Enono Yhoshu, Muneer Malik

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aims: Pleuro pulmonary blastoma (PPB), is very rare, highly aggressive and malignant, and originates from either the lungs or pleura. We do manage such patients.

Methods: A 3-year old male child presented with difficulty in breathing and respiratory distress on exertion for 3 months. He was treated for pneumonia initially, with no improvement. On further imaging studies, the child was diagnosed to have an intrathoracic mass lesion of variegated consistency, arising from the lung and occupying whole of the right chest. A provisional diagnosis of pleuropulmonary balstoma was made. In view poor response to chemotherapy, primary surgery was planned. Patient underwent right thoracotomy and excision of the tumour, in piecemeal, as the tumour was too large to be delivered en mass. In view of the large lesion, a special attention was required to minimize the blood loss. Histopathology examination confirmed the diagnosis. One year later, the patient showed a coin lesion in the right apical lobe. A segmentectomy was performed for the same. Post surgery, the patient underwent low dose lung irradiation and is recurrence free at 2 years.

Conclusions: There is no defined optimal treatment regimen PPB. Surgical resection is the mainstay of treatment with or without adjuvant therapy.

   Congenital Salivary Fistula: A Rare Case Report Category: Miscellaneous Top

Swapnil Pattanshetti, Prema Menon, Shailesh Solanki

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Congenital parotid salivary fistulas are rare entities that can be from accessory parotid glands or even more infrequently, from normal parotid glands through an aberrant Stensen's duct. There are very few case reports in literature. We present this case for its rarity.

Methods: A one year old female child presented with serous discharge from right cheek since birth which increased on chewing. On examination 1 mm x 1 mm fistulous opening was seen over the right cheek 2 cm lateral to angle of mouth. Intraoral examination was normal. Bilateral pre-auricular skin tags were present. Sinogram showed tubular sinus tract extending from external opening into right cheek postero-medially. There was no communication with oral cavity/mandible. At operation the fistulous tract was cannulated and gentian violet injected. Further dissection was done intra-orally. The fistula was found to communicate with the Stensons duct and was completely excised. At 1 year follow up, there is no recurrence with good cosmetic appearance.

   Outcome Analysis of N-Type Tracheo-Esophageal Fistula Category: GI Surgery Top

Prema Menon, KLN Rao

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aims: To analyse associations and outcomes of surgical intervention in all cases of N-type tracheo-esophageal fistulas (TEF) over a 10-year study period.

Materials and Methods: All children admitted in the pediatric surgical unit of a tertiary care centre from 2006-2016 were analysed retrospectively. Pre-operative investigations included plain radiographs of chest and abdomen, contrast study of esophagus, echocardiography, bronchoscopy and esophagoscopy. Patients were followed up regularly.

Results: A total of 10 patients, age 3 weeks–18 months underwent surgery. Patients mostly presented with feed intolerance, recurrent respiratory tract infections and failure to thrive. Associated anomalies were seen in other systems in 50% patients. Associated esophageal anomalies were seen in 2 patients. Contrast swallow and bronchoscopy were the most useful investigations. Fistula could be ligated from a lower cervical incision in all after initial cannulation by bronchoscopy. 3 patients required ventilatory care for a week–10 days. Patients had respiratory complaints for variable periods after surgery. Two patients required nasogastric tube feeding for 1 month.

Conclusions: Overall prognosis is excellent inspite of delayed diagnosis. Associated esophageal anomalies in N type TEFs are extremely rare and were associated with increased post-operative complications.

   A Series of 7 Cases of Infantile Hypertropic Pyloric Stenosis Presented in Neonatal Period Managed by Laparoscopic Pyloromyotomy Category: Laparoscopic Surgery Top

R Maniappan, R Velmurugan, Arun Kumar, Saravanan V, Anirudhen

Department of Pediatric Surgery, Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu, India

Aim: To study the outcome of laparoscopic pyloromyotomy for infantile hypertropic pyloric stenosis presented in neoatal period.

Methods: Duration – 1 year. 7 patient presenting with non-bilious vomiting in neonatal period, diagnosed as infantile hypertropic pyloric stenosis by ultrasonogram. After resuscitation and correction of electrolyte abnormality, laparoscopic pyloromyotomy was performed using hook diathermy. The following parameters were studied: age of presentation, duration of surgery, post operative adverse events, resolution of symptoms, duration of stay in hospital, follow up outcome. Results: All the 7 patients improved well and the symptoms resolved earlier without any complication. Discharged earlier and had good cosmetic results.

Conclusion: Laparoscopic pyloromyotomy for infantile hypertropic pyloric stenosis presenting at neonatal period is safe, effective, durable procedure and has good cosmesis.

   Missed Gastroesophageal Reflux Disease Leading to Bronchiectasis Requiring Lung Resection in an Immunocompromised Host Category: Thoracic Surgery Top

Muni Varma, Gaurav Singh, Rupa Banerjee, Aparajita Mitra, Satish Kumar Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Objective: To present a case of bronchiectasis with GERD and Combined Variable Immuno Deficiency (CVID) requiring lung lobectomy.

Case Report: A 7 year old boy was referred for surgical treatment of Left upper lobe bronchiectasis. There was a long standing history of LRTI (~4 years). He also gave history of vomiting for 4 years. Upper GI endoscopy was reported normal. Contrast Upper GI series revealed Gr. IV GER, CT Chest confirmed Left upper lobe bronchiectasis with destroyed lobe. There were mild bronchiectatic changed in the rest of the lung as well. He was put on anti-reflux treatment and underwent Left upper lobectomy. Post op recovery was smooth. Blood investigations revealed low levels of Immunoglobulins and a diagnosis of CVID was made. He is awaiting fundoplication.

Discussion: GERD is an underestimated disease which should be looked for and aggressively treated to avoid complications and surgical morbidity as seen in this case. A timely detection and treatment would have probably prevented bronchiectasis.

   Tracheo-Oesophageal Fistula Post Button Battery Ingestion Category: Thoracic Surgery Top

Muni Varma, Gaurav Singh, Rupa Banerjee, Sugandh Aggarwal, Aparajita Mitra, Satish Kumar Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Objective: To present a case of TEF following button battery ingestion, and successful staged management.

Case Report: A 21 month old boy developed severe respiratory distress and cyanosis following endoscopic removal of an ingested button battery from his oesophagus. Bronchoscopy revealed a large punch hole tracheo-oesophageal fistula with necrotic edges. He required ventilator support-the ET was placed beyond the fistula. A decompressive gastrostomy, feeding jejunostomy and lateral cervical oesophagostomy was done. A delayed repair of TEF was carried out after 6 months with strap muscle interposition. The child recovered fully. He required 2 oesophageal dilatations for post op oesophageal stenosis.

Discussion: Staged management with good supportive care is key to success. Delayed operative repair allows a leak free post op period. Oesophageal tissue should be left with trachea to prevent treacheal stenosis. Oesophageal stenosis is easier to manage by dilatation.

   Tracheoesophageal Fistula: Earlier the Diagnosis, Better Is the Outcome! Category: Neonatal Surgery Top

Nilesh Tank, Monika Bawa, Ravi Kanojia, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Objective: To compare the outcomes of early versus delayed presentation of patients with esophageal atresia and/or tracheoesophageal fistula (TEF).

Materials and Methods: Prospective study on 48 patients EA-TEF. Patients were grouped into two categories- Group A (n-29) - who presented within 72 hours of birth and Group B (n-19) who presented later. Various parameters were compared amongst the two groups.

Results: Preoperative inotropic support and ventilation was not needed in Gr A while it was needed in 42% and 36% respectively in Gr B. None of the patients of Gr A expired but 3 patients (15%) in Gr B succumbed pre-operatively during the resuscitation period. Pneumonia with consolidation was seen in 27.58% and 73.68% in Gr A and Gr B respectively. Blood culture on arrival was positive in 57% of patients in Gr B compared to 7% in Gr A. More episodes of de-saturation were noted intra-operatively in Gr B patients which led to increased intra-operative time. Post-operative ventilator support was needed in 7.4% in Gr A and 83.33% in Gr B. Total number of hospital days and the expenses spent on treatment were also found to be significantly higher in delayed presentation group. Overall moratlity was higher in Gr B.

Conclusion: Delay in diagnosis of tracheo-esophageal fistula definitely affects the results of this otherwise good outcome disease. Medical and paramedical staff working at the peripheral centers should be well- trained to diagnose the disease in time.

   Topical Timolol Ophthalmic Solution Causing Remarkable Improvement in an Ulcerated Hemangioma (Lumbar Syndrome) Category: Experimental/Basic Sciences Top

Richa Misra, BC Gowrishankar, S Ramesh

Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Infantile haemangioma are the most common childhood tumours. Uncomplicated haemangioma spontaneously regresses over the year but the complicated requires intervention. Ulceration is the most common complication of infantile haemangiomas (IH). Oral beta-blocker therapy has been reported to be of benefit. Topical timolol maleate gel-forming solution is suggested treatment for ulcerated cutaneous IH-but its is use disputed.

Methods: We describe the case of an infant with an ulcerated, haemangioma associated with LUMBAR syndrome, who responded significantly with oral propranolol and topical timolol 0.5% ophthalmic solution within 2 months.

Results: The combination of oral and topical propranolol resulted in a complete healing of ulcerated part as well as decrease in size of the haemangioma.

Conclusion: We suggest that timolol ophthalmic solution (0.5%) along with oral propranolol may be an option of management for children presenting for such lesions under close monitoring.

   Outcome of Vertical Island Flap Urethroplasty for Distal Hypospadias Category: Urology Top

B Meenalosani, Sudipta Sen, Pavai Arunachalam, Cenita J Sam

Department of Pediatric Surgery, PSG Institute of Medical Science and Research, Coimbatore, Tamil Nadu, India

Aims: To assess the outcome of vertical Island flap Urethroplasty technique for distal Hypospadias among patients who have undergone the procedure in the last 4 years.

Methods: All patients with distal hypospadias who have undergone vertical Island flap Urethroplasty in the last 4 years from June 2014 to May 2018 will be interviewed and examined and the complications will be assessed.

Procedure: SPC is done. Subcoronal incision is made all round the penis dorsally and extending around the meatus ventrally. Degloving of penis is done. Urethral plate is delineated and divided. Vertical quadrangular preputial island flap is raised and mobilised and brought ventrally by button- holing the soft tissue pedicle. Urethroplasty is done over a 8 feeding tube. Glans is divided on either side and neo urethral meatus is created at the tip. Glanuloplasty is done. Remaining penile skin is used to cover the shaft of the penis.

Results: Out of 37 patients 5% had small fistula which closed by itself. Other complications were minimal. Revision rate was nil.

Conclusions: This is an ideal technique for distal hypospadias with minimal complications.

   Diagnostic Accuracy of Gene Expert in Abdominal Tuberculosis in Children Undergoing Surgery Category: GI Surgery Top

Peter Daniel S Khairong, Archana Puri, Smita Singh

Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India

Aim: To study the diagnostic accuracy of Gene Xpert in surgical referrals of pediatric abdominal tuberculosis.

Methods: This observational study over a period of 18 months included 26 operated children of abdominal tuberculosis with histologically proven diagnosis. Nasogastric and sputum Gene Xpert testing was done at admission. Peritoneal pus if present was also sent for Gene Xpert testing. Demographic details, history of prior antitubercular treatment (ATT), radiological and operative findings was recorded and correlated with Gene Xpert positivity. Data was analyzed to determine the sensitivity of Gene Xpert.

Results: Surgical indications were perforation peritonitis (5,19%), obstruction (8, 31%), abdominal lump with sub-acute obstruction (12, 46%) and pyoperitoneum in 1 (4%) patient. Mean age at presentation was 9.5 years (range: 2-17 years) with female preponderance (1:2.7). The site of involvement was peritoneal (1), intestinal and mesenteric lymph node (13), and pan involvement involving all three in 12 patients. Gene Xpert was positive in 8 (30%) patients (nasogastric aspirate in 4; pus in 3; both in 1). Four patients were already on ATT for 4-6 weeks prior to admission and all of them had negative Gene Xpert testing. Gene Xpert showed no correlation with age at presentation, site of involvement but had positive correlation with loculated, septate ascites with internal echoes.

Conclusion: Gene Xpert in nasogastric aspirate and sputum has low sensitivity for diagnosing pediatric abdominal tuberculosis. However, it gives a better yield in presence of septate ascites (pyoperitoneum).

   Pseudo Prune Belly Syndrome: Rare Manifestation in Female Neonate and Literature Review Category: Miscellaneous Top

Pradeep Kumar Agrawal, Umesh Bahadur Singh, Srikesh Singh

Department of Pediatric Surgery, Goverment Medical College, Kota, Rajasthan, India

Introduction: Pseudo Prune Belly syndrome (PPBS) comprise unilateral abdominal wall deficiency or unilateral UDT and female neonates with abdominal wall laxity. We are reporting female neonate with PBS and reviewing the available literature focusing on female cohort of disease.

Case Report: The index case is a four months female, born full term uneventfully, weighing 6.2 kg. Antenatal Ultrasonography showed bilateral hydronephrosis. After birth neonate was asymptomatic, however abdominal wall was bulged and flabby. External genitalia and anal opening were normal. The USG KUB at 2 months of age, showed bilateral hydroureteronephrosis with megaureters. MCU showed grade-V VUR on left side. MRI was done that showed bilateral Megaureters and atrophic abdominal wall musculature. Renal functions were preserved andno scarring on DMSA scan. Radioisotope renography (Ethylenedicysteine scan) showed slow unobstructed urinary drainage. Patient is well on uroprophylaxis. So the final diagnosis was made as PPBS. Ureteric reimplantation would have been planned if risk of backpressure to the kidneys, obstructing the urine drainage or causing recurrent UTI with renal scarring. Abdominoplasty can be done later on growth and for need of cosmesis.

Conclusion: PPBS is now recognized entity and early recognition of symptoms is warranted in view of subtle presentation of disease.

   Rapunzel Syndrome Is not Just a Mere Surgical Problem: A Case Report Category: GI Surgery Top

Usha Gajbhiye

Department of Pediatric Surgery, Matruchhaya Hospital RRSH, Amravati, Maharashtra, India

Aim: Rapunzel syndrome is not just a mere surgical problem: A case report.

Materials and Methods: Presenting a twelve year old girl who had constipation, abdominal pain and vomiting. She was single parent child, slightly mentally subnormal, and lack of attention, she had history of trichotilomania and eating threads of cloths. Ultrasound abdomen done which showed large echogenic mass with post acoustic shadowing in epigastric region, adjecent to liver GB and spleen, likely calcific lesion, ? Foreign body in stomach or may be colon The patient underwent laparotomy. The whole trichobezoar from stomach, duodenum and jejunum was removed through an anterior gastrotomy in toto, thus confirming a diagnosis of Rapunzel syndrome.

Results: Post op she had good recovery except for her low protein status and anemia. The Girl was sent to Psychiatrist and Social worker for further treatment.

Conclusion: This case presents a unique and modern manifestation of Rapunzel syndrome. Surgical treatment most often is required when a patient presents with a massive gastric trichobezoar. Regular post-operative psychiatric follow-up is necessary to prevent recurrent episodes.

   Dysfunctional Elimination Syndrome: An under Diagnosed Entity? Category: Urology Top

V Kolanchiappan, G Rajamani, R Rengarajan, V Muthulingam, RP Dharmendra

Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Constipation in children increases the likelihood of urinary incontinence, bladder over activity, dyscoordinated voiding, a large capacity, poorly emptying bladder, recurrent urinary tract infection. We present a consensus related to the assessment, diagnosis and treatment of children with bowel dysfunction coexisting with a known disorder of urinary continence or voiding coordination.20 children with Chronic functional constipation (CFC) were evaluated. Age range of the children with CFC was 5-12 years. Detailed past and present history of UTIs or symptoms pointing to this diagnosis, enuresis, encopresis, urgency and urge incontinence was obtained. Urinalysis, urine culture and stool parasite analysis, bladder diary, abdominal ultrasonography, MCU, cystoscopy, Urodynamic studies, MRI LS spine were performed to evaluate the cause for constipation Frequency of UTI and urgency was statistically significant in those chidren. However, frequencies of urge incontinence, nocturnal enuresis, enuresis and residual urine detection in USG were not statistically significant. In conclusion, risk of UTI and urgency is increased in CFC, but that of other voiding dysfunctions like urge incontinence do not change significantly. Therefore, we suggest that UTI and urgency should be questioned in children with CFC and vice versa.

   Spontaneous Idiopathic Perforation of Gall Bladder: A Case Report Category: Hepatobiliary Top

V Kolanchiappan, G Rajamani, R Rengarajan, V Muthulingam, RP Dharmendra

Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Spontaneous biliary perforation in children is rare. The etiology of this pathology is idiopathic and various management strategies ranging from non-operative treatment to complex operations, such as biliary-enteric reconstruction are performed, with few reported outcomes. A 2 years old male child presented with abdominal pain and distension. An ultrasound was performed, which revealed generalized ascites and a poorly-defined collection. An emergency laparotomy confirmed perforation in the gall bladder and cholecystectomy was done. Rest of the extra hepatic biliary apparatus was normal. The fundus is the most common site of perforation and is suspected to result from local ischemia from a tenuous blood supply. The reported management of spontaneous perforation of the gallbladder among children include cholecystectomy, cholecystectomy with hepaticojejunostomy, primary repair and partial cholecystectomy with external drainage. Spontaneous perforation of the gall bladder in children is extremely rare and poorly documented condition and hence presented in this forum. Perforations of the extrahepatic biliary tree are however documented. Prompt surgical intervention remains the key to recovery in these cases.

   Ectopic Pancreas… a Rare Entity Category: GI Surgery Top

V Kolanchiappan,G Rajamani, R Rengarajan, V Muthulingam, RP Dharmendra

Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Ectopic pancreas is also referred to as pancreatic heterotopia, heterotopic pancreas, and accessory or aberrant pancreas. Ectopic pancreata can be found in various anatomical sites such as the stomach, duodenum, jejunum, gallbladder, esophagus, common bile duct, spleen, mesentery, mediastinum, and fallopian tubes. Although ectopic pancreata are usually an incidental finding, they can present with abdominal pain and subacute intestinal obstruction. Published literature reports have described rare instances of malignant degeneration in the ectopic pancreatic tissue. We present a one and half year old child with features of subacute intestinal obstruction with ultrasound features suggestive of ? malrotation (reversal of SMA and SMV axis). Intra operative findings revealed normally located ileo caecal junction and DJ flexure with no Ladds bands. An ectopic pancreatic tissue was present at the proximal jejunum. Excision with two layer closure of the bowel was done. Histopathological examination reveals pancreatic acini, ducts,  Islets of Langerhans More Details, and intervening connective tissue. The preoperative diagnosis of an ectopic pancreas is still challenging despite advanced diagnostic tools, and the frequent inability to differentiate it from neoplastic lesions warrants surgical excision. Despite keen clinical acumen and technological advances in diagnostic tools, the final diagnosis of ectopic pancreas in our case was made after excision on histopathology, hence explaining the “diagnostic dilemma.” In conclusion, although ectopic pancreas is a rare entity, clinicians should consider this as an important differential diagnosis lesions as a simple excision can be potentially curative.

   Torsion of an Intussuscepted Hernial Sac: A Case Report Category: Urology Top

Gaurav Singh, Muni Varma, Rupa Banerjee, Aparajita Mitra, Satish K Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aim: To consider torsion of the hernia sac as one of the differential diagnosis of the acute scrotum.

Case Report: A 4 year old boy was brought to Emergency with acute onset of pain, redness and swelling in right inguino-scrotal region. Physical examination revealed enlarged, erythematous and tender right hemiscrotum. Testis could not be palpated. Left testis was in scrotum. Doppler ultrasound was inconclusive. Inguino-scrotal exploration was carried out on suspicion of torsion testis. The testis and epididymis were normal. A tense, cystic, congested and pedunculated sac approx. 2 x 1.5 x 1 cm was found along the cord. The sac was found to be twisted at the stalk. The cyst was excised and hernia repaired by high ligation at the deep ring.

Results: The child recovered smoothly. Histology confirmed mesothelial lining in the cyst confirming its peritoneal origin and relation to the hernia sac.

Conclusion: Torsion of hernia sac is a rare differential diagnosis of acute scrotum. Only 11 cases have been reported in world literature. It is clinically difficult to differentiate from torsion of testis. Imaging may be misguiding. Scrotal exploration may be the best way for diagnosis and treatment.

   Choice of Therapy in Posterior Urethral Valves: the Step Ladder Management Protocol Category: Urology Top

Kashish Khanna, Minu Bajpai, Kashish Khanna, Prabudh Goel, Manisha Jana

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Background: For Posterior Urethral Valves (PUV), various options of therapy are available. Cases may differ with respect to choice of therapy, viz., Valve ablation, Vesicostomy and Ureterostomy.

Aim: To evaluate the efficacy of Step Ladder protocol in use for 3 decades in identifying the most appropriate therapy in a given case & minimizing multiple interventions.

Methods: While valve ablation remained the central approach to manage PUV, choice of therapy varied in the presence of adverse factors (deranged blood urea/creatinine, UTI, Sepsis, Metabolic derangement). In the latter circumstances, intervention was upgraded based upon the response of the previously taken Step (Step Ladder protocol), beginning with bladder catheterization, ultrasound guided percutaneous nephrostomy & ureterostomy. Vesicostomy was performed when small sized cystoscopes were not available.

Results: 402 patients presenting from 2 days to 15 years & mean follow-up of 7 years (2-18 years) qualified for analysis. Valve ablation was carried out in 84.2%, vesicostomy in 11.8% cases & ureterostomy in 3.9%. 2/3 patients chosen for ureterostomy recovered function.

Conclusion: This protocol helped in identifying the most appropriate choice of therapy in a given case with PUV. The protocol helped in minimizing the number as well as timely recognition of need for ureterstomy with optimal results.

   Unusual Case of Hypopigmentation with Gut Dysmotility Category: Neonatal Surgery Top

K Lalatendu Kumar

Department of Pediatric Surgery, Ankura Children's Hospital, Hyderabad, Telangana, India

Aims: To present an unusual case of hypopigmentaion with gut dysmotility in a newborn.

Methods: A 32 wk baby boy born with birth weight of 1915 gms to 3rd degree consanguinity parents (G5P2L1A2D1).1st female baby was delivered elsewhere with delayed passage of meconium, had 2 surgeries in view of suspected Hirschsprung's disease died at the age of 1 month. This baby was referred in view of not passed meconium after 72 hrs with abdominal distension. O/E baby had white forelock hair, white eye lashes, white lanugo hairs with hypopigmentation of both limbs. Abdomen was distended but soft, patent anal orifice.AXR was showing dilated small bowel loops with absent rectal gas. Lower GI contrast study was not classical of Hirscsprung's disease. But delayed AXR after 24 hrs showed retained contrast in the colon. with h/o suspected HD in the sibling and clinical features resembling Waardenburg syndrome exploratory laparotomy was done and multiple biopsies with ileostomy was done.

Results: Baby is gaining weight with special amino acid based milk formula. The biopsy report was s/o total colonic aganglionosis. The genetic workup results are awaited.

Conclusion: Shah-Waardenburg syndrome is a very rare syndrome with a higher incidence of Total colonic aganglionosis with or without small bowel involvement which leads to high morbidity and mortality in the neonatal age group.

   Role of Leucocyte Count and Ultrasound Scan in the Diagnosis of Acute Appendicitis in Children Category: GI Surgery Top

R Rajendran, Samir Hegab, Hani Fawsi, Hadi Ghazi Mukattash

Maternity and Children's Hospital (under MOH), Najran, Saudi Arabia

Introduction: 28%-57% misdiagnosis rate is reported in children with acute appendicitis (AA). Aim: to analyse the role of leucocyte count and USS in the diagnosis of AA.

Materials and Methods: Prospective cohort study. Total leucocyte count (TLC) and differential leucocyte counts were estimated in clinically diagnosed-AA or suspected-AA. In suspected AA, repeat assessment was done, and a diagnosis was arrived by clinical, TLC, neutrophil count (NC), USS and rarely by CT-scan also. AA patients underwent appendectomy +/- additional procedure and histopathologic examination (HPE). Data was analysed. TLC 10000/μl and NC 75% of TLC were considered as significantly elevated. Results: 208 cases operated. Mean age 10.22 y (range=70 d-14 y). M:F=2.78:1.

Uncomplicated-AA were 138, complicated-AA 62 and HPE-negative appendectomy 8 (3.85%). TLC was significantly high in 155 (77.5%) and NC in 130 (65%) AA. TLC was significantly high in 5 (62.5%) and NC in 3 (37.5%) of negative appendectomy cases. There was significant difference of NC between simple-AA and complicated-AA. USS in 119 HPE-confirmed AA cases including 10 with general peritonitis (GP) reported 85 (71.43%) as AA, but not diagnosed GP. In 2 of the 8 HPE-negative appendectomy, USS reported AA.

Conclusion: TLC and USS have limited contribution in diagnosing AA and complications. A very low (3.85%) negative appendectomy rate was achieved from repeated clinical assessment for diagnosis.

   Anatomical and Technical Considerations of Central Hepatectomy Category: Surgical Oncology Top

Shubha R Nayak, Nitin James Peters, Muneer A Malik, Ram Samujh, JK Mahajan, Sandhya Yaddanapudi, Akshay K Saxsena

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aims/Introduction: Surgical resection is the cornerstone of management of Hepatoblastoma (HB). Surgical resection of Central hepatoblastomas is challenging due to the vascular and biliary anatomy involved. We present a case of central hepatoblastoma who underwent central hepatectomy.

Case Report/Technical Aspects: A 1-year old male child, a diagnosed case of HB, Pretext III was evaluated for hepatic resection. CECT abdomen showed a mass lesion measuring 6*5*4.9 cm involving segment 5 and 8 and 4a. The lesion abutted right main portal vein and encased the MHV. Inflow (RPV and LPV and right hepatic artery) and outflow (RHV, MHV and LHV) controls were achieved. Segmental branches of portal vein and hepatic ducts were ligated, followed by parenchymal dissection using harmonic Scalpel. Segments 5,8, 4a and 4b were resected. Tumor was excised with 1 cm margin. Post operatively the child developed bile leak which was managed conservatively. Histopathology confirmed HB with tumor free margin.

Conclusion: Central hepatectomy describes the removal of the central liver segments IV, V, and/or VIII with preservation of the lateral segments. It is an alternative to extended right or left hepatectomies in selected patients. It avoids unnecessary sacrifice of functional liver parenchyma

   Anorectal Malformation with Rectosigmoid Perforation Category: GI Surgery Top

Uttam Rawate, SN Bhatnagar, Gayatri M

Department of Pediatric Surgery, Bj Wadia Hospital, Mumbai, Maharashtra, India

Aims: To study case of anorectal malformation with rectosigmoid perforation.

Methods: Male child delivered full term by LSCS 2 kg birth weight brought at day 2 of life with complaint of absent anal opening with abdominal distension x ray suggestive of gas under right dome of diaphragm exploratory laparotomy was done and intra op perforation found at rectosigmoid junction size 5mm x 3mm and primary repair was done and sigmoid colostomy done.

Results: Post operatively patient required ventilator support for five days managed conservatively and child extubated and recoverd well and stoma functioning well.

Conclusion: Anorectal malformation with rectosigmoid perforation is rarely reported. Literature reviews has shown only three cases and this is probably fourth case.early surgical decompression of colon may avoid complication.

   Frantz's Tumour of the Pancreas in Childhood: A Rare Case Category: Surgical Oncology Top

Vishal Michael, Dhruv Ghosh

Department of Pediatric Surgery, Christian Medical College, Ludhiana, Punjab, India

Aim: Solid pseudopapillary tumour of the pancreas is an uncommon neoplasm of low malignant potential. We present a case of Frantz case in a child.

Methods: Solid pseudopapillary tumor is a rare primary neoplasm of the pancreas that typically affects young women. It is a relatively a benign tumor, with a favorable prognosis. It is especially rare in children and shows different clinical features compared with adults. Complete resection is curative in most case.

Results: 12 yrs old girl admitted with abdominal mass, pain abdomen. CECT abdomen was done which was suggestive of Frantz's tumour. True cut biopsy confirmed the diagnosis. Patient underwent pancreaticoduodenectomy. Post operatively patient was discharged uneventfully.

Conclusions: Frantz's tumour is especially rare in children and shows different clinical features compared with adult. Surgery alone is curative.

   Outcome of Surgical Management of Symptomatic Congenital Lung Lesions: A Retrospective Study Category: Thoracic Surgery Top

Prathibha B Naik, Bikash Kumar Naredi, bibekanand Jindal, S Kumaravel, S Krishna Kumar

Department of Pediatric Surgery, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India

Aim: To analyse the outcome of surgical management of congenital lung lesions.

Methodology: A retrospective review of children with congenital lung lesions who underwent surgical management in the Dept of Pediatric surgery, JIPMER from Nov 2009 to July 2018. Medical records were reviewed for demographics, symptoms, type of lung lesion, surgical management, complications and outcomes.

Results: Twenty-three patients (7 girls & 16 boys) had 10 CLE, 10 CPAM, 1 BPS and two bronchogenic cysts. Antenatal detection in 13/23 patients others were in the postnatal period as presented with respiratory distress. CLE involved left upper lobe (6/10) more than the right middle lobe (5/10), one patient had both lobes. CPAM also involved left upper lobe (5/10) more than right middle lobe (3/10) >right upper lobe (1/10) > left lower lobe (1/10). All patients underwent thoracotomy and lobectomy depending on involvement. Two patient died which were operated during the neonatal period for respiratory distress due to CLE. One patient of CPAM developed the Bronchopleural fistula (BPF) require reoperation and muscle flap repaired.

Conclusions: CLE and CPAM are the most frequent congenital lung lesion and more than 50% detected on antenatal ultrasonography. Most universal Indication of surgery was respiratory distress. Mortality less than 10% in our series. Post lobectomy BPF may require reoperation.

   KK Sharma Award: Clinicopathological Correlation in Postoperative Outcome of Different Types of Jejunoileal Atresia Category: Neonatal Surgery Top

Hinglaj Saha, Kaushik Saha, Dipak Ghosh, Uttara Chatterjee, Aniket Halder

Department of Pediatric Surgery, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India

Aims: To assess the thickness of the smooth muscle layer using image morphometry and the presence of ganglion cells and interstitial cells of Cajal (ICC) in the proximal and distal segments of jejunoileal atresia using immunohistochemistry (IHC) and to correlate their association with postoperative outcomes.

Methods: Single centre observational study over a period of 1 year. Inclusion criteria were all neonates (<28 days). Exclusion citeria were major cardiac anomalies, age >28 days, unfit for anaesthesia and other types like duodenal and colonic atresia. Cases (n=15) and control (n=10). All the cases underwent laparotomy and resection. Sections were taken from proximal segment (at 3 cm, 5 cm & 8 cm), and the distal segment 2 cm.

Results: Mean thickness of inner (ICM) and outer circular muscle (OCM) at 8 cm proximal were significantly different than at 3 cm (p= 0.008), (p= 0.02) and 5 cm (p=0.0006), (p=0.0002) but were similar to distal (p = 0.09), (p=0.12) respectively. ICCs in proximal segments and distal were lower than the controls (p< 0.05). Density of S-100 were lower compared to controls. 3 patients had anastomotic leak. wound dehiscences (n=2), 7 of 15 patients surgery was uneventful. Average hospital stay was 8.3 days for uncomplicated cases. Conclusion: Image morphometry is a simple technique to assess the morphology of the intestinal muscle layer. Significant alterations in the nerve cells, ganglia and ICCs are associated with intestinal dysmotility and subsequent postoperative complications. Adequate resection proximal to the dilated portion with end to end anastomosis gives better results.

   Role of Gastrograffin for Conservative Management of Adhesive Intestinal Obstruction Category: GI Surgery Top

R Madhu, Apurva Arora, Selvapriya Bharati, Jegadeesh S, Prakash Agarwal

Department of Pediatric Surgery, SRMC and RI, Chennai, Tamil Nadu, India

Aim: Adhesions are one of the commonest cause of small bowel obstruction in pediatric age group and a bugbear to any pediatric surgeon. The aim of this study is to assess the therapeutic value of gastrograffin in the management of adhesive small bowel obstruction in pediatric patients

Materials and Methods: This was a Prospective study of 24 patients done in two tertiary care hospitals between December 2016 to May 2018 for children presenting with uncomplicated adhesive small bowel obstruction. Initial resuscitation include Nil oral, Nasogastric tube Decompression, Hydration with IV fluids and Antibiotics for 48 hours.children showing no improvement were given Gastrograffin at a dose of 5 ml/kg with equal dilution of saline.xrays were taken 4-6 hours later and 24 hours later. Dye reaching the caecum in 4-6 hours and reaching the rectum in 24 hours or passage of stools were taken as the end point of the study and oral feeds initiated. Failure of dye reaching the large bowel, bilious vomiting or copious bilious aspirate were regarded as complete obstruction and taken up for surgery.

Results: 24 children (12 male 12 female) were given the dye and results analyzed.19 cases (79%) responded well to gastrograffin and 5 underwent surgery (3 laparoscopic and 2 open adhesiolysis).

Conclusion: Gastrograffin use in children is safe and effective with no complications in adhesive small bowel obstruction reducing the need for surgery.larger studies are required toconclude these results.

   Esophageal Anastomotic Caliber Index After Thoracosocpic Repair of Esophageal Atresia with Tracheoesophageal Fistula: A Comparative Assessment with Open Repair for Esophageal Atresia-Trachea-Oesophageal Fistla Category: GI Surgery Top

Raj Kumar, Ravi Prakash Kanojia, Neerja Bhardwaj, Ram Samujh

Department of Pediatric Surgery and Anaesthesia Post Graduate Institute of Medical Science and Research, Chandigarh, India

Introduction: Thoracosocpic Repair of Esophageal Atresia with TracheoesophagealFistula (TREAT) is now an established procedure. The anastomosis done laparoscopically is always compared to the hand sewn anastomosis done in open surgery. There are few studies comparing open with TREAT. We compared Esophageal anastomotic caliber through a new index EACI, comparisons are made with open repair.

Patients and Methods: Patients of EA-TEF operated by open repair and by TREAT were evaluated. An Esophageal caliber anastomotic index (EASCI) was formulated based on measurements done on contrast esophagogram done at 3 months. The diameter of the esophagus at the level of anastomosis was measured. The ratio of radiologically measured values both above and below the anastomosis was done and an index was calculated. A value closer to 1 is normal and ratio < 0.5 is indicative of stricture. This EACI index from the open and TREAT groups of patients was compared to see the difference.

Results: Total of 15 patients were enrolled in each group. The mean diameter ratio was calculated by measuring the breadth of contrast enhanced esophagus at 3 levels as shown. The net EACI in open and TREAT group was 0.779 + 0.141 & 0.788 + 0.217 respectively. The mean follow up duration of these patiets is 1.75 years + 0.4 years. Clinical correlation was also done with 3 patients needing dilatation in TREAT group and 2 in open repair.

Conclusion: EACI is a numerical way to assess the caliber of esophageal anastomosis and it correlates clinically. In the present study, there was no significant difference between the EACI of the two groups showing that thoracoscopically done anastomosis is as good as open.

   Anorectal Malformations: Associated Anomalies and Impact on Outcome Category: GI Surgery Top

Kush Kumar Luthra, S Kush Luthra Manjiri, SK Padmalatha, Jeevak Shetty

Department of Pediatric Surgery, Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India

Aim: To analyse the incidence of associated anomalies and their impact on outcome in terms of need for surgical intervention and morbidity.

Methods: Retrospective observational study from 2007 to 2017. demographics, clinical presentation, investigations, management, post op stay and followup were analysed. with special consideration to associated anomalies (gastrointestinal, urogenital, neurological, chromosomal, cardiac and others) and their impact in terms of surgical intervention and outcome were studied.

Results: Out of 120 cases of ARM, 62.5% were male and 37.5% were females. 53.3% were diagnosed with associated anomalies (sub catogarized as cardiac, urogenital, gastrointestinal, chromosomal and others) 16.6% of which underwent surgical intervention and were found to have good outcome over all.

Conclusion: ARM has high burden of associated anomalies, early detection and timely appropriate intervention of which may significantly reduce the morbidity, improve quality of life and outcome in such patients.

   Reversal of Hypersplenism Sans Splenectomy in Patients of Extrahepatic Portal Vein Obstruction Category: Hepatobiliary Top

Ruchira Nandan, Minu Bajpai, Prabudh Goel

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Aim: Distal splenorenal shunt (DSRS) allows selective decompression of gastroesophageal varices via the splenic circulation while maintaining portal flow. The study aims to evaluate the reversal of hypersplenism and splenomegaly after DSRS for extrahepatic portal vein obstruction (EHPVO) in pediatric age group.

Methods: A retrospective analysis of prospectively collected data on patients of EHPVO post DSRS (n=32) was done. Follow up for 2.5 years (6 months-7 years) was done. Observation parameters included spleen size (extent in mid-clavicular line), hemoglobin, total leukocyte count and platelet count. Shunt patency was confirmed on USG Doppler +/- CT portography.

Results: Shunt patency varied from 30 /32 (93.75%) @ 6 months to 25/32 (78%) @ 2 years follow up. Splenic regression was observed in 30 patients with >50% reduction in 7/9 (with >1.5 years of follow up) and became impalpable in 4 /5 (with > 2 years of follow up). Reversal of hypersplenism and splenomegaly correlated positively while shunt block affected the parameters adversely.

Conclusion: DSRS offers amelioration of portal hypertension and relief for bleeding while preserving the spleen in paediatric patients. Regression of splenic size and hypersplenism has been observed subject to shunt patency.

   Outcomes of Biliary Atresia Post Kasai Portoenterosomy Category: Hepatobiliary Top

Vinod Raj

Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Aim: To evaluate epidemiology, associations of biliary atresia, surgical outcomes post Kasai portoenterostomy in respect to post operative survival rates and long term outcomes.

Materials and Methods: Data of 121 biliary atresia cases were collected and analyzed. Outcomes evaluated were survival with or without native liver, jaundice free survival status with native liver and occurrence of complications of liver cell failure.

Observations and Results: Total of 121 cases (75 M and 46 F) were evaluated of whom 120 underwent Kasai procedure. Age group ranged between 38 days to 240 days (mean of 102 days). Among 120 cases, 42 cases are alive, 46 cases are deceased and 32 lost to follow up. Ten cases were cystic biliary atresia, 5 had abnormal origin of hepatic artery, 3 associated with malrotation and 2 had situs inversus. With follow up period of 2 to 168 months, 29 are jaundice free, 10 have and 9 have persistent hepatomegaly.

Conclusion: Male to female ratio was 1.6:1. 47 % of cases are alive and of them 92 % survived with native liver. Jaundice clearance at 3 months post-surgery is a good early indicator of long term success. Although Kasai portoenterostomy is technically challenging surgical results are encouraging.

   Laparoscopic Management of Choledochal Cyst in 131 Patients Category: Laparoscopic Surgery Top

Ashwini Khanolkar, Ravindra Ramadwar

Department of Pediatric Surgery, NH SRCC Children Hospital, Mumbai, Maharashtra, India

Aim: Laparoscopic excision of choledochal cyst with hepaticojejunostomy (HJ) or hepaticoduodenostomy (HD) has evolved as an alternative to open surgery. The aim of our study was to assess our experience of laparoscopic approach in 131 patients over last 14 years.

Methods: Since 2003 all patients who underwent laparoscopic approach for choledochal cyst were reviewed. This was part of an ongoing prospective study on choledochal cyst. Presentation and operative approach were analysed.

Results: Since 2003, 131 patients (Age 4 weeks – 18 years)(Weight 2.3 - 52 kg) (M:F = 1:1.5) underwent laparoscopic excision. 3 patients had obstructive jaundice and cholangitis requiring preoperative intervention (2 ERCP stenting, 1 cholecystostomy). Six patients had severe pancreatitis at presentation. HJ was performed in 74 patients and HD was performed in 57 patients. The mean operative time was 175 minutes for HJ and 160 minutes for HD. Prolonged operative time was attributed to surgery being performed in different hospitals and varied infrastructure. 2 patients who underwent HJ were converted to open surgery in the initial period of our study. Overall 5 patients had leak (4 HJ, 1 HD). All leaks in HJ were treated conservatively, 1 patient with HD required surgical intervention (converted to HJ). Postoperative pain was seen in 3 HJ and 11 HD (resolved over 3 months). They will need endoscopic assessment at some point for bile gastritis.

Conclusion: Laparoscopic excision of choledochal cyst is good alternative to open surgery. There was no difference in results in HJ or HD. Only one patient required redo-surgery. HD patients will require endoscopic surveillance to assess long term effects of bile gastritis.

   Long Term Outcome of Cloacal Malformations Category: GI Surgery Top

Shilpa Sharma, Ranjana Bhanot, Devendra Yadav, Devendra Gupta

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Purpose: Though early outcomes following cloacal surgery are well reported, long-term outcome data are less comprehensive. We aimed to study long term outcome of common cloaca and associated genitourinary anomalies.

Methods: A retrospective review of patients treated from 1995 till date with regular follow up visits from April 2014 to June 2018 was done.

Results: 20 patients with cloacal malformations were studied. Age at presentation varied from 1 day- 4 years. Associated anomalies included solitary kidneys-2, renal dysplasia-1, Vesico-ureteric reflux-9, partial sacral agenesis-2, spina bifida-3, pouch colon-3, clitoromegaly-1, septate vagina-4 and bicornuate uterus in 5. 10 patients had common channel length of >3 cm. All patients underwent PSARVUP with an additional laparotomy in 7. 6 patients required vaginal replacement; 2 with ileum;2 with sigmoid colon; vaginal switch in 1 and hemirectum was used in one. Reduction clitoroplasty was done in 1. 4 developed mucosal prolapse. Urethro vaginal fistula in 1 patient closed spontaneously. At follow up of 1- 23 years, 5 patients had incontinence for urine and 4 had fecal soiling. Persistent VUR was found in 8, 5 received deflux. 1 underwent a ureteric reimplantation. Remaining 2 are on chemoprophylaxis. 2 patients of uterus didelphys are having menorrhagia. One patient died due to sepsis at the age of 7 months. Two patients died of renal failure. Renal functions remained normal in 16. One patient is undergoing dialysis.

Conclusion: As the common cloaca patient grows older, the associated genitourinary anomalies require attention. Regular follow-up is mandatory to manage these following PSARVUP.

   Improving Outcomes of Gastric Pull up for Oesophageal Replacement: 20 Years' Experience Category: GI Surgery Top

Satish Kumar Aggarwal, Shandip Sinha, Simmi Ratan, Sugandh Agarwal, Aparajita Mitra, Rupa Banerjee

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aim: To present techniques to improve outcomes of gastric pull up.

Methods: Review of 58 cases from 1997 to 2017, who underwent gastric pull up for Pure oesophageal atresia (24), EA/TEF (17), corrosive strictures (14), Barrett oesophagus strictures (2), oesophageal lymphoma (1) was done regarding demographics, pre operative work up, operative procedures, postoperative events and early outcomes. Five specific aspects were studied: Peri operative beta blockers, Preoperative bronchoscopy to assess tracheomalacia, lesser curve reduction gastroplasty, and omental transposition with stomach to wrap around the neck anastomosis, and feeding jejunostomy for early enteral feeds.

Results: Age range was 6 months to 12 years. Posterior mediastinal trans- hiatal route was used in 56 and retrosternal in 2. Surgery was done after bronchoscopic resolution of tracheomalacia. Pre operative Metoprolol was used in the last 34 cases. During surgery lesser curve reduction gastroplasty was done using stapler. Omentum was also transposed with the stomach in the neck to cover the anastomosis. Feeding jejunostomy was done in all. No mortality was seen after institution of pre op Metoprolol. Seven anastomoses leaked. Early dysmotility was seen in 22 cases of EA group and 3 in corrosive group.

Conclusions: Early outcomes of gastric pull up can be improved using the described techniques and pre operative preparation.

   Bridging the Gap in Long Gap Esophageal Atresia: A Novel Kimuras + Foker Technique Category: GI Surgery Top

Vikram Khanna, Rajiv Chadha, Partap Singh Yadav, Pinaki Ranjan Debnath, Subhashish Roy Choudhury

Department of Pediatric Surgery, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, India

Aim: To assess the outcome in LGEA patients undergoing Kimura and Foker procedure.

Methods: Records of patients with LGEA who underwent Kimura & Foker procedure over the last 10 years were reviewed and analyzed.

Results: Eight patients (4 pure EA, 2 LGEA primarily diverted & 2 EA+TEF patients diverted following leak) were included. Five patients underwent Kimuras extra-thoracic lengthening procedure alone for the upper pouch and 3 other underwent combined Kimuras procedure for the upper pouch & Foker technique for the lower pouch. All patients had a maximum of 1-2 lengthenings for the upper pouch enabling a gain of 3-4 cms. Delayed primary esophageal anastomosis was possible in 7/8 patients. Two patients died, one even before the esophageal anastomosis could be attempted and the other in the post-operative period after the esophageal anastomosis. All 6 patients underwent dilatations in follow-up and 3 patients required multiple resection-anastomosis (1-3) for recalcitrant strictures. All 6 patients also required anti-reflux surgery and were accepting orally at last follow-up.

Conclusions: Kimuras procedure either alone or a combined Kimuras+Foker technique is technically feasible in LGEA patients enabling the preservation of native esophagus.

   Long Oral: Hydronephrosis Severity Score: An Objective Assessment of Hydronephrosis Severity in Children Category: Urology Top

Ramesh Babu, Easwaramoorthy Venkatachalapathy, Venkata Sai

Department of Pediatric Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India

Aims: To develop a new hydronephrosis severity score (HSS) and analyze it with regards to inter-observer reliability, efficacy in assessing need for surgery and the role in assessing post operative resolution.

Methods: HSS was devised with a weight of 0-4 for three parameters (differential renal function, drainage curve pattern, and ultrasonogram grade); max HSS 12; minimum 0. HSS ranges were compared with clinical outcomes (resolution, persistence, or surgical intervention) by retrospective case record review of children with unilateral UPJO. Surgical outcomes were compared with changes in HSS at 6 months follow up. HSS was computed by three observers and inter observer variability was calculated.

Results: Among 125 case records analyzed; none (0/59) with HSS 0-4 required surgery, while 1/35 with HSS 5-8 progressed to require surgery, and all (31/31) with HSS 9-12 required surgery (p=0.001). Mean HSS was 2.1 in whom it resolved (n=65), 6.2 in whom it persisted (n=28) and 10.2 in those who required surgery (n=32); p=0.001. There was 94.4% median agreement between radiologists and surgeon (kappa 0.851) indicating a very good inter-observer agreement.

Conclusions: HSS is a useful tool to predict the need for surgery as well as assess resolution of UPJO. Only those with HSS>8 required surgery.

