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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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   Table of Contents - Current issue
September-October 2022
Volume 27 | Issue 5
Page Nos. 515-660

Online since Friday, September 9, 2022

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To Be or Not To Be Highly accessed article p. 515
Ashoke K Basu
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Focus of pediatric surgical reports during the SARS-CoV-2 pandemic: A narrative review Highly accessed article p. 517
Karina Miura da Costa, Thiago Elias Ferrari Khouri, Amulya Kumar Saxena
Background: Coronavirus disease-2019 (COVID-19) pandemic impacted surgical activity at health-care facilities and led to significant changes in the characteristics of publications in medical journals. This is a narrative review that outlines the focus of pediatric surgical reports during the ongoing COVID-19 pandemic. Methods: Publications on pediatric surgery during the pandemic were carefully reviewed, and data emerging from reports on COVID-19 were selected to address: (1) the impact of COVID-19 on pediatric surgical procedures; (2) children undergoing surgical intervention; and (3) expansion of telemedicine. Results: Regarding surgical activity in tertiary hospitals, there was a reduction in the number of elective surgeries, with reports of an increase in complicated appendicitis and in testicular torsions with symptoms for more than 6 h. The pandemic impacted specific surgical fields, with reports on trauma, appendectomies, urology, cardiac surgery, and kidney transplant. In children positive for COVID-19 that underwent surgery, postoperative complications were more indicative of the primary surgical pathology and there were no postoperative deaths. In a report of universal screening, <1% of children had positive reverse transcription-polymerase chain reaction (RT-PCR). In a report addressing telemedicine during the pandemic, it was well evaluated by both pediatric surgeons and patients' families, but most surgical departments did not provide the service. Conclusions: The pandemic brought significant changes in surgical care. As expected, there was a reduction in elective surgeries, RT-PCR-positive children did not present worse postoperative outcomes than negative ones but there is still a paucity of data regarding COVID-19 children, and telemedicine may play an important role in health care, especially in times of social distancing.
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Correlation of plasma renin activity values and resistive index on ultrasound doppler with findings of renal dynamic scan in patients with the society of fetal ultrasound grades 3 and 4 unilateral hydronephrosis Highly accessed article p. 521
Prashant K Zulpi, Yogesh Kumar Sarin
Background: Renal dynamic scans (RDS) despite being considered the gold standard for the diagnosis of pelvic ureteric junction obstruction (PUJO), fail to help resolve the dilemma about management issues in many patients. Multiple invasive and noninvasive methods are being studied to help the decision-making in these patients. We did this study to find correlation of plasma renin activity (PRA) values and resistive index (RI) on Doppler ultrasound with findings of RDS in patients with the Society for Fetal Urology (SFU) Grades 3 and 4 unilateral hydronephrosis (HDN) and also to determine the cut-off values of PRA and RI that could categorically acknowledge the success of pyeloplasty. Methodology: Twenty patients with SFU Grades 3 and 4 unilateral HDN due to PUJO were enrolled. Demographic details were recorded. All underwent Anderson-Hynes dismembered pyeloplasty. Based on the follow-up RDS scans, these patients could fall into one of three categories- improved (successful), status quo, or deteriorated (unsuccessful). Outcomes were compared based on RDS (split renal function [SRF]), ultrasonography, and Doppler findings were done at 3 months of postoperative period. Results: Follow up period was 3 months after Pyeloplasty. Seventeen patients had successful outcomes based on RDS findings, 12 had improvement in SRF (>5%), and 6 had normal drainage curves (t-t1/2 <10 min). Three patients had indeterminate curves (t-t1/2 between 10 to 20 min). Four had improvement on both the criteria, i.e., SRF and drainage curves. Among the three patients who showed no improvement in RDS, two were in “status quo” category and one patient showed deterioration. Seventeen patients also showed improvement in PRA and RI. No significant correlation between PRA and RI with SRF could be established. However, PRA was found to have good concordance with RDS (90%). Conclusion: No significant correlation could be demonstrated between SRF and the respective values of PRA and RI. However, PRA could act as an adjunct to predict the early success of pyeloplasty in view of good concordance with RDS. A larger trial with bigger cohort of patients is required to confirm our contention.
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Probiotics as prophylaxis for postoperative infections of under-five children following gastrointestinal surgery p. 528
Sheikh Mohammad Sabbir Enayet, Kaniz Hasina, Abdul Hanif Tablu
Purpose: Evaluation of the efficacy of use of probiotics as prophylaxis for postoperative wound infection in under-five children following gastrointestinal surgery. Materials and Methods: This randomized control trial was conducted over a period of 2 years in the pediatric surgery units of a tertiary level hospital in Dhaka, Bangladesh. A total of 60 patients undergoing gastrointestinal surgery under the age of 5 years were included in the study and randomly assigned to two groups – probiotics group (n = 30) and nonprobiotics group (n = 30). Patients in the probiotics group received probiotics in the preoperative (3 days) and postoperative period (7 days) along with traditional gut preparation (antibiotics and mechanical bowel wash). Patients in the nonprobiotic group got only antibiotics and traditional gut preparation. Outcome variables were surgical site infection, fever, c-reactive protein (CRP), total white blood cell (WBC) count, and neutrophil count. Results: Postoperative wound infection was less in the probiotic group (n = 2) compared to the nonprobiotic group (n = 3), but the difference was not statistically significant (P = 0