   Posterior Urethral Valves, the Oman Experience Category: Urology Top

Avirat Vaishnav, Taha Mohamed, MJ Al-Sajwani

Department of Pediatric Surgery, Avirat Vaishnav, Royal Hospital, Muscat, Oman

Aims: To retrospectively analyse the results of the treatment of posterior urethral valves from January 2006 to October 2017.

Methods: A total of 193 children were studies and divided into 2 groups. 120 children from January 2006 to June 2013 and the second group of 73 children from July 2017 to October 2017. The elements of study included 1) Total number of children, 2) Age of presentation, 3) Antenatal diagnosis, 4) Radiological procedures, 5) Pre op and Post op Creatinine level, 6) Presence of reflux, 7) Type of procedure, Fulguration vs Urinary Diversion or both, 8) Number of children up with renal failure.

Results: 114 (59.7%) were diagnosed antenatally. 145 children had fulguration as the primary treatment. 24 had vesicostomy as the primary procedure. 20 had concomitant fulguration and vesicostomy, while 4 children needed vesicostomy and ureterostomy followed by fulguration. 32 (16.85%) progressed to end stage renal failure, of these 23/32 had a pre procedure Creatinine higher than 150 uMol/L. 105 had vesicoureteric reflux, approximately half had bilateral reflux. 17/32 of ESRD had bilateral reflux. 20/32 were diagnosed under 1 month of age.

Conclusion: Age at diagnosis, bilateral vesicoureteric reflux and pre-procedure high Creatinine were good indicators of prognosis.

   Study of Changes in Testicular Size and Arterial Vasculature in Operated Cryptorchid Patients Category: Urology Top

AB Majid Wani, Amita Sen, UC Garga, Vijay Kumar Kundal, Pinaki Ranjan Debnath, Atul Kumar Meena

Department of Pediatric Surgery, PGIMER and DR. R.M.L HOSPITAL, New Delhi, India

Aim: To determine the changes in testicular size and vasculature in patients of unilateral cryptorchidism after orchidopexy.

Methods: This study included 30 cases of unilateral cryptorchidism in children with normal side as control from Oct 2016 to April 2018. Testicular size, volume and echogenicity were measured by ultrasound doppler on the cryptorchid side and normal side before and after surgery.

Results: Study revealed that the mean testicular volume of the undescended testes showed a highly significant increase (p<0.01) when reviewed at 3 months. The mean volume of cryptorchid testes in age group 0-3 years before orchidopexy was 0.39 ml while after orchidopexy was 0.49 ml. The postoperative testicular atrophy index (TAI) values decreased ranging from 10.39% to 4.85 % depending on patient's age. The mean peak systolic velocity of cryptorchid testes in all age groups was lower than that of contralateral testes in respective age group. The peak systolic velocity increased after orchidopexy in all age groups (3.68 to 4.27). While the resistive index decreased after orchidopexy in all age groups (0.59 to 0.56).

Conclusion: The TAI is a valuable and objective tool for qualifying patients with undescended testes for surgery as well as for monitoring the results of treatment.

   Rhomboid Flaps in Large Meningomyelocoele Defects Category: Miscellaneous Top

Digamber Chaubey, Sandip Kumar Rahul, Vijayendra Kumar, Ramdhani Yadav, Vinit Kumar Thakur, Zaheer Hasan

Department of Pediatric Surgery, Indira Gandhi Institue of Medical Sciences, Patna, Bihar, India

Aim: To study how wound dimension determines the choice between Primary and Rhomboid flap closure of skin defects following surgery for Neural tube defects.

Methods: A retrospective study was done on cases of Neural tube defects operated in the Department of Pediatric Surgery at a tertiary centre in the last 3 years from January, 2015 to December, 2017. All data regarding Clinical features, location, Wound dimensions following surgery, any bony deformity, method of closure used, distance of wound from anus and Postoperative complications were collected and analyzed.

Results: 114 cases were operated during this period; 86/114 had primary closure while 28/114 needed Rhomboid flap for tension-free cover. Primarily closed wounds had a mean (long axis)/ (short axis) ratio of 1.65, while those covered by Rhomboid flaps had a mean ratio of 1.25. All 6 cases with bony deformity needed rhomboid flaps. Lesions within 5 cm from the anal opening were at increased risk of post-operative wound infection.

Conclusion: Defect's position, its size and shape and any bony deformity determine the choice of closure of Post-operative wound. The versatile, safe, and universal Rhomboid flap is an aesthetic solution to the large skin defects in patients of neural tube defects.

   Long Term Results of Pulmonary Metastasectomy in the Management of Paediatric Malignancies Category: Miscellaneous Top

Jujju Jacob Kurian

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Aim: To determine the prognostic factors and long term results of pulmonary metastasectomy.

Methods: A retrospective analysis of 16 patients who underwent lung metastasectomy for paediatric malignancies from 2007 to 2017 was done.

Results: The primary tumors were Osteosarcoma (7), Wilms tumour (4), Alveolar rhabdomyosarcoma (2), Adrenocortical carcinoma (1), Neuroblastoma (1) and Ewings sarcoma (1). Lung metastasis was found at the time of diagnosis of the primary tumor in 62.5% of patients. A total of 26 thoracotomy/ thoracoscopic tumour excisions were performed. All except one were wedge resections of the metastases. Patients were followed up to a mean period of 35 months with a survival rate of 37.5%(6/16). Of the 6 surviving patients, 5 were disease free and one had disease progression at the time of last follow up. Patients with Wilms tumor had the maximum survival at 75%. Improved survival was seen in patients with 3 or less metastases, and in those with more than 32 months disease free interval.

Conclusion: Pulmonary metastasectomy is a safe and effective method which provides long term survival benefits in a subset of patients with metastatic paediatric tumours.

   Mediatinal Neuroblastoma: Is it a Blessing in Disguise? Category: Surgical Oncology Top

R Senthilnathan, S Vivek, N Karpaga Vinayagam, J Muthukumaran

Department of Pediatric Surgery, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India

Aim: To analyse to outcome and short term prognosis of children with posterior mediastinal neuroblastoma in our Institute.

Materials and Methods: This is a retrospective study from January 2015 to June 2018 of the posterior mediastinal neuroblastoma cases that were treated in our Institution.

Results: Out of the 37 neuroblastoma cases that were treated in our institute in the study period, 9 cases were posterior mediastinal neuroblastoma. All 9 cases were subjected to image guided trucut biopsy, neoadjuvant chemotherapy and surgical excision. 7 cases underwent open thoracotomy and complete excision. Two of them underwent thoracosopic excision in toto. Tumours after neoadjuvant therapy less than 5 cm were taken up for VATS procedure. All posterior mediastinal patients are alive and recurrence free on follow up. Whereas in the remaining patients (N= 28), 17 patients progressed relapsed and died on follow up during the same period with the mortality rate of 60.71%.

Conclusion: Posterior Mediastinal Neuroblastoma have a good prognosis and should be aggressively managed, despite the large size at presentation.

   Can Aggressive Perinatal Care of Cdh in a Multidisciplinary Team Overcome Hidden Mortality Associated With It? Category: Thoracic Surgery Top

Rahul Dey, V Pavithra, MM Zameer, C Vinay, Sanjay Rao, Ashley D'Cruz

Department of Pediatric Surgery, Narayana Health, Bengaluru, Karnataka, India

Aim: To determine true survival in a naturally unselected cohort of neonates, antenatally diagnosed with CDH delivered and managed in our institute.

Methods: This is a retrospective comparative study of neonates with CDH managed in Narayana Health between 2008 and 2018. Group 1 includes antenatally diagnosed neonates, delivered and managed in-house. Group 2 includes neonates who were diagnosed postnatally and delivered either in-house or outside and then referred.

Results: 28 neonates presented with CDH. Group 1 had 15 babies with 9 girls. Group 2 had 13 babies with 3 girls. 9 out of 13 were outborn. The various risk factors and outcomes were compared.

Conclusion: True survival in CDH is 60%. The outcomes in naturally unselected cohort of babies with CDH, managed aggressively from birth is comparable to outcomes in a naturally selected cohort of healthier and robust babies who make it to tertiary care centre after post-natal diagnosis.

   Surgical Techniques in Vaginoplasty: Audit Category: Urology Top

Pavai Arunachalam, Sudipta Sen, Cenita J Sam

Department of Pediatric Surgery, PSG Hospital, Coimbatore, Tamil Nadu, India

Aim: Retrospective clinical audit was conducted for the patients undergoing vaginoplasty in PSG hospitals.

Methods: Retrospective data collected were diagnosis, type of anomaly, investigations performed, the surgical procedure, the complications (such as rectal/urethral injury) and follow up. Patients were called back for the follow up to assess the cosmesis, urinary symptoms, necessity for dilatation, mucus discharge, prolapse, stenosis and necessity for red-do and female sexual satisfaction (when relevant).

Results: Twenty five patients were included in this study after fulfilling the inclusion and exclusion criteria. The disease conditions included congenital adrenal hyperplasia, cloaca, UGS, 46 XYDSD, OHVIRA, vaginal agenesis and atresia. The age group was from newborn period to 22 years of age. The different types of vaginoplasty were feminising genitoplasty, pull through vaginoplasty, bowel vaginoplasty, septoplasty, U flap vaginoplasty and abdominoperineal vaginoplasty. There was one rectal injury and one re-do for stenosis. Two were married and one had a child with a foster mother. There were no urinary symptoms in any of our patients.

Conclusion: Our protocol was to perform in infancy the perineal approach when low and pubertal age group when intermediate or high. The urinary incontinence and the overall results were satisfactory with our approach.

   Surgical Challenges and Outcomes in Single Functioning Kidney: Retrospective Study by Single Surgeon Category: Urology Top

M Srinivasa Rao

Department of Pediatric Surgery, Omni RK Hospital, Visakhapatnam, Andhra Pradesh, India

Aims: This 10 yr retrospective study aims at estimation of prevalence, clinical presentation, course, surgical treatment and outcomes of congenital anomalies of kidney urinary tract (CAKUT).

Methods: A retrospective observational study from 2008 to 2018 on a series of 24 children with SFK (13 unilateral renal agenesis, 11 post nephrectomy) was done focusing on surgical management, outcomes.

Results: Of 24 SFK children, 9 were normal and advised yearly consultations, 8 needed surgery (4 pyelopasties, 3 ureteric reimplantations and one baby of 6 months with obstructive mega ureter is waiting for surgery). Seven lost to follow up. 2/7 operated babies developed acute renal failure and further two had severe urosepsis in the immediate post operative period requiring prolonged ICU care, IV antibiotics and expert management by nephrologist.

Conclusion: The otherwise routine dismembered pyeloplasty and ureteric reimplantation surgeries can pose serious threats post operatively in SFK. Meticulous anastamosis, avoiding nephrotoxic drugs, upper tract diversion (nephrostomy), preparing the ICU team for this eventuality ease the management. Newer protocols suggest that these patients must be strictly advised on yearly follow up with the physician/nephrologist and the age related renal changes and ESRF can only be delayed by strict health regime.

   Management and Outcomes of Congenital Anomalies in Low-, Middle-, and High-Income Countries: Protocol for a Multi-Centre, International, Prospective Cohort Study Category: Miscellaneous Top

Dhruva Ghosh, Naomi Wright, Niyi Ade-Ajayi, Adesoji O Ademuyiwa, Emmanuel Ameh, Justine Davies, Kokila Lakhoo, Dan Poenaru, Nick Sevdalis, Andrew Leather, Vishal Michael, Dhruva Ghosh, Global PaedSurg Research Collaboration

Department of Pediatric Surgery, Christian Medical College and Hospital, Ludhiana, Punjab, India

Congenital anomalies are the 5th leading cause of death in children under 5-years of age globally with limited data from low and middle income countries which account for most of the deaths.

Aim: A multi-centre prospective cohort study of congenital anomalies to compare outcomes between low-, middle- and high-income countries (LM&HICs).

Methods: The Global PaedSurg Research Collaboration invites children's surgical care providers from around the world to participate in the study. Collaborators will be co-authors of resulting presentations and publication(s). Data will be collected on patients with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation and Hirschsprung's disease for a minimum of 30 consecutive days between Oct 2018 - April 2019. Online data on demographics, clinical status, interventions and outcome will be collected using REDCap. The primary outcome being in-hospital mortality and post-operative complications will be the secondary outcome. Chi-squared analysis will compare mortality between LM&HICs and multivariate logistic regression analysis will identify factors affecting outcomes.

Outcomes: The project aims to be the first large-scale, comprehensive, multi-centre prospective cohort study of a selection of congenital anomalies across the globe studying management and outcomes, aid advocacy and global health prioritisation, and inform future studies aimed at improving outcomes.

   Foreign Body Inhalation-A 30 Year Retrospective Review Category: Thoracic Surgery Top

Avirat Vaishnav, Himaanee Mirakhur, PM Nayar, Mohammed Jaffer Sajwany

Department of Pediatric Surgery, Royal Hospital, Muscat, Oman

Aim: A comprehensive review of Foreign Body Inhalation from January 1988 to May 2018 to raise awareness among pediatricians and general physicians, and highlight the importance of a high index of suspicion.

Methods: Retrospective analysis of 610 patients in the age group of 6 months to 13 years who underwent rigid bronchoscopy for suspected foreign body inhalation.

Results: 610 bronchoscopies were performed. There were 362 boys and 248 girls. 78 children were under one year, the youngest being six months. Foreign bodies were found in 86% of the cases and in 30% they were radio-opaque. 88% were bronchial, with right and left being nearly equal in numbers. Post procedure, there was 1 death, 4 required thoracotomy, 3 required repeat procedure and 2 needed tracheostomy. 4 children presented with mediastinal emphysema and 1 was detected on account of unexplained pneumothorax.

Conclusion: Foreign Body Inhalation is a common yet potentially fatal condition. If not managed promptly, it can rapidly progress to morbidity. Bronchoscopy continues to be the gold standard diagnostic and therapeutic tool. A good history and high index of suspicion aide with effective treatment. Among objects found, scarf pins were a significant number and posed a major challenge in treatment.

   Abdomino-Perineal Pull-Through by the “hanging Bowel” Technique – Synthesizing a New Paradigm from the Past Category: GI Surgery Top

Minu Bajpai, Ruchira Nandan, Prabudh Goel

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Aim: To describe results of Abdomino-Perineal Pull-Through (APPT) with Hanging Bowel Technique (HBT).

Methods: Prospective review of our results of APPT with HBT since 2011. Patients with anorectal malformation (ARM, n=32), Hirschsprung's disease (HD, n=9), sexual assault (n=1), juvenile polyposis coli (JPC, n=2), carcinoma rectum (n=1) were included. Observation criteria included 1) post-operative complications, 2) continence status (anal caliber, puckering, stretch-ability, squeeze and soiling), 3) bladder involvement, and 4) patient satisfaction. The surgical technique is described. Bowel mobilization was done laparoscopically (n=5, all HD) or by laparotomy.

Results: 45 children, age 4.9 years (Range: 3 day-58 years). Post-operative complications included wound dehiscence (n=2; secondary-suturing), vascular loss (n=1; redo-pull-through), adhesive obstruction (n=1; conservative) and perforation peritonitis (n=1; diversion). Post-operative results included anal puckering-all HD, non-HD n=32; 89%, calibre (adequate, n=41; 91%), mucosal prolapse (n=2) and anal stretch present (non-HD n=31; 86%), voluntary squeeze present (n=35; 78%), soiling (daily n=3; once a week n=5; infrequently n=6). Bladder control was worsened in 2 patients (recto-bladder-neck fistula; n=1 and pouch colon; n=1). Overall patient satisfaction score is 8/10.

Conclusion: APPT-HBT avoids colostomy, avoids posterior sagittal incision & rectoplasty, thus, avoiding injury to neurovascular innervation & perineal muscles & preserves the sub-mucosal plexus. It holds promise to improve functional outlook for these patients.

   Surgical Management of Umbilical Discharge: A 11 Year Institutional Experience Category: Miscellaneous Top

Rohith Srinivas

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Aims: To compare clinical features, surgical findings and histopathological reports of patients who underwent umbilical exploration for umbilical discharge.

Methods: Clinical data, surgical records and biopsy reports of patients who underwent umbilical exploration for umbilical discharge over a period of 11 years at Christian Medical College Vellore, was collected, tabulated and analyzed. Tests of significance were used to identify significant correlations.

Results: 125 children required surgical exploration of the umbilicus for umbilical discharge despite use of copper sulphate or ligation. 67% of children were male. Two thirds of patients had a granuloma on examination. 65% of them had a granuloma of size 1 cm or more and that was a significant indicator for presence of vitello-intestinal duct remnants (p=0.0015). 13.6% of patients had no clinical findings and none of them had any findings on histopathology. 93 children had biopsy reports of which 50% reported vitello-intestinal tract remnants and 36% had non-specific inflammatory changes. Wound infection rate was 8%. 9 children had persistent discharge due to either eczema or stitch granuloma. No child was reoperated.

Conclusions: Umbilical exploration is the treatment of choice for persistent umbilical discharge when conservative methods fail. It is associated with minimal morbidity but excellent outcomes.

   To Study the Clinical, Pathological and Epidemiological Profile of Paediatric Malignant Solid Tumours Category: Surgical Oncology Top

Rashmi Atmaram Patil

Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya, New Delhi, India

Aims: To study the clinical, pathological and epidemiological profile of paediatric malignant solid tumours.

Methods: A hospital based prospective study with 48 patients belonging to 0-12 years age group and with solid malignant tumours was done from October 2016 to March 2018 at a tertiary level hospital.

Results: The peak incidence was in 0-4 years age group with median age being 4 months and 1 year with male:female ratio 0.8:1. Patients mainly belonged to rural locality. Parents of most patients were illiterate, semiskilled workers belonging to upper middle socioeconomic class. There was no positive family history or antenatal exposure to carcinogens. Patients sought health care on an average after 99 days of symptom occurrence and visited our hospital after 107 days. The most common presentation was abdominal lump (54.16%) followed by fever (27%) and abdominal pain (22.91%). The preoperative clinical,(history and physical examination), biochemical (tumour markers), radiological (U.S.G., C.T. and M.R.I. scan) and pathological (F.N.A.C., biopsy) findings correlated with the final diagnosis (87.2%). Most patients had stage 3 tumours (35.4%). Germ cell tumours were the commonest (34%) followed by Wilms' tumour (19.1%) and Rhabdomyosarcoma (14.9%). Most were favourable histology tumours.

Conclusion: Most patients belonged to below 4 years of age and presented with an abdominal lump. Most cases presented late and with advanced disease. Germ cell tumour was the commonest malignancy. Geographic differences in the incidence and histologic types of paediatric malignant solid tumours do exist.

   Transanal Approach to Idiopathic Rectal Prolapse: the Ultimate Non Invasive Technique Category: GI Surgery Top

Subhasis Saha, Luis De La Torre, Sachchidananda Das

Department of Pediatric Surgery, Advanced Medical Research Institute, Mukundapur, Kolkata, West Bengal, India

Aim of Study: This is a retrospective study of a modification of Delorme's procedure done for idiopathic full thickness rectal prolapse through transanal route in 18 children with good short and medium term outcome. It is noninvasive and follows the principles of NOTES (natural orifice transluminal endoscopic surgery).

Materials and Methods: Eighteen children, aged between 2 to 17 years, underwent transanal modified Delorme's procedure between April 2014 and June 2018. Duration of prolapse before surgical treatment varied from 3 months to 60 months during which all patients underwent trials of conservative treatment and failed. Constipation was treated. Contrast enema, anorectal manometry and short colonoscopy were performed preoperatively in most patients. After thorough bowel preparation, patients were anesthetised and placed in lithotomy or prone positions. The rectal mucosa was prolapsed and infiltrated with adrenaline. Transanal resection of the redundant mucosa was done followed by mucosa – mucosal anastomosis with or without plication of the redundant muscle. The children were discharged within 3-4 days of surgery.

Results: Rectal prolapse was resolved in all patients. None of them required laparoscopy or laparotomy. None needed laxatives for more than 6 months. There was no case of postoperative incontinence. No child needed analgesics after discharge.

Conclusion: Transanal rectal mucosectomy for idiopathic rectal prolapse ticks all boxes for an ideal surgical technique. It is minimally invasive and is cost effective too. Long term followup is necessary to evaluate its effectivitiy.

   Male Gender Assignment in 46 Xx Congenital Adrenal Hyperplasia Category: Urology Top

Shilpa Sharma, P Viveka Jyotsna, Devendra Yadav, Anurag Srivastava, DK Gupta

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Aim: To evaluate the clinical outcome of male genitoplasty for 46 XX congenital adrenal hyperplasia (CAH) patients presenting late with severe virilisation, reared as males.

Methods: Of 206 children diagnosed with CAH, nine presented late with severe virilization and were reared as males. All were assigned male sex with removal of the female adnexa. Male genitoplasty and hormonal supplementation was done. Case records were studied and long term outcome assessed.

Results: The mean age at presentation was 8.5 (5 – 21) years. Six patients presented after puberty, three at 5-7 years age. Staged male genitoplasty; chordee correction, male urethroplasty, and bilateral testicular prosthesis was performed. Panhysterectomy with bilateral salpingo-ophorectomy was done. The mental makeup was masculine in 8 and bigender in one. Bilateral mastectomy was performed at puberty in all. Hormonal treatment comprised of glucocorticoids and testosterone. Eight patients were comfortable with outcome of genitoplasty. One had a short-sized phallus. At follow up of 4-28 years, social adjustments were good in all, except one who after 12 years of male genitoplasty expressed a strong feminine inclination. Female genitoplasty followed by bilateral breast implants was done after repeated psychological assessment. 2 years later she got married to a man and led a happy life.

Conclusion: Severe virilization in late presenting CAH patients may retain the assigned male gender, meeting the socioeconomic compulsions of society with satisfactory results. However, occasional cases may deviate from the assigned gender and need medical help.

   Glans Substitution and Frenuloplasty: A Novel Technique for Restoring the Normal Glanulo-Frenular Complex Category: Urology Top

Satish Kumar Aggarwal, Aparajita Mitra, KA Rashid

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aims: In hypospadias repair, a tight ventral glans closure often leads to ischemic complications like fistula and dehiscence. The concept of septum glandis and frenulum separating the ventral glans wings has recently been proposed. The conventional ventral glansplasty does not conform to this concept. We used a robust dartos flap with inner foreskin to recreate the glanulo-frenular complex (GFC) simulating normal anatomy.

Methods: Between January 2010 and December 2017, 276 new cases of hypospadias (age range 6 months to 11 years) were operated. Redo cases and proximal hypospadias were excluded. The degree of glans malformation was estimated by the distance between the glanular hillocks. Glans wings were raised. Urethroplasty was performed by standard TIP technique with a free inner preputial skin graft over the raw surface. The GFC was recreated using a pedicled flap of dartos on preputial skin tailored to the dimensions of the defect with dartos providing soft-tissue substitution and skin replacing the frenulum.

Results: The procedure was successful in all cases with a follow up of 6 months to 8 years. Complication rate was 2.1% [fistula formation in 3 (one Clavien-Dindo grade 3b), skin necrosis in 2 (healed spontaneously), meatal stenosis in one (responded to dilatation)]. Cosmesis was satisfactory to the parents and the surgeon. Uroflowmetry data from 140 patients (>3 years) showed normal flow patterns in 70%.

Conclusion: This is a useful technique to achieve tension free glansplasty, particularly where the glans anatomy does not allow tension free ventral closure.

   Poor Uroflow After Distal Hypospadias Repair: A Marker for Fixed Obstruction of the Neourethra? Category: Urology Top

Aparajita Mitra, Satish Kumar Aggarwal, Rajat Piplani

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aims: Abnormal uroflowmetry (UFM) curves are inherent to hypospadias in approximately 50% of cases, however, a normal pre-operative but abnormal post-operative flow may be suspicious for an obstructive complication. In our previous study, the best flow rates were observed when a circumferentially epithelialized urethra was constructed as opposed to only incising the urethral plate. We have further studied the pre- and post-operative flow rates in hypospadias undergoing repair with TIP with graft and glans substitution and frenuloplasty.

Methods: Thirty children (>3 years) were operated between February 2016 and January 2018. Glans substitution is a novel technique to re-create a natural glanulofrenular complex (GFC) with an intact symphysis glandis. Pre-operative and post-operative UFM (at 3 and 6 months) was done. Maximum flow rate (Qmax), average flow rate (Qav), total voided volume, voiding time and type of curve were seen.

Results: Of the thirty cases evaluated 17 (56.6%) had normal UFM at 3 months (of these, 7 previously had abnormal curves). Thirteen had poor post-operative flow of which 6 also had abnormal pre-operative UFM but no worsening. The latter group was subjected to more active surveillance with repeat UFM, ultrasonic post-void residue measurement and parental observation of urinary stream. Of the 7 who were normal pre-operatively but had poor flow after surgery, 3 improved, 1 remained abnormal and 3 are yet to be evaluated at the 6 month follow-up.

Conclusions: Abnormal flow rates after surgery are not synonymous with obstructive complications. Reconstruction of circumferentially epithelialized urethra, well supported by soft tissue (dartos and corpus spongiosum) and avoidance of constriction at the level of the glans by way of our novel technique of preserving the symphysis glandis and frenuloplasty provides grounds for improved post-operative flow rates.

   Developmental Status of Children Operated for Ea &tef Along with Caregivers' Stress, Their Quality of Life and Coping Abilities Category: Thoracic Surgery Top

Sandeep Agarwala, Vanita Kumari, Poonam Joshi, Anjan Dhua, Savita Sapra, M Srinivas, Sandeep Agarwala, Veereshwar Bhatnagar

Departmment of Pediatric Surgery and College of Nursing, AIIMS, New Delhi, India

Aim: To assess the developmental status of children operated for EA/TEF and caregivers' stress, their quality of life and coping abilities.

Methods: Descriptive cross sectional of children up to 5 years of age after surgical repair of EA and their caregivers. Tools used  Demographic datasheet. anthropometry assessment, child behaviour checklist (1.5-5 years) caregiver report form, Developmental Assessment Scale (DASII) and modified Vineland Social Maturity Scale (VSMS) for developmental assessment, parental stress scale (PSS), WHO QOL Bref and coping strategies checklist.

Results: Of 51 children, 47.1% had low/very low weight (VLW) for age, and 31.4% had height less than normal. Other anthropometric parameters like mid-upper arm circumference (MAC), skinfold thickness and head circumference were less than the reference age in 68.9%, 51.1% and 41.1% respectively. The developmental delay as measured by DASII and VSMS was observed in 40.63% and 37.5% of children respectively. Among the caregivers, 47% had moderate stress, poorest quality of life in environmental (60.1± 18.9) and psychological (60.8±18.8) domain. Most commonly used coping strategy by the caregivers was emotional outlet (29.41%).

Conclusions: Developmental delay was present in children operated for EA/TEF. Significant number of caregivers had stress affecting their quality of life and were using emotional outlet as their coping strategy.

   Outcome of Standard Risk Hepatoblastoma Treated with Cisplatin Monotherapy in a Resource Challenged Nation Category: Surgical Oncology Top

Divya Murali, S Agarwala, Divya Murali, A Dhua, M Srinivas, S Bakhshi, S Thulkur, M Jana, D Parthasarthy, V Bhatnagar

Department of Pediatric Surgery, AIIMS, New Delhi, India

Aim: To evaluate the effectiveness of Cisplatin monotherapy for standard risk Hepatoblastoma (SRHB).

Materials and Methods: Efficacy of Cisplatin monotherapy for SRHB was evaluated in terms of 5-year overall survival (OS) and recurrence free survival (RFS).

Results: Of the 62 HB patients treated in this period, 32 (51.6%) were SRHB. Ninteen of these 32 (59.4%) were started on monotherapy but 6 were subsequently upgraded to PLADO due to poor response. Therefore, 13/32 (40.6%) got exclusive monotherapy while 19/32 (59.4%) received PLADO. Overall of the 32 SRHB patients, 31 could be resected, while 1 died pre-operatively. Twenty-nine of 32 (90.6%) SRHB were alive, 5 (15.6%) recurred and 3 (9.4%) died giving a 5-year OS 0.89, RFS 0.79. Of these 5 recurrences, 3 are in CR after salvage therapy. Among the 13 monotherapy alone, all were alive in complete remission (CR) with no recurrences (5-year OS and RFS 1.0). Among the 19 who got PLADO, 16 (84.2%) were alive (15 CR; 1 PD) while 3 (15.8%) had died giving a 5-year OS 0.82 (95 CI 0.55-0.94), RFS 0.62 (95 CI 0.3-0.8).

Conclusion: The outcome of SRHB patients was good with a 5-year OS and RFS being 0.89 and 0.79. All the SRHB patients treated with monotherapy alone could be resected and had 5-year OS of 100% with no recurrences.

   Pediatric Penile Anthropometry Nomograms from India Category: Urology Top

Prabudh Goel, Minu Bajpai, Mani Kalaivani

Department of Pediatric Surgery, AIIMS, New Delhi, India

Objectives: To develop age-related penile length nomogram for Indian children, to define range of normalcy and develop age-matched controls for penile length assessment.

Materials and Methods: This is a cross-sectional study (Design) initiated post IEC clearance (Ethics) based on 1276 boys aged 1-14 years (Participants) presenting to pediatric-surgery clinic (Setting) for conditions not affecting penile length. Participants were registered for the study and their age (years), weight (kg) and stretched penile length (SPL) recorded (Intervention). Generalized additive models for Location, Scale and Shape (GAMLSS/ extension of LMS method) were used. Outcome measures included weight (mean/range) and SPL (mean/range/standard deviation/median/centiles). The four distribution parameters were modelled as non-parametric smoothing cubic-spline functions of x with Box-Cox-Power-Exponential (BCPE) distribution and centiles (3, 5, 10, 25, 50, 75, 90, 95, 97) were calculated for the stretched penile length.

Results: SPL increases with age and weight of the child in a non-linear fashion. A spurt in penile length has been observed in the age-groups of 2-4 years and 12-14 years.

Conclusions: This is the largest cross-sectional study on pediatric SPLin Indian population. The statistical analysiscomplies with the WHO Child Growth Standards. The data will serve as a useful resource for both parents and physicians in diverse clinical practices.

   Hepatic Perfusion Index- a Novel Non Radiological Method of Assessing Hepatic Blood Flow and Shunt Patency in Cases of Ehpvo Category: Experimental/Basic Sciences Top

Murali Krishna Nagendla, M Bajpai, Prabudh Goel, Rakesh Kumar, Anshul

Department of Pediatric Surgery, AIIMS, New Delhi, India

Aim: To assess hepatic perfusion index (HPI) in cases of EHPVO as a method for assessing hepatic blood flow in cases of EHPVO.

Methods: Ten individuals of EHPVO whom diagnosis was confirmed by radiological imaging were included in study. Among ten, five were preoperative and five underwent distal lienorenal shunt. All of them underwent radionucleotide angiography by 99mTc-mebrofenin, bromo- 2,4,6-trimethyl acetanilide iminodiacetic acid. Region of intrest (ROI) curves drawn from images. Time-activity curves generated from ROI. From the curves hepatic and portal flow are calculated. Hepatic perfusion index calculated by ratio of hepatic arterial to total liver blood flow.

Results: HPI is median of 51.7 in non-operated EHPVO cases. HPI median of 29.2 in operated cases. HPI raised in cases of EHPVO compared to normal (median 35.6+/-10) and near normal in operated cases.

Conclusion: HPI can be used for assessing hepatic blood flow in cases of EHPVO. HPI raised in cases of non-operated and comes to near normal range after shunt procedure, showing increased portal flow through and success of selective shunt.

   Laparoscopic Assisted Pull-Through for Hirschsprung's Disease: An Experience of 36 Cases Category: Laparoscopic Surgery Top

Satish Kumar Aggarwalj, Rupa Banerjee, Gaurav Singh, Aparajita Mitra, Shandip Sinha, Sugandh Agarwal, Simmi Ratan

Department of Pediatric Surgery, Sir Ganga Ram Hospital, Maulana Azad Medicasl College, New Delhi, India

Aim: To present challenges and solutions in Laparoscopic pull through for HD through our experience of 36 cases.

Materials and Methods: Records of 36 cases (30 boys and 6 girls), who underwent laparoscopy assisted pull-through for HD between June 2010 and June 2018 were reviewed for demographics, diagnosis, level of aganglionosis, management, early complications and outcomes.

Results: The age range : 3 months to 6 years. All had rectosigmoid disease. The diagnosis was confirmed by rectal biopsy in all. The level of pull through was decided by frozen section biopsy. Out of 36 cases 15 had preexisting stoma at the time of surgery. Thirty five underwent laparascopic assisted transanal pull-through and one had laparoscopic assisted Duhamel. All were successfully completed, there being no conversion.

Complications: One case had urethral injury during transanal dissection - he had a stricture at the site of rectal biopsy done elsewhere. The catheter had slipped out while changing the position. Urethra was repaired and there was no sequel. All had transient incontinence which improved with time. On follow up, 2 cases had anal stricture due to irregular dilatation and improved after dilatation.

Conclusion: Transanal dissection can be difficult after previous rectal biopsy. Catheter position must be confirmed at all times to avoid urethral trauma. Primary port should be placed higher than umbilicus in small babies.

   Three-Dimensonal Minimal Access Surgery:our Experience of Hitting a Century (First 100 Cases) Category: Laparoscopic Surgery Top

Kamal Kant Sharma, SV Parelkar, Beejal Sanghvi, Rahul K Gupta, Kedar P Mudhkhedkar, Rujuta Shah, Deepa Makhija, Kavi Illakya, Manish Kumar, Ashutosh Kumar Sharma, Soundharya Srinivasan

Department of Pediatric Surgery, GSMC and KEM Hospital, Mumbai, Maharashtra, India

Aims: To study and evaluate the experience of first 100 casesof 3D Laparoscopy.

Methods: ll 102 patients (M:F=73:19) with age group from 5 months to 13 years who underwent 3D laparoscopybetween 31 July 2012 and 31 July 2018 in our centre were included in this retrospective study. Results were assessed for various factors and difficulties with help of proforma based on Likert scale (0-10) like image definition, double vision.

Results: The most commonly performed 3D surgery was Laparoscopic Appendectomy (n=38) followed by Lap Nephroureterectomy (n=15) ;Lap Cholecystectomy (n=15);Lap Choledochal cyst (n=12); Lap Splenectomy (n=4) ; Lap Bronchogenic cyst excision (n=4); VATS Decortication (n=2); Lap Endoanal pull through (n=2) ;Lap Oophorectomy (n=2);Lap Pyeloplasty (n=2); Lap Bilateral Adrenalectomy (n=1); Lap Hernia repair (n=1). Till date no conversion to Open/2D needed. Somedifficulties commonly faced were related to adaptation of 2D to 3D.

Conclusion: This modality may be preferred over 2D especially in small working spaces for better tissue delineation specially while suturing which gets converted to minimal collateraldamage and complications specially in pelvic surgeries like Lap Endoanal pull through, Adrenalectomy. Complications, Follow up is almost the same in experienced hands however initial learning curve is less for surgeons practising 2D surgeries and even newly trained surgeons.

   Histological Abnormalities in Jejunoileal Atresia and Its Clinical Implications Category: GI Surgery Top

Archana Puri, Vaibhav Garg, Puja Sakhuja, Peter Daniel Khairong

Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India

Aim: To study the histology of resected specimens of JIA and its correlation with postoperative resumption of gut motility.

Methods: Biopsies were taken from the resected specimens of 32 patients of JIA. Sections were taken at the atretic ends and successively at 5 cm in resected proximal bowel. They were stained for light microscopy and immunohistochemistry for CD117, α smooth muscle antibody (SMA), neuron filament protein (NFP) and calretinin. Time taken to achieve full enteral nutrition (FEN) was recorded and correlated with CD117 count by non-parametric Spearman rank correlation coefficient.

Results: Light microscopy failed to detect any abnormality in majority (n=27, 84%) of JIA specimens. Mucosal ulceration (7.8%), submucosal inflammatory cells (8%), focal muscle thinning (3.4%), decreased ganglion cells and nerve fibers (3.8%) were noted on light microscopy. However all of them had normal α SMA, calretinin and NFP immunoreactivity. CD117 counts at the proximal cut end of atresia was less than 6 per high power field (hpf) in 15 patients (46.8%) while at the site of anastomosis a count of more than 6/hpf was observed in 73% patients. There was no direct correlation of ICC counts with attainment of FEN, but it was noted that ICC of more than or equal to 10 per HPF at the site of anastomosis predicted the probability of achieving FEN within 15 days with a sensitivity of 60%, specificity of 58.3%.

Conclusion: Absence of major morphological abnormalities in the proximal dilated bowel precludes massive bowel resection in JIA.

   Duodeno-Gastric Bile Reflux After Laparoscopic Hepatico-Duodenostomy for Choledochal Cyst: Evidence Based Cohort Study Category: GI Surgery Top

Saalim Nazki, Ravi Kanojia, Monika Bawa, Sadhna Lal, Ashwani Sood, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Background: Duodeno-Gastric bile reflux (DGBR) after laparoscopic Hepatico-Duodenostomy (LHD) for Choledochal cyst (CDC) is a concern in literature. There is insufficient data to support that LHD causes problems in early and late follow up.

Aim: To analyze LHD patients operated at our institute for clinically significant DGBR.

Patients and Methods: Bidirectional study in clinically proven CDCpatientsoperated by single surgeon. Six months follow up was mandatory. They underwent LHD either laparoscopically or by Robotic surgery. D2 anastomosis was done. Follow up at 3 months was done by clinical and biochemical evaluation, HIDA scan and Endoscopy for antral biopsy and gastric juice aspirate for bile pigments.

Results: Mean age of 56 patients (66.1% females) was 5.19±3.2 mths. Mean follow up duration was 22.17± 2.16 months. On HIDA scan 66 % patient showed no evidence of DGBR. Antral biopsy showed mild gastritis in 85.1% patients. Bile was seen in antrum in 80.90% patients. Gastric aspirate showed absence of bile pigments in 68% patients. 19% patients had evidence of DGBR on all 4 parameters of evaluation. Only 4% of patients were clinically symptomatic.

Conclusion: 19% of patients have DGBR with LHD. They have very mild symptoms and can be easily managed conservatively.

   Abnormal Anatomy of Bladder Sans Extroversion Category: Urology Top

Datar Govind Vasudeo

Department of Pediatric Surgery, KEM Hospital, Pune, Maharashtra, India

Aims and Objective: Traditional interpretation considers that defect is located on its anterior wall and closed as such. This conclusion is based study of everted bladder. When it studied on eliminating it, bladder changes its orientation raising questions regarding its validity.

Methods: Exstrophic Bladders were studied after reposing it under anesthesia and during bladder closure and observations about urachus, ureteric canal and trigon of bladder. Using these observations, bladder surface was mapped.

Observations: Bladder shows malrotation bring trigon to assume anterio-inferior location on its concave surface. Margin of bladder, fused with body wall defect and its surface above open prostate, is enclosed by two inferior edges. This surface, surrounds a large opening in conjunction with apex of trigon.

Conclusion: (1) Exstrophic bladder is in an abnormal state of rotation. (2) Anterior and posterior edge of anterio-inferior surface and apex of trigon provide identification of the 'defect' as malformed and ectopic internal urinary meatus. (3) Therefore, parts of bladder above its margin will contain internal vesical sphincter. (4 It is essential to change our strategy for its correction to favor natural voiding.

   Awareness, Compliance and Patience in Management of Chronic Constipation Category: Experimental/Basic Sciences Top

Akshay Kalavant, Venkatesh Annigeri, Anil Halgeri

Department of Pediatric Surgery, SDM College of Medical Sciences, Dharwad, Karnataka, India

Aims: To study the clinical presentation, contributing factor related to chronic constipation and to assess the outcome and compliance of parents for the treatment of constipation.

Material: Fifty patients aged between 2 and 14 years presenting to pediatric surgery OPD who were diagnosed as constipation by clinical features and/ or radiological investigation were included in the study. Patients assess was done between 1 November 2017 and 31 July 2018. Data were collected using the questionnaire and were assessed based on clinical feature and radiological examination. The patients were treated with the dietary protocol and laxatives. Disimpaction was done in necessary cases.

Results: Clinical presentation was varied ranging from pain abdomen (25/50 patients) to fecal incontinence. Parents of 22 children were not even aware their children were suffering from constipation. Ninety-two percent patients has poor dietary habits and reduced water intake. Almost all patients had history of consumption of packed snacks. Forty-eight percent patients had been treated elsewhere by pediatrician using laxatives. Only 20% of patients continue to have good follow up.

Conclusion: Awareness among clinicians and patients about the various presentation and causes of constipation is stepping stone for treatment. A detailed evaluation and significant investment of time by physician and parents are required for better outcome.

   Meconium Ileus: Spectrum of Presentation and Long Term Outcome Category: Neonatal Surgery Top

Subhasis Saha

Department of Pediatric Surgery, Advanced Medical Research Institute, Mukundapur, Kolkata, West Bengal, India

Aims: We retrospectively studied all the cases of meconium ileus and its variants admitted to our unit from May 2003 to June 2018. The spectrum of presentation, management and long term outcome were studied.

Materials and Methods: We dealt with 105 neonates with meconium disease in the last 15 years in our unit. 63 were preterm and 11 were small for date. Male : female ratio was 1:3. 22 of them were diagnosed antenatally on ultrasound evaluation. 5 of them were referred to as rectal atresia. In cases of meconium peritonitis (12), exploratory laparotomy was done. In uncomplicated meconium ileus cases (67), Gastrograffin study was done after proper hydration. In a majority of the cases (40), the obstruction was relieved with gastrograffin enema with / without irrigation with 4% N-Acetylcysteine. In 27 of the cases, babies needed laparotomy. Our preferred technique is enterotomy, irrigation with normal saline and Bishop Koop procedure. Nasogastric N-Acetylcysteine was continued alongwith stoma washes with normal saline. Within a span of 6-8 months, the stoma could be closed. Oral enzyme supplementation was started when baby was on full feeds.

Results: With prompt diagnosis, 59.7% cases of uncomplicated meconium ileus were resolved. All babies needing laparotomy in uncomplicated mec ileus survived. In cases of meconium peritonitis, 3 out of 12 cases needed long term total parenteral nutrition. All babies underwent screening for cytic fibrosis but only 18 out of 105 had genetic confirmation. Sweat test was done at 6 months of age and 14 out of 105 patients tested positive for cystic fibrosis. 6 children suffered from long term complications (distal intestinal obstruction syndrome, rectal prolapse, fibrosing colonopathy). all the three children developing fibrosing colonopathy were given enzyme supplementation for a prolong period. There were 4 overall deaths. 2 of them turned out to be cases of total colonic aganglionosis.

Conclusion: Meconium ileus presents as a spectrum. Clinical suspicion is paramount in early diagnosis. The overall outcome including survival is good.

   Urological Outcome Following Surgery for Tethered Cord Syndrome Category: Urology Top

Shubhalaxmi Nayak, Monika Bawa, Revanth Goda1, Navneet Singla2, Ravi P Kanojia, Ram Samujh

Departments of Pediatric Surgery, 1General Surgery and 2Neurosurgery, PGIMER, Chandigarh, India

Tethered cord syndrome (TCS) presents as a symptom complex of pain, neurological deficits, skeletal deformities, cutaneous stigmata and neurogenic bladder. The treatment is surgical detethering and aims at releasing tension on the cord.

Aim: To study the urodynamic profile of children with TCS and the changes in the post-operative period.

Materials and Methods: 26 patients of TCS who underwent de-tethering surgery aged < 18 years were included in the study. All patients underwent pre-operative and 6 months post-operative Urodynamic studies.

Results: Ten patients had urologic symptoms at the initiation of the study. Average maximum cystometric capacity was 76.7% in the preoperative period and was similar post-operatively. Mean compliance improved from 19.7 ml/cm H2O to 22.2 ml/cmH2O postoperatively in 18 patients with significant improvement noted in children <3 yrs (13.7 to 20.8 ml/cmH2O). The detrusor pressures (Pdet) remained constant in the pre-operative (41.7 cmH2O) and the postoperative (42.9 cmH2O).4 patients showed detrusor-overactivity (DO) in the preoperative period. Patients with bladder symptoms showed improvement in bladder profile with significant improvement in the MCC and Pdet.

Conclusion: Detethering leads to improvement in urodynamic profiles of patients of TCS with high-risk bladders. Improvement was significant in those who were symptomatic pre-operatively and were < 3 years of age.

   Laparoscopic Management of Choledochal Cysts: A Rapid and Feasible Evolve Category: Hepatobiliary Top

M Raghul, G Rajamani, R Rengarajan, V Muthulingam, RP Dharmendra

Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Congenital choledochal cyst (CCC) is characterized by either isolated or combined dilatations of the extra- and intrahepatic bile ducts. Surgical treatment of CCCs is associated with a high success rate and low morbidity and mortality. With improvements in laparoscopic surgical skill, surgery has been successfully carried out laparoscopically. A retrospective study was performed on prospectively collected data from the first 54 consecutive children with CDCs who underwent minimally invasive laparoscopic cyst excision and Roux-en-Y hepatico jejunostomy (LHJ) / duodenostomy (LHD) (27) and open Roux-en-Y hepatico jejunostomy (OHJ) (27) from April 2010 to April 2018 at Coimbatore Medical College Hospital, Coimbatore. Patient- specific factors included age, gender, length of history, Todani's classification type, and size of the cyst, operating time, blood loss, recommencement of enteral feeding, hospital stay and post operative complications. Fifty-four subjects were studied (LHD: n = 23, 4 boys, 19 girls; LHJ : 4, 1 boy, 3 girls OHJ: n = 27; 4 boys, 23 girls). Todani classification of choledochal cyst in LHJ & LHD patients was type 1A (n = 19) and type 4A (n = 8), and in OHJ patients, it was type 1A (n = 19) and type 4A (n = 8). There were significant differences between laparoscopic and open group with regard to mean operative time, mean blood loss, recommencement of enteral feeding and hospital stay (all P < 0.05). There were no intraoperative complications and one conversion to OHJ from LHD due to bile leakage. There were no significant differences between LHJ and OHJ for postoperative complications, which included minor bile leakage, anastomotic stricture, and intestinal obstruction. Except for the longer operative time (which improved over time), laparoscopic surgery was more advantageous than open surgery with regards to such as smaller incision, obscure scar, less postoperative pain, fast recovery of bowel peristalsis, and fewer intraabdominal adhesions. Patients in the laparoscopic group recovered sooner and were discharged earlier. Laparoscopic surgery is an equally effective and an ideal choice for the treatment of CCCs in children.

   Multivariate Analysis of Time Taken to Achieve Full Enteral Nutrition in Small Bowel Atresia Category: Neonatal Surgery Top

Vaibhav Garg, Archana Puri, Peter Daniel S Khairong, Puja Sakhuja

Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India

Aim: To study the factors affecting the time taken to achieve full enteral nutrition (FEN) in small bowel atresia (SBA).

Methods: All neonates operated for small bowel atresia (n=49; duodenal-17, jejunal-9, ileal-17 and multiple atresia-6) over a study period of 23 months were included and divided in 2 groups (Group 1: n=30, FEN achieved; Group 2: n=19, FEN not achieved). FEN was defined as time taken (days) to reach full enteral nutrition (100 ml/kg/day with no intravenous fluid supplementation) by oral route. The evaluated outcome variables were birth weight, gestation age, site of atresia, length and diameter of the remaining bowel. The 2 groups were compared using Pearson Chi square test and risk factors were identified by binary logistic regression.

Results: Mean time taken to achieve FEN varied significantly according to site of atresia. Babies with ileal atresia achieved FEN at the earliest (mean: 10.5 ± 3.9 days) followed by duodenal (14.6±6.8 days), multiple atresia (17±2.8 days) and jejunal atresia (23.5±12.8 days). The highest proportion amongst achievers was seen in ileal (70.6%), followed by jejunal (66.6%), duodenal (58.2%) and in multiple atresia (33.3%). Birth weight of more than 2.2 kg (p: 0.013, OR: 4.714), gestational age of more than 36 weeks (p:0.013, OR: 4.74214) and simple atresia (p: 0.021, OR: 4..44) were identified as factors favoring achievement of FEN. Mean time taken to achieve FEN was significantly more for complex atresia (26.7 ± 12.9 days) as compared to simple atresia (16.08 ±9.55 days). Anastomotic leak were usually associated with mortality and thus non -achievement of FEN (p: 0.010). Length and diameter of remaining bowel showed a negative correlation to FEN.

Conclusion: Birth weight of less than 2.275 kg, prematurity of less than 35.15 weeks, complex atresia and length of remaining bowel showed significant negative correlation with the time taken to achieve FEN.

   Disease Pattern of Malignent Tumour in Adolescents Category: GI Surgery Top

Uttam Rawate, SN Bhatnagar, Gayatri M

Department of Pediatric Surgery, BJ Wadia Hospital, Mumbai, Maharashtra, India

According to Indian demographic profile, pediatric and adolescent population represents 45.7% of the entire population. While most of pediatric malignancies are much researched, little is known about the malignant tumors in adolescents. This population poised between children and adults, has been called the “lost tribe.” An attempt is made here to study the demographics, disease patterns and overall outcomes vis-à-vis pediatric malignant solid tumors.

Methods: Patients aged 15-19 years with the diagnosis of malignant tumors, registered with two tertiary care hospitals in Mumbai, India from January 2012 to December 2016 were included. Basic demographic information, clinical, diagnostic details, histology grouping, treatment, outcome and survival were retrospectively studied.

Results: Of 36 patients, 20F, 16M, various types of tumors were encountered. In young girls (n=20), ovarian tumors (n=11), Ewing's sarcoma (n=4), ganglioneuroblastoma (n=2), Osteosarcoma (n=2), Papillary pseudotumor of the pancreas (n=1). Adolescent boys (n=16) showed, Rhabdomyosarcoma (n=6), Ewing's sarcoma/PNET (n= 4), testicular malignant Germ cell tumor (n=3), Osteosarcoma (n=2), Carcinosarcoma of abdomen (n=1). Pretherapy staging of the tumors revealed that 22/36 (61%) of the tumors were found to be stage 4, the metastatic nodules being present in the lungs (n=10), abdomen (n= 8), bone/bone marrow (n= 8). Upfront chemotherapy was given to all patients except 4/36. R0 resection of the primary could be achieved in 13/36 patients. Radiotherapy was utilized as adjuvant therapy in 19/36, including primary and metastatic sites. Metastatectomy was performed in 12/22 patients post-chemotherapy. Overall survival was 86%, even though all of them were not tumor free.

Conclusions: High incidence of advanced malignancies is seen in adolescent age in both boys and girls. The tumors which are encountered in this age group differ in type, biologic behaviour as well as response to therapy. An attempt at early detection and treatment is of vital importance to prevent the presentation at advanced age.

   Prime Poster: Management of Bilateral Spontaneous Pneumothorax with Unilateral Thoracotomy and Tisseel Application in Post Cardiotomy Infants: Two Cases Category: Thoracic Surgery Top

Chiranjiv Kumar, Meera Luthra

Department of Pediatric Surgery, Medanta- The Medicity, Gurugram, Haryana, India

Aim: To study management of bilateral spontaneous pneumothorax with unilateral thoracotomy and tisseel application in post cardiotomy infants.

Methods: First case was a four months old girl operated for AV canal malformation. On 8th POD she developed bilateral pneumothorax. Inspite of optimal ventilatory care, new pockets of air appeared intermittently requiring fresh chest tubes, until we had a total of 6 tubes (three on either side). On 14th POD, oxytetracycline was inserted in right chest for pleurodesis but the pneumothorax persisted. On 19th POD, left thoracotomy with bullectomy and pleurectomy and spray of tisseel sealant using an automative device was done. Second case was a three months old male operated for VSD. He developed bilateral recurrent pneumothorax on 11th POD which were managed with 4 chest tubes (two on either side). On 21st POD the baby underwent left thoracotomy. In both cases the worst side was operated upon.

Results: A combination of surgery, optimal ventilation and tisseel helped the babies to recover completely.

Conclusion: When we operate the worse side, the lung expands on the operated side and brings down the ventilator pressures. This allows the other side to recover without surgical intervention.

   Neonatal Surgery and Sepsis Category: Neonatal Surgery Top

Ritesh Kumar, Amita Sen, Rajasekhar Addagatla, Sandeep Kumar, Pinaki Rajan Debnath, Vijay Kumar Kundal, Atul Meena, Shalu Shah

Department of Pediatric Surgery, PGIMER and DR. R.M.L HOSPITAL, New Delhi, India

Aims: The present study was conducted to know the incidence, outcomes, and mortality rates of neonatal surgery in relation to neonatal sepsis.

Methods: (1) Place of Study: Department of Pediatric Surgery, PGIMER & Dr. RML Hospital, New Delhi. (2) Duration: 1st January 2017 to 30th june 2018. (3) Study design Study: A prospective observational. (4) •Sample Size: 61 cases. (5) 61 neonates were included and outcome measures were overall sepsis rate, mortality rate due to sepsis, complications, length of stay, day of onset of sepsis, ventilator used or not.

Results: there were total 61 cases in which 41 male and 20 female.there was 15 mortality (24.59%).most common anomalies were anorectal malformation (14-22.95%) and tracheoesophageal malformation 14 (22.95%).24 neonates got sepsis and there was 54 % mortality in septic neonates. Average lengh of stay was 12.40 days. 26 (42.66%) patients required ventilator support out of which 17 (65.38%) patients developed sepsis and 27 (44.26%) neonates developed complications.

Conclusion: Despite the improvement in neonatal surgery sepsis is major mortality and morbidity factor in neonates. Early diagnosis and timely intervention can prevent the mortality and morbidity in neonatal surgical sepsis.

   Mature Cystic Teratoma of Renal Pelvis; an Unusual Presentation at an Uncommon Site: A Case Report Category: Urology Top

BS Balaji, Sampath Karl

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Introduction: Retroperitoneal teratomas comprise 3.5 to 4% of all germ cell tumors in children. Primary renal teratoma is a rare entity. Only a few case have been described.

Case History: A ten year old boy presenting with abdominal distension was found to have on CT scan a large retroperitoneal cystic mass causing right hydronephrosis. There were no calcifications, fat density or vascularity. These features indicated a retroperitoneal lymphangioma. DTPA renogram revealed severe right renal dysfunction (9% function). AFP and beta HCG were normal. Assuming it to be a pelvi-ureteric junction obstruction with poorly functioning kidney, a right nephrectomy was performed. Histopathology revealed a cystic neoplasm containing tissue derivatives of all three germ layers. There were no immature elements or evidence of malignancy. It was reported as mature cystic teratoma arising from the hilar region of the kidney.

Conclusion: Renal mature cystic teratoma is rare. It can mimic cystic lesions of the kidney or hydronephrosis. There are specific imaging characteristics to identify the pathology. But findings can overlap with those of other cystic retroperitoneal lesions. Accurate preoperative diagnosis is not always possible. Complete surgical excision with negative margins is curative.

   Acceptability Foreskin Preservation in the Indian Socio-Cultural Milieu Category: Urology Top

BS Balaji, Tarun Jacob

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Aim: To study the attitude and practice of foreskin hygiene and acceptability of foreskin preservation in the Indian socio-cultural milieu.

Methods: Parents answered a questionnaire about foreskin removal and foreskin hygiene. The responses were tabulated against education, religion and relationship of the respondent to the child.

Results: 500 parents were interviewed from May to July 2018; 75% Hindus, 16% Christians and the rest Muslims. The majority of the responders were mothers. Most of them were educated until primary or secondary school level. Most of the non-Muslims favoured foreskin preservation. The reasons were either cultural or the operation was felt unnecessary. However, they were divided in their opinion about advantages of foreskin removal and foreskin uses. In contrast all Muslims favoured compulsory religious circumcision irrespective of awareness about foreskin uses. 86% parents believed in cleaning under the foreskin regularly. However, very few actually practiced it; the common reasons being ignorance about foreskin hygiene, fear of injury, presence of physiological phimosis.

Conclusion: Socio-cultural factors influence the decision of foreskin removal or preservation in addition to medical reasons. The dynamics underlying the decision of foreskin removal or preservation in India remains under studied. This study sheds light on this contentious issue to a limited extent and sets the stage to explore the role of foreskin preserving options.

   Foot in Perineum Category: Miscellaneous Top

Suresh Kumar Thanneeru, Sampath Karl

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Aims: Presenting a rare case of partial foot in perineum.

Methods: Child presented to us at 8 months of age, with only 2 lateral toes over the left foot. Remaining toes were attached to vulval region. Planned for transplantation of toes onto foot. She was kept on follow up for 4 years, MRI done to look for adequacy of vessel diameter.

Results: Vessel is traced back to inferior gluteal A to left internal iliac A, nerve to sciatic nerve. As the vessel diameter is very small, she was asked to wait for 1 more year. But parents and child want to get excise it, because of pyschosocial issues. It was excised and the child was given orthotics for foot deformity.

Conclusion: This might be a rarest form of Amniotic band syndrome. Usually ABS presents with disruption, interruption or crowding. Detachment of organ and getting implanted on other tissues is very rare. This might be the first case reported. If the vessel diameter is good, it is possible to do reimplantation.

   Accidental Ligation of Superior Mesenteric Artery during Radical Nephrectomy Category: Miscellaneous Top

Mainak Deb, Harish Jayaram, Jamir Dilip Arlikar

Department of Pediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India

Aim: Superior Mesenteric Artery (SMA) injury during left radical nephrectomy is an uncommon but recognized complication and we present a case and its management.

Methods: During radical nephrectomy on a 10 months infant with left upper pole Wilm's tumor, an artery arising from the aorta and thought to be entering the renal hilum behind the renal vein was ligated. A second renal artery was found during subsequent dissection and clipped, divided and the nephrectomy completed uneventfully. The patient developed multiple episodes of hematochezia in the post operative period and Doppler sonography and CT angiogram revealed a block at the origin of the SMA. On re-exploration, the SMA was found to be ligated behind the head of pancreas flush with the aorta. The renal artery stump was freshened and anastomosed to the SMA. The bowel perfusion improved immediately after declamping.

Results: The patient made an uneventful recovery and was discharged on full oral feeds on the 7th postoperative day.

Conclusion: SMA injury during radical nephrectomy has been well reported in literature. Primary anastomosis to the renal artery stump with successful revascularization has not been reported. Careful dissection and awareness of the potential for such an injury may help prevent this disastrous complication.

   Intussusception in Children Due to Burkitt's Lymphoma: A Report of 3 Cases Category: GI Surgery Top

Abirami Krithiga, Harish Jayaram, Mainak Deb

Department of Pediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India

Aims: Intussusception due to a pathological lead point is rare in children and Burkitt's lymphoma is a rare cause of the same. The presentation, evaluation and management of these cases have been reviewed.

Methods: The cases with Intussusception due to Burkitt's lymphoma during the period from Jan 2010 to May 2018 were reviewed.

Results: 3 children aged 9 years, 4 years and 8 months had presented with intestinal obstruction and on evaluation were found to have intussusceptions. The 9 year girl had multiple small bowel intussusceptions and large ovarian masses which was managed with laparotomy, multiple resections and anastomosis. The other two children had ileocolic intussusceptions with a localized ileal wall thickening as the lead point in the ileum. The 8 months infant had recurrence of intussusception after two sessions of hydrostatic reduction requiring laparotomy and resection. The biopsies confirmed Burkitt's Lymphoma on routine HPE and Immunohistochemistry. Two children have completed chemotherapies and are regular follow ups. The 8 months infant has been initiated on chemotherapy recently.

Conclusion: Burkitt's Lymphoma as a pathological lead point is rare in children. A high index of suspicion is required in cases of multiple or recurrent intussusceptions and with adjacent significant lymph nodal enlargements.

   Is the Vasculature to Testis More Compromised Than the Bowel in Incarcerated Hernia in Infants? Category: Urology Top

Abirami Krithiga, Mainak Deb, Harish Jayaram

Department of Pediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India

Aims: Hernia in Infants can present with irreducibility or incarceration, and bowel ischemia is a well known complication. However testicular ischemia is rarely reported. The incidence of the same was studied in this series.

Methods: All infants who presented with incarcerated hernia from Jan 2016 to May 2018 were included in the study. Reduction was attempted with or without sedation and un-successful reduction was an indication for immediate inguinal exploration. The presentation, management and outcomes were recorded.

Results: 14 infants presented with incarcerated hernia and reduction in the emergency was possible in 12 infants. 3 infants had symptoms of irreducibility of 10 to 12 hours. Inguinal exploration in these infants revealed a dusky bowel and blackish ipsilateral testis which was repositioned back in the scrotum. Follow up of all the cases showed testicular atrophy.

Conclusion: Testicular ischemia is a significant complication in cases of prolonged incarceration of inguinal hernia in infants which caused morbidity much more than bowel ischemia. The testis should be examined in every incarceration and tunica incision may be warranted to possibly salvage the testis.

   Comparative Study of Doppler Sonography and Diuretic Isotope Renogram in the Diagnosis and Follow up of Infants with Unilateral Ureteropelvic Junction Obstruction Category: Urology Top

AM Shubha, Neehar Patil, Kanishka Das

Department of Pediatric Surgery, St John's Medical College Hospital, Bengaluru, Karnataka, India

Aim: To document–Resistive index (RI) and Resistive Index Ratio (RIR) on Doppler USG & Perfusion index (PI) on isotope diuretic renogram in suspect unilateral UPJO and to correlate the changes in obstructed and non-obstructed kidneys at follow up.

Materials and Methods: 37 infants with unilateral hydronephrosis (APPD >15 mm) were divided into group A (0-6 months) and group B (6-12 months) based on age at diagnosis. The RI, RIR and PI were noted at diagnosis and at 3 and 6 months follow-up.

Results: There were 37 infants, M/F ratio was 31/6. Seven were managed conservatively with uro-prophylaxis and 30 had surgical interventions, largely pyeloplasty (26). The pre-operative RI was >0.7 and RIR >1 in obstructed renal units, the PI ranged from 43.2 to 49.38. After optimal intervention, the decrease in RI and increase in PI was conspicuous in all infants, especially in Group A at 3 months, with PI showing continued increase in this group even at 6 months follow up.

Conclusion: An increased RI and RIR and decreased PI are indicators of urinary flow obstruction in children with unilateral UPJO. The decline in RI and increase in PI with relief of obstruction is predictable and more marked in early infancy and with early intervention. There is a positive correlation between RI, RIR and PI that can monitor urinary flow impairment; hence RI/RIR may be reliably used for follow-up instead of isotope scintigraphy.

   A Rare Case of Intramural Hematoma with Mucosal Intussusception Causing Duodenal Obstruction Category: GI Surgery Top

L Arun Kumar, Rohith Srinivas, Harshjeet Singh Bal

Department of Pediatric Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Aim: Intramural small bowel hematoma is a rare cause of intestinal obstruction in children. Coagulation disorders or anticoagulant therapy are the most common cause followed by blunt trauma. Herein we present a rare case of duodeno-jejunal intramural hematoma causing small bowel obstruction in a child.

Case Report: A 1.5 year old boy, known case of gastroesophageal reflux disease had underwent upper GI endoscopy and biopsy elsewhere. Four days later, he presented to us with clinical features of small bowel obstruction. Computerised tomography of abdomen showed features suggestive of hemorrhagic duplication cyst. Explorative laparotomy revealed 15-20 cm of bowel from third part of duodenum to proximal jejunum filled with clotted blood and thinned out serosa. There was no evidence of intraluminal blood in the distal bowel loops. Resection of involved bowel with primary anastomoses was done. Histopathological examination of bowel revealed intramural hematoma associated with prolapse and intussusception of the mucosa. There was no evidence of duplication cyst or vascular malformations. Post operative period was uneventful. This case is being presented as there are no reported cases of duodenal hematoma with mucosal intussusception leading to obstruction in a child with no underlying risk factors.

   Analysis of Awareness Survey Conducted among Pediatricians of India About Common Pediatric Surgical Illness Category: Miscellaneous Top

Santosh Kumar Mahalik, Kanishka Das, Akash B Pati, Bikasha B Tripathy, Subrat K Sahoo, Manoj K Mohanty

Department of Pediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Aim: Delayed referrals of simple pediatric surgical illness such as hernia, hydrocele, undescended testis, torsion testis, anal fissure etc. are very common. This study was conducted to assess the awareness and knowledge about diagnosis and management of some common pediatric surgical illness encountered in day to day pediatrics practice.

Methods: A set of online questionnaire on Google forms was prepared consisting of 20 questions addressing common pediatric surgical conditions and it was distributed among Pediatricians colleagues of India via WhatsApp, Telegram and personal e-mails between May 2018 to July 2018. The responses were analyzed.

Results: We received 175 responses from 16 states and one union territory. Maximum responses were from Odisha (65, 35%) followed by Karnataka (29, 17%) and Punjab (26, 15%) and the rest are from other states. Percentage of correct answers given are as follows; 7% scored >75%, 56% score between 50 to 75%, 9% scored less than 50% marks. Surprisingly we found the awareness of management for simple problems like physiologic phimosis (37%), hypospadias (<50%), hydrocele (63%), inguinal hernia (<50%) and umbilical granuloma (9%); undescended testis and fissure-in-ano were very low.

Conclusion: Awareness for Pediatric surgical conditions among pediatrics of India is lacking and this clearly points to the need for including pediatric surgery as a separate subject in MBBS and MD Pediatrics curriculum. Distribution of education material via social networking sites, print media and televisions is required to address the issue.

   Quality of Life of Male High Anorectal Malformation Patients: Role of Bowel Wash Programme Category: GI Surgery Top

Vineet Binu, Monika Bawa, Ravi Kanojia, KA Muneer, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim: To assess the quality of life and social continence following bowel wash programme (BWP) in male high anorectal malformation (HARM) patients.

Materials and Methods: 200 post-surgical correction male HARM [include HARM and pouch colon (PC)] within age of 4 to 12 years were prospectively analyzed. They were categorized into fecal continent and incontinent based on the mean Kelly score (KS). The quality of life was assessed by using the GIQLI questionnaire. Following 1 year of dietary modification and BWP, based on the mean KS and GIQLI, they were re-categorized into social continent (SC) and incontinent (SI). The SI patients underwent MRI spine to assess for other neurological abnormalities.

Results: 110 patients (55%) were continent and 90 patients (45%) were incontinent. The mean KS was 2.9 and the mean GIQLI score 54 amongst the incontinent group. Following dietary modification and BWP for 1 year, amongst the SC HARM (92.8%), the mean KS was 5 and GQLI was 132 whereas in the SI group (7.2%) the mean Kelly score was 3 and GQLI 91. The mean KS and Average GIQLI in the SC PC group (57.1%) was 4.9 and 126 respectively and in the SI PC group (42.9%) it was 3 and 80 respectively. MRI spine revealed sacral agenesis in all SI patients.

Conclusion: The quality of life of this subset of patients can be improved significantly with proper structured and guided dietary modification with BWP.

   Study of Effectiveness of Percutanoeus Neurolytic Celiac Plexus Block in Children with Chronic Pancreatitis Category: GI Surgery Top

G Suhitha, Ramamurthy Kulkarni, Divya shyam, Ashraf Ahmed

Department of Pediatric Surgery, Yenepoya Medical College Hoospital, Mangalore, Karnataka, India

Introduction: Neurolysis of the celiac plexus has been found to be an effective way of palliating chronic pain due to non pelvic intra abdominal organ pathology like upper abdominal malignancies and chronic pancreatitis. In this study, the effectiveness of celiac plexus block (CPB) in children suffering from chronic pancreatitis and its sequelae have been studied.

Materials and Methods: Children in the age group of 3-10 years diagnosed to have chronic pancreatitis with intractable or recurrent abdominal pain having little or no relief with routine analgesic medications were subjected to celiac plexus block (Trans aortic route) under general anesthesia. Pain due to other causes including pancreatic malignancy was excluded. Intensity of pain pre procedure and post procedure at discharge and at 1 month and 3 month follow up were compared using the FACES pain rating scale.

Results: 11 children between age 3 and 10 years after careful candidate selection underwent CPB. 10 out of the 11 children were cheerful with significant pain relief at 1 and 3 months follow up. 1 child had an episode of acute abdominal pain and had symptomatic relief with antacids.

Conclusion: Neurolytic CPB was found to be effective in relieving chronic abdominal pain due to pancreatitis in pediatric age group. However, long term follow up with a larger study group is needed to support the effectiveness.

   Antenatally Diagnosed Thoracic Malformations and Their Postnatal Follow up and Treatment Category: Neonatal Surgery Top

Selva Kumar, Hemanth Kumar, Karuppasamy, Ravi Kumar, Harisvijila Rani, Aravindan, Srinivasa Kumar

Department of Pediatric Surgery, GRH, Madurai, Tamil Nadu, India

Aim: To determine the outcome of Antenatally diagnosed thoracic malformations.

Methods: Referred cases of Antenatally diagnosed thoracic malformations was included in the study. study group is divided into mediastinal mass, lung cyst, CDH and eventration of diaphragm. Follow-up was made during antenatal and postnatal period.

Results: Out of 37 cases, Congenital Diaphragmatic Hernia predominates (29 cases), lung cyst (6 cases), mediastinal mass (2). Out of 29 CDH cases,20 were expired.

Conclusion: Congenital diaphragmatic hernia constitutes the majority of Antenatally diagnosed thoracic malformations with 68% mortality rate.

   Solitary Penile Injuries in Boys Category: Urology Top

Nitin Pant, Ashish Wakhlu, Sudhir Singh, Anand Pandey

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aim: To highlight the etiology, spectrum of presentation, and management of penile trauma in boys.

Methods: Records of six boys, with solitary penile trauma from January 2015 to June 2018 were analyzed. Trauma was secondary to penile hair tourniquet in four. One following dog bite and the other was post circumcision.

Results: Spectrum of injury was – Complete urethral transaction at corona (n =2), Loss of penile urethra in a case of hypospadias (n=1), Complete loss of glans and glanular urethra (n=1), Penile transection at corona (n=1), and total penile avulsion (n=1). Management included - Surgery (n=3), simple calibration of meatus (n=1). One was lost in follow up while one is awaiting penile reconstruction. Degloving, coring of glanular urethra, mobilization of adjacent penile urethra and end-end anastomoses was done in 2. One underwent Bracka's staged repair. Urethro-cutaneous fistula developed in 2. One was post surgical while in the other the hair tourniquet was re-applied.

Conclusion: Penile injuries in boys are uncommon and can be attributed to social customs, parental and surgical negligence. Treatment should be tailored to the type of injury and may include repair or reconstruction. Overall outcome following surgery is good.

   Ureterorenoscopy for Ureteric Stones in Children Category: Urology Top

R Senthilnathan, S Vivek, N Karpaga Vinayagam, J Muthukumaran

Department of Pediatric Surgery, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India

Aim: To analyse the outcome of children undergoing ureterorenoscopy for management of ureteric calculi.

Materials and Methods: All Children with ultrasound diagnosed ureteric calculi between June 2017 to June 2018 are included in the study. Renal pelvic and calyceal calculi and vesical calculi were excluded.

Results: 9 children underwent ureterorenoscopy for ureteric calculi in the last one year. 7 children presented with calculi in the lower ureter near vesicoureteric junction. One presented with upper ureteric stone and one mid ureteric calculi. The ages of the patient were in the range between 3 to 12 years. All the children were subjected to CT KUB and Hounsfield units measured. The average stone size was 7 mm. All patients underwent ureterorenoscopic pneumatic lithotripsy followed by DJ stent insertion. Success rate was 100 % and there was no complication.

Conclusion: Ureterorenoscopy of 4.5 Fr/6 Fr is easily passable in children beyond 3 years of age. Endoscopic management of ureteric calculi is feasible and highly successful. Pediatric surgeons should utilize this modality of endo-urology for management of ureteric stones in children.

   Role of Sirolimus in Complex Lymphovascular Malformations Category: Miscellaneous Top

MM Zameer, Rakhesh, Pavithra V, C Vinay, Sanjay Rao, Ashley D'Cruz

Department of Pediatric Surgery, Narayana Health, Bengaluru, Karnataka, India

Introduction: Diffuse lymphovascular malformations carry significant morbidity and can be life threatening. Many are not amenable to excision. We present our experience in treating four such patients with sirolimus (mTor inhibitor with angiogenic effects). Adverse-effects requiring monitoring are hypertension, renal-failure and anemia.

Case Series: Two children aged 9 and 12 years, presented with recurrent respiratory distress due to pericardial and pleural effusion requiring emergency drainage. They were found to have diffuse anterior mediastinal lesions, which on biopsy showed lymphangiomatosis, which were not amenable to surgery. After starting sirolimus they remained well at 1 year follow-up. An 18 year old girl, presenting with chronic anemia, was found to have multiple stomach and small bowel AV malformations. She showed significant improvement on sirolimus. Fourth patient was a 13 year old girl with lymphovascular lesion of floor of mouth, tongue and upper neck. Neck lesion responded to local OK 432 injection. Tongue and floor of mouth lesion reduced in size within 1 month of starting sirolimus. Serum sirolimus level of 10-12 ng/ml was maintained. No patients showed major side effects.

Conclusion: In complex lymphovascular anomalies, not amenable to surgery, sirolimus is effective with minimal side effects. However, treatment duration needs to be determined.

   Laryngeal Cyst: A Rare Cause of Stridor in Children Category: Thoracic Surgery Top

MM Zameer, Abhishek BR, V Pavithra, C Vinay, Sanjay Rao, Ashley D'Cruz

Department of Pediatric Surgery, Narayana Health, Bengaluru, Karnataka, India

Aim: To study the demographics, symptomatology, types, management and outcomes in children with Laryngeal cyst.

Materials and Methods: This is a retrospective observational study of children with Laryngeal cysts who were managed in the Department of Paediatric Surgery in Narayana Health between April 2015 to April 2018.

Observations and Results: Five children with laryngeal cysts were included, 4 were girls. Age ranged from 1 day to 10 yrs (median 7 months). Weight ranged from 3.5 kg to 40 kg (median 4.7 kg). All presented with respiratory distress & stridor. In 1 child there was history of previous airway intervention. Three out of 5 children had co-morbid conditions, one each with Leucocyte adhesion deficiency type -1, atrial septal defect & PHACES syndrome. One child had tracheostomy done outside. Two other children had tracheostomy done at presentation. All children underwent MLB. The cysts were 2 subglottic cysts, vallecular cyst, inflammatory and haemangioma. Three out of 5 were operated of which 2 underwent simple endoscopic excision of cyst, 1 underwent endoscopic de-roofing of cyst and airway reconstruction with anterior costal cartilage graft.

Conclusion: Laryngeal cyst is a relatively rare cause of stridor in newborns. Once diagnosed they are managed surgically with minimal post operative complications.

   Cytomegalo Virus Infections Masquerading as Surgical Problems Category: Miscellaneous Top

Chinny Catherine, Pavithra, MM Zameer, C Vinay, Sanjay Rao, Ashley D' Cruz

Department of Pediatric Surgery, Narayana Hruduyalaya, Bengaluru, Karnataka, India

Worldwide approximately 1 in 100 to 500 babies are born with congenital CMV of which 5 – 10% are symptomatic.

Methods: A descriptive case series of 3 children with surgical problems who were found to have CMV infection as aetiology.

Results: CASE 1: 2 week neonate presenting with lower respiratory tract infection. Radiological evaluation showed a large solid mass in the upper left thorax, highly suggestive of a tumor. Child underwent left upper lobectomy. Histopathology showed viral inclusion bodies. CMV IgG and IgM titers were elevated and child was treated with ganciclovir. CASE 2: 1 month old boy presented with antenatally diagnosed left CAM at 28 weeks. Postnatally child was diagnosed as left upper congenital lobar emphysema. She underwent left upper lobectomy.HPE showed viral inclusion bodies and blood and urine CMV PCR was raised. she was started on Gancyclovir and is doing well. CASE 3: 1 yr old boy with biliary atresia post liver transplant developed pneumoperitoneum. Laparotomy showed jejunal perforation which was closed. Biopsy showed viral inclusion bodies suggestive of CMV infection. He was started on ganciclovir.

Conclusion: Cytomegalovirus is a viral agent that may be involved in surgical pathology in children. Children with symptomatic congenital CMV infection have a multi-system disease with significant morbidity.

   Autologous Renal Transplant for Renal Artery Stenosis Category: Urology Top

Avantika Tiwari

Majumdar Shaw Medical Center, Narayana Health, Bengaluru, Karnataka, India

Introduction: Renal artery stenosis is the most common cause of secondary hypertension in children. Its management whether with endovascular intervention or open surgery is associated with challenges due to small-sized arteries.

Case Report: A 5 yr old girl presented with hypertension since 2 years. She required four antihypertensives drugs. CT Angiogram showed long stenotic segment at the origin of right renal artery which was not amenable to dilatation. DMSA scan showed functioning right kidney (27%). Intraoperative finding was a stenotic segment of right renal artery which was excised. she underwent a right renal autotransplantation. Renal vessels were cut and kidney perfused with HDR solution. Renal artery and vein anastamosed to internal iliac artery and common iliac vein respectively. HPE was suggestive of fibromuscular dysplasia of vessel wall with no inflammatory infiltrate. Her recovery was uneventful. Antihypertensive drugs were weaned off over 5 months. 1 year post follow up her BP is maintained without antihypertensive drugs.

Conclusion: Patients in whom renal artery revascularization by conventional balloon angioplasty cannot be done, autologous renal transplantation is good option.

   Appendico-Caecal Intussusception: A New Technique to Create Anti-Reflux Mechanism for Malone's Antigrade Continence Enema Category: GI Surgery Top

Kanoujia Sunil, Archika Gupta, Shiv Narain Kureel

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aim: To report a new technique of creating appendico-caecal intussusception providing unidirectional flow for Malone's antigrade continence enema.

Methods: Seven patients of High Anorectal Malformation, all stages completed but persistent fecal incontinence were selected. Age at procedure ranged between 5 to 6 years. Appendico-caecal junction approached via curved incision at right iliac fossa. After opening the peritoneum; appendix, mesoappendix and caecum were delivered. Opening created at tip of appendix. Caecum was distended by pumping saline via feeding tube passed from tip with clamps placed at ileum and proximal caecum. Withdrawal of tube resulted in saline leak from tip. For creating appendico-caecal intussusception, 25 mm segment of proximal appendix was selected. Micro-vessels entering this segment were disconnected. Using Raynold's scissors, taking 2 mm wide appendicular seromuscular bite at a time, smooth muscle layer was removed leaving intact submucosa and microvascular plexus. Sutures were pre-placed between edges at appendicular and caecal serosa. Submucosal sleeve was intussuscepted in caecal lumen with vascular forceps. Pre-placed sutures were tied off keeping submucosa intussuscepted. Repeat saline distension test revealed no leak from appendicular tip. Outcome assessment criteria: Successful anti-reflux mechanism without leak and complications.

Results: There was no backflow of caecal content via tip of appendix in all without complications. Passage of feeding tube through cutaneous stoma into the caecum was smooth.

Conclusions: This technique of creating appendico-caecal intussusception is simpler and effective for creating unidirectional flow mechanism for antigrade continence enema.

   Sigmoid Volvulous in 8 Year Old Male Child: A Case Report Category: GI Surgery Top

Jatin M Jadav, Ankur Patel, Jaishri Ramji, Rakesh Joshi

Department of Pediatric Surgery, BJ Medical college, Ahmedabad, Gujarat, India

A 8 year old male child admitted with abdominal distention and bilious vomiting. X ray suggestive of multiple air fluid level with dilated sigmoid gas shadow. Exploratory laparotomy done showed sigmoid volvulous. Sigmoid colectomy and double barrel stoma done.

   An Interesting and Rare Case of Torsion of a Wandering Spleen Managed Conservatively Category: GI Surgery Top

Dhruva Ghosh, Rohen Skiba, Andrew Barker

Department of Pediatric Surgery, Princess Margaret Hospital for Children/Perth Children's Hospital, Nedlands, Australia

Aim: Wandering spleen is a rare pathology accounting for 0.5% of splenectomies. We present a case of torsion in a wandering spleen managed conservatively.

Methods: A wandering spleen can be a diagnostic dilemma. Torsion in a wandering spleen presents as an acute abdomen with diagnostic being confirmation on an ultrasound abdomen and contrast CT scan. Traditionally splenic torsion has been managed by splenopexy or splenectomy. Non-operative management of splenic torsion has been out of favour based on historic data suggesting a high rate of morbidity with only one case report having a favorable outcome.

Results: A two-year-old girl presented to the emergency department with abdominal pain for one week which was diagnosed to be a torted and avascular wandering spleen. She was managed conservatively. The girl remains symptom free 9 months after hospital stay with presence of Howell Jolly bodies indicating hyposplenism.

Conclusions: When managing patients non-operatively they require close monitoring through the period of infarction to ensure they do not develop sepsis. They also require appropriate antibiotic prophylaxis and vaccinations for functional asplenia. The benefit of non-operative management is that the patient avoids an operation. Non-operative management allows the natural process of auto-splenectomy following splenic infarction.

   Bronchogenic Cyst - Two Cases Category: Thoracic surgery Top

Aamer Iqbal, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Tarun Gupta

Department of Pediatric Surgery, SJKCT Paediatric Surgery Centre and P.G Institute, Sangli, Maharashtra, India

Aim: To study 2 cases of bronchogenic cyst.

Methods: 8 month male presented with dyspnea, cough and fever since 2 months. On examination there was tachypnea and decreased air entry. History of insertion of ICD for left pneumothorax. Xray chest showed obstructive emphysema. Ct chest revealed bronchogenic cyst. Excision of cyst was done. 6 years male presented with cough and fever since past 1 year. Had 2 episodes of dyspnea for which he was admitted and ICD was inserted into left chest. The patient recovred but still had bouts of cough and dyspnea. Xray chest showed collapse consolidation of the lung. Ct chest revealed bronchogenic cyst.. Excision of cyst was done.

Results: Both the patients are doing well post operatively and are on regular follow up. Conclusion: Bronchogenic cyst has a variety of presentations and its excision is not easy.

   Urinary Diversion for Neonatal Bilateral Vesicoureteric Reflux Category: Urology Top

Aamer Iqbal, Sudhakar Jadhav, Dinesh Kittur, Santosh Patil

Department of Pediatric Surgery, SJKCT Paediatric Surgery Centre and P.G Institute, Sangli, Maharashtra, India

Aim: To study three cases of neonatal bilateral vur with uraemia who underwent urinary diversion.

Materials and Methods: Three male neonates presented with urinary tract infection, urosepsis and uraemia. All three were diagnosed of bilateral gross vesicoureteric reflux were put on chemoprophylaxsis. On examination all patients were lethargic, pale, febrile. Bladder was not palpable. Creatinine were 1.6, 1.9, 1.7 respectively. All patients were stabilized by catheterisation, giving good hydration, treating metabolic acidosis. In view of uraemia and urosepsis – urinary diversion - Vesicostomy was done in all patients and babies settled after that.

Results: All patients did well post operatively and is on regular follow up.

Conclusion: Early urinary diversion may be needed with gross bilateral vesicoureteric reflux.

   Acute Abdomen - a Rare Cause - Mesocolic Hernia Category: GI Surgery Top

Tarun Gupta, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur

Department of Pediatric Surgery, SJKCT Paediatric Surgery Centre and P.G Institute, Sangli, Maharashtra, India

Aim: To study a case of Mesocolic Hernia causing Acute Intestinal Obstruction.

Methods: This is a study of 3 cases who presented with abdominal distension and bilious vomiting. USG revealed collapsed distal most small bowel loops and colon. On exploration, huge sac of mesocolon was seen containing small bowel loops herniated into it. Excess mesocolon was excised and defect in it was closed. Patients had uneventful recovery. There was one case of Right Mesocolic hernia and two cases of Left Mesocolic Hernia.

Results: Patients did well post operatively and are on regular follow up.

Conclusion: Mesocolic Hernia causing acute intestinal obstruction is a rare entity.

   Unusual Case of Congenital Lobar Emphysema Category: Thoracic Surgery Top

Aamer Iqbal, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur, Tarun Gupta

Department of Pediatric Surgery, SJKCT Paediatric Surgery Centre and P.G Institute, Sangli, Maharashtra, India

Aim: To study a rare case of congenital lobar emphysema.

Methods: 2 month male presented with intermittent episodes of breathlessness and tachypnea since 1 month. No history of cough and fever. On examination there was chest indrawing and decreased air entry on right side. Xray and CT chest revealed right upper and lower lobe congenital lobar emphysema. Right upper and lower lobectomy was done.

Results: Patient is doing well post operatively and is on regular follow up.

Conclusion: CLE of the right upper and lower lobe is rare.

   Lingual Dermoid: A Case Report Category: Miscellaneous Top

Tarun Gupta, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur

Department of Pediatric Surgery, SJKCT Paediatric Surgery Centre and P.G Institute, Sangli, Maharashtra, India

Aim: To study a case of swelling below tongue – Dermoid cyst.

Methods: Two years male patient presented with c/o swelling below the tongue since birth. On examination, it was single midline swelling with dimensions of 3 x 3 x 2 cms. In past, Incision & Drainage for tongue abscess was done 1.5 years back. Excision of swelling was done which was found to be Dermoid cyst of tongue.

Results: The patient recovered well and is on regular follow without recurrence.

Conclusion: Dermoid cyst of tongue is a rare entity.

   An Institution Experience in Surgery for Cleft Lip and Palate Category: Miscellaneous Top

B Ujjwal Singh Trivedi, S Sethunath, GM Asok Kumar, Vivek P. Sarma

Department of Pediatric Surgery, Government Medical College, Thiruvananthapuram, Kerala, India

Introduction: Since 1950 S surgeries of cleft lip and palate being performedroutinely in the department of paediatric surgery, govt.medical college Thiruvananthapuram, Kerala pioneered by Prof. Raman Nair, who has personally trained with surgeons like millard.

Aim: To analyse the erperience of surgical treatment of all cases of cleft lip and palate operated at a single tertiary hospital during a five year period

Materials and Methods: A retrospective analysis of hospital records including pre-operative assessment, operative notes and postoperative results of all cleft lip and palate patientsoperated during January 2013 to December 2017 was done. Mean follow up period available was six months to years.

Results: Total 49 Cases of cleft lip repairs and 104 cleft palate repair done during the period. cleft lip cases were individually studied as unilateral/bilateral, complete / incomplete and types of surgery, early and delayed complications were assessed.

Conclusions: Cleft lip and palate surgery can be done with good results in a tertiary paediatric surgical center with sufficient expertise and training.

   Bilateral Vu Reflux: A Rare Case Category: Urology Top

Tarun Gupta, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur

Department of Pediatric Surgery, SJKCT Paediatric Surgery Centre and P.G Institute, Sangli, Maharashtra, India

Aim: To study a case of Bilateral Complete duplex systems with Bilateral VU Reflux.

Methods: One year male patient presented with h/o 5 episodes of UTI. Per abdomen examination was normal. S. creatinine was 0.68. USG abdomen revealed B/L hydroureteronephrosis& B/L complete duplex systems. MCU revealed B/L Grade 5 VUReflux. Both kidneys were small in size and contracted in DMSA scan.B/L ureteric reimplantation was done followed by cystoscopic removal of stents after 1 month.

Results: The patient recovered well and was on regular follow up.

Conclusion: Bilateral Complete duplex systems with Bilateral VUR-in lower moiety is a rare entity.

   Role of Endoscopic Management of Upper Airway Obstruction in Pediatric Cases Category: Thoracic Surgery Top

Vinod Raj

Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Aim and Objective: To demonstrate role of endoscopic management of upper airway obstruction in the pediatric population.

Methods: A retrospective review of pediatric patients with upper airway obstruction undergoing endoscopic airway procedures at a tertiary care centre.

Results: Three patients (one male and two female) were treated between August 2015 and September 2017 for upper airway obstruction by endoscopic therapeutic interventions only. The age of the patients ranged from 3 months to 5 years. The first patient (female) had acquired subglottic narrowing. The second patient and the third patient were diagnosed with multiple subglottic cystic lesions. All three patients underwent tracheostomy after being diagnosed with grade III subglottic narrowing. First patient was treated with serial bronchoscopies and dilatations for persistent subglottic narrowing following laryngo-tracheal reconstruction. Second patient underwent laser de-roofing of subglottic cysts and serial dilatations following the de-roofing. Third patient underwent serial subglottic steroid injections with dilatations.

Conclusion: Endoscopic management of upper airway obstruction can be used as adjunctive treatment as well as a primary modality in pediatric population. Endoscopic management of paediatric upper airway obstruction should always be considered as it may obviate the need for expensive, painful, difficult reconstructive surgeries in children with subglottic narrowing.

   What to Do When You Do not Find Appendix While Doing Laparoscopic Appendectomy? Category: Laparoscopic Surgery Top

Sikchi Rupesh Suresh, Kirtikumar Rathod, Avinash Jadhav, Arvind Sinha

Department of Pediatric Surgery, AIIMS, Jodhpur, Rajastan, India

Aims: To standardize treatment in patients with perforated appendix when you are unable to find appendix while doing laparoscopic appendectomy.

Methods: 10 years old female child with pain abdomen (right side) for 10 days and fever since 2 days with RIF tenderness on examination. Preoperative USG suggestive of appendicular perforation/ periumbilical collection of 3.5 x 2.6 cm. Appendix explored laparoscopically, appendix base could not be located, completely sloughed off retrocaecal appendix with around 30- 40 ml thick pus collection was found. Pus was drained, peritoneal lavage done, drain inserted in retrocaecal space. USG before discharge found to be normal. Patient discharged successfully. We have done 3 similar cases in the past with equal results.

Results: Patient managed with laparoscopic drainage of pus and lavage, without stump ligation due to unidentification of appendicular base while performing laparoscopic appendectomy. Patient is discharged successfully and has no complaints on first follow up.

Conclusion: while performing laparoscopic appendectomy when the operating surgeon does not find the base of appendix, one can simply drain the collection after lavage and insert retrocaecal drain for further drainage. This technique can be effectively utilized.

   A Ruptured Ovarian Mass Masquerading as Acute Abdomen Category: Surgical Oncology Top

Vinod Raj

Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Aim: To evaluate a case of ruptured ovarian mass.

Materials and Methods: 11 year old female with acute onset pain in lower abdomen with fever and vomiting. She had a firm, tender mass in the midline. Radiological investigations revealed a right adnexal mass which was confirmed on a CT scan. Tumour markers done showed only elevation of LDH. Rest of the tumour markers was normal.

Results: Underwent exploration and a large ruptured, twisted right ovarian mass was seen. Tumour mass ruptured on its posterior inferior aspect. Hemoperitoneum noted while peritoneum and omentum were free of tumour seedlings. Underwent right Salphingo-opherectomy. Histopathology revealed it to be a DLBCL of the right ovary which accounts for less than 2% of paediatric ovarian tumours. Now on chemotherapy.

Conclusion: The risk of rupture, although less, has a significant impact on the course of ovarian tumour management. Rupture upstages the tumour and requires chemotherapy post operatively.

   Role of Chemo-Ports in Children with Malignancies Category: Surgical Oncology Top

Vinod Raj

Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Aim: To identify the complications and study preventive and therapeutic measures for chemoports in children.

Materials and Methods: A total of 72 chemoports were inserted in 69 patients from December 2002 to May 2017. Sixty-four children had haematological malignancies and 5 had solid tumours. Records were analysed retrospectively for age, indication, route of insertion and postoperative complications. A protocol based post insertion handling by trained nursing staff/doctors was instituted, including a periodic training program for those concerned.

Results: Chemoport related complications were infection in three (4.16%), necessitating port removal in one patient. The rest two were managed by antibiotic-lock therapy. The other problems were catheter tip occlusion in one (1.38%) and extravasation in two patients (2.77%). An unsightly scar in four (5.55%) and granuloma formation at scar site in one (1.38%) patient were noted.

Conclusion: Totally implantable chemoports are preferred in children with solid and haematological malignancies because low rates of infection and ability to maintain patency for long term. Despite significant advantages over other types of central venous access, chemoports have their own complications. It was also noted that rate of complications can be minimized by periodic training of all personnel concerned and following protocol based handling of ports.

   Analysis of Surgical Management of Congenital Hyperinsulinism Category: GI Surgery Top

Vinod Raj

Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Aim: To evaluate the outcomes of subtotal pancreatectomy in cases of congenital hyperinsulinism with failed medical management.

Methods: Four children referred between 2010 and 2016. The preoperative diagnosis was confirmed by recurrent non-ketotic hypoglycemia, inappropriately high insulin levels and augmented glucose requirements. All the patients underwent subtotal pancreatectomy (80%) for failed medical management.

Results: The post operative outcomes have been good irrespective of histopathology report. All patients have attained normal milestones until date with no neurological deficits and none have pancreatic endocrine or exocrine insufficiency.

Conclusion: In our limited experience with subtotal pancreatectomy for HI, we have had a very good outcome, with no incidence of recurrent hypoglycemia, endocrine deficiencies and neurological deficiencies. Hence, we recommend subtotal (80 %) pancreatectomy as the primary modality of surgical intervention in Diffuse HI. This minimizes the chances of postoperative diabetes mellitus, and redo surgery can always be considered if there is recurrent hypoglycemia.

   Mayhems of Mismatch Repair Genes: A Case of Three Synchronous Malignancy Category: Surgical Oncology Top

Vinod Raj

Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Aim: To evaluate a case of multiple synchronous solid organ malignancies in a child.

Materials and Methods: Eleven month male presented with change in voice, increased weight and body hair found to have elevated levels of serum cortisol and testosterone showing three synchronous malignancies in the liver, left adrenal and posterior mediastinum.

Results: The malignancies were diagnosed to be hepatoblastoma, neuroblastoma and adreno-cortical tumour. Gene mutation studies revealed TP53, MLH3 and N-MYC positivity. He underwent surgical resection of all the three malignancies and is currently on chemotherapy. In this child with TP53 and MLH3 mutations being present, he has risk of developing malignancies at any time and due to the TP53 mutation subjecting him to chemotherapy and radiotherapy will further increase the risk for development of tumours. To the best of the author's knowledge, this is the first case report with three solid organ synchronous tumours in paediatric population.

Conclusions: It is critically important to evaluate such children with multiple malignancies to identify genetic defects. Once detected it requires a multidisciplinary care and management. To strike balance in therapy is critical.

   Delayed Presentation of Inadequately Operated Vestibular Fistula: Rectoplasty and Redo Psarp, a Success Story Category: GI Surgery Top

Sikchi Rupesh Suresh, Kirtikumar Rathod, Avinash Jadhav, Arvind Sinha

Department of Pediatric Surgery, AIIMS, Jodhpur, Rajastan, India

Aims: to describe a complicated case of inadequately operated vestibular fistula (Primary PSARP was done in infancy by rectoplasty and redo PSARP.

Methods: 7 years old girl child presented with intestinal obstruction due to severe constipation. There was past history of some perineal operation done for ?vestibular fistula in neonatal period.on examination under anaesthesia anal opening was not inside the sphincter complex. A diverting sigmoid colostomy in emergency as an initial operation. Distal colostogram showed massively dilated rectum so it was decided to do tapering rectoplasty by posterior saggital approach and positioned neoanus in the sphincter complex. Child did well after operation and colostomy was closed after 6 weeks of Redo PSARP. Presently child is asymptomatic and passing stools normally without any medications or enemas.

Conclusion: rectoplasty should be included as a part of PSARP in case of delayed presentation of anorectal malformation with severe constipation for better results.

   Primary Tuberculosis in a Thigh Abscess Category: Miscellaneous Top

Vinod Raj

Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Aim: The children with thigh abscess are evaluated for tuberculosis in this study.

Materials and Methods: Between 2016 and 2017, seven children who presented with thigh abscess were included. The age, sex, clinical history, vaccinations, immune status, radiological images, surgical and medical management were recorded. The follow up period was between 9 months to 12 months. The time period to heal the wound and number of dressing were also recorded.

Results: Out of seven children four were male and three were female. The mean age was 9.2 months (3 -17 months). All children had received BCG vaccination during neonatal period and DPT vaccination during infancy. X-ray of hip and femur was done in all children, ultrasonography in five children. All children received antibiotic course for few days, but no response was seen and all underwent incision and drainage of the abscess. The cultures grew acid fast bacilli and tissue showed caseous granulomatous reaction. All children were started on anti-Koch's treatment. The minimum time period to heal the abscess was 2 to 4 months. All children required at least 6 and maximum 8 dressing for wound healing.

Conclusion: Tuberculosis should be considered in children who present with thigh abscess and merits anti-Koch's therapy when the diagnosis is confirmed.

   Tubular Colonic Duplication Presenting as Meconium Pseudocyst Category: GI Surgery Top

Raj Kumar, Nitin Peters James, Ram Samujh

Department of Paediatric Surgery, PGIMER, Chandigarh, India

Aim: Duplication cysts may present in many ways ranging from asymptomatic to intestinal obstruction and gangrene. We present a case of tubular duplication of the transverse colon, presenting as meconium pseudocyst in the neonatal period, and its subsequent management.

Case Report: 5 days old female child presented with abdominal distension and not passing stools since birth. Plain Xray showed calcificationa and the patient was operated with a preoperative diagnosis of meconium pseudocyst. Intraoperatively there was a large pseudocyst in the left abdomen encompassing the splenic flexure. After cyst excision and delineating the transverse colon there was a Y shaped tubular extension from the right transverse colon. Ileostomy and DMF was performed in the neonatal period. Distal cologram showed a tubular transverse colon duplication. It was excised at the time of stoma reversal at 8 months of age.

Conclusion: Colonic tubular duplication may rarely present as meconium pseudocyst in a neonate. Tailored approach to these patients with emergency procedure followed by definitive surgery as a second stage may be helpful in sick neonates.

   Intraperitoneal Juvenile Myofibroblastoma with Unknown Origin Category: Surgical Oncology Top

Abhishek Anand, Ashok Kumar Basu, Tapanjyoti Banerjee

Institute of Child Health

Aims: To present medical puzzle before learned audience.

Methods: 8 year old boy had fever since 2 months. All investigations done including investigation for pyrexia of unknown origin which were normal. PET-CT was suggestive of rhabdomyosarcoma. MRI whole abdomen and CT guided biopsy suggestive of inflammatory juvenile myofibroblastoma which was confirmed by immunohistochemistry and FISH technique. Tumor was excised completely at laparotomy and sent for histopathological examination. Postoperative period was uneventful. Patient is under regular follow up and till date there are no signs of recurrence.

HPE : (1) Inflammatory myofibroblastoma (2) Ig G 4 related disease.

Results: No recurrence over a six month follow up period.

Conclusion: We must include investigation to exclude hidden malignancy in patient of pyrexia of unknown origin.

   Down Staging of Urinary Diversion during Undiversion Category: Urology Top

VK Gopi

Department of Pediatric Surgery, Baby Memorial Hospital, Kozhikode, Kerala, India

Aim: Urinary undiversion is a crucial step in the ongoing management of posterior urethral valve. This paper aims to report a new concept of down staging of urinary diversion during undiversion.

Methods: There were children who plunged into problems during urinary undiversion of pyelostomy and ureterostomy and eventually had to divert again. To overcome the complex issues involved in urinary undiversion, down staging of diversion was done by resorting to vesicostomy.

Results: Children with posterior urethral valve on pyelostomy and ureterostomy underwent undiversion with the support of downstaging of diversion in the form of vesicostomy. Post-operative issues were better tolerated and managed in those who underwent downstaging.

Conclusion: Children with posterior urethral valve on ureterostomy and pyelostomy pass through difficult times during undiversion. With downstaging in the form of vesicostomy undiversion is better tolerated and there is no need for reverting back to diversion.

   Management of Progressive Nonresponsive Disease in Bilateral Wilms' Tumor Category: Surgical Oncology Top

Leonard J Ezung, Artap S Yadav, S Roy Choudhury, R Chadha, Amit Gupta, Vikram Khanna, Peter Daniel S Khariong, S Dilip, Vipan Kumar

Department of Pediatric Surgery, Kalawati Saran Children Hospital, Lady Hardinge Medical College, New Delhi, India

Aim: To present challenges in the management of a case of bilateral Wilm's tumor with PNRD.

Methods: A one and half year old girl was admitted with a mass occupying almost whole of the right side abdomen, with another smaller mass in left lumbar region. Ultrasound abdomen and CECT scan revealed bilateral renal masses, FNAC showed triphasicWilms' tumor from right kidney. DD4A regime started, but evaluation after 6 weeks of chemotherapy showed increase in size of masses on both the sides, confirmed on CECT scan of abdomen revealing 20% increase in size of the lesion (progressive disease). Tru cut biopsy showed presence of mature rhabdomyomatous elements on both sides. Right partial nephrectomy was done followed by left multiple tumor enucleation after 10 weeks. Post operative course uneventful, no urinary leak. Chemotherapy course completed. After discussion with pediatric oncologists and radiation oncologists, radiotherapy deferred. Follow up of 1 yr, asymptomatic, normal ultrasound KUB scans.

Conclusion: The outcome for patients with a rhabdomyomatous differentiation or mature stromal elements, despite being non responsive to chemotherapy is favourable as compared to those with anaplasia.

   Recurrent Intussusception Category: GI Surgery Top

Yogesh Tiwari, Sudhakar Jadhav, Santosh Patil, Dinesh Kittur

Department of Pediatric Surgery, Sudhakar Jadhav Institute, Sangli, Maharashtra, India

Aim: to study a case of recurrent intussusception in a span of 3 days.

Materials and Methods: 5 month male child presented with blood in stools since 1 day. On examination patient was dull, poor response to pain and had tachycardia. Lump was felt on palpation. On PR, lump was touching the finger. USG revealed an intussusception of the large bowel extending into the rectum. Hydrostatic reduction was attempted but did not reduce. Exploratory laparotomy revealed an ileo –colo- colic intussusception extending into rectum. Manual reduction was done successfully. Patient had passed stool on post-op day 1 and sips of water were started. On post op day 2 patient had bilious vomiting, patient was kept NBM. On Post op day 3 repeat USG revealed ileo-ileal intussusception. Laparotomy showed the same and manual reduction done.

Results: Patient did well postoperatively and is on regular follow up. Conclusion: Recurrence of intussusception at other site is very.

   Acquainting Male Cloaca: Rare Anorectal Malformation Category: GI Surgery Top

Shilpa Sharma, Devendra Yadav, Devendra Gupta

Department of Pediatric Surgery, AIMS, New Delhi, India

Aim: Male cloaca is described as a single opening in perineum for passage of urine and meconeum.

Methods: Cases of MC were ambispectively studied, prospectively from July 2007 to June 2018 and retrospectively for last three decades.

Results: Eight cases of MC were identified, between the ages of newborn-4 years (median 10 days). Two missed cases underwent a colostomy, posterior sagittal anorectoplasty, and urethroplasty. One patient has associated tracheoesophageal fistula and underwent colostomy and primary repair of the tracheoesophageal fistula. Two cases underwent perineal urethrostomy and anoplasty followed by urethroplasty. In one case, part of the rectal wall was used to form urethral tube and urethrostomy. Three cases underwent posterior sagittal anorectourethroplasty with mobilization of rectal pouch and common channel, separation of common wall between the urethra and rectum, urethroplasty varying from 1.5 to 3 cm, perineal body reconstruction, perineal urethrostomy and anoplasty. One patient underwent PSARP under colostomy cover and retaining the common channel as a perineal urethrostomy; followed by colostomy closure and chordee correction later. Follow-up of 7 patients varied from 20 months to 23 years. One case is lost to follow-up. Four patients have completed repair. Complications included a discharging sinus and a urethral fistula in one case each. One patient died while awaiting urethroplasty. Two patients are awaiting formal urethroplasty.

Conclusion: Appropriate diagnosis of this anomaly is important for proper management. Early recognition can avoid a neonatal colostomy in selected patients if the decompression is adequate through the cloacal opening.

   Proximal Hypospadias: Looking Beyond the Urethra Category: Urology Top

Satish Kumar Aggarwal, Aparajita Mitra, Rupa Banerjee, Gaurav Singh, Muni Verma, Sugandh Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aims: To study the extent to which the management of proximal hypospadias (PH) is confounded by other issues like disorders of sexual differentiation (DSD), upper tract anomalies, pseudovaginal diverticulum (PVD), penoscrotal transposition (PST) and bifid scrotum and urethrovasal reflux (UVR), besides the urethral reconstruction itself.

Materials and Methods: Data from 122 children with PH operated between January 2007 to January 2017 was analysed retrospectively (age range 6 months to 17 years). All were operated by a single-surgeon and included redo cases (n= 38). PH was defined as a meatal opening penoscrotal or more proximal.

Results: All 84 primary cases underwent staged repair. Stage 1 included cystoscopy for assessment of PVD, chordee correction (Nesbit procedure in 14, division of urethral plate and degloving in 70), proximal tubularization, distal Bracka graft (inner preputial free skin) and scrotoplasty. Thiersch-Duplay tubularization was done in Stage 2. Further, 70% required PST correction. Redo cases were addressed as per their complexity (staged repair using buccal mucosa in 26, split thickness skin graft from the inner thigh in 12). PVD with obstructing membrane required cautery incision in 4 and excision in 1 case. Associated malformations were VUR in 3, UPJO in 1 and low ARM in 3. UVR was seen in 13 cases who developed epididymo-orchitis after stage two (1 required vasectomy). DSD included 46XX DSD (True hermaphrodite reared as male), 8 with 5 alpha-reductase deficiency and 1 with mixed gonadal dysgenesis.

Conclusion: PH requires an individualized approach. Pre-operative evaluation for urinary tract anomalies, DSD and a problematic PVD is essential. Staged repair including scrotal repair is suggested. Careful follow-up of UVR is necessary as this may be an inherent problem which becomes evident after reconstruction.

   Robot Assisted Laparoscopic Repair of Retrocaval Ureter: A Beginner's first Impression Category: Laparoscopic Surgery Top

Aparajita Mitra, Satish Kumar Aggarwal, Ajay Sharma, Rupa Banerjee, Muni Verma

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aim: Retrocaval ureter is an uncommon embryological anomaly. Rarely, if symptomatic, it presents later in life. Our first experience with Robot-assisted correction is discussed and application of points of technique and their customization to suit the patient and the operative set-up are highlighted.

Methods: A ten year old boy with a history of recurrent right flank abdominal pain and vomiting for the past 2 years was found to have right hydronephrosis on ultrasonography. A “fish-hook appearance” typical of a retrocaval ureter, was seen on IVP. Serial DTPA scans showed a fall in relative renal function and GFR. He was subsequently planned for robot-assisted surgical correction.

Results: The total console time was 95 mins (using two working and an assistant port) with minimum blood loss. The dilated renal pelvis with upper ureter was approached first and dissected till the IVC. Tracing the distal ureter retrograde from the pelvic brim till the IVC allowed one to define the anomaly. Extensive spatulation was necessary to correct the co-existing intrinsic functional obstruction (suggested by a forceful jet of urine on dismemberment). Ureteroureterostomy was achieved over a Double J stent with 5/0 vicryl suture. Though fragile and difficult to handle, the 5/0 size is best suited to the pediatric group. Post-operative recovery was uneventful. The stent was removed six weeks later. He remains asymptomatic with unremarkable imaging.

Conclusions: The Robotic approach to this surgery is elegant and truly minimally invasive. The high magnification and Endowrist technology allow the fine suturing so essential for a well-functioning anastomosis.

   Comparison of the Serial Diuretic Renal Scans Performed with 99mtc-L, L-Ec and 99mtc-Mag3 in Children with Pelviureteric Junction Obstruction Category: Urology Top

Divya Murali, V Jain, S Arora, A Passah, K Mani, DK Yadav, P Goel, DK Gupta

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Aim: To compare the serial diuretic renal scans (DRS) performed with 99mTc-L, L-EC and 99mTc-MAG3 in children with Pelviureteric junction (PUJ) obstruction.

Methods: A retrospective study was performed and children with PUJ obstruction who had serial DRS performed with both 99mTc-L, L-EC and 99mTc-MAG3. Children with any intervention in between the serial scan or a gap of more than 2 months in between renal scans were excluded. The dose of each radiotracer used was 0.1 mCi/kg (3.7 MBq/kg) with a minimum dose of 1 mCi (37 MBq). DRS was performed using F+0 protocol. The differential renal function, Tmax, T1/2, drainage pattern and hepatic uptake of the radiotracer were recorded and compared. Bland Altman plot was used to assess agreement in between the two radiotracers.

Results: Sixteen children were included in the study. A total of 18 obstructed and 14 normal renal units were available to us for study. The values of DRF as well as Tmax and T1/2 of the two radiotracers were in agreement. In three obstructed kidneys in which T1/2 on 99mTc-MAG3 was > 20 mins, 99mTc-L, L-EC showed T1/2 values of 13.3 minutes or less. 99mTc-L, L-EC showed nonobstructive drainage in 3 patients which had shown partial obstruction on 99mTc-MAG3 scan. The hepatic uptake of 99mTc-L, L-EC was also lower as compared to 99mTc-MAG3.

Conclusion: To conclude 99mTc-L, L-EC is an useful radiotracer for evaluation of children with PUJ obstruction with better assessment of drainage and lower hepatic uptake as compared to 99mTc-MAG3.

   Varied Clinical Presentation of Pediatric Ovarian Tumours Category: Surgical Oncology Top

Jaya Prakash, G Rajamani, R Rengarajan, N Venkatesa Mohan, V Muthulingam, RP Dharmendra

Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Ovarian tumours are uncommon in childrens accounts for 2%of all types of cancer in childrens. Hereby presenting a case series of ovarian tumours managed in our hospital. Various presentations are precocious puperty, retroperitoneal mass, mesenteric cyst, adnexal mass, Although rare, ovarian tumours must be included in the differential diagnosis of abdominal mass in female child. Neoplastic lesions are more readily diagnosed & completely characterized with advances in biochemical, immunohistologic and cytogenetic technology. surgery and platinum-based chemotherapy remains mainstay in the management. Preservation of endocrine & reproductive function is the paramount importance in the management of ovarian tumours.

   Congenital Anterior Urethral Diverticulum in Children Category: Urology Top

Rajat Piplani, Deepak Bagga, Samir K Acharya, Nidhi Sugandhi, Amit Jadhav, Pratheep Samraj

Department of Pediatric Surgery, V.M.M.C and Safdarjang Hospital, New Delhi, India

Congenital Anterior Urethral Diverticulum (CAUD) is an uncommon condition in children and may present itself at any age, from infant to adult. Most children present with difficulty in micturition, dribbling of urine, poor urinary stream, or urinary tract infection. Patients with large anterior urethral diverticulum with poor spongiosal support also complain of cystic ventral penile swelling during micturition. In this series, we present five cases of CAUD, out of which three cases were managed by cystoscopic fulguration of valves while other two cases with large anterior urethral diverticulum required excision of the diverticulum and primary urethral reconstruction.

   Rectovestibular Fistula with Colonic Duplication: A Rare Association Category: GI Surgery Top

Rajat Piplani, Deepak Bagga, Samir Kant Acharya, Nidhi Sugandhi, Amit K Jadhav

Department of Pediatric Surgery, V.M.M.C and Safdarjang Hospital, New Delhi, India

Anorectal malformations associated with colonic duplications are rare. Colonic duplications may have different presentations according to its location and size and has incidence of less than 15% of all gastrointestinal duplications. Double termination of tubular colonic duplication in the perineum is even rarer. We report three cases of rectovestibular fistula along with underlying tubular colorectal duplication managed successfully by different surgical approaches. These cases illustrate the diagnostic challenge and variable presentation of colonic duplications. Tubular colonic duplication should always be ruled out when a diagnosis of perineal canal is considered in cases of vestibular fistula with a normal anus.

   Renal Oncocytoma Category: Urology Top

Ashutosh Kumar Sharma, Kedar, Deepa, Kamal

Department of Pediatric Surgery, KEM Hospital, Mumbai, Maharashtra, India

Aims: This is a case report of 12 year old child of renal oncocytoma which highlights the fact that in well preserved patients not in the age group for Wilms tumour, this differential diagnosis can be a possibility.

Methods: Renal oncocytomas are benign, epithelial tumours composed of uniform and well differentiated oncocytes, incidence of 3 to 7% of primary renal tumours. Mostly present in the seventh decade of life. Only five cases of Paediatric Oncocytoma have been reported. Surgical excision is treatment of choice. Renal oncocytoma was traditionally regarded as a benign neoplastic tumour; however, chromophobe renal cell carcinoma can coexist. Renal oncocytomas and renal clear cell carcinomas can present with oncocytic features, which necessitates immunohistochemical analysis for diagnostic distinction. A 12 years old female presented with pain and lump in abdomen. 11 x 10 x 10 cm solid cystic mass was seen on CECT abdomen, suggestive of Wilms Tumour with cystic degeneration and intrarenal haemorrhage. Patient underwent right radical nephroureterectomy.

Results: Histopathology with IHC confirmed renal Oncocytoma and good postoperative recovery. This child is one of the youngest ones till date.

Conclusion: Although rare, renal Oncocytoma needs consideration as differential diagnosis of paediatric patients with renal mass.

   Systematic Review of Epidermal Inclusion Cyst of the Penis in Children Category: Urology Top

Minu Bajpai, Prabudh Goel, Minu Bajpai, Sachit Anand, Prasenjit Das

Department of Pediatric Surgery, AIIMS, New Delhi, India

Objective: To conduct a systematic review of available literature on penile epidermal inclusion cyst in pediatric age-group.

Methods: We searched PUBMED, PUBMED Central, PMC, Google Scholar, Ovid and the Cochrane Library from 1997-2018. Studies reporting cases of epidermal inclusion cyst of the penis in children were included for the review.

Results: Eleven studies were found suitable for the review. Data was extracted to study the geographic origin of paper, age of the patient, exact anatomical location of cyst, clinical presentation, duration of swelling, etiology (congenital or post-surgery/trauma), time lag between surgery and appearance of swelling, size of cyst, growing or static in size, proximity to incision site in post-surgical cases, local and systemic symptoms, diagnostic investigation, surgical procedure, histopathology, follow-up and other relevant parameters. Data has been depicted as tables and figures in view of small numbers not suitable for significant statistical analysis.

Conclusions: A comprehensive review of the available literature on epidermal inclusion cysts of the penis in children has been presented within the limitations imposed by the limited number and type of publications (images and case reports), length and breadth of representative data (within the available reports) and publication bias.

   Previously Undescribed Anomalies of Hepatic Artery and Portal Venousanatomy in a Case of Extra-Hepatic Biliary Atresia and Its Implications Category: Hepatobiliary Top

Minu Bajpai, Prabudh Goel, Minu Bajpai, Kanika Sharma, Priyanka Naranje

Department of Pediatric Surgery, AIIMS, India

A search on PUBMED and Web of Science revealed scarcity of literature on anomalies of hepatic artery or portal vein and presence of arterio-portal fistula in biliary atresia although it has long-lasting implications for both the patient and the surgeon including hepato-pancreatico-biliarysurgeons, pediatric surgeons (who perform Kasai's portoenterostomy), liver transplant surgeons and interventional radiologists. We report a case of extra-hepatic biliary atresia with multiple anomalies involving the hepatic arteries, portal vein, cystic artery, arterio-portal fistula and shunting, intra-hepatic portal vein radicals, kidney and external genitalia. The merits of the case from various standpoints including its implications related to etio-pathogenesis, caution during surgery anesthesia or post-operative management and enrichment of literature have been discussed.

   An Enigmatic Route to the Contralateral Pelvicalyceal System on Antegrade Pyelogram Category: Urology Top

Minu Bajpai, Prabudh Goel, Minu Bajpai, Devasenathipathy Kandasamy

Department of Pediatric Surgery, AIIMS, New Delhi, India

Introduction: The authors present the rare yet enigmatic phenomenon of 'pyelo-renal' backflow.

Case Presentation: An eight-month-old boy with multiple congenital anomalies underwent left Anderson-Hynes Pyeloplasty for pelvi-ureteric junction obstruction. Antegrade dye-study done through the nephrostomy revealed obstruction at the level of the pelvi-ureteric junction, yet the contrast was visualized in the pelvis of contralateral kidney and urinary bladder (pyelo-venous backflow) masquerading as vesicoureteric reflux. The phenomenon of 'pyelo-renal' backflow along with pyelo-tubular, pyelo-interstitial, pyelo-sinusal and pyelo-lymphatic backflow have been described and the respective mechanisms discussed.

Conclusion: The phenomenon is known to happen in the presence of obstruction to outflow from renal pelvis thereby creating a closed compartment. Injection of contrast at a pressure above the critical limit may result in forniceal tears and back-flow of contrast into the renal tubules and beyond.

   Perineal Hypospadias with Ectopic Anus Covered by Skin: An Unusual Case of Male Perineal Canal Category: Neonatal Surgery Top

Aravindh Radhakrishnan, Sujoy Neogi, Sachin Bansal, Priti Kumari, Yogesh Kumar Sarin

Department of Pediatric Surgery, Maulana Azad Medical College and Assoc. Lok Nayak Hospital, New Delhi, India

We report a rare case of a new born chid who presented with absent anal orifice with mid-penile hypospadias. On examination the child had a mid-penile meatus and a fistulous opening just proximal to the urethral meatus from where meconium was leaking. The child underwent sigmoid colostomy and perineal evaluation. The skin of the perineum, retrospectively a perineal canal, was incised which revealed a slightly anteriorly placed ectopic anus with a perineal hypospadias for which anoplasty was done. A contrast study performed later showed no communication between rectum and urinary tract. This is the second known case reported in the English literature.

   Median Sacral Artery Ligation in a Case of Sacro Coccygeal Teratoma Category: Laparoscopic Surgery Top

Ayushi Vig, Kirtikumar Rathod

Department of Pediatric Surgery, AIIMS, Jodhpur, Rajastan, India

Median Sacral artery is the source of life threatening haemorrhage in sacro-coccygeal teratoma (SCT) excision. We describe a case of a neonate in whom we did a laparoscopic clipping of median sacral artery before surgical excision of SCT.

Case Report: A 8 day old full term female neonate weighing 2800 grams was referred to us with swelling in sacral region. It was not detected on pre-natal ultrasonography. CT scan abdomen showed Type II SCT measuring approximately 18 X 12 X 10 cm with solid and cystic components. Solid component showed it was very vascular. We did laparoscopic dissection in the pre sacral space using 5 and 3 mm instruments. Retro rectal space was created on the left side using an ultrasonic dissector. Ureter was positively identified and dissection was done away from it. Median sacral artery was identified and clipped using 5 mm clip applicator. Laparoscopic procedure took only 30 min. Ports were closed and the baby was turned in prone position. SCT was excised by raising flaps by standard method. There was minimum bleeding during the operation.

Conclusion: Laparoscopic ligation of median sacral artery in neonatal period is feasible and safe. It not only prevents haemorrhage but also makes the surgery easier.

   Esophageal Conduit- Our Experience Category: GI Surgery Top

P Praveen, J. Muthukumaran, R Senthilnathan

Department of Pediatric Surgery, Institute of Child Health, Madras Medical College, Chennai, Tamil Nadu, India

Aim: There are numerous conduits available for esophageal replacement. This year we had 2 cases of esophageal replacements – gastric pull through and colonic pull through.

Methods: A male child with pure esophageal atresia who underwent cervical esophagostomy and feeding gastrostomy in new born period underwent gastric pull through at one year of age. A six year male child who had suspicious acid ingestion at 10 months of age who had underwent tracheostomy and feeding gastrostomy underwent colopharnyngoplasty where his ascending and transverse colon were used as esophageal conduit.

Results: Both the children survived. The child with gastric pull through had a stormy immediate post operative period but had no leak. The child with colonic pull through had an uneventful immediate post operative period but later developed enterocutaneous fistula due to ileal perforation and contained leak for which he underwent re-laparotomy.

Conclusion: Gastric pull up has advantages of relative technical ease, excellent healing power of the anastomosis, wide anastomotic stoma at the neck and only one single anastomosis is required. But it is frequently associated with postprandial symptoms probably related to loss of the gastric reservoir. These are less common in colonic conduit because the distal third of the stomach is retained within the abdomen and the interposed colon functions as additional reservoir.

   Rectal Duplications in Children Category: GI Surgery Top

Swapnil Pattanshetti, Jai Kumar Mahajan, Enono Yhoshu, Muneer Malik

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aims: Rectal duplication (RD) cysts are rare congenital anomalies. Aim of this study was to analyse the incidence, presenting features and outcome of rectal duplications.

Methods: The cases records of all patients operated for intestinal duplications between 2014 and 2018, were retrospectively analyzed.

Results: Thirty one cases of intestinal duplications were seen over a period of 4 years, out of which 5 were rectal duplications. There were 4 females and 1 males and age of the patients ranged from 1 day to 10 years. While the neonate presented with a meconium discharging sinus besides normal anus, rest presented with constipation and variable degrees of fecal soiling. One patient had sacral anomaly, whereas the other with anovestibular fistula was incidentally diagnosed to have rectal duplication at operation. Magnetic resonance imaging was performed in all patients. Two patients, neonate and the other with sacral anomaly required preliminary colostomy and others could be operated primarily. Complete excision was possible in 3 cases and 2 patients required mucosal stripping as the common wall did not allow complete excision. One patient had wound infection and major breakdown while rest of the patients are doing well in the follow up.

Conclusions: Rectal duplications are uncommon and may or may not communicate with the rectal lumen. Imaging to delineate the anatomy is important. Results of surgical excision are good and continence is not affected.

   Unusual Presentation of Giant Cell Tumour of Soft Tissue Category: Miscellaneous Top

Mamta Sengar, Vivek Viswanathan, Anup Mohta, Lavleen Singh

Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya, New Delhi, India

Aim: to highlight an unusual presentation of giant cell tumour of soft tissue.

Case Report: A 6 year old girl presented to us with a history of a swelling of the left hip noticed incidentally since 2 months. It was slightly painful and slowly increasing in size. On examination there was a firm nodular swelling approximately 2*2 cm size over the left hip which was non tender and immobile. A provisional diagnosis of fibroma was made. The child was taken up for excision of the cyst and the specimen was sent for histopathology review. Histopathology reporting revealed a well circumscribed lesion in the deep dermal plane which showed an intricate admixture of mononuclear cells, osteoclast type giant cells and haemosiderin laden macrophages alongwith focal osseous metaplasia, features consistent with giant cell tumor of the soft tissue.

Discussion: There are only about 70 reported cases worldwide, of giant cell tumor of soft tissue, that too in adults, because they are so inherently rare. The potential for recurrence in cases of incomplete excision and the chances of malignancy make it necessary for the patient to be put under close observation.

   Iso-Peristaltic Gastric Tube: Experience from a Tertiary Care Centre and Long-Term Results Category: Urology Top

Minu Bajpai, Minu Bajpai, Prabudh Goel, Manisha Jana, Puneet Khanna

Department of Pediatric Surgery, AIIMS, New Delhi, India

Aim: To present our experience including long-term results of iso-peristaltic gastric tube (IGT) procedure for esophageal replacement.

Materials and Methods: Prospective study since 2006 on 33 patients (M:F=24:9) who underwent IGT in follow-up cases of intractable corrosive structure (n=22) and diverted esophageal atresia (n=11). Mean age at surgery 58 months (11 months-13 years) and mean follow-up 52 months. Observation parameters included clinical symptomatology, complications, need for esophageal dilatation, barium swallow & cine-esophagogram, esophageal manometry, 24-hour pH monitoring and Tc99 scan.

Results: IGT was offered in 32/33 patients. Splenectomy or pancreatic mobilization were not required;. (31/32) are well without reflux related symptoms. One had partial graft necrosis & the tube was taken down. Leaks observed in 11: minor, n=7, managed conservatively and major, n=4, required diversion & 1 death. Dysphagia in 7. Results of Cine esophagogram, esophageal manometry, 24-hour pH monitoring and Tc99 scan were encouraging.

Conclusions: IGT offers mucosa-lined, serosa-covered conduit for esophageal replacement with potential for extra-length for strictures involving the hypopharynx.

   Single Stage Trans-Vestibular Foleys Assisted Female Epispadias Repair and Bladder Neck Tightening Category: Urology Top

Minu Bajpai, Kanika Sharma, Prabudh Goel, Manisha Jana, Dalim Baidya

Department of Pediatric Surgery, AIIMS, New Delhi, India

Aim: To present our results of Single Stage Trans-Vestibular (SSTV) Foleys Assisted Female Epispadias Repair and Bladder Neck tightening.

Methods: Retrospectively collected data on eight consecutively operated cases of female epispadias with this technique over 4 years with mean follow up of 1 yr 10 months (range 6 months- 3.5 years). Observation parameters include post-operative complication, urinary continence, post-void residue, Oblique micturating profile on VCUG and upper tract status.

Results: The surgical technique is discussed and demonstrated. Post-operative complication- none significant. No episodes of UTI. Continence status: 6 patients had good stream of urine, 1 had dribbling while voiding and post void dribbling noted in 1. Occasional wetting of underpants noted in 2. In VCUG: 1 patient demonstrated unilateral Vesicoureteric reflux. In Ultrasound KUB: Postvoid residue (PVR) was noted (insignificant,=6, 18 ml in 1 and 40 ml in 1 patient). Upper tracts: (appearance or worsening of HDUN, fall in GFR or new scars on DMSA scan) was noted in none.

Conclusion: The feasibility of the technique is enhanced by the short female urethra and co-existig pubic diastasis. The results are promising in the short term, and all patients are being closely followed up.

   Congenital Giant Megaureter with Duplex Renal Moiety Presenting as an Abdominal Lump in a Toddler Category: Urology Top

Aravindh Radhakrishnan, Ashish Kumar Tiwari, Shishir Kumar Jha, Yogesh Kumar Sarin

Department of Pediatric Surgery, Maulana Azad Medical College and Assoc. Lok Nayak Hospital, New Delhi, India

Background: Congenital giant megaureter (CGM) with duplex renal moiety is uncommon in the pediatric population.

Case Report: A 2-year-old male child presented with a mildly tender, cystic abdominal mass occupying right lumbar and right iliac fossa region. He also had a right impalpable undescended testis. Ultrasonography showed mild right hydronephrosis with an elongated tortuous structure from right renal pelvis to urinary bladder of diameter 4.2 cm. MCUG revealed indentation on dome of bladder on right side;no VUR. Renal diuretic scan revealed mildly hydronephrotic, good-functioning right kidney. DMSA also showed similar findings; no scars. The cystic swelling was drained via pigtail catheter which drained 200-300 ml of urine daily for initial few days then started draining purulent fluid. Contrast study revealed a blind ending structure. An MRU would have been a better option but could not be done. Cystoscopy revealed a rather medially placed left ureteric orifice and laterally placed right ureteric orifice that allowed passage of guide wire. No ureterocele was noted. Exploration revealed right renal duplex moiety. The upper moiety was just a nubbin of parenchyma and its ureter was massively dilated and ended blindly with no communication with the bladder. Right upper moiety nephro-ureterectomy and right orchidopexy was done. HPE revealed dysplastic upper moiety.

Conclusion: CGM should be considered as one of the differential diagnoses in children presenting as abdominal mass.

   Is Propranolol Useful in Hepatic Vascular Lesions? Category: Hepatobiliary Top

Prema Menon, Shailesh Solanki, KLN Rao

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aims: To assess the effectiveness of propranolol in liver hemangiomas.

Materials and Methods: All patients of liver hemangiomas during the past 4 years were included in this study. Serum AFP, ultrasound with Doppler and CECT abdomen were performed. Patients were managed on medical management with oral propranolol given at 1 mg/kg/dose twice a day. They were assessed for reduction in size of the lesions based on ultrasonography with Doppler and CECT abdomen in the follow up.

Results: Three patients aged less than 1 year were managed during this study period. The lesions occupied a significant area of liver. All responded to propranolol with no side effects. There was considerable reduction in size in the first 3 months of start of therapy. There were no side effects of the drug.

Conclusions: Propranolol is useful in visceral hemangiomas similar to its effect noted in cutaneous lesions.

   Gubernaculum Preserving Orchidopexy Category: Urology Top

Muni Varma, Gaurav Singh, Rupa Banerjee, Sugandh Aggarwal, Aparajita Mitra, Satish Kr. Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aim: Testicular survival after Fowler Stephens (FS) staged orchidopexy is about 50%. We present gubernaculum preservation during 2nd stage Fowler Stephens procedure to augment testicular blood supply.

Methods: Three cases of intra-abdominal testes (Unilateral) underwent FS 2 staged orchidopexy with gubernaculum preservation between Feb.2016 and March 2018. All the testes could be brought down in the scrotum. The interval between FS 1 and FS 2 was 9-13 months. All were done with laparoscopic assistance. Inguinal incision, as in open orchidopexy, was made to dissect the gubernaculums, which was left attached to the scrotum and the testis.

Conclusion: All 3 were successful. Short term follow up has shown no testicular atrophy. Limitation of this technique is that Prentiss manoeuvre cannot be done.

   Duodenum Inversum with Trachea-Esophageal Fistula: An Unusual Association Category: Neonatal Surgery Top

Shubhalaxmi Nayak, Monika Bawa, Jaskaran Randhawa, Ravi Kanojia, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim: Duodenum Inversum (DI) is a congenital malformation in which third portion of duodenum, instead of continuing leftward to ligament of Treitz, reverses direction and travels in a superior, posterior track prior to crossing the midline above the pancreas. It is usually associated with pancreatic anomalies. It's association with trachea-oesophageal fistla (TEF) has not been reported in the literature to the best of our knowledge.

Method: To present diagnosis and management of 2 cases of incidentally diagnosed Duodenum inversum in operated cases of Tracheo-esophageal fistula.

Results: Two newborns underwent right postero-lateral thoracotomy, fistula ligation and an end to end anastomosis of the esophagus for type C TEF. Post-operative period was uneventful and they were discharged on oral feeds on post-operative day 13 and day 10 respectively. Contrast esophagogram done at 3 months follow up revealed duodenal inversum. Both the patients are now almost two years old and are asymptomatic.

Conclusion: DI is a rare, often asymptomatic condition which may occur in association with EA-TEF. This emphasizes the need to look for this condition in the contrast esophagogram and consider DI as an entity which might lead to increased symptoms of GERD in these patients.

   Intraoperative Dilemmas in Polyorchidism: Orchidopexy Versus Orchidectomy!! Category: Urology Top

Priyanka Garg, Nitin James Peters, Muneer A Malik, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Background: Polyorchidism is the presence of more than two testicles. It is a rare urogenital disorder, with fewer than 200 cases reported in medical literature. Intraoperative decision of orchidectomy or orchidopexy depends upon the type of supernumerary testis. We present 2 cases and review the management guidelines.

Case Report: Two boys, 5 years and 4 years old respectively, presented with the complaint of absent testis in left hemiscrotum since birth. In both patients testis were palpable in the superficial inguinal pouch. Both patients underwent inguinal exploration. Intraoperative findings – Patients 1: 1*1.5 cm testis was found in inguinal canal along with another structure 0.75*0.75 cm with separate vas deferens and epididymis. Patient 2: 1*1.2 cm testis along with another structure measuring 1*1 cm with separate vas deferens and epididymis was seen found in the inguinal canal. Sub dartos pouch orchidopexy was done for both testis, in both boys. Viability of supernumerary testis was confirmed with doppler study in the postoperative study. Both patients are doing well on a close follow up over 1.5 years.

Conclusion: Malignant and fertility potentials need to be kept in mind while deciding about orchidopexy or orchidectomy. These patients need to be followed up, clinically and radiologically, over an extended period of time.

   Lessons Learnt from Antenatal Detection of Abdominal Malformations Category: GI Surgery Top

Nilesh Tank, Monika Bawa, Ravi Kanojia, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Objective: To study the various presentations and outcome analysis of fetal abdominal anomalies.

Materials and Methods: 59 mothers with antenatally detected various abdominal anomalies in fetus were studied prospectively from 2015 to 2018. Absence of stomach bubble (ASB), prominence of stomach bubble (PSB), double bubble (DB), echogenic bowel (EB) and abdomino-pelvic cyst (APC) diagnosed antenatally were included in the study.

Results: Out of 521 mothers antenatally detected with some fetal anomaly, 59 had abdominal malformation including ASB (12/59), PSB (8/59), DB (8/59) and APC (20/50). Average gestational age at diagnosis was 23.4 weeks. ASB was found to be associated with other systemic malformations (9/12) and carried a poor prognosis. PSB fetuses were born with normal stomach (6/8). Other two succumbed due to associated systemic malformation. Double bubble sign predicted duodenal atresia in almost all patients (7/8). Echogenic bowel carries a good prognosis as 10 out of 11 fetuses were born normal. Meconium pseudo cyst was found in 3 out of 20 patients of APC while urachal cyst and omphalocele were seen in 2 and 1 patient respectively. These patients were operated in post-natal period. Remaining 14 patients had benign cyst (average size -39.6 x 35.5 mm) in abdomen and are being managed conservatively.

Conclusion: Fetal abdomino-pelvic cysts carry a good prognosis and do not necessarily require surgery. Double bubble is a strong diagnostic sign of duodenal atresia. Prominent stomach bubble should not be a cause for worry.

   Giant Bednar Tumor in a Child: A Rare Clinical Entity Category: Surgical Oncology Top

G Vidhya, Nitin James Peters, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim: Bednar tumor is a rare pigmented variant of dermatofibrosarcoma protuberans (DFSP). It has intermediate malignant potential. We present a case and its surgical management.

Case Report: A 2 year old male, presented with a painless slow-growing, pigmented and hairy mass over the lumbosacral region since birth. On examination there was a 8 x 7 cms firm to hard bosselated mass over the LS region. The mass was freely mobile over the back muscles. There were three other small pigmented lesions (1 x 3 cms). MRI and FNAC suggested possibility of DFSP. The patient was treated complete excision of the tumor with 2 cms margins and local rotational flap cover. Histological examination of the biopsy specimen revealed Bednar tumor. Patient is disease free over a 1.5 years old followup.

Discussion/Conclusion: DFSP is an uncommon disease in children and Bednar is a rare variant. Wide surgical margins are curative however these patients need to be followed up due to the intermediate malignant potential.

   Mediastinal Enterogenous Cyst in a Neonate: Challenges in Management Category: Neonatal Surgery Top

Shubha R Nayak, Nitin James Peters, Ram Samujh, Sandhya Yaddanapudi

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim/Background: Mediastinal cysts presenting with respiratory embarrassment at birth are rare. We present a case and discuss the management options.

Case Report: A preterm male, antenatally diagnosed, left mediastinal cyst presented with respiratory distress at birth. Ultrasound and Xray were suggestive of a large 5 x 3.3 cm cystic lesion in the left upper chest with mediastinal shift. In view of poor ventilatory compliance and circulatory collapse, the patient underwent USG guided aspiration of cyst. CECT chest showed, two cystic lesions 4 x 3 cms and 2 x 2.5 cms in the posterior mediastinum, with no definite communication with oesophagus or the trachea. After initial stabilization, the patient underwent thoracotomy and cyst excision. Intraoperatively, a large thick walled bilobed cyst of size correlating with CT scan was seen arising from the posterior mediastinum. No communication was identified with the oesophagus or the tracheobronchial tree. Histopathology revealed features of jejunum. The patient is doing well on a 9 months followup.

Conclusion: Management protocols for neonates with large mediastinal masses, depend upon severity of the symptoms, size of the mass & physiological derangements. A staged approach of aspiration followed by definitive surgery is a sound treatment protocol, in cases with respiratory distress.

   Is Pneumothorax Always a Pneumothorax? Category: Thoracic Surgery Top

CN Vysakh, Ranjith P

Department of Pediatric Surgery, Goverment Medical College, Kozhikode, Kerala, India

Aim: To present a case series of atypical presentation of CDH with partial gastric volvulus managed initially as pneumothorax.

Materials and Methods: 5 patients with atypical presentation of CDH with partial gastric volvulus, who were managed initially as pneumothorax elsewhere were studied. All had trivial trauma, followed by respiratory distress. 2 patients were treated with ICD, one with thoracocentesis were referred to our center for further management. Other 2 patients were send to our department for emergeny ICD insertion. All these patients were further evaluated in our department and found to have CDH with gastric volvrulus.

Results: All were managed with emergency laparotomy and CDH repair. Perforation was closed and gastrostomy done in 2. One patient had post op collection which demanded a relaparotomy and drainage. All patients are asymptomatic on follow up.

Conclusion: Atypical presentation of CDH may mimic pneumothorax, especially in older children with history of trauma. Gastric contents on thoracocentesis, contrast studies and emergency CT may help in these situations.

   Rare Benign Renal Tumors in Pediatric Age Group Category: Surgical Oncology Top

Saalim Nazki, P Menon, KLN Rao, S Solanki, M Bawa, M Muneer

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Background: Renal tumours other than Wilms' tumor especially benign ones are extremely rare in childhood.

Aims: To review all cases of benign renal tumors presenting between 2006 to 2018.

Materials and Methods: All cases of benign renal tumors in children surgically managed in a tertiary care pediatric surgery centre were reviewed. Patients with Wilms tumor, rhabdoid tumor, lymphoma and other malignant tumors were excluded from study.

Results: Total of eleven patients presented with benign renal tumor, 91% being male age varying from 6 weeks to 15 years. Most common presenting symptom was accidentally noticed swelling 9 (81%), one patient had gross hematuria and other was a case of antenatally diagnosed renal mass. All patients had preserved renal function. Complete excision of the tumour along with Gerota”s fascia was possible in all cases without tumour rupture or spillage. Histopathology confirmed multilocular cystic/multicystic/cystic nephroma 4 (36%), mesoblastic nephroma 4 (36%), angiomyolipoma 2 (18%), and immature teratoma 1 (9%) with no malignancy and infiltration. All patients did well in the immediate and long term follow up.

Conclusions: All renal masses are not wilms tumor and the less common histopathological variants should always be considered while dealing with them. The future line of management and prognosis changes entirely for malignant and benign tumors

   Esophageal Atresia Associated with Other Gastro Intestinal Malformations: Retrospective Analysis Category: Neonatal Surgery Top

Swapnil Pattanshetti, Prema Menon. KLN Rao, Bawa Monika, Muneer Malik, Nitin Peters, Shailesh Solanki, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

To analyze the outcome of neonates having esophageal atresia (EA) associated with other gastrointestinal (GI) malformations.

Methods: A retrospective study of neonates having EA with or without tracheoesophageal fistula (TEF) with other GI malformation like Ano-rectal malformations (ARM) and Duodenal atresia (DA) from 2005 to 2018. Demographic details, age at presentation, weight, type of surgery, duration of surgery, complications and outcome were analysed.

Results: Total 88 eligible patients were studied. There were 52 males and 36 females. 68/88 (77 %) patients had ARM,23+4/88 (30 %) patients had DA. 10/88 (11%) had Triple atresia (TEF+ARM+DA). Analysis revealed that the survivors had significantly better birth weight, better gestational age, negative sepsis screen, no cardiac diseases, no pneumonia. Survival rate in study was more than 60 %.

Conclusion: It is challenging to manage TEF with multiple GI anomalies. Mortality rates in such associations, especially in triple atresia remains high.

   Does Laparoscopic Appendectomy Score over Open Appendectomy in Complicated Appendicitis? Category: GI Surgery Top

Richa Misra, GS Murali, S Ramesh, BC Gowrishankar

Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Introduction: Laparoscopic appendectomy in Complicated appendicitis (CA) has reservations as it is technically demanding.

Aim: To compare the outcomes between open appendectomy (OA) and laparoscopic appendectomy (LA) in (CA).

Methodology: In the retrospective study of 95 patient performed at a tertiary care referral hospital who underwent appendectomy (lap or open) for (CA) included appendicular abscess/mass/and perforation with localized/disseminated peritonitis detected pre/ intra-operatively. Data analyzed based on duration of intra-operative findings, operative time, conversion to open appendectomy and the reason for conversion. Post-operative details - hospital stay, complications and resurgery were noted.

Results: A total of 95 patients underwent surgery for (CA) Of which 39 / 95 patients underwent (LA) whereas 56/92 patients underwent (OA). 9 / 37 (LA) was converted to (OA). Operative time for (LA) was longer comparatively Average duration of hospital stay was shorter in (LA). The Post-operative complications were noted in both the groups were 12 /39 of (LA) and 18 /56 in (OA). Common complications in laparoscopic group were observed as SAIO followed by IAA in (OA) most common complication was SSI. Re surgery was required in 8 number of patients of which 5 were in laparoscopy group and 3 in (OA).

Conclusion: Laparoscopic appendectomy is definitely feasible in complicated appendicitis and despite its few challenges has advantage over (OA)

   Non-Neonatal Presentation of Congenital Diaphragmatic Defects Category: Thoracic Surgery Top

Manisha Reddy, Narendra Kumar, Anil Balraj, Srirampur Srinivas, Syam Babu Peeka

Department of Pediatric Surgery, Niloufer Institute of Women and Child Health, Hyedrabad, Telangana, India

Aim: To study the age of presentation, mode of presentation, management and complications of congenital diaphragmatic defects in non-neonatal patients.

Materials and Methods: An observational study of 26 non-neonatal cases that presented to the Department of Pediatric Surgery, Niloufer Instituite for Women and Child health, Hyderabad, Telangana over a period of 2 yrs (june 2016- june 2018).

Results: 26 (47%) out of 55 cases of congenital diaphragmatic defects observed in 2 y period, presented beyond the 1st month of life. Out of the 26 patients, 10 (38%) presented with left diaphragmatic eventration, 9 (35%) patients presented with right diaphragmatic eventration, 4 (15%) had anterior diaphragmatic defects, 3 (11%) presented with hiatus hernia. 2 out of the 26 patients presented with failure to thrive and acute abdomen due to gastric volvulus, which resulted in mortality of 1 patient.

Conclusion: 47% of the cases of diaphragmatic defects presented late in life, over a period of 2 m of age to 13 yrs of age, concluding that nearly half of the cases remain undiagnosed till they become symptomatic with acute upper respiratory tract infections or rarely with acute abdomen. Although most of the non-neonatal cases present with mild symptoms, risk of mortality is high when the patients present with acute symptoms thus mandating a vigilant outlook for patients with non-specific symptoms.

   A Case Report of Non-Neonatal Duodenal Perforation Category: Neonatal Surgery Top

Manisha Reddy, Narendra Kumar, Anil Balraj, Srirampur Srinivas, Syam Babu Peeka

Department of Pediatric Surgery, Niloufer Institute of Women and Child Health, Hyedrabad, Telangana, India

Review of Literature: Spontaneous duodenal perforation in newborn period is a rare entity. Perforations of foregut are rare of which gastric and ilea are common. The common cause of perforation being, Necrotising enterocolitis, aggressive resuscitation, distal obstruction or stenosis. Case Report: A 2 day of life male child with no history of trauma, instrumention or comorbid conditions presented with abdominal distension. X Ray erect abdomen revealed pneumoperitoneum. Intraoperative findings included a perforation in the posterior aspect of first part of duodenum. Perforation was closed in a single layer with a Graham's patch, feeding jejunostomy done.

   Initial Management of Cloacal Exstrophy with Omphalocele: A Case Report Category: Miscellaneous Top

TK Jayakumar, Kirtikumar J Rathod, Avinash Jadhav, Arvind Sinha

Department of Pediatric Surgery, AIIMS, Jodhpur, Rajastan, India

Cloacal exstrophy is a rare congenital abnormality where there is exstrophied cecum with hemi-bladders on either side. Cloacal exstrophy with omphalocele, imperforate anus and spinal abnormality (OEIS complex) with reported incidence between 1 in 3-4 lakhs. Etiology is unknown. Management includes omphalocele repair, separation of ileocecal plate from hemi-bladders, stoma formation and bladder repair.

Case Report: A full term baby born through normal vaginal delivery was brought to hospital on first day of life. On examination the baby had anterior abdomen wall defect, large omphalocele, exstrophied cecum with hemi-bladders on either side with visible ureteral orifices in respective hemi-bladder plates, no anal opening, ambiguous genitalia, pubic bone diastasis, club foot, and atrial septal defect on ECHO. Karyotyping revealed 46XX. Surgery was done on day 2 of life. Intraoperatively omphalocele contained liver, small bowel, and spleen. Cecum was foreshortened, blind-ending, was separated from the hemi-bladders and midline suturing of the bladder plate was done. Ileostomy was made. Omphalocele was repaired and abdomen wall was closed.

Conclusion: Cloacal exstrophy is a challenging disease to be managed and requires multi-disciplinary support involving pediatric surgeons, pediatricians, pediatric anesthetists, radiologists and cardiologists.

   Short Oral: Type Iv Congenital Pouch Colon in Male Children; Anatomical Variation and a Proposed New Classification Category: GI Surgery Top

Shailesh Solanki, Prema Menon, Shubha Laxmi, KLN Rao, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Background: Congenital Pouch Colon (CPC) is a rare variant of anorectal malformation. In male patients, CPC communicates distally with the urogenital tract by a large fistula. Here we are discussing the CPC cases which do not fulfill the criteria as mentioned in the classical description along with its pertinent literature.

Materials and Methods: Retrospective study from Jan 2004 to Dec. 2017 of male children with type IV CPC. We evaluated clinical presentation, primary management, anatomical relationship, previous surgical intervention, definitive management, result and outcome in terms of continence status on Templeton score.

Results: Fifty one children were included in the study and it was found that 36 children with CPC had colovesical fistula (group 1) and 15 children (group 2) had no communication of pouch with the genitourinary tract. For group 2 children, the clinical presentations and management were varied; four children underwent primary pull through procedure while eleven children underwent staged procedure, including three children where anal canal was preserved during definitive procedure. On continence assessment, only one child in group 1 and four children in group 2 had “good” continence score.

Conclusion: CPC can present without genitourinary tract communication (fistula), contrary to its emblematic description. Awareness about anatomical variations and adaptation of surgical technique accordingly is vital. The identification of the anal canal (nonetheless it seems dysplastic) and incorporation of this in bowel continuity, leading to better outcomes

   Our Experience of Laparoscopic Pyloromyotomy with Ultrasound-guided Parameters Category: Laparoscopic Surgery Top

Aboli Hukeri, Abhaya Gupta, Paras Kothari

Department of Pediatric Surgery, LTMGH, Mumbai, Maharashtra, India

Aims: The aim of this study was to assess the use of ultrasound guided parameters for laparoscopic pyloromyotomy.

Methods: This is a retrospective study, carried out from June 2012 to June 2017 in a tertiary center, in which 48 patients were operated by laparoscopic pyloromyotomy. After initial resuscitation of patients with IHPS, laparoscopic pyloromyotomy was carried out. We took the help of ultrasound parameters to plan our length of pyloromyotomy and of the blade of endoknife. We used the non insulated part of the grasper to plan the length of our incision on the tumor. The length of the endoknife, used for pyloromyotomy incision, was kept 1 mm less than the size of pyloric muscle thickness (estimated by pre-operative ultrasound) to prevent any accidental mucosal injury. At the end of procedure, adequacy of pyloromyotomy was confirmed once the estimated operative length equaled or exceeded the ultrasound measurement. Mucosal integrity was checked by inflating air in stomach.

Results: None of our patients of laparoscopic pyloromyotomy suffered from inadequate pyloromyotomy or mucosal perforations.

Conclusion: We found 'use of ultrasound guided parameter for laparoscopic pyloromyotomy' as an attractive and considerable option to achieve adequacy and safety.

   Using a Flap to Bridge the Gap in Robotic Dismembered Pyeloplasty: A first Report Category: Urology Top

Vijaymahantesh S Samalad, VijayMahantesh Samalad, M Aparajita, P Rajiv, V Sripathi

Department of Pediatric Surgery, Apollo Children's Hospital, Chennai, Tamil Nadu, India

Aims: During Robot Assisted Laparoscopic Pyeloplasty (RALP), after dismemberment and ureteral spatulation, a large gap was bridged by utilising a flap from the renal pelvis. This is a modification of Anderson-Hynes concept proposed in 1949. In this paper we outline our results with this new technique.

Materials and Methods: All children undergoing RALP at our institution were reviewed. Those children in whom a flap was used were analysed in detail for various parameters and outcomes.

Results: In the last five years 113 children underwent RALP. In 32 a pelvic flap was used. Seven were infants. Pre-operative functional studies revealed >50% had ipsilateral function of less than 40%. Average pelvic diameter requiring a flap was 3.2 cm. Average console time was 84.8 min with no conversions. Average hospital stay was 4.2 days. Two infants developed severe urosepsis in the post-operative period which necessitated placement of a percutaneous nephrostomy. In one infant the cause was a slipped DJ stent. One child had an equivocal drainage who is under follow-up. In all other cases there has been a satisfactory improvement in drainage and function as well as resolution of hydronephrosis after stent removal.

Conclusions: Pelvic flap creates a dependant, funnel shaped and wide anastomosis. Ureteric traction and ischemic strictures at the PUJ are prevented. In those children with poor renal function and a large pelvis the need for a flap should be kept in mind. To our knowledge this concept has not been reported to date in paediatric MAS literature.

   Shehata Traction Orchiopexy Category: Urology Top

Kedar P Mudkhedkar

Department of Pediatric Surgery, SETH GS Medical College and KEMH, Mumbai, Maharashtra, India

Objective: To demonstrate Shehata Traction Orchiopexy, a novel 2 stage procedure used in nonpalpable undescended testis, where elongation of testicular vessels is achieved by applying gradual traction. The weight of the intestine and regular and repeated movement of the abdominal muscles aid in the stretching of the vessels.

Methods: Laparoscopically, the gubernaculum is divided and the peritoneum lateral to the testicular vessels is incised. The testis is fixed near the contralateral anterior superior iliac spine. The Second stage is planned after 6 months.

Results: Testicular position, size and vascularity are assessed by USG and colour Doppler. Parameters for success of the procedure are scrotal testis, normal size and good vascularity as assessed by Doppler whereas high scrotal position, impaired vascularity and smaller size are considered to be a failure. In our experience, 4 patients have undergone both stages with 2 completing a follow up at 6 months, with the testis well positioned at the bottom of the scrotum.

Conclusions: Shehata's technique is a safe and feasible novel method which provides adequate length for placing the testis comfortably in scrotum. However more studies are required and longer follow up to assess results in detail.

   Stem Cell Therapy in Cerebral Palsy Category: Experimental/Basic Sciences Top

Sagar Jawale

Department of Pediatric Surgery, Jawale Institute of Pediatric Surgery, Jalgaon, Maharashtra, India

Introduction: Institutional Ethics Committee (IEC) and institutional Committee for Stem Cell Research (IC-SCR) permission taken. Stem cell laboratory established in just Rs. 50,000 instead of Rs. 30 lacs and cost of therapy dropped to Rs. 50,000 instead of 3-5 lacs in India.

Method: In last 3 years I did 28 cases of CP with stem cell therapy, 15 cases were quadriplegic, 11 paraplegic and 2 monoplegic. 18 patients had squint in the eyes. 61 cases were put as control, 30 were quadriplegic, 28 paraplegic and 3 were monoplegic. 31 cases had squint in the control group. The patients were examine at 3 monthly intervals. Maximum follow up was 3 years and minimum of 6 months.

Procedure: Since these children are malnourished and fat has 3000 times more stem cells than bone marrow, half the omentum was excised to be used as a source for stem cells. It is reported for the first time in medical literature. Stem cells obtained by enzymatic digestion of fat with Type 1 collagenase enzyme. Half the quantity is given IV and another half intrathecally into CSF with 20 mg/kg methylprednisolone drip.

Results: The spasticity was significantly reduced in 25 out of 28 patients in 6 months. The squint was regressed completely in 15 patients and partially in 3 in 6 month time (reported first time) 7 patients had faulty deglutition and 6 of them had 75 % regression of symptoms. There was no mortality. 11 patients had improvement in hearing and 7 patients had improved vision according to parents.

Conclusions: Stem cell therapy is safe and effective in cerebral palsy. Although the early results are encouraging, we need more research on it to prove it in cerebral palsy.

   Pancreatico-Duodenal Trauma in Children- Our Experience Category: GI Surgery Top

Subhankar Chakravorty, Somak Krishna Biswas. Kalyani Saha Basu. Sumitra Kumar Biswas

Department of Pediatric Surgery, Nil Ratan Sarkar Medical College and Hospital, Kolkata, West Bengal, India

Pancreatico-Duodenal injuries, though rare, pose a mighty challenge to the surgeon…. in both diagnosis and management. even more so in children, where the patho-physiologic threshold is low. In this era where life travels in the fast lane, high speed Road Traffic Accidents floods the emergency rooms, of metropolitan city referral hospitals and suburban centres alike. We, here at NRS medical college & hospital, a regional referral tertiary care teaching hospital in Kolkata, studied, over 2 yrs. The epidemiology of RTA's with special reference to management of Pancreatico-Duodenal injuries.

Aim: (1) To study the incidence of abdominal trauma and focus on diagnosis and management of pancreatico duodenal injuries. (2) To find out the mortality and morbidity of such patients at our hospital and compare them with the standard world literature. (3) In the process, establish standard operating protocols and institutional guidelines for management of pancreatico-duodenal traumas.

Methods: (1) NRSMCH. (2) July 2016-july 2018. (3) Descriptive observational.

Results: Between July 2016 to July 2018, 238 cases of abdominal trauma were managed in our department. Out of which pancreatico duodenal trauma were found in 8 patients, pure pancreatic trauma in 3 and duodenal only in 3. Associated injuries include jejunal - 4, colonic - 1 and vascular injury in 1 baby.

Conclusion: Diagnosis of pancreatico duodenal injuries require high index of suspicion and early diagnosis. There should be provision for good post operative care with multidisciplinary approach and facilities for parenteral nutrition should be available.

   Choledochal Cysts: A Retrospective, Single Institutional Study Category: Hepatobiliary Top

Rajasekhar Addagatla, Amita Sen, Ritesh Kumar, Sandeep Kumar, Pinaki Ranjan Debnath, Vijay Kumar Kundal, Atul Meena, Shalu Shah

Department of Pediatric Surgery, PGIMER and Dr RML Hospital, New Delhi, India

Aim: To study the clinical and management aspects of pediatric choledochalcysts (CC).

Methods: This is a retrospective study conducted in the department of pediatric surgery at PGIMER & Dr. Ram Manohar Lohia Hospital, New Delhi comprising 16 patients of choledochal cysts treated surgically from March 2010 to April 2018. We reviewed the data of patients of CC attending the follow up clinic and documented clinical, surgical and follow up details.

Results: Our study comprises 16 children with CC with an average age 6.62 years (ranging from 11 months to 15 years), 13 children had type I CC and 3 had type IVa. Cyst excision with Roux-en-y Hepatico-jejunostomy (RYHJ) was performed in 13 and Hepatico duodenostomy (HD) was done in 2 patients, ERCP and stenting in one patient. Complications like choledochal stones (3), cholangitis (3), wound infection (2) and pancreatitis (1) were seen. Mean follow up period was 24.2 months (ranging from 3 months to 52 months).

Conclusion: CC is very rare congenital anomaly (1 in 30,000), needs a proper preoperative diagnosis and subtype identification to provide prompt surgical therapy and requires long term follow up to identify late postoperative complications and malignancy.

   Laparoscopic Management of Complicated Diaphragmatic Eventrations Category: Laparoscopic Surgery Top

R Madhu, Apurva Arora, Selvapriya Bharti, Jegadeesh Sundaraman, Prakash Agarwal

Department of Pediatric Surgery, SRMC and RI, Chennai, Tamil Nadu, India

Background: Eventration of diaphragm associated with gastric volvulus is a rare but potentially life threatening condition. Wandering spleen and gastric volvulus are two rare entities that have been described in association with diaphragmatic hernia. We describe two such cases which have been successfully managed by laparoscopic repair.

Materials and Methods: Case 1 - 10 yr old boy presented with acute pain abdomen and vomiting was diagnosed to have left eventration of diaphragm with gastric volvulus with wandering spleen and ascended left kidney. He was successfully treated with laparoscopic left eventration repair with splenopexy and gastropexy. Intra and post op was uneventful. Case 2 - 1 yr old infant presented with multiple episodes of non bilious vomiting and abdominal distension. On evaluation infant was diagnosed to have eventration of diaphragm with gastric volvulus. Child underwent laparoscopic detorsion of the stomach, eventration repair and gastrostomy. There were no intra and post op complications.

Conclusion: The association between diaphragmatic eventration, gastric volvulus, and wandering spleen is rarely described and laparoscopic management though technically challenging is safe, effective procedure with low morbidity.

   Evaluation of Effect of Propranolol on Serum Vegf and Timp 2 Levels in Infantile Hemangioma Category: Experimental/Basic Sciences Top

Anand Pandey, Wahid Ali, Abhishek Singh, SN Kureel, A Gupta, A Wakhlu, Jiledar Rawat

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Introduction: Currently, propranolol is preferred drug for treating hemangioma. In this study, we attempted to assess whether propranolol has any effect on VEGF and TIMP 2 over a period of time, and if it is there, how long it affects it.

Materials and Methods: Propranolol was administered in the dosage of 2-3 mg/kg. The first serum sample was collected before starting the propranolol treatment. Thereafter, samples were collected at monthly intervals up to a total of six samples. The samples were assessed for TIMP-2 and VEGF using ELISA kit.

Results: The total number of patients in this study was 10. Eight patients responded to treatment. The mean value of baseline VEGF was 0.234±0.059 and that of TIMP-2 was 1.338±0.679. As compared to baseline value, the p value was statistically not significant in any of sequential values. The patients in the good response category showed statistically significant changes in mean VEGF levels at the end of first month only. TIMP-2 mean values also showed statistically nonsignificant variation in the levels observed at different interval.

Conclusion: Despite its beneficial action in regression of hemangioma, the exact mechanism is yet to be identified. The exact duration of treatment needs further evaluation.

   Significance of Penile Anthropometry as a Tool for Assessment of Postoperative Outcome in Distal Hypospadias Repair Category: Urology Top

Hinglaj Saha, Kaushik Saha, Dipak Ghosh

Department of Pediatric Surgery, Nil Ratan Sircar Medical and Hospital, Kolkata, West Begal, India

Aims: To assess the postoperative outcome of patients who underwent urethral mobilization by comparing the anthropometric data in cases of same age with distal type of hypospadias with and without complications. Anthropometric datas include midglans diameter at glans level, midpenile diameter, ventral length of glans penis, urethral plate width and stretched penile length.

Methods: An observational longitudinal study from August 2016 to Jan 2018. 52 patients out of 70 were included in the study population after excluding genital, genetic, cardiac and endocrine anomalies, unfit for anesthesia, beyond age limit (1 to 12 yrs). Penile anthropometry was measured using Vernier skin calliper preoperatively. All cases underwent urethral mobilization and postoperative outcome was analysed with anthropometry values of the same age group with same type of hypospadias with and without complications.

Results: Complications were meatal retraction (n=3), wound dehiscence (n=2), urethrocutaneous fistula (n=1), meatal stenosis (n=1). Group A, 2 yrs, distal penile type (urethrocutaneous fistula with wound dehiscence), Group B, 11 yrs, coronal type (meatal retraction with wound dehiscence), Group C, 5 yrs distal penile with retraction compared with Group A', B', C' without complication respectively revealed (p= 0.227, p=0.170, p=0.202 respectively) significant. Positive correlation was seen between age and the anthropometric variables. Coefficient Correlation was between r= 0.30 to 0.40 for SPL, VL, Gdcl, MPW.

Conclusion: Penile anthropometry provides a guide to predict the outcome of hypospadias repair which in turn will help in preoperative counselling of patients. It was found that where the distance between the glans tip and the hypospadiac meatus is less than 1.5cm, the results are comparatively better. It can become an important documentation for future assessment of a surgical procedure helping us to choose the better technique for same type of hypospadias.

   Functional Evaluation of Results of Tips Repair with Uroflowmetry Category: Urology Top

Shyamendra Pratap Sharma, Pranay Kumar Panigragi, Arjdeo Upadhyay, Sarita Chowdhary

Department of Pediatric Surgery, Institute of Medical Sciences BHU, Varanasi, Uttar Pradesh, India

Aim: To determine the functional results of Tubularised incised plate urethroplasty technique in Distal penile hypospadias using uroflowmetry.

Methods: The study carried out in the Department of Pediatric Surgery, Sir Sunder Lal Hospital IMS, BHU. 8 Patients with distal penile hypospadias was included in the study. All patients underwent TIP urethroplasty. All patients in the study underwent uroflowmetry preoperatively and postoperatively at 3 months, 6 months. The parameters (maximum urinary flow rate [Qmax], voiding volume [VV], collected. Miskolc normogram were used to compare results were from the two follow ups (Qmax in relation to voided volume and age.

Results: In 8 patients mean age was 6 (4-10) year, none of the patients had chordee,3 has meatal stenosis preoperatively. Preoperatively Qmax mean 7.84 (3.1 – 14.7) ml/sec, postoperatively at 3 months Qmax mean 7.92 (1.8 – 14) ml/sec, at 6 month Qmax 11.3 (4.1 to 18.7) ml/sec. Preoperatively voided volume (VV) mean 161.5 (67- 301) ml, postoperatively VV at 3 month mean 125.8 (60-260) ml, VV S at 6 month mean 155.1 (55-253) ml.

Conclusion: We found increasing trends of Qmax after TIPS repair, results are statistically significant after 6 month follow up. The study is ongoing and patients will be further followed up after 1 year and 5 year.

   Comparative Study of Surgical Outcome Using Tunica Vaginalis Flap, Dartos Flap and Spongioplasty in Distal Hypospadias Surgery Category: Urology Top

Md. Shahid Murtaza, Amita Sen

Department of Pediatric Surgery, PGIMER and Dr RML Hospital, New Delhi, India

Aims: Best possible interveining tissue in single stage distal hypospadias surgery and to compare the risk of urethro cutaneous fistula in all the three procedures.

Methods: The study group consisted of 45 patients of 1 to 12 years of age diagnosed by clinical examination. Children with distal hypospadias underwent urethroplasty with tunica vaginalis flap, dartos flap and spongioplasty. After discharge patients were followed at 2 weeks, 1 month and 3 months for postoperative complication. The patients were randomly distributed in A, B and C group. Each group consisted of 15 patient. All patient were repaired by single stage urethroplasty. Single surgeon performed single type of distal hypospadias repair.

Results: Overall UCF was present in 20.0% (n=3) of TIP/DF, 26.7% (n=4) of TIP/SPONG and 46.7% (n=7) of TIP/TVF cases. On comparing DF with spong. P value was 0.666 which was insignificant. On comparing DF with TVF P value was 0.121 which was insignificant. Overall P value was 0.260 which was insignificant.

Conclusion: In our study we found that incidence of UCF fistula was lowest in DF followed by spongioplasty and TVF. Hence the best layer in our study was DF.

   Symptomatic Mullerian Remnants Category: Urology Top

K Anit Joseph, K Sivakumar

Department of Pediatric Surgery, Government Medical College, Thiruvananthapuram, Kerala, India

Aim: To investigate the clinical characteristics, diagnostic methods, surgical management of prostatic utricular cysts.

Methods: A retrospective analysis of the clinical data and management of three cases of prostatic utricular cysts were done.

Results: All the three cases had recurrent urinary tract infection. Two of them had hypospadias. One among them had papillary adenocarcinoma with distant metastasis, who expired during chemotherapy. The other two underwent excision of the cysts through posterior sagittal Kaplan Piconi approach.

Conclusion: The clinical presentation of Mullerian duct remnant can vary from recurrent urinary tract infection to malignancy and distant metastasis. Surgical excision of the cysts through posterior sagittal approach Kaplan Piconi method is technically feasible and with favourable outcome.

   Role of Mis in Placement of Tenckhoff Catheter for Peritoneal Dialysis Category: Laparoscopic Surgery Top

Subhasis Saha, Sushmita Banerjee, Rajiv Sinha

Department of Pediatric Surgery, Advanced Medical Research Institute, Kolkata, West Bengal, India

Aim: The optimal mode of management of children needing renal replacement therapy remains peritoneal dialysis. We have an experience of managing such children for the last 15 years including with laparoscopic assistance for the last 6 years. In this study we aimed to evaluate the benefits of minimal invasive surgery for this procedure.

Materials and Methods: From May 2003 to July 2018, 45 children (age 2 yr – 16 yr) underwent primary or corrective Tenckhoff catheter placement, 14 of them with laparoscopic assistance. Pneumoperitoneum was achieved by Veress needle technique. Three ports were inserted, umbilical camera port (5 mm), and two 3 mm working ports and the right and the left infraumbilical pararectal areas. Omentectomy was done using ultrasonic energy source. The resected omental segments were kept on the superior surface of the left lobe of the liver. A 10 mm port was inserted under vision on the left rectus muscle a little above and to the left of the umbilicus. The resected omental tags were removed through this port. The 10 mm port was removed thereafter and the Tenckhoff catheter was introduced through the port site. The distal cuff was placed just external to the peritoneum and the peritoneum was tied with a pre placed purse string suture with a bite on the cuff. Tunneling was made to the right and the proximal part of the catheter was taken out by Seldinger technique, the counter incision being made such that the proximal cuff is 2 cm inside the skin exit point. The patency and the back flow of dialysate was checked with passage of 10 ml/kg of heparinized saline. The advantages and disadvantages of open and laparoscopic methods were analysed.

Results: 9 children underwent primary laparoscopic assisted Tenckhoff catheter placement. Average operating time was 65 minutes (50 – 105 minutes). Blood loss was almost nil. 5 patients underwent laparoscopy for blocked or malfunctioning catheter. In 4 of them, the end of the blocked catheter could be taken out from a suprapubic 5 mm port and the blockage removed by flushing with normal saline, and reintroduced. In 1 patient, it had to be replaced.

Conclusion: Laparoscopic approach is beneficial for peritoneal dialysis placement in many ways. It offers a near complete omentectomy. The final position of the tip of the catheter can be checked and if necessary replaced. The patency of the catheter can be documented. Any concomitant inguinal hernia can be repaired.

   Single Port Laparoscopic Inguinal Hernia Repair in Girls Using the Percutaneous Internal Ring Suturing Technique Category: Laparoscopic Surgery Top

Ramesh Tanger, Aditya Pratap Singh

Department of Pediatric Surgery, S.M.S. Medical College, Jaipur, Rajasthan, India

Aim and Objective: Percutaneous internal ring suturing (PIRS) is a percutaneous closure of the internal inguinal ring under the control of laparoscope placed through the umbilicus. We evaluated the usefulness of the PIRS technique in the girls only.

Materials and Methods: 38 girls underwent surgery using this method in our institution between Jan.2016 and June 2018. We used telescope (5 mm, 30°), spinal needle (20 Gauze), and non-absorbable polypropylene 3-0 suture. The insufflation pressure in the peritoneal cavity was maintained at 8 mm to 10 mm Hg.

Results: We selected the isolated cases of the inguinal hernia in the girls only. Only one case need of conversion to open surgery in our study. The recurrence was seen in two cases. One treated by open herniotomy another by laparoscopic PIRS. We did follow up with local clinical examination only.

Conclusion: PIRS technique is an alternative for the open inguinal surgery. It is effective and minimally invasive surgery and without visible scar. It is also useful to detect the other abnormalities and can perform other procedure in same session as contralateral inguinal hernia

   Laparoscopic Pylorpmyotomy Vs Open Pylorpmyotomy Category: Laparoscopic Surgery Top

Jatin M Jadav

Department of Pediatric Surgery, Civil Hospital, Ahmedabad, Gujarat, India

Aim: To study whether laparoscopic pyloromyotomy or open pyloromyotomy is the most effective intervention for treating hypertrophic pyloric stenosis.

Methods: A retrospective study comparing laparoscopic pyloromyotomy and open pyloromyotomy performed at this institution over the period of last 1 year. Both the methods were compared and studied in terms of operating time, time to start first feed, post operative vomiting, length of the hospital stay, post operative complications like wound infection, mucosal perforation, incomplete pyloromyotomy.

Results: Total 40 patients underwent surgery for hypertrophic pyloric stenosis out of which 14 were operated by laparoscopic method and 26 were operated by open method. There is no major difference for operating time and time to first feed in both the methods. Length of the hospital stay is 5-6 hours shorter in laparoscopic method. Postoperative vomiting is more common in open method. No major post operative complication is reported in either of the method.

Conclusion: There is no major difference between the laparoscopic and open pyloromyotomy. Although laparoscopic method has an edge over open method in experienced hands and in tertiary institutes.

   Dorsal Vertical Island Flap Urethroplasty in Children with Hypospadias: Our Experience in 75 Patients Category: Urology Top

GV Ramana Naik, G Chalapathi, J Veeraswamy, G Rajeev Kumar

Department of Pediatric Surgery, Kurnool Medical College, Kurnool, Andhra Pradesh, India

Aim: To assess the results and complications of dorsal vertical island flap (DVIF) Urethroplasty.

Patients and Methods: 175 children were operated for hypospadias in medical college hospital during the period between june 2012- july 2017. Out of 175 children 41 with proximal hypospadias having severe chordee, required two staged urethroplasty. In 18 babies with glanular hypospadias MAGPI procedure was done. In 25 babies with mid and distal penile hypospadias, tabularised incised urethral plate urethroplasty (TIP) was the option.16 babies with unhealthy urethral plate and chordee, were choosed for dorsal vertical tube urethroplasty after excision of urethral plate. Rest of 75 babies with, mid or distal penile hypospadias with no or minimal chordee after degloving and poor urethral plate were choosed for DVIF. These 75 babies with DVIF were followed up for 3 months-3 years to assess complications like urethrocutaneous fistula, meatal stenosis, glans dehiscence, megalo urethra or urethral diverticulum, stricture, penile torsion/rotation.

Results: A total of 75 patients with proximal, mid or distal penile hypospadias in whom DVIF was used during the study period were included in the study. The mean age was 3.7 years, ranging from 8 months to 14 years. 14 patients developed complications (18.6%). Commonest complication Urethrocutaneous fistula was seen in seven[9.3%]. Glans dehiscence was seen 5 Patient [6.6%], one child had meatal stenosis with diverticulum formation. Skin necrosis was noticed in one. In 61 patients stream was good, no torsion, good cosmetic appearance was observed.

Conclusions: Dorsal vertical island flap is good alternate to TIP, in mid and distal penile Hypospadias. Our early experience with DVIF showed acceptable rate of complications and good Cosmetic results.

   An Institutional Experience in the Surgical Treatment of Hepatoblastoma Category: Hepatobiliary Top

Aswathy Ravikumar, GM Asok Kumar, PS Vivek, CS Aravind

Department of Pediatric Surgery, Sree Avittom Thirunal Hospital, Thiruvananthapuram, Kerala, India

Aim: To analyse the clinical profile and outcome of children with hepatoblastoma at a tertiary unit of Pediatric Surgery and Oncology.

Methods: A retrospective observational analysis of all children with hepatoblastoma who underwent surgery between April 2014 and April 2018 was done. All preoperative investigations, operative details and postoperative follow up were reviewed.

Exclusion Criteria: children with hepatoblastoma who were inoperable, received only chemotherapy or underwent only biopsy were excluded.

Results: 12 children were operated for hepatoblastoma in this study period. Median age of presentation was 32 months, 66.7% were males. 91.6% presented with abdominal mass. All children were taken up after neoadjuvant chemotherapy. PRETEXT stage was I in 4 cases, II in 7 cases, III in one case. Complete surgical resection was done in all. Early and late complications were reviewed. Median follow up period was 32 months.

Conclusion: The present series of hepatic resection in hepatoblastoma following upfront chemotherapy demonstrated no significant morbidity and good outcome.

   Necrotizing Fascitis in Children with Assessment of Risk Factors That Influence Outcome Category: Miscellaneous Top

Dilip Kumar Singh, Rajiv Chadha, Partap Singh Yadav

Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India

Aims: To study the presentation, etiological profile, results of laboratory evaluation and assess the risk factors influencing outcome in children (NB- 18 years) with necrotizing fascitis (NF).

Methods: All consenting pediatric patients fulfilling the clinical criteria for diagnosis of NF were included in this prospective observational study. Patients underwent detailed evaluation including clinical, laboratory, radiology and histopathology studiesaccording to a predesigned proforma and were managed as per established protocols.

Results: Thirty eight patients with a mean age of 1.6 years were included in the study; m:f ratio was 1.66:1. Most common site of involvement was lower limb. Boils were the initiating factors in 54% of patients. Mean LRINEC score was 6.39. MRSA was isolated in (48%) followed by MSSA (32%). Mortality rate was 13.15%; majority had sepsis with MODS. Surviving patients didn't have long term sequelae. Need for mechanical ventilation, anemia at presentation & need for transfusions, thrombocytopenia, hypoglycemia at presentation, deranged KFT's, anuria, hypotension and need for inotropes, hyponatremia, acidosis, raised sr lactate, CRP>150 mg/L, hypocalcaemia, delayed debridement affected the outcome.

Conclusions: Necrotizing fascitis affects all age groups, majority of patients have an inciting cause. Most of the pediatric NF is mono microbial and approximately fifty percent are caused by MRSA. Above mentioned risk factors affect the prognosis in NF.

   Outcome of Antenatally Diagnosed Abdominal Malformations Category: Neonatal Surgery Top

Leonard J Ezung, Amit Gupta, S Roy Choudhury, Partap S Yadav, Vikram Khanna, Manisha Kumar, Abha Singh

Department of Pediatric Surgery, Kalawati Saran Children Hospital, Lady Hardinge Medical College, New Delhi, India

Aim: To study the outcome of antenatally diagnosed abdominal malformations.

Materials and Methods: This prospective observational study included all consenting cases of antenatally diagnosed abdominal malformations managed over a two year period.

Results: Out of 34 cases of antenatally diagnosed abdominal malformations, 13 different anomalies were detected. The antenatal diagnosis correlated with the postnatal diagnosis in 22 patients (76%). There were 29 live births (79%), 11 patients (38%) were delivered preterm, 3 patients (fetal ascites-2, echogenic bowel-1) were delivered still born and 1 pregnancy with omphalocele major underwent medical termination of pregnancy. The most common anomaly was duodenal atresia (n=12) followed by mesenteric cysts (n=4). Sixteen patients (50%) were low birth weight; fifteen patients (52%) required surgical intervention postnatally, 2 patients (omphalocele and gastroschisis) succumbed pre-operatively and 12 patients were managed conservatively. Survival to discharge for antenatally detected abdominal malformations was 68% (23 patients), postoperative mortality occurred in 4 patients (27%), all with duodenal atresia. Follow up for three months was uncomplicated.

Conclusion: Antenatal diagnosis helped in prognosticating and planning postnatal management by paediatric surgeons in the appropriate hospital setting. The timely interventions and close follow-up led to favorable outcome.

   Mis: the Best Way to Manage Complicated Appendicitis Category: Laparoscopic Surgery Top

Subhasis Saha, Poonam Guha Viz

Department of Pediatric Surgery, Advanced Medical Research Institute, Mukundapur, Kolkata, West Bengal, India

Aim of Study: Appendicitis is one of the most common pediatric surgical emergencies in children. Laparoscopy is the gold standard for the management of uncomplicated appendicitis, but opinions are divided when it comes to cases of appendicular lump, abscess or perforation. This study aims at reviewing all cases of complicated appendicitis dealt with at our unit and analyse the role of minimal invasive surgery (MIS) for the same.

Materials and Methods: We reviewed 106 cases of complicated appendicitis operated laparoscopically at our centre in the last 8 years. Our protocol is to go for laparoscopic appendicectomy in all cases unless it is a fully formed lump and Oschner-Sherren regime has helped to make the patient symptom free.

Results: We could complete the procedure laparoscopically in most of them. In 3 cases required conversion to open, two developed port site infection and one had non-specific pain persisting after the surgery. In one of the patients conversion was done to assess the completeness of resection. Oral feeds could be started within an average of 2 days (1-3 days). Most of them were out of bed on the second postoperative day. All patients were treated with intravenous antibiotics for 7 days and hence discharged thereafter.

Conclusion: Beyond the learning curve, laparoscopy is an invaluable tool in these circumstances, provided certain basic principles are adhered to. The benefits of laparoscopy in these situations include excellent visualization, delicate handling of gut loops, thorough peritoneal lavage, thorough adhesiolysis through small incisions with reduced chances of wound infection. Also laparoscopy plays a pivotal role in cases of pain abdomen with diagnostic dilemma.

   Urological Anomalies Associated with Anorectal Malformation Category: Urology Top

Jatin M Jadav, Ankur Patel, Jaishri Ramji, Rakesh joshi

Department of Pediatric Surgery, B.J. Medical College, Civil Hospital, Ahmedabad, Gujarat, India

Aim: To evaluate the incidence and nature of urological anomalies in patients with anorectal malformations.

Methods: A retrospective study of 512 patients born with ARM for their associated urological anomalies. Their incidence, complications, investigations and treatment part is studied. All patients were underwent ultrasound KUB, micturating cystourethrogram, DMSA scan, cystoscopy as and when required.

Results: Overall incidence of urological anomalies associated with ARM is 55%. Of this hydronephrosis, vesico ureteric reflux, solitary kidney, ectopic kidney, ectopic ureter, multicystic kidney were encountered most.

Conclusions: Urological anomalies are more commonly associated with male ARM than female ARM. High variety is associated with more complex urological anomalies than low ARM.

   Results of Injection Sclerotherapy with Bleomycin in Pediatric Patients with Lymphatic Malformations Category: Miscellaneous Top

Vipan Kumar, S Roy Choudhury, V Khanna, PS Yadav, L Ezung, D Singh, R Chadha

Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India

Aims: To evaluate the results of injection sclerotherapy with bleomycin in paediatric patients with lymphatic malformations.

Methods: In this prospective observational study all consenting paediatric patients with macrocystic lymphatic malformations were managed with ultrasound guided sclerotherapy with injection Bleomycin (0.5 mg/kg not exceeding 5 mg at a time). Patients were reassessed at three weekly intervals and injections repeated if required up to 4 times. The response to therapy was assessed clinically as well as by size and volume on ultrasound study. Response was classified as excellent response meaning complete regression, good response >50% regression, poor response <50% regression.

Results: Fifty two patients with lymphatic malformations were enrolled in the study, mean age was 1.3 years, M: F 3:1. Most common site of the lesion was in neck (51.9%) followed by axilla (11.5%) and flank (7.6%). The response to sclerotherapy was excellent in 38 (73.07%), good in 10 (19.23%) and poor in 4 (8.5%) patients. Majority (54%) showed excellent response with two to three injections. Two patients required surgical management of the residual lesions. Complications noted were fever in five and local pain in two patients.

Conclusions: Sclerotherapy with Bleomycin is safe and efficacious in macrocystic lymphatic malformations in children.

   Clinical Presentation and Surgical Management of Neonatal Tumors: Retrospective Analysis of Last 12 Years Experience Category: Neonatal Surgery Top

Shailesh Solanki, Prema Menon, KLN Rao, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aims: Neonatal tumors include a group of diverse neoplasms that are diagnosed within the first 30 days of life. The aim of this study is to know their clinical presentations, management options and outcome from our own data.

Methods: All patients from 0 to 1 month age admitted from 2006 to 2018 with solid tumors were studied. The age, sex, presentation, type of tumor and management were analysed. Final diagnosis was made with histopathology in all cases. We excluded patient with incomplete data, lost to follow up, vascular tumors or without tissue diagnosis.

Results: Total of 33 patients were included in the study. Most common tumor was sacro coccygeal teratoma (16) followed by teratoma at other sites (5), fibrosarcoma (3), hamartoma (3) and other rare tumors. For most of the patients, complete surgical excision was done. Only three patients were diagnosed antenatally. There was one mortality in this group. Five patients had postoperative complications including one local recurrence requiring excision.

Conclusion: Neonatal tumors have varied presentations and require a highly structured work up to plan a proper management. Early diagnosis followed by complete surgical excision is most often curative.

   Total Colonic Aganglionosis in Children: A 20 Year Experience Category: GI Surgery Top

Shalini Hegde, AM Shubha, Kanishka Das

Department of Pediatric Surgery, St Johns Medical College Hospital, Bengaluru, Karnataka, India

Aim: Analysis of children with TCA over 20 years (1997-2017) from a tertiary care hospital highlighting the salient clinical features, investigation modalities and ascertaining changing treatment trends.

Methods: 18 Children with TCA were retrospectively analyzed. They were divided into two groups depending on the differences in their surgical management. Groups 1 included children who underwent colonic patch pull thorough and Group 2, who underwent ileal pull though Duhamel. Their clinical profile and respective outcomes were collated. Growth and Bowel adjustments were assessed at follow up by a protocolized questionnaire.

Results: Group 1 consisted 5 children and Group 2, 13. Clinical symptoms were predictable in most. However, radiology was inconclusive in 80% with morphological and histological discordance noted in 50%. Post op complications were comparable in both, though perianal excoriation was commoner in group 2 children. Regularization of bowel movements was marginally longer in Group 2.

Conclusions: An accurately leveled ileostomy is crucial for a future favorable outcome. A definitive ileal pull through is a simpler alternative and the results are comparable to the conventional colonic patch pull through

   Cholestatic Jaundice/surgical Jaundice in Pediatric Age Group: A Diagnostic Dilema, Another Pandora's Box? Category: Hepatobiliary Top

Kush Kumar Luthra, S Manjiri, SK Padmalatha, Jeevak Shetty

Department of Pediatric Surgery, Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India

Aim: To evaluate and diagnose children with neonatal cholestatic jaundice with normal intraoperative cholangiogram and role surgical management in such cases.

Methods: Its an observational study over period of 5 years (2013 to 2018), including 24 cases of neonatal jaundice, 13 of which were confirmed as biliary atresia on OTC and underwent Kasai''s procedure and 11 patients presenting as diagnostic dilemma with normal intraoperative cholangiograms.

Results: All 24 cases were evaluated for surgical jaundice after ruling out infectious causes.12 cases were confirmed to have biliary atresia and underwent kasai''s portoenterostomy but on table cholangiogram was normal in 11 cases and histopathology was suggestive of early onset liver cirrhosis. 2 cases were suspected to have PFIC, all cases were started on UDCA and one child benefited with cholecystostomy (biliary drainage).

Conclusion: Negative intraoperative cholangiogram does not rule out the future need of surgical intervention in children with cholestatic jaundice. Such cases may be benefited with biliary diversion or liver transplant in future if liver cirrhosis sets in. Role of genetic work up should be emphasized in such cases.

   Technical Modification for Laparoscopic Choledochal Cyst Excision Category: Hepatobiliary Top

Vaibhav Pandey, Ajay Narayan Gangopadhyay, Saroj C Gopal, Shiv Prasad Sharma

Department of Pediatric Surgery, I.M.S. B.H.U., Varanasi, Uttar Pradesh, India

Aim: Laparoscopic excision is proven for management of Choledochal cyst in children. We present our technical modification for safe Laparoscopic Choledochal cyst excision.

Methods: Choledochal cysts were dissected medially and laterally for small portion. Cystic duct was dissected up to the cyst. Then keeping cystic duct as land mark, incision was made transversely over the cyst. The transverse incision was gradually increased circumferentially along with dissection of cyst. Once cyst completely divided in two portions, lower portion was dissected off portal vein under vision. It was dissected inferiorly till it started tapering and was divided from duodenum without ligation. Cystic duct with cuff of cyst was dissected from the upper portion. Common hepatic duct was fashioned and hepatico-duodenostomy was performed.

Results: 12 patients with choledochal cyst have been managed with this modification from July 2016-June 2017. The mean operative time for the patients with modified technique was less when compared to conventional technique (p value= 0.004). Further, the rate of conversion to open for excision was significantly lower with this technical modification (p value= 0.001).

Conclusion: This little technical modification was extremely useful with minimal chances of portal vein injury.

   H Type Tracheo-Esophaegeal Fistula: Technique of Identification of Fistula and Outcomes of Surgery Category: Thoracic surgery Top

Divya Murali, S Agarwala, V Jain, A Dhua, V Bhatnagar

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Introduction: Trachea-esophageal fistula without esophageal atresia or H type TEF is a rare type of congenital anomaly with incidence of about 4% of all cases of EA-TEF. We hereby describe the technique of surgery and outcomes of patients with H type TEF.

Methods: Patients of H type TEF operated between Jan 2014 to July 2018 were included.

Results: Seven patients of H type TEF operated between Jan 2014- June 2018 were identified. All were symptomatic since birth with varied ages of presentation ranging from 3 days to 9 years. Three were diagnosed with an oral contrast study, 2 by fiberoptic bronchoscopy and 1 underwent rigid bronchoscopy on basis of clinical suspicion. At the time of surgery, 6 out of 7 underwent rigid bronchoscopy and cannulation of the fistula followed by endotracheal intubation and retrieval of catheter by esophagoscopy and cervical exploration while one underwent thoracotomy and fistula repair. All underwent a contrast study on day 7 after surgery. All were discharged on feeds without any complications.

Conclusion: H type TEF may have a varied age of presentation. Diagnosis is a challenge but outcomes after surgery are favourable.

   Role of Negative Pressure Wound Therapy in Paediatric Age Group Category: Experimental/Basic Sciences Top

Subhasis Shah, Subhasis Saha, Rajan Tondon

Department of Pediatric Surgery, Advanced Medical Research Institute, Mukundapur, Kolkata, West Bengal, India

Aims and Objectives: Promote wound contraction and neovascularisation, maintain optimum moisture and reduce bacterial count in large, infected wounds, which are otherwise difficult to manage with conventional dressings.

Materials and Methods: 5 patients between 9 days to 8 years of age, having infected wounds were treated by NPWT dressings, in sinusoidal mode, for optimizing the wound prior to definitive reconstruction. 4 patients had open leg fractures with extensive soft tissue and skin deficit (Gustilo 3B type), while one patient (9 days old) had gangrene of left anterolateral ankle skin following chemical burn. In 4 patients, the NPWT dressing, in continuous mode, was used to immobilize the skin graft to the wound bed to ensure satisfactory take of the grafts. NPWT dressings were changed every 3-5 days, depending on the amount of wound exudate. The period of NPWT dressings ranged from 2- 4 weeks.

Results: The initial debridement & NPWT dressing was done in the hospital. Once the wound was free of slough and pus and sepsis control was achieved, the patients underewent NPWT dressings at home to help prepare the wounds for reconstruction. Thereby, reducing cost of total treatment and ensuring a hospital holiday, which in turn minimizes the incidence of nosocomial infections. All the wounds healed well and the limbs could be salvaged, with no deformity or joint contracture.

Conclusion: NPWT is a useful tool to optimize and prepare infected wounds for definitive reconstruction. Further, it may be used to immobilize skin grafts to the wound bed to improve graft take.

   Mid Pouch Approach for Dissection of Upper Pouch for Repair of Esophageal Atresia Category: Neonatal Surgery Top

Vaibhav Pandey, Ajay Narayan Gangopadhyay, Saroj C Gopal, Shiv Prasad Sharma

Department of Pediatric Surgery, I.M.S. B.H.U., Varanasi, Uttar Pradesh, India

Aim: We herein describe a simple technical modification for dissection of upper pouch which decreases the chances of injury to the trachea and esophagus in cases with esophageal atresia.

Methods: Patients undergoing primary repair of esophageal atresia were divided into two groups A and B. In group A the dissection of upper pouch was started from the distal most part (conventional) whereas in group B the dissection was started from about 2 cm proximally to achieve an area of circumferential dissection and then the dissection proceeded in proximal and distal directions. All the cases were performed by senior residents in 2nd or 3rd year of training after assisting at least 5 cases with each technique. The outcome was recorded in form of achievement of dissection without injury to trachea and esophagus and the mean time taken for dissection.

Results: Out of 22 patients in group A 2 had serosal tear of esophagus and 2 had tracheal injury. In Group B none of the patients had these complications. The mean time in Group B was same as that of group A.

Conclusion: This simple modification is useful for fellows during early part of their learning curves.

   Complexities and Challenges Involved in the Management of Conjoint Twins Category: Miscellaneous Top

Kashish Khanna, M Bajpai, K Khanna, P Goel, M Jana

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Background: The incidence of Conjoined twins (CT) is 1 per 200,000 live births. While some are unsalvageable, others may be surgically salvageable but involve complex systemic anatomies.

Aim: To study the anatomic complexities involved in the management of CT.

Materials and Methods: The systemic anatomy of 6 cases of CT managed between Jan 2001 to June 2018 was studied in detail.

Results: Of the 6 pairs of CT, 4 were salvageable and 2 non salvageable. Salvageable CT:1) epigastric heteropagus CT-salvaged by removal of the parasitic twin after ligation of the feeder vessel from the left subclavian artery;2) omphalopagus CT-fused hepatobiliary system but no bony or other systemic connections, were separated after a meticulous surgery;3) pyopagus CT having similar anatomy (2)- separate spine, fused sacrum but they share a common anal opening (awaiting surgical separation with guarded prognosis). Non salvageable CT:1) thoraco-omphalopagus CT-fused hepatobiliary system and an inseparable complex cardiac morphology;2) dicephalus parapagus dibrachius dipus CT-parallel vertebral coloumns, but shared sacrum and pelvis;4 lungs, 2 fused livers, separate gastrointestinal system till the large bowel but a single anal opening and a complex cardiac anatomy, hence were unsalvageable.

Conclusion: A multidisciplinary team approach is necessary to plan appropriate management in complex cases of CT.

   A Rare Case of Transverse Testicular Ectopia Category: Urology Top

Mrinal Arora, Rajeev Kulshrestha

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aims: To report a rare case of transverse testicular ectopia.

Materials and Methods: Transverse testicular ectopia (TTE) is also named as testicular pseudo-duplication, unilateral double testis or transverse aberrant testicular mal-descent. It is a rare anomaly in which both the testes descend through a single inguinal canal and lie in the ipsilateral hemi-scrotum. We came across one such case. We are discussing the etiology of the disorder and management.

Results: The various sites for ectopic testis are superficial inguinal, femoral, perineal, pubo-penile, and crossed. Incidence of crossed ectopic is rare. Less than 100 cases has been reported in the literature. We had discussed the management options and surgical option available Management is orchidopexy, either trans-septal or extra-peritoneal transposition. Laparoscopy can be both diagnostic and therapeutic.

Conclusion: TTE is a rare anomaly and its pathogenesis is still unclear. Ultrasonography and laparoscopy play an important role in diagnosis. All cases should be evaluated for the presence of associated anomalies. As there is risk of malignant transformation, it is recommended to do orchidopexy at the earliest possible. Tran-septal orchidopexy gives a good tension free fixation of the testis in the contralateral scrotum. Laparoscopy is a useful modality for both diagnosis and management of TTE and to look for associated anomalies.

   Congenital Primary Bladder Diverticula in Boys Category: Urology Top

Sudhir Singh, Jiledar Rawat, Nitin Pant, Gurmeet Singh

Department of Pediatric Surgery, KGMU, Lucknow, Uttar Pradesh, India

Aim: To highlight the spectrum of presentation and management of congenital primary bladder diverticula in children at our center.

Methods: Records of 10 patients with congenital primary bladder diverticula managed from 2006-2017 were retrospectively reviewed with respect to demographic profile, clinico- radiological findings, management and follow-up. Average follow-up period was 3 years.

Results: Mean age of presentation was 3 years (6 months to 7 years). Presentations were recurrent urinary tract infections (n=3), dysuria and straining during micturition (n=3), urinary retention (n=3), and dribbling of urine (n=1). Ultrasound KUB and voiding cystourethrography was done in all. Six had diverticulum on right side and four patients on left side. Three had ipsilateral high grade reflux (grade IV-V) on VCUG. Cystoscopic confirmation done before a definitive procedure. Open surgical excision of diverticulum was done in all. Ureteral reimplantation was done simultaneously in three patients. Resolution of symptoms was seen in nine of ten patients. There was no recurrence.

Conclusion: Diagnosis of bladder diverticula requires a high index of suspicion. Ultrasound and voiding cystourethrography are mandatory along with cystourethroscopy. Open surgical approach provides good results.

   Spontaneous Biliary Perforation: A Case Series Category: Hepatobiliary Top

Rahul Dey, V Pavithra, MM Zameer, C Vinay, Sanjay Rao, Ashley D'cruz

Department of Pediatric Surgery, Narayana Health, Bengaluru, Karnataka, India

Aim: To describe two cases of spontaneous biliary perforation who were managed in our unit.

Methods: A retrospective descriptive study of two patients with Spontaneous Biliary perforation, who presented to Department of Paediatric Surgery, Narayana Health Bangalore.

Results: There were a total of 20 children who presented with neonatal cholestasis out of which there were 2 children (1 boy & 1 girl) with Spontaneous biliary perforation. Both were 3 months old. Both presented with jaundice, pale stools and non bilious vomiting. Both had imaging (USG & CECT abdomen) done showing heterogeneous loculated intraperitoneal collection in right upper abdomen. The boy had HIDA scan showing tracer accumulation in subhepatic space. Operative cholangiogram in both showed perforation at the confluence of CBD and cystic duct and non passage of dye into duodenum. Both underwent Bilio-enteral drainage procedures - Roux-en-Y hepaticojejunostomy in the boy and hepaticoduodenostomy in the girl. Post op period was uneventful for both with LFTs for both coming back to normal.

Conclusion: Spontaneous biliary perforation is a rare cause of neonatal cholestasis. The principle of management is drainage of bile from peritoneal cavity. Surgical drainage by bilio-enteric bypass becomes essential when there is complete obstruction of the bile drainage.

   Portal Vein Complications and Its Management in Pediatric Liver Transplantation Category: Hepatobiliary Top

Cherian Jerin Oommen, Vivek BR, pavithra V, MM Zameer, C Vinay, Sanjay Rao, Ashley D'Cruz

Department of Pediatric Surgery, Narayana Health, Bengaluru, Karnataka, India

Aim: This is a retrospective and descriptive study. Early portal vein complications are defined as thrombosis of PV within 28 days and late portal vein complications account after 28 days and are either thrombosis and / or stenosis. Study is period from 2005 to 2018. Data collated from ongoing data base.

Results: Eighty two children underwent liver transplant (46 had biliary atresia). PV complications were seen in 16 of 82 transplants (19%). Sixteen LTx were performed in 15 children (one had re Tx). Thirteen were boys. Mean age at Tx was 31 months (range 8 – 144). Mean weight was 10.2 kg (range 4 – 15 kg). Twelve children had biliary atresia and 7 of whom had narrowed PV pre-Tx. Early PVT occurred in 8 children, of whom had surgery to re-establish portal flow. Five children had successful re canalization. Eight out of 16 had chronic PV stenosis. Four out 8 had features of hypersplenism and 3 received PV dilatation. The remaining 4 were asymptomatic. In cohort of 15 children, 11 are alive and 4 died (3 acute PVT, 1 for unrelated cause). Those who are alive are on regular follow up and have normal liver functions tests.

Conclusion: Incidence of PV complication was 20%. Half occurred in early post-op and this was associated with significant mortality. Early surgical recanalization salvages about 60% of grafts. Late PV stenosis can result in symptoms like hypersplenism over long periods.

   Outcome of Early Neonatal Intestinal Obstruction from a Pediatric Center of Nepal Category: Neonatal Surgery Top

Geha Raj Dahal, Rameshwar Prasad Pokharel

Department of Pediatric Surgery, IOM, Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Introduction: Neonates having clinical features of intestinal obstruction like vomiting, abdominal distension and failure to pass meconium is a common phenomenon. At times, it is difficult to decide for surgical intervention.

Aims: The aim of this study is to analyze the outcome of neonates presenting with features of intestinal obstruction.

Methods: The study was done in Tribhuvan University teaching Hospital, Kathmandu, Nepal over a period of one year. All neonates, presenting with vomiting, abdominal distension and failure to pass meconium were included in this study. Antenatal factors, investigations, clinical courses, management, surgical procedures and outcome were evaluated.

Results: During the period of one year (July 2017- July 2018), 64 neonates had clinical features of intestinal obstruction. Antenatal risk factors were present in 21 (33%) and adverse intranatal event was in 25 (39%). Vomiting was the most common symptom and meconium gastritis was the most common diagnosis. Surgical intervention was needed in 12 (19%) patients. The sensitivity of antenatal diagnosis for surgical intervention was 63% and specificity was 97%.

Conclusion: Most neonates presenting as vomiting and abdominal distension do not require surgical intervention. Antenatal diagnosis of intestinal obstruction has high sensitivity and specificity.

   Extra-Gonadal Germ Cell Tumor in Children: Primary or Metastasis? Category: Surgical Oncology Top

Basant Kumar, Vijai D Upadhayaya; Sheo Kumar

Department of Pediatric Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India

Objetives: Primary extra-gonadal germ cell tumors are rare. Their histogenetic origin is still a matter of debate. We describe four patients in which two were presented as primary germ cell tumors without clinical evidence of testicular tumor while two patients had retroperitoneal GCT with history of orchiectomy.

Methods: Two children aged 14 months and 22 months were presented with feature of sub-acute bowel obstruction; having retroperitoneal masses. Trucut biopsy confirmed the diagnosis of Yolk-Sac Tumor. In both patients, testicular palpation was not suspicious and testicular ultrasound was normal. Other 2 patients (aged 2 year and 16 year) with history of orchiectomy had large retroperitoneal mass, in which one patient had lung metastasis.

Results: All children had raised serum alfa-fetoprotein levels and received cisplatin based neo-adjuvent chemotherapy (PEB regimes). Residual mass were excised in 3 patients and rest chemotherapy were completed. They are under follow-up without recurrence (3 month to 6 years). But child with lung metastasis was died in follow-up.

Conclusion: Although PEGGCT is rare, it is a known entity in children and it to be considered as metastases from viable testicular cancer in normal has looking testes. It is highly chemosensitive and prognosis is good. A focused examination including testicular ultrasound in is mandatory.

   Iatrogenic Injuries in Vestibular Fistula: High Pay for Minor Errors Category: GI Surgery Top

Basant Kumar, Vijai D Upadhyaya, Nijagal Mutt, Manish K Gupta, Rajanikant Yadav

Department of Pediatric Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India

Aims and Objectives: Here we present our experience with few female patients having vestibular fistula underwent inadequate previous surgeries or developed complications related with surgical techniques.

Materials and Methods: We retrospectively reviewed clinical and electronic records of all patients operated for anorectal malformations in our institute from June, 2013 to May, 2017. All patients with vestibular fistula re-operated after unsuccessful previous surgery or developed complications; were included in the study.

Results: During mentioned period, there were 12 patients re-operated. Indications of revision surgery include iatrogenic recto-vaginal fistula (5), anteriorly placed neoanus (3), neoanus stenosis (3) and rectal prolapse (1). All patients were operated outside of our institute for vestibular fistula and referred to us with ongoing problems of constipation, stool impaction with overflow incontinence and perineal soiling. 2 patients had mega rectum. Almost all patients improved after revision surgery. Constipation resolved with reduced need of laxatives and rectal washouts. Soiling resolved or significantly reduced (easily manageable).

Conclusion: All these complications had clear explanations and are well described in literature. Revision surgery in such cases has good outcome. Adequate surgery with knowledge of anatomy is important to avoid such complications.

   Ongenital Pyloric Atresia - Nine New Cases: Single Center Experience of the Long Term Follow up and the Lessons Learnt over a Decade Category: GI Surgery Top

Monal Kansara, V Shankar Raman, Kamal Kishore, Sanat Khanna, Bipin Puri

Department of Pediatric Surgery, Army Hospital R and R, New Delhi, India

Background: Congenital pyloric atresia (CPA) is a rare anomaly with an incidence of 1 in 100,000 live births. Depending on the type of anomaly patients can either present in the neonatal period or later in life with subtle nonspecific signs and symptoms. We present our institute's experience in handling these cases over the last decade and highlight lessons learnt.

Materials and Methods: We retrospectively reviewed records of patients diagnosed with CPA and managed at our center between Jan 2006 to June 2016. We looked into the period of gestation, birthweight, gender, age at onset of symptoms, age at presentation to the hospital, symptoms, investigations, associated anomalies, management and outcomes and follow up periods.

Results: Nine patients were operated during the ten year period of study (6 males and 3 females). The median age at onset of symptoms was 06 months (01 day-36 months) and the median age of reporting to the hospital was 07 months (01 day-44 months) with a mean delay of 5 months between onset of symptoms and reporting to hospital. Six patients (67%) had associated anomalies including one with posterior urethral valve which has been reported for the first time in literature. Four out of five (80%) late presenters underwent an upper gastrointestinal endoscopy for diagnostic confirmation. All patients were operated upon and Type 1 CPA was seen in five patients (56%), Type 2 in two patients (33%) and Type 3 in one patient (11%). The overall survival was 89% as one patient with associated Epidermolysis Bullosa expired after 4 months due to fulminant sepsis. Three patients were lost to follow up and amongst the remaining five; the median follow up period is 36 months.

Conclusion: CPA is a rare entity that may present late with subtle signs like failure to thrive and non bilious vomit. A high index of suspicion is mandated in these cases and an Upper Gastrointestinal Endoscopy will help in early diagnosis and avoid further unnecessary investigations. A feeding jejunostomy may benefit malnourished sick children before definitive surgery.

   A Pilot Study on Histopathology of the Jejunoileal Atreisa: Can We Determine the Length of Adequate Resection? Category: GI Surgery Top

Anand Pandey, Abhishek Singh, Preeti Agarwal, Archika Gupta, Jiledar Rawat, SN Kureel

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aims: There are certain studies which report that there is abnormality in the histopathological structure of the atretic bowel in jejuno-ileal atresia (JIA). We have made an attempt to assess sequential histopathologic changes in the resected atretic segment.

Methods: The histopathology of the resected segment was evaluated at 1, 3, 5, 7, 9, and 11 cm from atretic end (Sections A to F respectively). Thickness of outer and inner muscle layers of mucscularis propria was evaluated by NIS-Element software. The ratio of inner and outer muscle layer was calculated at every section.

Results: During study period, we evaluated four JIA and two control specimens. In control set, the ratio of inner and outer muscle layer was 1.03. In the JIA patients, the ratio was 0.68 to 0.9 at section A. This ratio varied at various sections in all specimens. In section F, this ratio was 0.95 to 1.09, which is close to control ratio.

Conclusion: It appears that the bowel proximal to the atresia is abnormal for a varied length. It may be a possibility that this abnormality is present at least up to about 10 cm proximal to atresia. Adequate resection appears to be important for optimal outcome.

   Bishop–koop Procedure for Jejunal and Proximal Ileal Atresia: Outcome Analysis Category: Neonatal Surgery Top

Gurmeet Singh, Anand Pandey, Gaurav Shandilya, Archika Gupta, Jiledar Rawat, Ashish Wakhlu, SN Kureel

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aims: To review the Bishop–Koop procedure as a treatment option with grossly dilated proximal segment in jejunal and proximal ileal atresia.

Methods: This was a retrospective study conducted from January 2012 to June 2018 in the Department of Paediatric Surgery at the Medical University. The outcome, complication rate, nutrition status and the follow up study for postoperative adverse outcomes were assessed.

Results: Thirty two neonates underwent Bishop–Koop procedure. The mean duration of the hospital stay was 20 days. Oral feeds were initiated on 7th postoperative day. The mortality rate was 50% (16/32). The complication rate was 43.7% (14/32) including anastomotic leak, intestinal obstruction, high output stoma and cholestasis. In long term follow up, problems like repeated admissions (5), discharge from stoma (3), and excoriation (1) were observed.

Conclusions: Bishop–Koop procedure appears to be a technically efficient method in desperate cases of jejunoileal atresia with grossly dilated proximal segment, although larger studies may be needed to compare Bishop–Koop procedure and other operation techniques.

   Esophageal Replacement by Gastric Tube in Pure Esophageal Atresia and Long Gap Tef: Three Stage Surgery Category: Thoracic Surgery Top

Gurmeet Singh, Jiledar Rawat, Sudhir Singh, Abhishek Kumar Singh, Gaurav Shandilya

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aims: To present and highlight three stage surgery in patients of esophageal atresia by using isoperistaltic gastric tube.

Methods: This is a retrospective study carried out from January 2006 to June 2018 at our centre including twenty cases of esophageal atresia (PEA) and long gap Tracheoesophageal fistula, treated at birth by cervical oesophagostomy and feeding gastrostomy. In second stage at the age of 9-12 months, isoperistaltic gastric tube based on right gastroepiploic vessel was created and pulled retrosternal up to neck. The gastric stoma was placed adjacent to cervical oesophagostomy and in third stage (after 2 months) cervical oesophagostomy was anastomosed with gastric stoma.

Results: Twenty patients underwent three stage repairs. Four patients had diagnosis of Long gap TEF+ EA and sixteen patients were PEA. Three patients had minor cervical leak, managed conservatively, one patient require endoscopic dilatation of stricture in cervical oesophagus anastomotic site. All patients are doing well, gaining weight and no significant GERD.

Conclusion: Three-stage surgery may avoid major complications because of short operative time and less intervention. Second stage procedure avoids anastomotic leak and stenosis in a long oesophageal suture line. This may be a useful alternative under a resource-limited condition, with optimal outcome.

   Ovarian Preservation for Ovarian Torsion in Pediatric Age Group: A Single Centre Experience Category: Miscellaneous Top

Lydia Mary, GM Asok Kumar, CS Aravind, Vivek Sarma

Department of Pediatric Surgery, SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala, India

Aims: The aim of this study was to report our experience with ovarian preservation approach in ovarian torsion.

Material: Retrospective review of case records of patients with ovarian torsion managed in our department.

Results: 20 cases of ovarian torsion were managed between March 2015 and June 2018 in our centre. Age of patients ranged from 9 days to 12 years (average-7 years) and the pathology varied from 7 cases of ovarian torsion without any cyst,13 cases of ovarian torsion with simple cyst. We performed ovarian preservation in all patients with laparoscopic detorsion in 12 cases and laparoscopic cystectomy in 8 cases. All patients were followed up with ultrasound and all were found to have normal size and blood flow on the affected side.

Conclusion: Ovarian torsion is not a contraindication for ovarian preservation. The way to confirm viability at surgery is by gross visual inspection and even those ovaries which appear edematous, congested at surgery will have normal morphology on follow up Ultrasound.

   Dj Stent Removal Trial: Cystoscopy in or Vs Loop Method in Ward Category: Urology Top

Sharada Sundaramurthy, Jujju Kurian, Reju Thomas, Jeyaseelan, Koushik Herle, John Mathai

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Aims: To study the efficacy of the suture loop method for removal of indwelling DJ stents as compared to cystoscopic method.

Methods: n=30 patients with indwelling DJ stents were enrolled for the study between and randomized by unequal allocation to cystoscopic and suture loop method removal arms. The suture loop method involves placing a loop of suture material within an infant feeding tube and using the routine catheterization procedure to snare the DJ stent within the urinary bladder. The success rate of removal, cost difference was compared between both methods.

Results: The success rate of suture loop method and cystoscopy was found to be 82.6% (n1=19/23) and 100% (n2=7/7) respectively in our series. The p value was found to be insignificant (p=0.77). The average cost for cystoscopic removal of stent under GA and suture loop method was Rs 12,384 and Rs 3102 respectively. No adverse events were reported during the study.

Conclusion: While cystoscopy has the advantage of visualization of the stent within the bladder it does not give any additional information in a case of routine stent removal. We have devised a novel technique for stent removal which can avoid need for General anesthesia, expensive equipment and operating theater time.

   180° Rotated Intestinal Anastomosis in Neonates: A Large Series Category: Neonatal Surgery Top

T Vidhya, S Namasivayam

Department of Pediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India

Aim: Preliminary study of the 180 degree rotated intestinal anastomosis in neonates showed good results in neonates with compromised bowel and general condition. In this large series the results, immediate and long term complication rates of this technique are presented. Microanatomical and micro perfusion study of intestinal vasculature studies in literature support this technique.

Methods: 180 degree rotated intestinal anastomosis in which the cut end of the distal bowel is rotated to 180 degrees with respect to cut end of the proximal bowel so that antimesenteric end of the distal bowel is anastomosed to the mesenteric end of the proximal bowel. Since 1995 this technique is performed for all the neonatal intestinal anastomosis.

Results: The analysis of this series show good results with less immediate and long term complications particularly when the anastomosis is carried out in neonates with compromised bowel and general condition.

Conclusion: Authors suggest routine use of this technique of anastomosis for all neonatal intestinal anastomosis particularly for neonates with compromised bowel and general conditions.

   Giant Abdominal Cysts in Children: Case Series Category: GI Surgery Top

Uday Bhaskar, S Namasivayam

Department of Pediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India

Aim: A series of Giant abdominal cysts presented for the types, presentation, differential diagnosis and management. To highlight the problems in delineating the anatomy in imaging.

Methods: This is a retrospective study of Giant abdominal cysts presented during the period from 2005 to 2018. Presentation, types, differential diagnosis, diagnosis and treatment of these giant cyst are analysed. Histopathological correlation is carried out. Laparoscopy, conversion to open surgery related to differential diagnosis of hydatid cyst and preservation of adjacent organ involved are analysed.

Results: Imaging modalities other than ultrasound did not give much help in delineating anatomy and differential diagnosis. Laparoscopic excision was carried out in some. Others required open excision of giant cysts and organ preservation.

Conclusion: This study helped to evolve a protocol for management of Giant abdominal cysts.

   Germ Cell Tumor: A Series of Cases and Some Thoughts Into the Aetiology Category: Surgical Oncology Top

Ashitha K Unny, S Namasivayam

Department of Pediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India

Aim: look in to the incidence, types, presentation, treatment and results of series of Germ cell tumours presented to us. To compare the results of this series results to that of literature. To look in to the histopathology of the specimen for association of coccyx with the tumour aetiology and the need for it's removal.

Methods: Retrospective analysis of the cases of Germ cell tumours presented to our unit between 2000 to 2018. Analysis for comparison of the incidence, types, presentation, management and results between this series and literature evidence is carried out. Histopathological analysis of the coccyx and the adjacent tumour in the specimen to look for any abnormal cells in the coccyx was carried out. Th results of cases where coccyx was removed is compared to that of cases where coccyx was not removed.

Results: There were lot of changes happened to the line of management of Germ cell tumours in the past. The change of chemotherapy to Platinum based method, reducing the interval between chemotherapy, modification of chemotherapy to reduce the toxicity without reducing the survival and organ sparing management followed in the cancer centres has similar effect in this series.

Conclusion: Overall results of different types of Germ cell tumour is good. Non removal of coccyx did not alter survival. There was no evidence of abnormal cells in the coccyx and adjacent areas in the excised specimens.

   Cystic Lesions of the Gastro Intestinal Tract Presenting as Acute Abdomen Category: GI Surgery Top

Sasidhar Thorlikonda, A Narendra Kumar, T Anil Balraj, S Srinivas

Department of Pediatric Surgery, Niloufer Institute of Women and Child Health, Hyedrabad, Telangana, India

Aim: to study the incidence, etio-pathogenesis, and morbidity of cystic lesions involving gastrointestinal tract presenting as acute abdomen.

Materials and Methods: observational study of cases presented to the department of pediatric surgery from January 2016 to June 2018 at Niloufer hospital for women and children, Hyderabad. Cases diagnosed with mesenteric cysts or omental cysts or chylolymphatic cysts and duplication cysts were included and ovarian cysts were excluded from the study. All cases were subjected to laparotomy and the diagnosis was confirmed with histopathological examination.

Results: a total of 24 patients presented with above diagnoses during the study period with age ranging from birth to 12 years. 3/24 cases were detected antenatally. Female children (18/24) were commonly affected. Commonest presentation was mobile lump abdomen seen in 16/24 cases. 8 out of 24 patients presented with acute abdomen. 7/8 cases presented with distension, vomitings and pain. 1 out of 8 acute cases presented with shock. Common cystic lesion causing acute abdomen is mesenteric cyst due to infection/ hemorrhage or volvulus.

Conclusion: early detection and early intervention can reduce the rate of resection and associated complications and morbidity even in asymptomatic cases of cystic lesions involving the gastrointestinal tract.

   Is Configuration of the Ureteric Orifice a Better Indicator of Success Than Grade of Reflux in the Management of Vesicoureteric Reflux Category: Urology Top

Vinod Raj, Santosh Karmarkar, Swathi Krishna, Shruti Tewari

Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Aim and Background: Is configuration of the ureteric orifice a better indicator of success than grade of reflux in the management of vesicoureteric reflux - A pilot study to test this hypothesis.

Materials and Methods: Forty eight renal refluxing units were treated by endoscopic management (grade 2 to grade 4). At cystoscopy -location, size, shape and the orientation of the orifice were noted. Based on the above findings, the configuration of the orifice was termed as either “suitable” or “unsuitable” for injection. Repeat MCU performed 6 weeks later showing resolution of reflux was considered as a successful outcome.

Results: There were a total of 48 RRU's, 8, 19 and 21 each in grade 2, 3 and 4 respectively. Based on the above factors for configuration of orifice, there were 33 “suitable” and 15 “unsuitable” orifices. Among them 32 resolved following single injection and 40 resolved after 2nd injection. 8 of them wished to undergo ureteric reimplantation. Among the 33 suitable orifices, 31 had resolved (93%) and 2 opted for reimplantation, while among the 15 unsuitable orifices only 9 resolved (60%) while 6 opted for reimplantation. This was statistically significant with a p-value of 0.003. We also found that the coefficient of correlation between grade of reflux and configuration of orifice was only 6.7 %.

Conclusion: The orifices with suitable configuration have better rates of resolution while those with unsuitable configuration had higher failure rates. The suitability of orifice correlated with the grade of reflux in only 6.7 times over 100. So the hypothesis – “configuration of orifice is a better predictor of success than grade of reflux” – is valid statistically and directs future research - with larger numbers, for stricter definitions of suitable vs unsuitable orifice and for further correlation of grade and suitability.

   Practical Lessons Learnt for Improving the Operative Results of Bladder Augmentation Category: Urology Top

Vinod Raj, Santosh Karmarkar, Swathi Krishna, Shruti Tewari

Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Aim: To analyse the factors for improving the operative results following augmentation cystoplasty.

Materials and Methods: Data collected of the 50 cases of augmentation cystoplasty performed over last 10 years. The evolution of changes in the operative technique and perioperative management were studied and analysed.

Results and Conclusion: with simple changes and modifications in the operative technique and perioperative management, the results have vastly improved over the years. Important changes which have improved the results include (1) the technique of de-tubularization and re-configuration of the augment patch from Cap to patch (2) hitching of the conduit channel to all the layers of abdominal wall, (3) non-usage of ureteric catheters (4) Meticulous check of leaks before closure (5) The type of collecting apparatus. These will be discussed in the presentation.

   Benign Hepatic Tumors in Children: A Single Centre Experience Category: GI Surgery Top

G Rajeev Kumar, G Chalapathi, J Veera Swamy, Ramana Naik

Department of Pediatric Surgery, Kurnool Medical College, Kurnool, Andhra Pradesh, India

Background: To assess the incidence and management of benign liver tumors.

Patients and Methods: Retrospective analysis of patients who were admitted with benign liver tumors in a medical college hospital in southern part of India during the period of 2006 to 2016 were analyzed.

Results: We have treated a total of 10 cases of benign liver tumors during the period of 2006 to 2016. The mean age of presentation was 2.1 year. Seven of the ten cases were haemangiomas, two babies had mesenchymal hamartomas, one had focal nodular hyperplasia. Of the seven babies with Haemangiomas, four had focal, two had diffuse involvement of liver, one baby had giant haemangioma. Three of the 4 babies with focal haemangiomas regressed during follow up, one baby lost follow up. One of the two babies with diffuse hemangioma developed on high output cardiac failure but responded to digoxin, diuretics and steroids and now under follow up. The new born baby with giant haemangioma is involving left lobe of liver also had high output heart failure which was refractory to medical therapy and required left lobectomy. Two babies had large mesenchymal hamartomas involving right lobe and required surgical resection. One patient with focal nodular hyperplasia was managed conservatively. Mean follow up was 36 months. There were no deaths.

Conclusion: Benign liver tumors are rare, most of them are Hemangiomas. Only few of them require surgery. Large mesenchymal hamartomas can be promptly treated by resection with minimal mortality.

   Scrotal Flap Technique for Undescended Testis Category: Miscellaneous Top

M Raghul, VR Ravikumar, G Rajamani

Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Orchidopexies in undescended testis have been done with various surgical techniques essentially based on the location of testis and age of the child. Mobilisation of the testis adequately to reach the scrotal sac has been the ultimate goal to prevent subfertility and testicular atrophy. However, in a) undescended testis in older children, b) children with abdominal testis who have undergone ligation of testicular vessels at an earlier stage and c) testis high inguinal in location, there has been difficulty in bringing them down into the scrotum inspite of various maneuvers. In those children in whom after adequate mobilization the testis could reach only to the supra scrotal region we had devised a scrotal flap technique to cover the testis. Here the subcutaneous tissue and fat is removed from the suprascrotal position and a scrotal flap is devised to cover the testis so that the testis is well within the scrotal sac but at a higher level. These children were followed up and found to have an aesthetically acceptable testicular position while retaining the testicular size on a long term. Children with undescended testis where testis cannot be brought down into scrotum and lies in supra scrotal position even after thorough mobilization, a scrotal flap technique will help to cover the testis with improved aesthetic outcomes with the fond hope that it will facilitate future fertility. In this paper the technical aspect and the pictures of long term outcome are presented. Similar technique has not been published on search of literature.

   Pediatric Non-Wilms Renal Tumors Category: Surgical Oncology Top

Shilpa Sharma, Devendra Yadav, DK Gupta

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Aim: To evaluate clinical presentation, histopathology and outcome of non-Wilms renal tumours (NWRT) in children.

Methods: Patients registered in Pediatric Surgery Tumour Clinic from Jan 2015 to Jun 2018 who were diagnosed as NWRT were studied prospectively.

Results: Out 45 cases of renal tumors, 32; 13 had Wilms; non-Wilms Tumors. Their ages at presentation ranged from new born to 11 years. All patients underwent nephroureterectomy with lymph node sampling. 4 cases were congenital mesoblastic nephroma, one was invasive adherent to liver, retroperitoneum and inferior vena cava. 2;1;1;2;3 patients had clear cell sarcoma of kidney (CCSK); intra renal neuroblastoma (NB); renal peripheral neuroectodermal tumor (PNET); Xp11 translocation renal cell carcinoma (TRCC); cystic nephroma. Eight patients were treated with nephrectomy alone. Five required chemotherapy including 2 neoadjuvant chemotherapy (CCSK, NB). At follow up of 6-40 months, two patients died. The causes of death were advanced malignancy with ruptured tumor (NB) and chemotoxicity after week 18 chemotherapy (CCSK). Two patients of TRCC developed local recurrence (one- twice) and metastasis, one with lung metastasis necessitating metastatectomy, other with vertebral metastasis advised palliative therapy. Rest 9 patients are healthy.

Conclusion: Though the clinical presentation of NWRT is similar to Wilms tumour, the outcome varies depending upon Histopathology. TRCC;CCSK;NB have poor prognosis.

   Renal Failure in Puv Category: Urology Top

Purnendu Bhardwaj, MM Zameer, C Vinay, Sanjay Rao, Ashley

Department of Pediatric Surgery, Narayana Hruduyalaya, Bengaluru, Karnataka, India

Aims: To diagnose and determine the stage of CKD in children with PUV on follow up.

Materials and Methods: A retrospective, observational study, evaluating children with PUV who underwent treatment in our centre from February 2008 to March 2018. All data was collated from MRD files and analysed. Using creatinine based Schwartz equation (2009), GFR was calculated and the children were grouped into stages of CKD based on the National Kidney Foundation Kidney Disease and Outcome Quality initiative (KDOQI).

Results: In a cohort of 78 children, average age of diagnosis was 5.6 months, with an average creatinine of 1.56. Post intervention, fulgration/ vesicostomy, mean nadir creatinine reached was 0.65. In our cohort present mean creatinine is 1.06. Mean GFR is 50.92. with a follow up of 1 – 16 yrs in the cohort, only 24 children creatinine have a creatinine normal for their respective ages. All 78 children were under 25th centile for height and under 50th centile for weight. More than 60% (49 out of 78) of the children are hypertensive. All the 78 children were found to have CKD with 6 in Stage 1, 20 children in Stage 2, 39 children in Stage 3, 9 children despite full treatment were in Stage 4 and 5.

Conclusion: Children with PUV, despite full surgical trewatment have features of growth failure and many are hypertensive. All patients have CKD ranging from Stage 1 to Stage 5.

   Re-Audit of Surgical Site Marking and Verification of Marking Category: Miscellaneous Top

Govind Murthi, Zoe Ball, Elizabeth Shepherd

Pediatric Surgery Unit, Sheffield Childrens Hospital NHS Foundation Trust, United Kingdom

Aims: Re-Audit of Surgical Site Marking and Verification of Marking and adherence to standards and recommendations set out by National (UK) Organisations and WHO.

Methods: A questionnaire related to the observation of practice regarding surgical site marking and verification of marking was filled in by Anaesthetists and Operating Department Practitioners for every patient attending theatres for a surgical procedure over a two-week period (2017); results were compared to previous audit (2016).

Results: This re-audit re-measured compliance with recommendations through a patient's journey from admission to operation and discharge. Compliance with the following issues were recorded and compared: correct surgical site marked, documented and signed, verification of marking at different stages as per WHO Guidelines for Safe Surgery 2009 ('time out'), adequacy of marking, if indelible ink used, types of marks drawn, visibility of mark after skin prep and draping, whether operating surgeon marked or not and whether he/she was present at 'time out'. Whilst both audits showed a high level of compliance with recommended standards, in none of the areas were 100% results achieved.

Conclusions: Implementation of local institutional guidelines for surgical site marking are essential to ensure patient safety. Deficiencies in achieving compliance remain and should be addressed through audit and education of staff involved.

   Sharp Foreign Bodies of the Aero-Digestive Tract: Endoscopic Removal by the “kangaroo” Technique Category: Thoracic Surgery Top

Minu Bajpai, Aparajita Mitra, Prabudh Goel, Alisha Gupta, Abhimanyu Varshney, RK Batra

Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Aims: Removal of sharp foreign bodies in the aero-digestive tract may inflict iatrogenic damage to the esophagus, trachea or other vital structures in case of impalement. We describe the 'Kangaroo' technique for safe and effective removal of sharp objects from the upper aero-digestive tracts.

Case History: Index Case 1: One-year old boy presented to us with an open (un)safety-pin lodged in the upper esophagus. The technique of removal of the pin by the Kangaroo technique, along-with the mechanics of en-pouching the (un)safety-pin has been described. Index Case 2: Eight years old boy presented with accidental aspiration of a razor blade. The removal of the blade from his trachea was executed by the Kangaroo technique.

Discussion: The Kangaroo technique is described for safe endoscopic extraction of sharp foreign body from the aero-digestive tract while protecting the surrounding tissues, to maintain control of the object during extraction and to avoid causing iatrogenic damage by enclosing the foreign body in a 'kangaroo pouch'. The advantages and limitations of the technique have been discussed.

Conclusions: The Kangaroo technique is safe, effective and reproducible way to effect removal of sharp object from the aerodigestive tract while preventing iatrogenic injury to the surrounding organs.

   Factors Affecting the Outcome of Kasai Portoenterostomy for Biliary Atresia Category: Hepatobiliary Top

Ashitha K Unny, Priya Ramachandran

Department of Pediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India

Aim: The aim of our study was to identify routine clinical, laboratory or histological factors that affect the outcome of portoenterostomy (PE) for biliary atresia (BA).

Methods: Care of children referred to our centers for PE was standardized. All surgeries were performed by a single surgeon. The only contraindication for surgery was synthetic liver dysfunction. All patient data was recorded prospectively to create a database. Outcome of jaundice clearance was defined as serum bilirubin of <2 mg/dl within 6 months of PE. Factors affecting the outcome were studied using standard statistical analysis.

Results: In a 5 year period, 62 PEs were performed. Mean age at operation was 80.4±26.7 days. 25 (40.3%) children cleared jaundice post PE. On univariate analysis, aspartate to platelet ratio index (APRI) < 2 (p=0.04) and use of steroids ((p=0.04) were the only factors that correlated significantly with jaundice clearance. However, on multivariate analysis, neither factor was found to be significant. Post PE, children who had a successful cleared jaundice had a 6-month native liver survival rate of 88.9% compared to 26.3% in those who failed to clear jaundice (p<0.001).

Conclusion: There were no routine clinical or diagnostic factors that adversely affected the outcome of PE. Hence there is no need to rationalize the use of PE and it must be offered to all children with BA who do not have synthetic liver failure.

   Occult Spinal Dysraphism and Tethered Cord in Children: Experience from a Spina Bifida Clinic Category: Miscellaneous Top

Kanishka Das, Rajkiran S Raju, Shalini G Hegde, AM Shubha, M Kiran, AR Prasanna Kumar

Department of Pediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Aim: To review the clinical profile, management and outcome of Occult Spinal Dysraphism at a Spina bifida clinic.

Methods: 50 cases of OSD-tethered cord surgically managed and followed up are included. Demography, clinical presentation, anatomic and functional imaging, surgical details and outcome were collated and analysed.

Results: 3/50 were antenatally diagnosed. The age ranged from 3 mo-14 yrs (median 2 yrs) and they were equally distributed among the sexes. 12/50 had no neurological deficits at presentation but 15/50 had multiple neurocutaneous markers. A low lying cord tethered at L5-S1 was noted in 13 (26%). The final diagnosis were lumbosacral lipoma (24), split cord malformations (12), Dermal sinus tracts- Dermoids (11), taut filums (3) and combinations of these (10). All underwent laminectomy, detethering and repair; additional procedures included two level laminectomy and urological reconstructions. At mean follow up of 7 (2-16) years, the neurological status has improved in 6, remains stable in 40 & has deteriorated in 4. Renal function is preserved in 45, 5 are in CKD.

Conclusion: Optimal surgical management in select cases of OSD can arrest the appearance /progression of neurologic deficits. A stringent follow up protocol is central to the treatment strategy.

   Histopathological Study of Testicular Nubbin: Vascular Insult Versus Primary Intrinsic Atrophy Category: Urology Top

Saravana Balaji, S Namasivayam

Department of Pediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India

Aim: Pathology report of Testicular nubbin in Undescended testis (UDT) usually carry a non- specific terminology like Vanishing testis or Testicular regression rather than Primary atrophy or Vascular insult. This is a retrospective study to carry out histopathological review of the excised specimens of nubbins found in UDT with impalpable testis to look for evidence of the cause of nubbin whether primary atrophy or vascular insult. In this study histological features of Primary atrophy and Vascular insult are looked for to classify them in to Primary atrophy or Vascular insult is the cause of nubbin.

Methods: Retrospective Histopathological review of 30 specimens of nubbins excised from the unilateral cases of UDT with impalpable testis were conducted. The histopathological features of Primary atrophy, Complete vascular insult and Partial vascular insult were studied. These histological features are taken from the past publications and from proved cases of Complete vascular insult and partial vascular insult of our own cases.

Results: Out of 30 specimens 25 showed features of complete vascular insult, four showed partial vascular insult and one showed primary atrophy.

Conclusion: It is possible to classify the testicular nubbins of UDT into that of primary atrophy, complete and partial vascular insult. A larger study may show the true incidence of each categories. This may have a predictive value in the risk of malignancy in future.

   Comparison of Dartos Fascia Versus Tunica Vaginalis for Neourethral Coverage during Byars Stage 2 Repair of Severe Hypospadias Category: Urology Top

K Lalatendu Kumar, VVV Chandrasekharam

Department of Pediatric Surgery, Ankura Children's Hospital, Hyderabad, Telangana, India

There are 2 main techniques for 2nd layer cover of neourethra after urethroplasty; there is controversy regarding the best tissue for this purpose. The aim of this study is to compare dartos fascia versus tunica vaginalis for neourethral cover in 2-stage Byars repair of severe hypospadias.

Method: The surgical and follow-up records of all children that underwent Byars 2-stage repair for severe hypospadias by a single surgeon were analysed for patient data, technique, results and complications. The children were divided into 2 groups: Group 1 received dartos fascia cover to the neourethra, while group 2 received tunica vaginalis cover. Both groups were compared for various parameters, including complications at latest follow-up.

Results: Over the 3-year period, 56 children with severe hypospadias underwent 2-stage repair using Byars technique, with at least 6-months follow-up. Thirty-five received dartos fascia cover (group 1), while 21 received tunica vaginalis cover (group 2). Both groups were comparable for age and pre-operative testosterone treatment; there was no significant difference in complications between both the groups.

Conclusion: Both dartos fascia and tunica vaginalis are equally suitable to cover neourethral suture line after 2-stage repair of severe hypospadias using Byars flaps. Thus, where available, dartos fascia may be the first choice for this purpose.

   Effectiveness of Video Assisted Teaching on Knowledge and Practice of Parents of Children with Clean Intermittent Catheterization Category: Urology Top

Sandeep Agarwala, Ashitha M Varghese, Manju Vatsa, MS Cecilia, M Bajpai, V Bhatnagar, Sandeep Agrawala

Department of Pediatric Surgery and College of Nursing, AIIMS, New Delhi, India

Aim: To develop a video assisted teaching on clean intermittent catheterization and to assess its effectiveness.

Methods: Quantitative research design - pre experimental one group pretest post test was used. Thirty parents of children doing CIC attending were included in the study. Knowledge questionnaire and practice checklist used for pretest and two weeks after the video assisted teaching were validated and reliable. Video on CIC of eight minute duration was developed and validated. One to one video assisted teaching was provided.

Results: Majority of the participants were females. The mean post test knowledge score was increased from 10.03±3.337 to 17.23±1.87 which was significant at p<0.000. There was a significant (P<0.05) increase in post test practice score from 8.73±1.552 to 13.7±1.179. The pretest and post test scores of knowledge and practice had no significant association with variables such as age, sex, education, occupation and monthly family income of parents. Increase in knowledge and practice was independent of parents socio-economic status.

Conclusion: Video assisted teaching was effective in significantly increasing knowledge and practice of parents of children doing CIC. Thus the video can be used to teach children and parents regarding CIC in outpatient and indoor settings.

   Feasibility of Enhanced Recovery Protocol Usage for Stoma Reversal in Children: Early Experience Category: GI Surgery Top

Uday Bhaskar, Lakshmi Sundararajan, S Namasivayam, R Priya

Department of Pediatric Surgery, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India

Aim: Enhanced recovery protocol (ERP) has shown promising results in adults and few paediatric studies. We report our early experience with enhanced recovery protocol for colostomy closure at our institute.

Methods: ERP was used in children who underwent colostomy reversal at tertiary care children hospital by a single surgeon. No bowel preparation was given preoperatively, early feeding and mobilization instituted and non-opioid analgesia preferred. Feed establishment, length of hospital stay and any complications were noted. In the early part of study, feeds were started after 48 hrs (in 5 pts.) but in subsequent cases (4 pts.) within 24 hours. These results were compared with (TP) traditional care protocol (mechanical bowel preparation, opioids used, delayed feed establishment) for colostomy closure in 9 pts, during the same time period.

Results: ERP was used in nine children who underwent colostomy reversal during study period. Early feed establishment and early discharge seen in ERP as compared to TP. Feeds were started in ERP by Day 0-3 (median 2 days) and in last 4 cases within 24 hrs; in TP feeds started by Day 3-5 (median 5). Post-operative hospital stay was 2- 5 days in ERP (median 4), and 6-11 days (median 7) in TP group. No complications (abdominal distention, wound infection) were encountered in ERP group, 22% had wound infection in TP group.

Conclusion: Enhanced recovery protocol for stoma closure is feasible and safe in pediatric population undergoing colostomy closure. It reduces morbidity and hospital stay as well as burden on health care system as compared to traditional care protocols.

   Role of Intralesional Bleomycin and Triamcinolone Compared to a Combination of Both in Residual Haemangioma Flowing Propranolol Therapy Category: Miscellaneous Top

Arj Deo Upadhyay, Vaibhav Pandey, Rakesh Kumar, Shiv Prasad Sharma

Department of Pediatric Surgery, I.M.S. B.H.U., Varanasi, Uttar Pradesh, India

Aim: This study aims to assess and compare the role of intralesional bleomycin and triamcinolone versus a combination of both in patients with residual heaemangioma following propranolol therapy.

Methods: 134 children with residual haemangioma were assigned randomly to receive either intralesional bleomycin (group A, n = 42) or intralesional triamcinolone (group B, n = 44) or a combination of both (group C, n=48). The response to treatment was assessed using clinical photographs and histological response was assessed by evaluation micro vessel density calculated by immunohistochemistry.

Results: In Group A, 38.09 % had an excellent response, 35.7% a good response and 11% had no response. In Group B, 25.0% had an excellent response, 43.1% a good response and 31.8% had no response. In Group C, 60.4% had an excellent response, 36.6% a good response and 6.25% had no response. There was no difference in response among group A and B (p=0.425) There was significant difference in response between group A and C (p=0.018) and between B and C (p=0.0005). The response in group C was also better compared to combined Group A and B (p=0.0005).

Conclusion: Combination of intralesional bleomycin and triamcinolone is better for residual haemangioma than each alone.

   Cluster of Nhl Category: Surgical Oncology Top

A Michael, G Kolandaivelu

Department of Pediatric Surgery, Thanjavur Medical College, Thanjavur, Tamil Nadu, India

Five cases of NHL were seen within a span of six months. All of them were living within ten km stretch. All of them were living in villages. They all had lesions in the mediastinam. Hence they presented with superior vena caval syndrome. The disease was confirmed by needle biopsy. All had chemotherapy. Two were alive for five months. Three died within fifty days of diagnosis. Probably environmental factors played a role in the aetiology.

   A Novel Approach to Unfavorable Anatomy in Long Gap Esophageal Atresia: A New Dimension to Thoracoscopy Category: Thoracic Surgery Top

Minu Bajpai, Prabudh Goel, Rahul Anand

Department of Pediatric Surgery, AIIMS, New Delhi, India

Background: The most-common esophagus-preserving approach in patients with long-gap esophageal-atresia incorporates delayed-primary-anastomosis.

Objective: Preliminary communication to present a protocol including thoracoscopy to address long-gap esophageal-atresia, while preserving native esophagus.

Materials and Methods: Prospective study over ten months on four patients of long-gap esophageal-atresia [male:female=1:1; mean birth weight=1.9 kg; mean gestation at birth=35 weeks]. Neonates with long-gap esophageal-atresia and fit for thoracoscopy were included in this study. The protocol will be discussed in detail.

Results: Following our protocol, a delayed primary anastomosis over a #6 infant feeding tube was possible in all four neonates after a mean waiting period of 8.75 weeks (9, 8, 8, 10 weeks respectively). Per-oral dye study performed ten days after repair excluded any leak in each of these patients with no hold-up of contrast. The first two patients are in the process of being weaned; the other two are on milk feeds. The third patient manifested choking while feeding at three months post-repair and responded to antegrade dilatation. All four patients are doing well in follow-up (6 mths, 5.5 mths, 3 mths, 3 mths respectively).

Conclusions: The authors continue to evaluate this protocol based on encouraging results in the first four patients.

   Prospective Study to Evaluate the Effect of Vasodilatory Caudal Block in Pediatric Patients Category: Urology Top

Prabudh Goel, Minu Bajpai, Purnima Narsimhan, Teg Rabab, Mani Kalaivani, Puneet Khanna, Rahul Anand

Department of Pediatric Surgery, AIIMS, New Delhi, India

Aim: Recent reports have incriminated caudal block in urethro-cutaneous fistula formation post-hypospadias repair due to vasodilatation. To study the vasodilatory effect of caudal block.

Methods: Pediatric patients (n=41) undergoing elective infra-umbilical surgery under general anesthesia with caudal block were included. The effects of caudal block on penile length (resting and stretched), penile girth (base, mid-penile and coronal), scrotal temperature and capillary filling time (nail bed and sole) were observed (time points for observations:prior to caudal, 10 & 20 minutes after caudal).

Results: The study witnessed a statistically significant rise in resting penile length (mean: 3.74 to 4.30) at ten-minutes with a tendency to ameliorate at twenty-minutes (mean 4.08). Similar pattern was observed in penile volume (27.09@pre, 34.76@post-10& 32.10@post-20) and scrotal temperature (96.85-vs-95.900 F). The capillary filling times were reduced significantly at 10-minutes (0.56-sec-vs-0.84-sec) with a tendency to return towards normal at 20-minutes (0.67-sec).

Conclusions: Administration of caudal block results in increased resting penile length, penile volume and scrotal temperature with a concomitant decrease in capillary filling time (lower limbs: nail-bed and sole) suggestive of vasodilatation. However, the effect is transient and starts to wain off at 20-minutes.

   Birth Defect Clinic: An Integrated Approach to the Perinatal Management of Antenatally Diagnosed Anomalies Category: Miscellaneous Top

Deepa Makhija, Rujuta Shah, Kedar Mudkhedkar, Beejal Sanghvi, Sandesh Parelkar, Pooja Tiwari, Kavimozhy Illakiya, Manish Khobraghade, Ashutosh Sharma, Kamalkant Sharma, S Soundarya

Department of Pediatric Surgery, G.S.M.C and K.E.M Hospital, Mumbai, Maharashtra, India

Aim: To highlight the importance of comprehensive and multidisciplinary management of birth defects.

Methods: Antenatal counselling clinic started at Department of Paediatric Surgery, KEM hospital from January 2014. It is a multidisciplinary approach where experts from various fields counsel the expecting couple and their relatives regarding the nature of anomaly, prognosis of baby and prepare them for postnatal management.

Results: More than 1500 families have been counselled. ANC patients (Pregnant females with ultrasound diagnosed anomalies) form the majority among the families counselled. Genitourinary tract anomalies are the commonest followed by anomalies of the central nervous system. Severe and multiple anomalies are identified in less than 10 % of ANC patients.

Conclusion: This clinic is an initiative to provide comprehensive and integrated multidisciplinary management for children with birth defects. It provides platform for the expectant parents to voice their concerns regarding the unborn baby diagnosed as anomalous. It allays their anxieties and prepares them for the appropriate management of the baby after birth.

   Systematic Review of the Randomized Controlled Trials on Hypospadias in Children for Quality Assessment Based on Adherence to the Picot Criteria or Consort Guidelines Category: Miscellaneous Top

Manish Pathak, Prabudh Goel, Rahul Saxena

Department of Pediatric Surgery, AIIMS, Jodhpur, Rajastan, India

A significant part of the surgeon's knowledge is based on data available in literature. Hence, it is important this database be based on sound principles and methodology.

Aim: To make a quantitative Quality Assessment of the reported Randomized Controlled Trials (RCTs) on hypospadias in children using the 2010 Consolidated Standards of Reporting Trials (CONSORT) and PICOT statements.

Materials and Methods: Comprehensive literature search was undertaken on PUBMED and Web of Science (WOS) to identify the RCTs in English language on hypospadias in children during 2000-2018. Each article was reviewed to check adherence to CONSORT and PICOT checklists and quality of reporting score was generated individually.

Results: Of the initial results (PUBMED/n=72 and WOS/n=167), 54 duplicates were removed. After a preliminary abstract and a subsequent full-text screening, n= studies were included for final analysis. The relative relevance of results from two databases was obser ved. Three scores were generated for each paper (CONSORT, PICOT and Overall Quality Score). The studies were stratified based on quality and the trends studied.

Conclusions: The study surfaced the sub-optimal reporting standards of hypospadias literature. The quality was better for studies published in the latter half of the study-period, those based on larger sample-sizes and those published from certain centres.

   Peritoneal Vaginoplasty in Vaginal Reconstruction Category: Urology Top

TS Dily, Vinay Jadhav, M Narendra Babu, S Ramesh

Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Introduction: Peritoneal pull through vaginoplasty, initially popularized by Davydov, may be a good alternative for vaginal reconstruction if bowel is not feasible for conventional intestinal vaginoplasty. Herewith, we are presenting our experience of peritoneal vaginoplasty in two cases.

Materials and Methods: Of the two cases, one was Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome with anorectal malformation repair in the past. Another case was a pure vaginal atresia. Adequate vaginal space was created from the perineum by dissection between bladder and rectum. Then, peritoneal flaps were initially raised by laproscopically then converted to laparotomy. After adequate mobilization the peritoneal flaps were pulled to the perineum through the pouch of douglas. The incision over the pouch of douglas was closed with purse string sutures and the vagina was reconstructed by suturing the flap to the perineum.

Results: The cases were followed up for a period of 6 months. One case was found to have good cosmosis and adequate size. The other case has minimal vaginal stenosis and may require dilatation.

Conclusion: Peritoneal vagionplasty is a feasible alternative for vaginal reconstruction where conventional bowel vaginoplasty is not possible.

   Y-Duplication of the Urethra: One Anomaly, Myriad Presentations Category: Urology Top

Rupa Banderjee, Aparajita Mitra, Gaurav Singh, Satish Kumar Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Background: Urethral duplication is a rare anomaly and each case has a unique anatomy. Management must be individualised. We present our experience with this entity and highlight the variations in anatomy and surgical approach.

Materials and Methods: Sixteen (16) boys underwent surgery for primary or complicated urethral duplication between December 1997 to December 2017 (10 were previously operated elsewhere). Data was collected retrospectively regarding demography, presentation, clinical features, surgery, complications and outcomes.

Results: Age range was newborn to 13 years. All had a Y-duplication of the urethra in the sagittal plane. Four had associated upper tract anomalies, 4 had seminal vesicle cysts and 2 had associated ano-rectal malformation. Ventral urethra was connected to the bladder/posterior urethra in all except 1 case. One had epispadias with duplication. Reconstruction was done using various combinations of buccal mucosa (13), preputial skin (3), split thickness graft from thigh (2), Monti sigmoid (1) and pedicled appendix (1). All repairs were staged. Upper tract and seminal vesicle cysts were tackled as per clinical indications. Complications occurred in 7 cases including stenosis, lip deformity, graft failure, and epididymitis.

Conclusion: Ours is one of the largest single-centre series for urethral duplication. The existing classifications do not do justice to the fine variations in anatomy. Management planning requires case based anatomical study. Initial surgery should aim at good calibre, mucosa lined urethra constructed from the anorectum and brought to the perineum. Buccal mucosa, preputial skin and split thickness skin graft are good for reconstruction but scrotal or perineal skin causes complications.

   Does Rectus Flap Prevent Wound Dehiscence in Exstrophy Epispadias Complex Repair Category: Urology Top

TS Dily, Vinay Jadhav, M Narendra Babu, S Ramesh

Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Background and Objective: Bladder and abdominal wall dehiscence remains a bugbear in the repair of Exstrophy Epispadias Complex (EEC), contributing to a significant failure rate. Rectus flap mobilization (RFM) is a technique described to reduce the dehiscence. We share our experience of this technique in 25 cases of bladder exstrophy.

Materials and Methods: We had 40 cases of EEC over the past 7 years. The initial 15 cases were done without RFM with single/double osteotomy and external fixator. The latter 25 cases underwent RFM. In this technique we isolate one rectus muscle either left or right, commonly left. Separate the lower rectus muscle from anterior rectus fascia. By keeping the vascularity by inferior epigastric vessels to the rectus intact we detach the rectus at its inferior tendinous intersection and rotate the inferior rectus muscle medially to cover the EEC defect over the bladder. Rotated rectus muscle is fixed to opposite pubic tubercle and opposite rectus fascia. Subcutaneous tissue and skin are closed in the midline.

Results: In the 15 cases where RFM was not done, 2 cases had complete dehiscence and 3 cases had wound dehiscence with bladder neck give-way. However, none of the 25 cases with RFM had any abdominal/bladder dehiscence. But, in 3 cases glans breakdown was noted.

Conclusion: Rectus flap technique offers significant benefit by eliminating the chances of abdominal wall dehiscence and bladder give-way. This may have a significant bearing on the final outcome in cases of EEC.

   Intestinal Obstruction in the Post Operative Period: Dilemmas in Decision Making Category: GI Surgery Top

P Balamourougane

Department of Pediatric Surgery, Dr Mehta Children's and Apollo Children's Hospital, Chennai, Tamil Nadu, India

Aims: To report on the experiences and dilemmas faced in post operative patients with possible Intestinal obstruction.

Methods: Patient 1- 3 months old male child with antenatally diagnosed Choledochal cyst underwent laparoscopic excision and Hepatico jejunostomy. Passed greenish stools but had high NG aspirate and feed intolerance. Contrast study showed free flow of contrast and restarted on feeds. Child again developed features of obstruction- re explored by Laparoscopy- herniation of loop through 3 mm port site with obstruction. Patient 2- Neonate with distal small bowel obstruction- Meconium ileus- 2 stage repair done. Started on feeds and discharged on pancreatic enzyme supplements- IRT screening negative. Had persistent distension and failure to thrive. Needed rehospitalisation multiple times- responded to washes and enemas. CFTR gene positive. Enzyme dosage and scheduling readjusted. Contrast study showed hold up at terminal Ileum-?anastomotic stricture/adhesions- re explored- narrow caliber terminal colon-proximal tube enterostomy done to flush and dilate. Patient-3: Proximal Jejunal atresia with gangrenous distal bowel till 5 cm from IC junction. Residual bowel was around 35-40 cm. 2 stage repair done with anastomosis close to IC junction within 5 cm. Baby passed stools but had rec distension with dilated loops- Contrast enema and GI series both showed anastomotic patency. Re explored after failure of conservative management- segment between anastomosis and IC was adynamic- resection done. Patient 4: Neonatal Cholestasis- EHBA- Kasai's Porto-enterostomy done. Drain readjusted on POD 2 due to hole outside. Persistent distension and mucoid stools. Contrast study showed hold up in small bowel. Reexplored with suspicion of obstruction at Jejuno-jejunostomy. Surgery revealed hold up at terminal Ileum due to extrinsic compression by drain.

Conclusion: Post operative intestinal obstruction is a difficult problem and rare causes in different scenarios need to be kept in mind in managing these patients.

   Is There a Role for Ventricular Reservoir in the Management for Complicated Hydrocephalus? Category: Miscellaneous Top

C Sridhar, Gowri Shankar, GS Murali, S Ramesh, J Deepak

Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Aim and Introduction: To review our experience with placement of ventricular reservoir in complicated hydrocephalus in neonates & infants and to assess its utility. Neonates & Infants with complicated hydrocephalus like meningitis, Intra Ventricular hemorrhage (IVH), CSF with High protein level, etc are not suitable candidate for Ventriculo Peritoneal (VP) Shunt insertion. In these babies, repeated ventricular taps are often the only treatment option available. Placement of VR in these babies may be a good measure for repeated aspiration and Intra ventricular antibiotic instillation.

Materials and Methods: We had a total of 31 cases where VR was inserted over the last 3 years. We review our experience with VR insertion and the outcome of these cases.

Results: Of these cases, 17 babies recovered completely and VP shunt inserted with in a mean of 21 days. 12 babies whose preexistent general condition was bad, 3 babies expired & 9 babies had taken against medical advise. 1 baby had a transient hydrocephalus which settled with just a VR placement. 1 child underwent Endoscopic Third ventriculostomy. Overall 19 out of 31 babies (61 %) had a positive outcome with VR placement.

Conclusion: Placement of VR is quite useful in babies with complicated hydrocephalus and avoids the complication of repeated ventricular taps or external ventricular drainage. The VR provides a safe conduit for repeated aspiration as well as antibiotic instillation when indicated. When the child is fit, the reservoir can easily be connected to VP shunt.

   Postnatal Diagnosis and Need for Surgical Intervention in Patients with Antenatally Diagnosed Hydronephrosis Category: Urology Top

Sandeep Singh Sen, Prema Menon, Muneer Ahmed Malik, Kushaljit S. Sodhi, Shaileh Solanki, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim: To study the outcome of patients with antenatally diagnosed hydronephrosis (AHN) with respect to postnatal diagnosis and need for surgical intervention.

Methods: Prospective [Jan. 2017-March 2018] and retrospective study of previous five years. AHN was divided into mild, moderate and severe, based on antero-posterior diameter of pelvis on ultrasonography and gestational age. Area under receiver operating characteristic (ROC) curve was studied.

Results: A total of 167 patients (221 units) were studied. The most common postnatal diagnosis was transient hydronephrosis (101 units) followed by pelvi-ureteric junction obstruction (76 units). Chances of requiring surgery based on degree of HN in second and third trimester was; mild HDN: 11.32% and 9.52%, moderate HDN: 34.21% and 37.03% and severe HDN: 85.71% and 86.27%. Mean APD in the second and third trimester in conservatively managed patients (n= 101) was 6.42± 2.19 mm and 9.75±4.58 mm and in surgically managed patients (n=71) 12.15± 5.65 mm and 20.86± 8.46 mm respectively [P =.000]. Mean increase in APD between 2nd and third trimester was higher in surgically managed patients (P<.002). Area under ROC curve showed an APD of 8.2 mm in the second trimester and 12.85 mm in the third trimester associated with a higher chance of postnatal surgery.

Conclusion: A cut off value of APD derived from this study can be used during antenatal counseling. The mean increase in APD between second and third trimester was higher in the surgical group. Repeat level 2 scan may be done in third trimester in selected patients keeping the above 2 parameters in mind

   Recurrent Urinary Tract Infection in Hypospadias Category: Urology Top

VK Gopi, PR Babu, M Narayanan, KT Muralikrishnan, TP Joseph

Department of Pediatric Surgery, Baby Memorial Hospital, Kozhikode, Kerala, India

Aim: To report on unusual causes of urinary tract infection in children with hypopspadias.

Methods: Three children who had urethroplasty for proximal penile hypospadias with chordee presented with recurrent attacks of urinary tract infrction. Urologic evaluation made the diagnosis of Posterior urethral valve in two children and one child had posterior urethral valve associated with anterior urethral valve.

Results: MCU was the only investigation to ascertain the presence of posterior urethral valve. In one child catheterization was not possible due to anterior urethral valve and had to proceed with cystourethroscopy. Valve fulguration resulted in relief of symptoms.

Conclusion: Posterior urethral valve and Anterior urethral valve are rare associated anomalies in hypospadias. Poor urinary stream and recurrent urinary tract infection are the main mode of presentation.

   ”cullen Sign” Secondary to Acute Hemorrhagic Pancreatitis in a Case of Choledochal Cyst Category: Hepatobiliary Top

Sandeep Singh Sen, Prema Menon, Shailesh Solanki, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim: Cullen sign is a rare presentation seen with acute pancreatitis, seen in 3% of patients with associated mortality of 37%. The reported incidence of acute pancreatitis in patients of CDC is 0 to 76%, with increased association with type 1 and 4A due to abnormal pancreaticobiliary junction. We managed a patient of acute pancreatitis with classical Cullen sign who was later diagnosed to have CDC.

Case Report: A 3 year female presented with severe pain abdomen, recurrent bilious vomiting and abdominal distension. She was dehydrated, lethargic with pulse rate of 120/min. On abdominal examination abdomen was tense anddistended with positive “Cullen Sign”. Serum Amylase was raised. USG abdomen shows 3.6 x 5.6 cm collection with internal septation seen in lesser sac, pancreas bulky and another heterogeneouslarge cystic lesion 3.3 x 5.3 cm in the head of pancreas. CECT abdomen showing necrotic collections in the pancreas, dilatedcommon bile duct, gross ascites, left pleural effusion and inflammatory mural thickening of stomach. The patient responded to initial conservative management. In follow up, MRCP showed type 2 Choledochal cyst, and pseudo pancreatic cyst formation. A rare case of pancreatitis with Cullen sign in a patient of CDC is presented.

   Cystic Lesion of Falciform Ligament in Neonates: Two Case Reports Category: Hepatobiliary Top

Manasa Reddy, Shailesh Solanki, Prema Menon

Department of Pediatric Surgery, PGIMER, Chandigarh, India

A falciform ligament cyst (FLC) is rare in neonates. The falciform ligament extends from the umbilicus to the diaphragm. These cystic lesions often present as abdominal wall abscess or progressive abdominal distension. Because of its rarity and obscure location, a definite diagnosis of a FLC is often difficult on ultrasonography. Here we report two cases of FLC, both neonates having a different presentation. Both patients were successfully treated with excision of cyst along with the entire falciform ligament. Early consideration for falciform ligament pathology is crucial for diagnosis and proper treatment.

   Tracheo Esophageal Fistula Secondary to Ingestion of Small Coin Foreign Body Category: GI Surgery Top

Ashwini Khanolkar, Ketan Parikh, Amit Nagpure

Department of Pediatric Surgery, NH SRCC Childrens Hospital, Mumbai, Maharashtra, India

Aims: To stress on a rare complication of a forgotten benign foreign body (FB) in the esophagus and its successful surgical management.

Methods: A 10-year girl, presented with cough with expectoration, breathlessness, and moderate grade fever since 2 weeks. An X-Ray chest had shown a bilateral basal pneumonitis but also showed a rounded foreign body in the upper mediastinum. A lateral view showed the FB to be in the trachea. On further questioning, the parents confirmed the history of ingestion of a foreign body at the age of 2 years for which apparently an X-ray of the abdomen was done which was reported to be normal and thus no further treatment was carried. The patient gave a history of difficulty of ingestion of solid foods since childhood and she has been on soft diet all these years. A bronchoscopy confirmed the presence of a coin in the trachea, but the coin could not be extracted via the glottis using a rigid bronchoscope. The bronchoscopy also demonstrated a fistulous opening in the posterior wall of the trachea. Since the coin could not be extricated through the trachea, it was pushed into the esophagus through the fistula and was retrieved with a rigid esophagoscope. On extrication, it was a 25 paise coin (a denomination which had been out of circulation for almost 5 years). A Barium swallow and a CT scan done on the following day confirmed a wide trachea-esophageal fistula (TEF) just above the bifurcation of trachea. After, preliminary stabilisation, the patient was subjected to a right thoracotomy for division and repair of T-E Fistula with interposition of pleura.

Results: Post-operative recovery was satisfactory. Gastrograffin swallow study performed on post-operative 8th day demonstrated free flow of contrast onto the stomach without any leak, diverticulum or obstruction. She was subsequently started with oral feeds and was discharged on post-operative day 10.

Conclusion: Acquired TEF have been reported with FBs which get impacted in the esophagus but these are either corrosive FBs (like batteries) or sharp FBs. To the best of our knowledge this is the first reported case of a small coin lodging itself into the esophagus and causing a TEF after almost 8 years by not chemical but mechanical pressure and corrosion, with almost negligible symptoms during the intervening period.

   Spectrum of Lower Urinary Tract Dysfunction in Children Category: Urology Top

Mamta Sengar, Vivek Viswanathan, Niyaz Khan, Chhabi Gupta

Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya, New Delhi, India

Aim: to highlight the spectrum of Lower Urinary Tract Dysfunction in Non PUV patients b/w 3-14 years of age, encompassing a wide variety of other disorders like those in association with hypospadias, ARM's, neurogenic bladder in those with an obvious spinal deformity, and non neurogenic neurogenic bladder.

Materials and Methods: Patients were categorised into three broad categories depending on symptoms, volume frequency diary, USG KUB, and MCU/Cystoscopy findings i.e. 1) Overactive Bladder 2) Bladder Sphincter Dyssynergia & 3) Hypotonic Bladder. The categorisation was done without the support of urodynamic evaluation. Treatment given and the treatment response was noted. The cases requiring invasive treatment and those not showing adequate response to treatment were noted.

Results: Of the 30 patients in our series the male to female ratio was approx 3:1 (22 M:8 F). The commonest symptoms were dribbling f/b constipation. Those with actual spinal cord deformities i.e Neurogenic bladder were 6 in number, of which one was post traumatic in nature (post gunshot injury). Eight were non neurogenic neurogenic lesions, of which one had a penoscrotal hypospadias and two had ARM's. 4 were diagnosed to have bladder sphincter dyssynergia of which one had to have an SPC done due to non compliance with CIC. Three were diagnosed to have lazy bladder. One presented with rectal prolapse and features consistent with LUTD. 9 had overactive bladder. One had a hypotonic bladder. Of these, 18 had an ultrasound done, 9 had MCU's and 6 had MRI spine done. Cystoscopy was done in 12, with fulguration of incidentally detected minivalves in 2. Voiding diary was noted in almost all patients. The most common treatment given was Oxybutynin alongwith dietary and behaviour modification, CIC and laxatives. Prazosin was used in those with bladder neck hypertrophy.

Conclusion: Urodynamic evaluation is essential but not mandatory for the diagnosis and management of LUTD's in all cases and behavioural modification alongwith supportive medical and dietary management provides good results in most patients.

   Trans-Renal Percutaneous Anchorage of Double J Stent Category: Urology Top

VK Gopi, PR Babu, M Narayanan, KT Muralikrishnan, TP Joseph

Department of Pediatric Surgery, Baby Memorial Hospital, Kozhikode, Kerala, India

Aim: To report on Trans-renal Percutaneous anchorage of double J stent to minimize stent related complications and retrieval without anesthesia.

Methods: In 102 children this technique was carried out. Stent removal was done without anesthesia as an outpatient procedure.

Results: In 2 out of 102 children, intervention was required due to stent breakage.

Conclusion: Trans-renal percutaneous anchorage of double J was found to be a feasible technique. It was found to prevent stent migration and avoid cystoscopy for it's removal under anesthesia.

   Comparative Assessment of Upjo Patients Undergoing Open and Laparoscopic Pyeloplasty Using Renal Drainage Index: A New Quantitative Assessment Tool Category: Urology Top

Rishi DwivediRajat Gupta, Ravi Kanojia, Ashwini Sood, Monika Bawa, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim: outcome of UPJO after pyeloplasty is measured on various parameters. We present a unified assessment scheme for evaluating outcomes of UPJO. This eliminates heterogeneity in assessment.

Patients and Methods: Patients diagnosed with UPJO were evaluated retrospectively and divided into 2 groups. Group A for Open pyeloplasty and Group B for Laparoscopic pyeloplasty. Pre-op evaluation with IVP and diuretic renal scan was done. Three key parameters on Drainage on EC, Percentage Function on EC, IVP appearance were given a score ranging from 1-3,1-4 and 3-6 respectively. The findings in contralateral normal kidney was also scored and taken as control. After pyeloplasty score was calculated at 6 months. A two-way evaluation was done with intra group and inter group comparison of scores was done.

Results: Sixty one patients were studied. NA=30 & NB=31. Mean age was 2.74 yrs. Mean RDI score for A & B in pre-op was 8.5 & 8.6 and for post op 11 & 10.55 respectively proving significant improvement. RDI score were significantly higher within the group and across the group.

Conclusion: quantitative scoring of renal improvement after surgical intervention is made easy with the use of the proposed scoring system. There was significant improvement in the RDI of operated kidney in the 2 groups and the improvement in laparoscopic group was comparable to the open group.

   Anterior Urethral Valve: How Different Is Its Clinical Course from Patients with Posterior Urethral Valves? Category: Urology Top

Prema Menon, KLN Rao

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aims: To analyse presentation, mode of surgical intervention and long term post-operative results in boys with anterior urethral valves (AUV).

Materials and Methods: All patients operated upon for AUV between 2006 and 2016 were reviewed. Demographic factors, presentation, investigations, operative modality (endoscopic/open excision) and immediate and late post-operative results were analysed.

Results: A total of 23 patients were reviewed. Age of presentation ranged from 11 days-12 years. Dribbling of urine since birth was the most common presentation. RCUG was required in some patients apart from MCUG for diagnosis. Associated posterior urethral valves were seen in 4 (17%) patients. 5 (22%) presented with abnormal renal function tests. 50% had impaired function/poor drainage of one or both kidneys on nuclear scans. Patients underwent endoscopic fulguration alone and/or open surgery. 2 patients underwent nephro-ureterectomy. Although stream normalised in all, some patients had persistent bladder instability and renal impairment affecting growth.

Conclusion: The management of AUV has similarities and dissimilarities with that of PUV. Diagnosis is delayed if imaging is not done properly or the condition is not thought of due to its rarity. AUV patients need long term follow up.

   Antenatally Detected Thoracic Lesions: Prognosis and Outcome Category: Thoracic Surgery Top

MD Mokarram Ali, Monika Bawa, Nilesh Tank, Ravi Kanojia, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Objective: To study prognostic markers and outcome of antenatally detected thoracic lesions.

Materials and Methods: Antenatally diagnosed thoracic lesions over a period of two years were prospectively studied in terms of nature, laterality, frequency, size, lung head ratio (LHR) and congenital pulmonary malformation volume ratio (CVR). A regular follow up in the antenatal period and postnatally was done to assess their outcomes.

Results: Out of 23 patients, congenital diaphragmatic hernia was noted in 8. Patients with LHR of 1.3 were found to have a good survival though LHR of 0.9 and the ones with stomach and liver carried a poor prognosis. CPAM was diagnosed in 9 patients. MTP was advised for two patients with CVR of > 1.7. Out of the remaining seven patients with an average CVR of 1.1, only one needed excision due to severe respiratory distress. Rest are being managed conservatively. Two patients of CHAOS were still born.

Conclusion: Antenatal diagnosed thoracic lesions and CDH need close observation during pregnancy. LHR, CVR and contents are useful markers for prognostication. An institutional delivery improves the postnatal care. Surgical excision is recommended only in symptomatic patients. Ones on conservative management need a regular follow up.

   Fetal Central Nervous System Anomalies- How to Prognosticate Category: Neonatal Surgery Top

Nilesh Tank, Monika Bawa, Ravi Kanojia, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim: To assess the prevalence and outcome of antenatally diagnosed central nervous system malformations (CNS).

Methods: Prospective study conducted on antenatal mothers who were diagnosed with fetal central nervous system anomalies (brain and spine) on ultrasound over a period of two years. Detailed data was recorded in terms of gestational age at diagnosis, comorbidity, TORCH infection, triple screening, ultrasound, associated anomalies. Outcome was analyzed as need for MTP, fetal and neonatal demise, need of surgery and overall outcome.

Results: Out of 521 antenatally detected congenital malformations, 163 patients (31.28%) had CNS malformation with isolated choroid plexus cyst (CPC) being the commonest (39.26%). Average size of CPC was 7.8 mm (3-15 mm) and it disappeared in all. Isolated corpus callosum agenesis (CCA) was seen in 6.74%, prominent cisterna magna (PCM) in 7.36 %, CPC with ventriculomegaly in 4.9%. Isolated ventriculomegaly was found in 44 patients (26.99%), while 11 patients had ventriculomegaly with associated malformations. 16 patients with >15 mm ventricular size had a poor outcome postnatally. 12.88% had isolated NTD. MTP was advised in 9.81% and 3.06% died after birth. 11% patients underwent surgery.

Conclusion: Isolated CPC, isolated ventriculomegaly of < 15 mm, isolated CCA, isolated PCM carry a good prognosis hence the parents should be counselled positively.

   Surgical Conditions Masquerading as Intractable Ascites Category: GI Surgery Top

Richa Misra, BC Gowrishankar, GS Murali

Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Aim: A grossly distended abdomen need not be always ascites, some surgical conditions may mimic intractable ascites and can misleading to unnecessary investigation and delay in diagnosing and intervention. We reviewed our experience in handling cases with surgical condition which presented as intractable ascites.

Methodology: We came across 9 children presenting with intractable ascites over last 4 years. They were initially evaluated and treated for various medical conditions with little avail. We evaluate these children with further imaging like Contrast enhanced computed tomography to identify surgical conditions. Contrast enhanced Imaging was diagnostic with characteristics like clumping of bowel in the centre with loculations and calcifications. Out of 9 cases 6 were infected omental cyst ;2-mesenteric cyst;1- ruptured pseudocyst of pancreas. After the diagnosis, these children were treated accordingly.

Conclusion: A high index of suspicion is needed to identify uncommon surgical conditions presenting as medical diseases, adequate imaging can lead to a timely diagnosis and a prompt intervention.

   Outcome Analysis of Antenatally Diagnosed Unusual Congenital Malformations in Singleton and Twin Pregnancies Category: Miscellaneous Top

Shubhalaxmi Nayak, Monika Bawa, Nilesh Tank, Ravi Kanojia, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim: To analyze prevalence, associations, significance and prognosis of antenatally diagnosed uncommon congenital malformations in single or multiple pregnancies.

Methods: Antenatal mothers and/or twin pregnancy mothers with uncommon malformations detected on ultrasound were enrolled for the study. 15 multiple and 40 singleton pregnancies with unusual malformations like hydrops, pleural and pericardial effusion skeletal deformity, polyhydroamnios and aberrant right subclavian artery (ARSCA) were followed regularly to study their postnatal outcomes.

Results: Six fetus with isolated skeletal deformity had good postnatal outcomes while the rest five with associated anomalies had fatal outcome. Five fetus were diagnosed with hydrops and advised institutional delivery though only two delivered at our centre and were managed with drainage of pericardial and pleural effusion. Both are doing well. Rest had a poor outcome and succumbed. Isolated ARSCA in 9 patients had a good outcome while the rest three with associated h congenital heart diseases died postnatally. Single umbilical artery and ARSCA were commonest anomalies detected amonst twins and triplet pregnancies.

Conclusion: Antenatally diagnosed isolated ARSCA and skeletal deformities carry good prognosis. Twin pregnancies need a closer follow up. Patients with Hydrops, should be encouraged for institutional delivery which might improve their outcome.

   Pre Pubertal Germ Cell Tumors: Clinical Profile and Surgical Management Category: Surgical Oncology Top

G Vidhya, Nitin James Peters, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Background/Aim: Pre pubertal germ cell tumours are rare in children. They are unique for their varied clinical presentations. We present our experience over 2 years.

Materials and Methods: Retrospective analysis of teratomas operated between June 2016 and June 2018. We studied clinical presentation, surgical management and outcomes of these patients.

Results: There were 9 boys and 8 girls. Age ranged from 2 weeks to 12 years. Ten patients had CT Scan and MRI was done in the rest. Preoperative AFP levels range from 2 to 2 lakh ng/ml. There were 5 gonadal (2 testicular and 3 ovarian) and rest extragonadal GCTs. Four were sacrococcygeal teratomas, 4 retroperitoneal, 2 mediastinal, 1 pelvic and 1 patient had a presacral teratoma. All patients underwent complete surgical resection of the tumor. 4 out of those 17 lesions were found to be malignant and received adjuvant chemotherapy. AFP and USG was done on followup. All patients are doing well on a 6 months to 2 years follow up.

Conclusion: Pediatric germ cell tumors require a tailored surgical approach. Complete excision and occasionally post operative chemotherapy is curative in most patients. AFP can be used in addition to clinical and radiological parameters for a close followup.

   Laparoscopic Vs Retroperitoneoscopic Pyeloplasty: A Comparative Study Category: Laparoscopic Surgery Top

M Raghul, G Rajamani, R Rengarajan, V Muthulingam, RP Dharmendra

Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Minimally invasive pyeloplasty for ureteropelvic junction (UPJ) obstruction in children has gained popularity over the past decade as an alternative to open surgery. The present study aimed to compare the outcomes of laparoscopic (LP) and retroperitoneoscopic pyeloplasty (RP). The records of 50 consecutive patients with a history of retroperitoneoscopic pyeloplasty or transperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction were reviewed retrospectively, of whom 25 underwent attempted retroperitoneoscopic pyeloplasty and 25 underwent laparoscopic pyeloplasty Retroperitoneoscopic pyeloplasty was performed using an anterolateral approach and Laparoscopic pyeloplasty repair was performed using a transmesenteric approach for left ureteropelvic junction obstruction or after right colon mobilization for right repairs. Dismembered pyeloplasty was performed over 3 / 3.5 Fr stent. Parameters studied were patient age, operative time, postoperative analgesic requirement during hospitalization, hospital stay and success rate. No difference was observed between the two groups in patient age, success rate, hospital stay or analgesic narcotic requirement. Average operative time for retroperitoneoscopic pyeloplasty was significantly longer than for laparoscopic pyeloplasty which gradually decreased over time). Overall success rates were also statistically equivalent (24 of 25 retroperitoneoscopic and 25 of 25 laparoscopic pyeloplasties). Four children, including 3 with retroperitoneoscopic and 1 with laparoscopic pyeloplasty, had transient urinary extravasation postoperatively. One patient in the retroperitoneoscopic group had port site infection and was managed conservatively. There were no major complications following either technique. In our experience no major difference exists between the retroperitoneoscopic and laparoscopic approaches for correcting ureteropelvic junction obstruction. The difference in operative time likely reflects the learning curve for laparoscopic suturing and dissection. The two techniques should be considered equal with regard to the successful correction of ureteropelvic junction obstruction.

   Primary Vaginoplasy for Vaginal Atresia Using Native Vaginal Tissue Category: Miscellaneous Top

Usha Gajbhiye

Department of Pediatric Surgery, Matruchhaya Hospital RRSH, Amravati, Maharashtra, India

Aim: Cervicovaginal or vaginal agenesis with functioning endometrial tissue is rare. We report the construction of a vagina from upper vaginal pouch to allow menstruation.

Materials and Methods: We report 14 girl with lower vaginal agenesis, who presented with painful cryptomenorrheoa and abdominal lump. Ultrasound and CT scan showed the huge uterus, cervix and upper Vagina filled with blood. The distended elongated cervix and upper vaginal pouch in the girls with vaginal agenesis is used to make a neovagina to allow her to menstruate normally.

Results: Neovagina functioning effectively, providing an egress for regular painless menstruation.

Conclusions: The vagina is good and natural source, no added skin is need which might contract and may give vaginal orifice stenosis and needs to keep it open with regular dilatations.

   Coexistence of Obstruction at the Pelvi-Ureteric and Vesico-Ureteric Junctions: A Tough Road to Go Category: Urology Top

Gaurav Singh, Aparajita Mitra, Rajeev Kulshrestha, Alpana Prasad, Satish Kumar Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aim: Four cases of co-existing PUJO and VUJO are presented with focus on diagnosis and management.

Methods: Case records of patients who underwent pyeloplasty between Feb 2016 and July 2018 were reviewed for DJ stent / nephrostent placement, and further management.

Results: 104 patients (81 male, 23 female) underwent pyeloplasty for PUJO. Age range: 12 days to 7 years. DJ stent could not be inserted in 30 cases. They underwent nephrostogram on 7th post op day. Total VUJ obstruction was seen in 4 out of 30, their ages being 7 weeks, 11 weeks, 12 weeks and 4 years). In 3 a ureteric reimplant was carried out while the 4th had a nephrectomy. Two had an antenatal diagnosis of bilateral hydronephrosis. One had associated anorectal malformation. The ureter was not dilated in any of them. One had UTI as the presenting feature.

Conclusion: The incidence of VUJO in PUJO cases is 4%. It is difficult to diagnose the coexistence of PUJO and VUJO before surgery. Absence of ureteric dilatation is possibly because of their young age and upstream obstruction.

   Surgical Management of Pediatric Solid Tumors: A Single Surgical Unit Experience over 2 Years Category: Surgical Oncology Top

Priyanka Garg, Nitin James Peters, Ram Samujh

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Background/Objectives: We present our experience of the surgical management of pediatric solid tumors at a tertiary care center.

Materials and Methods: This is a retrospective study in which patients of solid tumors undergoing surgery between June 2016 and July 2018 were analyzed in terms of presentation, neoadjuvant and adjuvant therapy, surgery perioperative events and outcomes.

Results: There were 39 boys and 23 girls, ages between 7 days to 13 years. Forty-two patients had abdominal solid tumors, the commonest being Wilms' Tumor (WT), which accounted for ~ 30% of all cases. Other tumors predominantly included Neuroblastoma and Ganglioneuroma (n=8), Hepatoblastoma (n=6), Germ cell tumors (n=12). The extra abdominal group included Chest Wall Ewings (CWT) (n=8) amongst others. Patients underwent chemotherapy, surgery and radiotherapy as per standard protocols. Relapse within 1 year was seen in 5 patients (8%). The remaining are doing well. 3 patients have succumbed to their disease.

Conclusions: WT is the commonest disease in our series. Perioperative management needs adequate planning in terms of protocolized approach, surgery and perioperative care. Critical care support may be required in extensive resections. Most pediatric solid tumors can be managed well in a multidisciplinary setting and have reasonably good outcomes.

   To Assess Outcomes of Primary Posterior Saggital Anorectoplasty in Patients of Vestibular Fistula Category: GI Surgery Top

Harshita Kour, Nidhi Sugandhi, Deepak Bagga

Department of Pediatric Surgery, VMMC and Safdarjung Hospital, New Delhi, India

Aim: To assess prospectively the short term results of primary Posterior Sagittal Anorectoplasty (PSARP) in females with vestibular fistula.

Materials and Methods: This observational prospective study included 30 female patients upto 2 years with vestibular fistula, all underwent primary PSARP. Oral feeds were withheld 6 hours before surgery and fistula washes were given three times before surgery. Postoperatively, daily multiple washes of the wound were carried out and patients were kept NPO for 5 days or till the patient passed stools. Results were assessed at one week, third week, 3rd month and 6th month.

Results: The mean time for starting oral feeds was 2.53 days (1-7 days) ;12 (30%) patients were given feeds on first postoperative period. The mean post operative stay was 6 days. None of the patients had wound infection. Five (16.66%) patients developed wound dehiscence in the postoperative period -only one required diverting colostomy on 13 th postoperative day. 3 (10%) patients developed mucosal prolapse; only one required mucosectomy. Constipation was present in 12 (40%) patients.

Conclusion: Primary anorectoplasty is feasible in properly selected cases of vestibular fistulae with good results. It avoids colostomy and multiple surgeries. The practice of total gut irrigation, catheterisation and prolonged fasting was found to be unnecessary.

   An Audit of Central Venous Access Devices in Pediatric Oncology Category: Surgical Oncology Top

Shalini Mishra, Deepankar Bhattacharya, Sandeep Jain, Gauri Kapoor

Department of Pediatric Surgery, Rajiv Gandhi Cancer Institute, New Delhi, India

Aim: To evaluate the safety of CVADs in children.

Materials and Methods: Retrospective analysis of CVADs [peripherally inserted central catheter (PICCs), chemoports and Hickman catheters] placed from June-2015 to May-2016. Demographic details, catheter life (number of catheter days), and adverse events (AE)[namely- infection, blockage, extrusion, port-tip migration and exit site skin excoriation] were noted. Risk factors for AE were underlying disease, age of patient, type of CVAD and number of catheter days.

Results: 147 CVADs were placed in 138 patients with a median age of 7.5 years (range 10 months-18 years) and a male: female ratio of 100:38. These included 117 PICCs, 23 chemoports and 7 Hickman catheters. Three patients were excluded. The remaining 135 patients were followed-up for 151 median catheter days (range 8 – 375 days). Overall incidence of AE was 0.828/1000 catheter days (19/22,924 catheter days). AE for PICC lines and surgically implanted catheters was 0.725 and 1.204 per 1,000 catheter days respectively. No patient had clinically significant complications at the time of insertion. Age, diagnosis and type of catheter were not statistically significant but number of catheter days was a statistically significant predictor of AE (P=0.0063).

Conclusion: CVADs are a safe and a reliable for securing vascular access in children with malignancies. Hickman has higher complications compared to PICC.

   Factors Causing Recurrence and Failure in Usg Guided Saline Reduction for Intussusception Category: GI Surgery Top

CN Vysakh, Prathap Somnath

Department of Pediatric Surgery, Goverment Medical College, Kozhikode, Kerala, India

Aim: To study factors causing recurrence and failure in usg guided saline reduction for intussusception.

Materials and Methods: 198 patients who presented in our casualty with intussusceptions during a period of one year were studied (june 2017- june 2018). All children presented with usg proven intusssuscetion were included in study, children with peritonitis,>13 years, prolapsed intussusceptum were excluded. All patients underwent usg guided hydrostatic saline reduction. Failed reduction even after 3 attempts underwent laparotomy.

Results: Total 198 patients presented with intussusceptions, of which 186 were treated successfully with saline reduction. First attempt saline reduction was succcessful in 146 patients.35 required second attempt and 5 cases got reduced after 3 attempts.12 failed reductions underwent laparotomy. Laparotomy group included 5 patients with resection anastamosis,6 with manual reduction and one with spontaneous reduction. All failed first saline reduction patients had symptom duration >24 hours, failed second reduction had symptom duration >48 hours and had a palpable mass. 26 had bleeding PR history.4 children who underwent laparotomy had a leading point.

Conclusion: USG guided saline reduction for intusssuception is easy and safe. Some of the factors causing failure of this method are longer duration of symptoms, history of bleeding PR, definite mass on palpation, intussusceptions with a leading point and older children with intussusception.

   Prostatic Utricle: Incidence and Anatomical Variants in Severe Form of Hypospadias Category: Urology Top

Mamta Sengar, Anup Mohta, Alisha Gupta, Chhabi ranu Gupta, Niyaz A Khan, Yousuf Siddiqui

Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya, New Delhi, India

Aim: To study anatomical variants of Prostatic Utricle on cystoscopy in severe form of hypospadias.

Materials and Methods: Seventy patients of severe form of hypospadias were enrolled for the study over a period of two years. Urine analysis, Ultrasonography evaluation and Cystoscopy were done in all these patients and findings were recorded. Cystoscopic grading was given on basis of size of utricle and it was then correlated with the symptomatology, USG KUB and urine analysis findings.

Conclusion: PU in hypospadias is usually wide mouthed and less likely to cause any significant effect. Cystoscopy is good diagnostic tool for knowing the presence of utricle as well as to see its configuration.

   Laparoscopic Pyeloplasty: If I Can Do It, Why Can't You? Category: Laparoscopic Surgery Top

G Moorthy

Department of Pediatric Surgery, Chettinad Medical College, Chennai, Tamil Nadu, India

Aim: To determine safety, efficacy and outcome of laparoscopic pyeloplasty by a single surgeon without qualified assistant(s).

Materials and Methods: A retrospective analysis of data of all pediatric laparoscopic pyeloplasties done by a single surgeon without any qualified assistants was done. Study period was from 2013 to 2018 and parameters included were duration of the procedure, blood loss, Intra/post operative complications, analgesics requirement, duration of hospital stay and outcome. Success of the procedure was defined by improvement in symptoms, reduction of hydronephrosis and improved cortical thickness on renal ultrasound and Improved drainage on nuclear renogram.

Results: 56 patients with a mean age of 3.2 years (1 month to 9 years) and male:female = 4:1 were included in the study. All patients underwent 3 port (one 5 mm and two 2 mm) laparoscopic dismembered pyeloplasty. Mean operative time was 160 minutes and mean blood loss was minimal (< 10 ml) and mean hospital stay was 3 days. 4 patients were converted to laparoscopic assisted open pyeloplasty through small incision (<2 cm) for various reasons. Follow-up data analysis of renograms and renal ultrasounds showed significant improvement in drainage with 52 (93%) patients. 4 patients with poorly functioning kidneys showed equivocal drainage but no further deterioration of function. None of the patients required redo surgery.

Conclusion: Laparoscopic pyeloplasty is feasible, safe and effective even in single surgeon department and long term results were very encouraging.

   Swapna Dutta Award: Changes in Values of Urinary Transforming Growth Factor-β1 Preoperatively and Postoperatively in Posterior Urethral Valve Patient and Its Significance as Prognostic Marker Category: Urology Top

Sarita Chowdhary, Pranay Panigrahi, Shyamendra Pratap Sharma, Shiv Prasad Sharma

Department of Pediatric Surgery, Institute of Medical Sciences BHU, Varanasi, Uttar Pradesh, India

Aim: The aim of our study is to evaluate changes in values of urinary Transforming Growth Factor-β1 (TGF-β1) preoperatively and postoperatively in Posterior urethral valve patient and its significance as prognostic marker in it.

Materials and Methods: Prospective case-control study WHICH include children diagnosed as PUV in Sir SunderlalHospital between September 2016 to March 2018. Clearance from Institutional Ethical Committee will be taken. The record of patients will be reviewed regarding the time of valve fulguration, adequacy of fulguration on micturating cystourethrogram (MCU) and serum creatinine and estimated GFR was calculated. Urinary levels of TGF- β1 will be measured preoperatively (a day before intervention), post operatively on 1st month & at an interval of 3 months.

Results: Urinary TGF-beta 1 excretion was significantly greater in patients with PUV (range 32 ng/ml – 345 ng/ml) and falls significantly after valve ablation.TGF-beta 1 is significantly lower in healthy child (mean 80.09 ng/ml) compared PUV patients. There was positive correlation between urinary TGF beta 1 excretion and serum creatinine and negative correlation estimated GFR.

Conclusions: Results from this study suggest that TGF beta 1 may contribute to progressive renal insufficiency in patients with PUV, which is non invasive and easy technique.

   Outcomes of Tip Repair in Distal Hypospadias Category: Urology Top

Jatin Jadav, Dhruti Kalsaria, Aniz Ratani, Jatin Jadav, Ankur Patel, Jaishri Ramji, Rakesh Joshi

Department of Pediatric Surgery, BJ Medical college, Ahmedabad, Gujarat, India

Aims: To evaluate patient outcomes and complications in distal hypospadias repair.

Methods: A prospective observational study of consecutive 100 patients of distal hypospadias who underwent TIP repair were studied at tertiary care center.

Results: A total of 100 patients with distal hypospadias who underwent TIP repair from 2015 to 2018 were studied. Mean age of presentation was 5.5 years. Fistula rate of 14% was noted. Other complications were meatal stenosis (2%), glans dehiscence (2%) and penile rotation (2%). Urethral plate width <8 mm was associated with 33% fistula rate, compared to >8 mm urethral plate width with fistula rate of 7.8%.

Conclusion: Age, urethral plate characteristics, different operating surgeons have effect on outcome of the procedure. TIP repair creates a functional urethra of uniform caliber with a vertical slit like meatus almost at the tip of the glans penis, with excellent cosmetic outcome in terms of glanular meatus, conical glans configuration, adequate urinary stream and straight penis.TIP repair is the procedure of the choice for patients with distal penile hypospadias, having good urethral plate (>8 mm) and good glans width (>14 mm), in younger age group of patients.

   The Neonate with Puv-The Place of Primary Valve Ablation in 59 Neonates Category: Urology Top

Harshjeet Singh Bal, Sudipta Sen, Harshjeet Singh Bal, Pavai Arunachalam, Cenita J Sam

Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Aims: To note the babies presenting with antenatal diagnosis of PUV and if the presence of renal failure, gestation of diagnosis, UTI and radiological features have any role in the management of either fulguration /diversion and their long-term follow-up.

Methods: Retrospective review - The patients with antenatal and newborn diagnosis of posterior urethral valve were included in the study from year 2000 to 2018 and their records were collected from hospital database. A study of the antenatal diagnosis and degree of obstruction with presence of renal failure was done and analyzed to see if this has affected the management of either primary fulguration or diversion.

Results: Total number of 59 patients were included in this group. Primary valve fulguration was performed in 50 patients and 16, in addition, had pop-off diversion such as ureterostomy. Another 4 had to have pop off diversion after some time and hence a total number of 34 patients were managed only with fulguration. Nine patients had primary diversion and then fulguration. This was due to urosepsis or technical reason. 22 patients of 29 diverted patients have been undiverted (one with augment) and are stable. Seven are still diverted. Pop off mechanisms have given us time for the bladder to recover.

   Significance of Third Trimester Ultrasound in Detecting Congenital Abnormalities of Kidney and Urinary Tract: A Prospective Study Category: Urology Top

Mrinal Arora, Alpana Prasad, Rajeev Kulshrestha, Ashok Baijal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aims: To determine the significance of third trimester ultrasound in detecting cases with hydronephrosis and those requiring intervention.

Materials and Methods: This prospective observational study is performed on a cohort of 250 antenatally diagnosed fetal hydronephrosis, presenting at our institution over a period of 3 years from June 2013 – May 2016. All cases of hydronephrosis and hydroureteronephrosis with RPD ≥ 4 mm in second trimester and RPD ≥ 7 mm in the third trimester were included in the study.

Results: 32,443 women were screened for anomalies in the fetal medicine unit and hydronephrosis was detected in a total of 269 cases. Incidence of hydronephrosis came out to be 0.83%. Though second trimester scan is more sensitive in detecting cases with hydronephrosis, about 60 % of them resolve in utero and third trimester scan is more predictive of postnatal outcome.

Conclusion: All cases of antenatal hydronephrosis should be followed with a repeat scan in third trimester. If RPD is ≥ 10 mm in third trimester scan then the possibility of CAKUT on left side is 30% and on right side is 22%.

   Calyx to Parenchyma Ratio and Its Utility in Follow up After Pyeloplasty Category: Urology Top

Ketaki Gharpure, B Jindal, BK Naredi, A Subathra, H Dhanapathi, K Sriram, S Kumaravel, G Krishnakumar

Department of Pediatric Surgery, JIPMER, Puducherry, India

Aims: We aim to assess the utility of Calyx to Parenchyma ratio (CPR) parameter in follow up after pyeloplasty and compared it with the commonly used Antero-posterior Transpelvic diameter (AP-TPD) and renal scintigraphy.

Methods: During the study period of 15 months, 73 pyeloplasties were done. 62 cases met all inclusion criteria. One lost to follow up. Of the 62 pyeloplasties, 4 were done in neonates, 39 in infantile period and 19 in children >1 year. All children underwent Ultrasound and Renal scintigraphy EC scan and then underwent pyeloplasty. AP-TPD and CPR values were compared with nuclear scan outcomes in these children in the pre-operative versus post-operative period.

Results: Mean AP-TPD value recorded in the pre-operative period was 3.67 cm which decreased to 1.67 cm post-operatively. The mean CPR value decreased from 5.96 in the pre-operative period to 2.57 post-operatively which was 56.8% lower. Using logistic regression analysis, it was seen that with an overall accuracy of 95.1%, change in CPR was a better predictor of success after pyeloplasty as compared to change in AP-TPD which had an overall accuracy of 85.2%.

Conclusions: Change in CPR is a better predictor of successful surgical outcome and can be used routinely in postoperative follow-up after pyeloplasty.

   Safety and Efficacy of Supra-Costal Approach for Pediatric Percutaneous Nephrolithotomy in Pediatric Patients: Application of Clavien Classification System Category: Urology Top

P Ashwin Shekar, Priyank Yadav, MS Ansari

Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Aims: To evaluate the success and morbidity of pediatric percutaneous nephrolithotomy (PCNL) performed through supracostal puncture and compare it with the subcostal approach.

Methods: Between January-December 2015, data of 55 children who underwent PCNL was collected prospectively. Patients were divided into two groups: those with supracostal (group 1, n=25) and subcostal access (group 2, n=30). Patient characteristics, stone location, stone burden, number and location of the access point, operative time, visual pain score, success rate, hospital stay and complications according to the modified Clavien classification were compared between them.

Results: Stones bulk (median 2.5+1.9 cm) and locations were comparable in both the group. The stone-free rate was 84.8% and 85.36% in groups 1 and 2 respectively after one session of PCNL which increased to 96.0% and 97.6% respectively after auxiliary procedures (p=0.982). Change in hematocrit level (p=0.261), visual pain score/need of analgesia (p=0.368) and hospital stay (p=0.231) were not statistically significant in two groups. Complications were documented in 27 patients (49%, group 1=28%, group 2 =21%, p=0.799), which were classified by modified Clavien system into Grade-I (17,30.1%), grade-II (8,14.5%) and grade IIIb (2,3.63%). Grade-IIIb complications were recorded in group 1 only.

Conclusions: Supracostal PCNL in selected cases is effective and safe with acceptable complications. The modified Clavien system provides a standardized grading system for complications of PCNL in pediatric patients.

   Factors Predicting Result of Pyeloplasty in Children Category: Urology Top

Aadil Farooq, MS Ansari

Department of Pediatric Surgery, SG-PGI, Lucknow, Uttar Pradesh, India

Objectives: To analyze the sonographic and urinary biochemical parameters, predicting the improvement in renal function after pyeloplasty.

Materials and Methods: This is a prospective study including 104 patients with mean age of 4.26 years having PUJO, who underwent pyeloplasty from January 2015 to December 2017 at our tertiary care centre, with a minimum follow up of 6 months. Pre-operative USG findings recorded were APD, cortical thickness, pelvic volume and pelvi-cortical ratio (PCR). Spot urine Pr/Cr ratio was measured intraoperatively from renal pelvis and bladder. Based on changes in differential renal function on diuretic renogram the patients were divided in three groups, Group I: Stable DRF with < 5% change, Group II : improved DRF by > 5% and Group III: deteriorated DRF by > 5%. Data analyzed by SPSS 17 with cross tabulation, nonparametric tests and logistic regression.

Results: In sonograpahic parameters only the APD (p = 0.018) and PCR (p = 0.038) were significantly different among the three groups. Difference in bladder sample Pr/Cr ratio was not significant (p=0.69), while pelvic urine Pr/Cr ratio was significant (p = 0.001). The APD, pelvic sample Pr/Cr and PCR ratio was less than 50 mm, 0.5 and 15 respectively in all patients with improved renal function.

Conclusion: Sonographic and urinary biochemical parameters may predict improvement in renal function after pyeloplasty. Pelvic APD, PCR and pelvic urine protein/creatinine ratio are the most useful parameters.

   Ombradanne's Preputial Flap Technique for Stage I Hypospadias Repair: Overcoming Odds in Severe Chordee in Proximal Hypospadias with Prepenile Scrotum Category: Urology Top

M Raghul, VR Ravikumar, G Rajamani

Department of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India

Surgical techniques for correction of severe proximal hypospadias along with chordee attract significant surgical challenges and single stage corrections are often associated with complications and re operations. In staged procedures, release of chordee during Stage I or resurfacing with buccal mucosal grafts or Byars flap have been practiced widely. However buccal mucosal has the disadvantage of graft shrinkage and the need to harvest from lip and cheek with attendant pain and discomfort. We devised an Ombradanne's preputial flap technique as a rotational flap in children with severe chordee and proximal hypospadias with a prepenile scrotum as stage I repair. In this procedure after release of chordee the resultant raw area extending to the base of the scrotum was resurfaced with preputial flap that was buttonholed and brought ventrally. After three months the second stage of urethral reconstruction was done. The well vascularised flap take is excellent and skin is adequate not only for tubing but also to cover the dorsal and ventral area. Glanuloplasty can be achieved comfortably without any resultant chordee. The long term outcomes in these children have been extremely rewarding. Ombradanne's method allows non hair bearing skin right up to the base of the scrotum for urethral reconstruction and since it is a well vascularised flap unlike buccal mucosal graft the complications are minimal. To conclude, Ombradanne's preputial flap staged technique is a safe and reliable technique in terms of minimal complications and good long term outcomes. The technical aspects of the procedure are outlined in the presentation.

   Androgen Insensitivity Syndrome - Experience from a Gender Clinic Category: Urology Top

Pramod R Pillai, Belinda George, Vijaya Raman, Shalini G Hegde, Rajkiran S Raju, M Kiran, AR Prasanna Kumar, AM Shubha, Kanishka Das

Department of Pediatric Surgery, St Johns Hospital, Bengaluru, Karnataka, India

Aim: To profile the presentation, management and outcome of androgen insensitivity syndrome (AIS) in children.

Materials and Methods: A retrospective review of all children with AIS (complete, partial) at a multidisciplinary Paediatric Gender Clinic over 6 years was conducted.

Results: Of 80 children, 16 were AIS. (14-PAIS, 2-CAIS). The age (range 0-30, median 3 yrs) and presentation varied. Most (8/16) presented as ambiguous genitalia, the rest as inguinal hernia (4) and abnormal voiding (4). Mean time from parental discovery to seeking medical attention was 35.8 months. The diagnosis was based on information from karyotype, imaging, genitoscopy and hormonal profile.10 were reared initially as male (all PAIS) and 6 (PAIS-4, CAIS-2) as females. The genital phenotype was that of a feminized male in PAIS (varying gonadal position/ symmetry and proximal hypospadias), and female in CAIS. Individualized surgical management (orchidopexy 3, orchidectomy 2, urethroplasty 11) after presurgical testosterone was adopted to suit the sex of rearing in a staged fashion. A pseudovaginal pouch was excised in 4 prior to staged urethroplasty. 3 of the 4 PAIS initially reared as female were reassigned a male sex after counseling while one, chose to remain a female. A vaginoplasty is planned at puberty in 3. The mean number of surgical interventions was 1.5. Eight are peripubertal and all are well adjusted psychologically.

Conclusions: The management of AIS involves an algorithmic diagnosis and interventions at a multidisciplinary gender clinic, the goal being genital reconstruction with minimal psychosexual aberration

   Dtpa Verses Dmsa Scan in Managing Patients with Posterior Urethral Valves Category: Urology Top

Mamta Sengar, Yousuf Siddiqui, Chhabi Ranu Gupta, Niyaz A Khan, Anup Mohta

Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya, New Delhi, India

Aim of the Study: Assessing the efficacy of DTPA verses DMSA scan to evaluate patients with PUV after valve ablation.

Materials and Methods: Retrospective data analysis was done on patients, who underwent posterior urethral valve ablation in our institution and were in regular follow up.

Study Period: July 2013 to June 2018 (Five Years).

Results: During study period, 86 (Eighty Six) PUV patients were enrolled. (1) DMSA scan only : 25 (Twenty Five) patients were followed; (2) DTPA scan as well as DMSA scan: 20 (Twenty) patients were followed; (3) DTPA scan only: 41 (Forty One) patients were followed. Conclusions were drawn based upon percentage of patients achieving normal creatinine values, duration for achieving normal creatinine values, no. of episodes of UTI (post valve ablation) and the growth pattern achieved.

Conclusions: DTPA scan aids in assessing the adequacy of bladder dysfunction, so is a better choice in evaluating and following up PUV post-valve ablation cases. DMSA scan is also helpful and may be reserved for select cases.

   UC Chakraborty Award: Corelation of Hepatic Artery Resistive Index with Portal Pressure and Serum Nitric Oxide Levels in Patients with Extra Hepatic Portal Venous Obstruction Category: Hepatobiliary Top

Abhishek Gupta, V Bhatnagar, Anjan dhua, Manisha Jana, Archana Singh, Rohan Malik

Department of Pediatric Surgery, AIIMS, New Delhi, India

Aim: To study the correlation of Hepatic Artery Resistive Index (HARI) with the portal pressure (PP) and its surrogate marker serum Nitric Oxide (NO) levels and to determine the validity of HARI as non- invasive indirect marker of PP in Extra Hepatic Portal Venous Obstruction (EHPVO), pre and post-operatively.

Methods: Prospective study was conducted on 19 patients with EHPVO undergoing proximal Lienorenal shunt or devascularisation from February 2016 to Dec 2017. HARI, calculated from doppler sonography & NO were measured pre-operatively and 14,30,90 days post-operatively. Intra-operatively PP was measured before splenectomy and both PP and NO were measured post-shunt.

Results: Mean age was 10.58±2.85 years, M: F ratio was 15:4. LR shunt was done in 16 while 3 patients required devascularisation. There was significant fall in the HARI (0.06±0.02, p=0.02), NO (14.31±2.66 μmol/l, p<0.001) and PP (11.81±1.03 mmHg, p<0.001) following shunt surgery. However, fall in HARI did not correlate with fall in PP. Pre-operative HARI also did not correlate with pre-shunt/devascularisation PP nor with pre-operative NO. Post-operatively HARI did not correlate with NO at 14, 30, 90 day follow-up.

Conclusion: HARI bears no correlation with PP or NO. Hence, it cannot be used as an indirect marker of PP.

   Etiology and Characteristics of Pediatric Urethral Strictures in a Developing Country in the 21st Century Category: Urology Top

P Ashwin Shekar, Priyank Yadav, MS Ansari

Department of Pediatric Surgery, Sanjay Gandhi Institute of Post Graduate Medical Sciences, Lucknow, Uttar Pradesh, India

Aims: We determined the current etiology and clinical features of urethral stricture disease in pediatric population in the developing world.

Methods: We retrospectively analyzed the data of 199 children with urethral stricture disease, who had undergone treatment in our tertiary center from 2001 to 2017. The database was analyzed for clinical presentation, possible causes of stricture, site and number of strictures, length of stricture and for previous interventions.

Results: A total of 204 strictures were identified in the cohort of 199 children. The common causes of pediatric urethral stricture were traumatic, iatrogenic and idiopathic. Overall iatrogenic causes (due to catheterization, hypospadias repair and valve fulguration) accounted for majority of anterior urethral strictures with trauma being the major reason for posterior urethral strictures. Younger children had a tendency to have an iatrogenic and idiopathic cause for strictures while older children have an traumatic etiology.

Conclusion: Iatrogenic causes such as catheterization and hypospadias repair account for majority of anterior urethral stricture disease in pediatric population especially the younger age group however, as the child grows there is a gradual preponderance of traumatic posterior urethral strictures due to pelvic fracture.

   A Novel Technique for Prevention of Gastro – Esophageal Reflux in Staged Repair of Long Gap Esophageal Atresia with Tracheo – Esophageal Fistula Category: Neonatal Surgery Top

Vipul Prakash Bothara, Vipul Prakash Bothara, Gyan Prakash Singh, SN Kureel

Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Aim: To report a novel technique of preventing gastro-esophageal reflux and air leak from fistula to stomach in patients of tracheo-esophageal fistula with long gap atresia, to buy time for staged procedure.

Methods: Seven patients of tracheo-esophageal fistula with upper pouch of esophagus at 2nd thoracic vertebra, were selected for staged procedure. Weight ranged from 1.7 Kg to 1.8 Kg. During 1st stage surgery for gastrostomy, midline strip of linea alba attached to xiphoid process was harvested and slinged around the gastro-esophageal junction, along with right cervical esophagostomy. After radio-nuclear scan demonstration of abolition of gastro-esophageal reflux, gastrostomy feed was started. 2nd Stage surgery performed after 6 weeks, included mobilisation of esophagostomy, release of sling, thoracotomy and tension free esophageal anastomosis. Outcome measurement - 1) Prevention of air leak from esophagus into stomach. 2) Abolition of gastro-esophageal reflux. 3) Ability to start gastrostomy feeds. 4) Reversal of occlusion after release of sling.

Results: Placement of linea alba sling and elevation of gastro-esophageal junction, abolished air leak from fistula to stomach in all. Radio nuclear scan demonstrated abolition of gastro-esophageal reflux in 6 with weight gain after gastrostomy feeding. One patient expired due to sepsis. One patient underwent final repair with reversal of occlusion with release of sling.

Conclusion: Using a sling of the linea alba around the cardio-esophageal junction, prevents gastro-esophageal reflux and escape of air from esophagus into stomach, gives time to improve the respiratory and nutritional status of the patient, for a subsequent safer delayed primary anastomosis.

   Role of Urinary and Serum Ca 19-9 as Biomarker in Antenatally Diagnosed Isolated Hydronephrosis Category: Urology Top

Reyaz Ahmad Wani, Jai K Mahajan, Anish Bhattacharya, Jyotdeep Kaur, Kirti Gupta

Department of Pediatric Surgery, Postgraduate Institute of Medical education and Research, Chandigarh, India

Aims: To evaluate, the role of urinary and serum CA 19-9 as biomarker, in the diagnosis and follow up of antenatally diagnosed isolated hydronephrosis (ADH).

Methods: The prospective study included consecutive patients of ADH, who were followed up with serial urinary and serum CA 19-9 estimations and ultrasound measurements (USG) of kidney pelvis (APD). The renal units with increasing APD or >10 mm were further investigated with radionuclide scan and/or intravenous urography at 3 months. The units with unambiguous obstruction underwent pyeloplasty. The urinary and serum CA 19-9 levels were assessed again at 3 months after pyeloplasty and at 3 and 6 months of age for conservatively followed up patients.

Results: Out of 209 renal units, 191 were on conservative management while 18 needed pyeloplasty. About 42 % of hydronephrotic units resolved by 6 months of age. Mean serum and urinary CA 19-9 levels in operative group (31.0217 ± 20.21045 and 150.6722 ± 199.87154 IU/ml) were significantly higher as compared to the group managed non-operatively. (20.8610 ± 20.23396 and 40.3870 ± 68.43047 IU/ml (p values= 0.048 and 0.032). Post-operative serum and urinary CA 19-9 levels were significantly lower than the preoperative levels (p< 0.05). Sixty nine percent (11/16) of the pyeloplasty specimens were positive for CA 19-9 on immunohistochemistry. The mean levels of CA 19-9 also correlated positively with APD on USG, drainage pattern on renogram curves and positivity of immunohistochemistry.

Conclusions: The urinary and serum CA 19-9 levels can act as a biomarker for diagnosis and follow-up in majority of the patients of ADH.

   To Evaluate the Protective Effect of High Dose Gonadotropin Releasing Hormone Analogue (Leuprolide)/hcg After Testicular Torsion in a Rat Model Category: Experimental/Basic Sciences Top

B Meenalosani, Pavai Arunachalam, Pananghat A Kumar, L Vidhyalakshmi L

Department of Pediatric Surgery, PSG Institute of Medical Sciences, Coimbatore, Tamil Nadu, India

Aims: To study the protective role of HCG/ GnRH analogue (Leuprolide) after a testicular torsion in a rat model.

Methods: It was done as a randomised controlled study. Wister rats were selected for this experimental study. Torsion testis was created artificially for 24 hours and rats were divided into three groups. Each group was treated in a different way. Group 1 –detorsion and orchidopexy, Group 2- HCG pre op followed by detorsion and orchidopexy, then HCG twice weekly for 3 weeks; group 3- GnRH pre op followed by detorsion and orchidopexy followed by an injection after 3 weeks. Sacrificed after 6 weeks and contralateral testes was biopsied for morphological and structural changes.

Results: In our study, it was noted that both in Group II and III, higher percentage of animals have exhibited satisfactory levels of spermatogenic activity, compared to group I.

Conclusion: Protective agents such as Leuprolide / HCG can decrease the injury after testicular torsion and show improvement in spermatogenesis.

   Study of Clinical Outcomes in Neonates with Inguinal Hernia: A Prospective Study Category: Neonatal Surgery Top

Rupa Banerjee, Alpana Prasad, Pankaj Garg

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aims and Objectives: To determine incidence of peri-operative complications like incarceration and post-operative apnea in neonates with inguinal hernia and follow them for post-operative complications.

Materials and Methods: A prospective observational study was conducted between February, 2015 and December, 2017 including 6 months follow-up. A total of 141 neonates (term newborn up to 4 weeks of age and preterm newborns up to 40+4 weeks of post conceptional age) with inguinal hernia were enrolled in this study. They were followed through the entire course from diagnosis to surgery and six months post-operatively.

Results: In this study a total of 121 (85.8%) babies were born pre-term. Mean birth weight was 1900 ± 784 grams. Out of 141 babies, 123 (87.2 %) presented with unilateral inguinal hernia (right – 65, left – 58). Out of 121 pre-term, 104 had significant perinatal history. Mean post-conceptional age at diagnosis was 35.8 ± 4.8 weeks. Eighty seven cases (61.7 %) were operated before 48 weeks of gestation and rest 54 cases underwent herniotomy between 48 – 60 weeks. Majority cases (98.5 %) were operated electively with mean wait time of 87.7 ± 43.1 days. Two neonates were operated early because of irreducibility. Mean weight at surgery was 3801± 956 grams. All babies were followed up post-surgery at 1 week, 1 month, 3 months and 6 months. Post-operative apnea was seen in 9/141 (6.4 %) cases and all were preterm. At one week follow-up visit, 3 (2.1%) had minor superficial wound infection and 4 (2.8 %) had hydrocele which improved spontaneously. At one month and 3 months follow-up, 7 (6.9 %) had recurrence of hernia. Secondary testicular ascent was seen in 1 case at 3 months follow up visit.

Conclusion: We observed that risk of incarceration or irreducibility can be minimized in babies discharged with known diagnosis of hernia. Recurrence of hernia is higher in pre-term neonates undergoing surgery before 48 weeks.

   Video Session: Laparoscopic Nephrouretectomy and Laparoscopic Vesicolithotomy in Single Sitting: A Rare Occurrence. How We Did It? Category: Video Session Top

Avinash S Jadhav, KirtiKumar. Rathod, Ayushi Vig, TK Jayakumar, Arvind Sinha

Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajastan, India

3 year old female came with h/o dribbling & burning sensation on micturition for 7 months. Patient had past history of lt ectopic ureter, for which patient underwent tapering and open Cohens reimplantation of left ureter. Patient was alright for one year after that surgery. On evaluation patient was found to vesical calculus of 2.6 cm. on DTPA scan patient had a non functioning left kidney. Blood parameters were within normal limits. Patient underwent laparoscopic left nephroureterctomy with laparoscopic vesicolithotomy. Prior to the procedure patient underwent Cystoscopy and vaginoscopy and dye test to r/o vesicovaginal fistula, there wasn't any. Patient developed colonic pseudo-obstruction in post op period, which was managed conservatively. Patient was discharged on post op day 6 with normal vitals and on full diet and normal urinary stream. On follow up patient was asymptomatic and doing well.

   Laparoscopic Right Adrenalectomy for Benign Adrenal Adenoma Category: Video Session Top

Vaibhav Pandey Ajay Narayan Gangopadhyay, Saroj C Gopal, Shiv Prasad Sharma

Department of Pediatric Surgery Institute of Medical Sciences BHU, Varanasi, Uttar Pradesh, India

Aim: The most commonly encountered pediatric adrenocortical tumors are adrenocortical adenoma (ACA). Focal adrenal lesions can occur from a variety of underlying congenital and acquired causes in the pediatric population. We present a case of androgen producing right congenital ACA in a male child.

Methods: A 4 year male with complaint of coarse facial features and stunted growth, endocrine workup reveals androgen secreting focus, CECT confirming soft tissue mass arising from left suprarenal with dominant absolute contrast washout in comparison to relative washout (82% Vs 46%). It was planned for laparoscopic right adrenalectomy. Intraoperative and postoperative period was uneventful with removal of an 4 cm diameter soft mass, histopathologically came out to be adrenal adenoma without capsular breach. Patient was discharged on postop Day 3.

Concluson: Adrenal adenoma should be differentiated from congenital adrenal hyperplasia and adrenocortical carcinoma by proper hormonal assay and imaging like MRI/CT which remains gold standard. Surgical resection is the current management of choice for hormonally active (functional) adrenal adenomas, but surgery is not indicated for nonfunctional adrenal adenomas. Moreover, Minimal invasive approach is a step ahead in terms of cosmesis and postoperative comfort.

Link: https://drive.google.com/file/d/1mrpMJx0fy51p6tue-PAx729IfaeGXzLV/view?usp=sharing

   Cystoscope Guided Endoscopic Third Ventriculostomy Category: Video Session Top

Ramesh Chand Tanger

Department of Pediatric Surgery, S.M.S. Medical College, Jaipur, Rajasthan, India

Aims: Endoscopic third ventriculostomy is becoming more popular as an alternative to shunting in the management of obstructive hydrocephalus. The goal of this procedure is to fenestrate the floor of the third ventricle between the mamillary bodies and the infundibular recess, and thus establish flow of cerebrospinal fluid between the ventricles and the basal subarachnoid spaces.

Methods: compact cystoscope, grasping forcep and bugbee (ball electrode) used to fenestrate the floor of the third ventricle. The main indication for endoscopic third ventriculostomy was obstructive hydrocephalus. Endoscopy tried in total 5 cases.

Results: Endoscopy done in total 5 cases (Age 8 month to 18 months), ETV done successfully in 3 cases while vision lost in 2 cases. These 2 cases managed by shunt surgery. longest follow up 26 months.

Conclusion: Cystoscope guided Endoscopic third ventriculostomy is a good alternative to shunt surgery for obstructive hydrocephalus. Good knowledge of ventricles anatomy and experience in endoscopic surgery are prime requirement for good result and minimise complications.

   Exit Surgery in a Case of Giant Cervical Lymphangioma: Management Challenges Category: Neonatal Surgery Top

Ashish Prasad, Prashant Jain, Kumar Ankur, Sanjeev Chetry, Alka Sinha, Tarannum Shakeel, Kanta M Rahul

BLK Centre for Child Health, BLK Super Speciality Hospital, New Delhi, India

Background: EXIT is performed if the fetus requires intervention at birth but before division of the umbilical cord. The particular intervention varies by indication and may involve securing the airway, resecting an intrathoracic mass, or inserting a cannula for extracorporeal membrane oxygenation. EXIT allows extended uteroplacental support while the airway is secured by direct laryngoscopy, rigid or fiberoptic bronchoscopy, or tracheostomy. However, it has its management challenges which requires extensive team work and planning.

Aim: This study discusses about EXIT procedure performed on a fetus who was diagnosed at 30 weeks gestation with a large neck mass compressing trachea with potential airway obstruction.

Methods: The mother and the fetus were closely monitored and after detailed planning EXIT procedure was successfully performed at 36th week of gestation. The baby was successfully intubated within 10 minutes once the fetus was partially delivered. After EXIT, the baby was evaluated and underwent excision of the lesion on day 5 of life.

Conclusion: This report shows that EXIT procedure is technically feasible in fetus with severe upper airway abnormalities which impede resuscitation and may prove lifesaving to achieve a safe, successful outcome for the mother and child.

   Incidental Asymptomatic Malrotation Diagnosed during Laparoscopic Pyeloplasty- What to Do? Category: Video Session Top

Shandip Kumar Sinha, Rajat Piplani, Rakesh Handa

Department of Pediatric Surgery, Madhukar Rainbow Children Hospital, New Delhi, India

Aim: To present a video of Incidental asymptomatic malrotation diagnosed during Laparoscopic pyeloplasty and discusses approaches of its management.

Materials and Methods: case and video records were reviewed.

Results: 3 year old male underwent laparoscopic pyeloplasty for right PUJ obstruction. During surgery, ascending colon was not found at its normal position. Dismembered Anderson Hynes pyeloplasty was done. Child is doing well during six months of follow up.

Conclusion: Although no robust conclusion can be made upon single case report, asymptomatic malrotation incidentally found can be left alone.

Google drive link https://drive.google.com/open?id=1MjgU14Cvq2VI-ijNBHVv7L2q7RvU4UUC

   Laparoscopy in Intra-Abdominal Cystic Lesions: Our Experience Category: Laparoscopic Surgery Top

Pavai, Cenita J Sam, Meenal Soni, Sudipta Sen

Department of Pediatric Surgery, PSG Hospitals, Coimbatore, Tamil Nadu, India

Introduction: Laparoscopy plays an important role in intra abdominal cystic lesions. Cysts can occur in all organs and can be easily tackled with minimal morbidity and cosmetic scars.

Aim: Retrospective study to analyse all children who have undergone laparoscopy for intra abdominal cysts in our hospital.

Methodology: Case sheets were analysed to see the location of the cyst, organ of origin, size of the cyst, antenatal diagnosis and symptomatology when presenting later. In addition the conversion rate and associated morbidity was analysed.

Results: In our series we had ten ovarian cysts which were operated in the newborn period, ten ovarian cysts in later age group, three mesenteric cysts, two retroperitoneal cysts, four choledochal cysts, two gastric duplication, three splenic cysts, three cystic lesions in the omentum.

Discussion: Laparoscopy plays an important role in cystic lesions inside the abdomen. Even in large cysts, they can be decompressed and removed easily. In difficult situations, lap assisted procedures can be performed with ease.

Conclusion: Laparoscopy plays an important role in the intra abdominal cystic lesions and can be considered as a gold standard as it helps in diagnosis and management.

   Laparoscopic Cystogastrostomy in Management of Pseudopancreatic Cyst in Children Category: GI Surgery Top

Ashutosh Kumar Sharma, Kedar mukhedakar, Deepa Peswani, kamal Kant sharma

Department of Pediatric Surgery, KEM Hospital, Mumbai, Maharashtra, India

Aims: To assess feasibility of management of pseudopancreatic cyst by laparoscopic posterior approach.

Methods: A 2 _ year female child presented with abdominal lump. Examination revealed well defined lump of 15 x 10 cm in left hypochondrium extending to epigastric & umbilical region. It was firm in consistency with smooth surface and partially mobile side to side. Both USG and CT abdomen showed large cystic lesion separate from stomach and duodenum with internal echoes suggestive of? Mesenteric cyst?? Pseudopancreatic cyst. Tumour markers were within normal limits. On diagnostic laparoscopy, a large thick walled cyst in the area of lesser sac between the stomach and transverse colon was found raising a doubt of Pseudopancreatic cyst. Hence cyst fluid was sent for amylase which was very high (77,480 IU/L). Intraoperative frozen section confirmed benign pathology. Laparoscopic cystogastrostomy with posterior (lesser sac) approach was performed.

Results: Postoperative recovery was good. Adhesions between posterior gastric wall and pseudocyst determine the choice between anterior and posterior laparoscopic approach.

Conclusion: Single incision on stomach wall with wide anastomosis is the advantage of posterior (lesser sac) approach for pseudocyst of pancreas.

   Adenomucinosis: A Rare Complication of Surgery for Ano-Rectal Malformation Category: Laparoscopic Surgery Top

Rupa Banerjee, Gaurav Singh, Aparajita Mitra, Satish K Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aims: Adenomucinosis is a rare complication after colorectal surgery. It is characterized by accumulation of large volumes of gelatinous mucinous material, most commonly in the peritoneal cavity. We report a rare case of Subperitoneal Pelvic Adenomucinosis) after redo surgery for ano-rectal malformation.

Case Report: A 39 years old married woman presented with recurrent abdominal pain and diarrhoea of several years duration, but acute exacerbation for the past 4 months. Twelve years prior she had been diagnosed as “Left simple ovarian cyst” and was being managed conservatively. In the past she had been operated for ARM (recto-vaginal fistula) in her infancy. At the age of 12 years, she had undergone a redo repair of ARM because of vaginal diverticulum rectal prolapse and incontinence. We investigated her for current GI symptoms. CECT and MRI revealed a complex pelvic lobulated cyst with septations, encompassing the recto-sigmoid. She underwent laparoscopic excision of cystic lesion. She became asymptomatic. Histology confirmed Adenomucinosis.

Discussion: Subperitoneal pelvic adenomucinosis is a rare complication of ARM surgery. It has been anecdotally reported following surgery for ulcerative colitis and appendicectomy for mucinous adenoma. Entrapment of hindgut endothelium during previous surgeries for ARM is a possible cause in our case. In literature this is the second such case.

   Uncommon Urethral Polyp Presenting as Enuresis Category: Urology Top

Usha Gajbhiye

Department of Pediatric Surgery, Matruchhaya Hospital RRSH, Amravati, Maharashtra, India

Aim: Congenital urethral polyp, presented with features of voiding dysfunction and obstruction rare mystery. We present our experience of male urethral polyps in boy and video.

Materials and Methods: 3 year old male child presented with continuous wetting of pants Later child was not allowed to sit in the school as re remained wet throughout the period. He was admitted twice at the age of 1 yrs 4 months and 2 yrs respectively with hypospadias repair and UTI. A trial of prophylactic antibiotics and the oxybutinin was given for three months without any relief. Investigated, USG Normal on July 2017, so the child underwent cystourethroscopy, diagnosed posterior urethral a polyp broad based just on the right side of the veru, Underwent resection of the polyp with monopolar cautery. The polyp was removed with nitinol basket. Histopathology is suggestive of benign fibro epithelial polyp.

Results: The only diagnostic tool for male urethral polyp is the cytsourethroscopy. Transurethral resection was applied with satisfactory results.

Conclusions: Urethral polyps, should be considered in the differential diagnosis of voiding dysfunction in male.children. A high index of suspicion and possibly screening may be of help in knowing the exact incidence.

   Rare Complication of Tracheoesophageal Fistula and Esophageal Atresia Repair Category: GI Surgery Top

Usha Gajbhiye

Department of Pediatric Surgery, Matruchhaya Hospital RRSH, Amravati, Maharashtra, India

Aim: Rare Complication of Tracheoesophageal fistula and esophageal atresia repair.

Materials and Methods: Three year old female child present with difficulty in swallowing even liquids for week, she is known case of TOF with oesphageal atresia. There was follow up for first one year after lost followup. Parents also gave history of girl eating mud and stones in the past few months. Investigated done were X ray and Ba Swallow. Reported stones lined up in the upper pouch of esophagus and very narrow stricture with fairly normal esophagus below stricture. Child had removal of stones from the upper pouch, almost a fistful, as big as betel nut and as small as sand. Stone clearance was complete. Child did well and could swallow liquids after surgery.

Results: Post surgery child evaluated and tried for balloon stricture dilatation, It was not possible to negotiate the pediatric ballon. Child is awaiting resection of Stricture and Anastomosis.

Conclusions: Stricture post Tracheoesophageal fistula and esophageal atresia repair are seen occasionally but child presenting with stones in stricture oesphagus causing total obstruction are rare.

   Results of Thoracoscopic Repair of Congenital Diaphragmatic Hernia at Our Center and Highlight Some Aspects of Technique to Simplify the Repair Procedure Category: Neonatal Surgery Top

Gaurav Shandilya, Gurmeet Singh, Nitin Pant, Ashish wakhlu

Department of Pediatric Surgery, King George's Medical University, 48 Lucknow, Uttar Pradesh, India

Aim : To present the results of thoracoscopic repair of congenital diaphragmatic hernia at our center and highlight some aspects of technique to simplify the repair procedure.

Methods: Thoracoscopic repair of congenital diaphragmatic hernia was performed in 17 neonates. The age range was 5 to 9 days. There were 12 male babies. All had left sided CDH without a sac. 12 babies were born in Lucknow and 5 referred from other nearby cities. Antenatal diagnosis had been done in 5 babies, who were subsequently delivered in our hospital. Surgery was undertaken at the age of 5 days when the baby had crossed the critical period. Three ports were used, a 5 mm second left interspace trocar was inserted for the telescope. The hand instruments were inserted directly through the chest wall in the third interspace to triangulate the ports. CO2 pressure was kept at 4 mm of mercury and a 24 gauge IV canula inserted into the peritoneal cavity in the left subcostal region to create a small thoraco abdominal pressure gradient. This aided gentle reduction of the bowel into the abdomen in all patients. The spleen was intrathoracic in 6 babies and could be manipulated into the abdomen without incident in all.

Results: The post-operative recovery was uneventful in all patients, without the need for ventilation. Discharge was between the 5th and 8th post operative days.

Conclusion: thoracoscopic repair of congenital diaphragmatic hernia is feasible in the neonates and will become standard of care in future.

   Thymopharyngeal Duct Cyst : Combined Cervical and Thoracoscopic Excision Category: Video Session Top

Gaurav Singh, Sugandh Aggarwal, Rupa Banerjee, Satish Kumar Aggarwal

Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India

Aim: To present combined cervical and thoracoscopic excision of a thymopharyngeal duct cyst.

Case Details: An 8 years male presented with one year duration of a progressively enlarging left sided swelling in the neck. There was no fever, hoarseness of voice, trauma or discharge from the swelling. The tense cystic swelling extended from angle of mandible to suprasternal notch, with ill-defined lower margin. CT revealed multiloculated mass coursing adjacent to the carotid sheath, extending in the mediastinum. A diagnosis of thymopharyngeal duct cyst was made. The cyst was excised by Combined approach - open cervical and thoracoscopic. Cervical portion was dissected first through a longitudinal incision. Neck dissection was stopped at suprasternal notch. Rest of the dissection was carried out thoracoscopically, saving the phrenic nerve. The specimen was delivered through the neck.

Results: The cyst was removed successfully. Post op course was smooth. Child was discharged on Post op day 3. X- Ray after 2 months showed completely expanded left lung.

Conclusion: Thymopharyngeal duct cyst is rare. It develops from the remnants of one of the paired tracts of embryological thymus during its descent. The common differential diagnosis are second branchial cleft cyst and lymphangioma. It requires meticulous dissection and good knowledge of anatomy is essential for surgery.

   Three-Dimensional Laparoscopic Hemisplenectomy for a Recurrent Non-Parasitic Splenic Cyst in a Paediatric Patient Category: Video Session Top

Kamal Kant, SV Parelkar, BV Sanghvi, Rahul K Gupta, Kedar P Mudhkhedkar, Rujuta Shah, Deepa Makhija, Pooja Tiwari, Kavimozhy Illakya, Manish Kumar, S Soundharya

Department of Pediatric Surgery, GSMC and KEM Hospital, Mumbai, Maharashtra, India

Aims: To study 3D laparoscopic hemisplenectomy.

Methods: A case of a 12 year old boy, who had undergone a cyst deroofing for an NPSC 2 years back, and now presented with a recurrent abdominal lump and abdominal pain. On evaluation he was found to have a recurrent splenic cyst. He underwent a 3-D laparoscopic upper pole hemisplenectomy.

Results: Child underwent a 3-D laparoscopic upper pole hemisplenectomy, with an uneventful post-operative period. The child is asymptomatic on follow up.

Conclusion: on-parasitic splenic cysts (NPSC) are rare. Although their true incidence is not known, they represent 10% of all benign splenic cysts. They can be either congenital with the presence of epithelial lining that originate from invagination of the capsular mesothelial lining or post-traumatic with absence of epithelial liningDeroofing of the cyst has been an acceptable first line of surgical management for NPSC, but in recent years a lot of studies have shown high rates of recurrence. Partial splenectomy has very low rates of recurrence and the benefit of preserving the spleen and avoiding the complications of a total splenectomy, especially in the paediatric population.

   Laparoscopic Hydatid Operation in Children Category: Video Session Top

Sarita Chowdhary, Pranay Paingrahi, SP Sharma, Shyamendra P

Department of Pediatric Surgery, Institute of Medical Sciences BHU Varanasi, Uttar Pradesh, India

Introduction: Appropriate surgical intervention to obtain the best results with the lowest rate of recurrence and minimal morbidity is mandatory for the management of hepatic hydatid disease.

Aim: To evaluate the efficacy of laparoscopically treated liver hydatid cysts in children.

Patients and Methods: From September 2016 to april 2018 2014, 3 hydatid cysts of the liver underwent laparoscopic treatment in pediatric surgery unit in SS Hospital BHU, Varanasi. Umbilical 5 mm port, another two 5 mm ports inserted and used as working site. The procedure were the same as in open surgery, puncture, aspiration, injection of scolicidal agent, reaspiration, removal of proligerous membrane and placement of drain in cavity if suspect bile leakage. All patients received antiparasitic drugs.

Results: The patients' mean average age was 6 years to 12 years. The number of cysts ranged from one to two with a diameter of 60 to 150 mm (mean diameter, 85.5 mm). The average operating time was 90 minutes (45 min-95 min). The average length of hospital stay was three days (range, 2-4 days). At 2 to 49 months follow-up, no recurrence has been reported.

Conclusion: Laparoscopy represents a safe approach for the treatment of hydatid cyst of the liver in children.

   Nursing CME abstracts: A Descriptive Study to Assess Breast Feeding and Complementary Feeding Practices in Children Less Than 2 Years of Age Attending Pediatric Opd, Advanced Pediatric Center, Pgimer, Chandigarh 2015–2016 Category: Miscellaneous Top

Manpreet Kaur,Jaspreet Kaur, Shivalli Sirswal, Sarita Kumari, Nikita Thakur, Bhawna Duna, Prabhjot Kaur1, Geetanjli Kalyan2, Pankaj C Vaidya2

Departments Pediatric Surgery and 2 Pediatrics, PGIMER,1 Department of Pediatric Surgery, National Institute of Nursing Education, PGIMER, Chandigarh, India

Aims: The current research was aimed to assess breast feeding and complementary feeding practices in children less than 2 years of age attending pediatric OPD, Advanced Pediatric Centre, PGIMER, Chandigarh 2015-16.

Methods: Approval was taken from institute's ethics committee. Written informed consent was taken and mothers of 200 children less than 24 months of age were interviewed using a semi-structured interview schedule developed from various standard guidelines (Government of India, Global Opinion Panels, USAID and UNICEF, and FAO).

Results: Slightly more than 1/3rd received breast feed with in 1-2 hours of birth. Only 5% were not breastfed till 2 years of age and those who were breastfed out of them 2/3rd children were exclusively breastfed. More than two third mothers initiated complementary feeding at the age of 6 months whereas rest started it at the age of 7-9 months and only 23% of children received complementary feeding in adequate quantity and consistency.

Conclusion: It is concluded that initiation of breastfeeding after delivery was not within a recommended guidelines for majority of children. Whereas, majority of mothers followed standard guidelines related to the number of times a child should be breastfed in a day and initiation of complementary feeding at 6 months.

   Development of Stakeholder's Guidelines on Feeding Pattern and Physical Activity of Under-Five Children Visiting Day Care Centers Category: Miscellaneous Top

Priyanka M

Department of Pediatric Surgery, PGIMER, Chandigarh, India

Aim: To develop stakeholder's guidelines on feeding pattern and physical activity of under-five children visiting day care centers.

Methods: Approval was taken from Institutional Ethical Committee. The data was collected form 3 crèches of Tri-city and written informed consent was taken from all the participants. In pre-assessment initially the practices were assessed by cover participatory observation using by checklists prepared based on standard guidelines and then expressed current practices of stakeholders were assessed by conducting six focus group discussions in group of 3-4 members each. Based on finding of pre-assessment phase and extensive review literature the guidelines were developed. The content validity was established by conducting Delhi rounds. We further plan to test guidelines and calculate reliability.

Results: The content validity all four areas that is clarity, relevance, simplicity and ambiguity after 1st round were 0.88 and after 2nd round were 1.00.

Conclusion: Thus a valid Guidelines on feeding pattern and physical activity for stakeholders in day care centers was prepared. Guidelines can be used for educating the stakeholders and checklist to assess the implementation of guidelines and calculate reliability.

   Family Integration: Perspectives, Barriers, Facilitators and Suggested Remedial Measures as Per Indian Parents Category: Miscellaneous Top

Geetanjli Kalyan, Sushma Saini, Praveen Kumar, Sandhya Ghai, Sukhwinder Kaur

Department of Pediatric Surgery, National Institute of Nursing Education, PGIMER, Chandigarh, India

Aim: To find out the perspectives, barriers, facilitators and suggested remedial measures related to family integration as per Indian Parents.

Methods: The parents of preterm neonates who were admitted in neonatal units of tertiary care centre, PGIMER, Chandigarh, India were included in study. Institutional ethical clearance was taken and after obtaining written informed consent eight focus group discussions were conducted in group of 5-12 members each for approximately 25-45 min. All the interviews were recorded, transcribed, read and re-read, and thematic analysis was done.

Results: Major themes include involve family in care as this will equip them to care the neonate at home after discharge, family can learn and care better, and father is a priority. The main barriers were mother's health is neglected, no orientation policy, fathers is considered unwanted, anguish due to misbehavior of some health care providers, and stress among mothers. The facilitators were mother is included into care, fathers are allowed inside for some time to facilitate bonding, KMC classes and good behaviors of some nurses and doctors. Suggested remedial measures include orient the families to unit, educate families especially along with mother of baby, provide skill training to families and provide information considering it as a right of parents.

Conclusion: Indian parents along with their families desire to be part of care of their neonate and feel that this will help them in care of neonate after discharge.


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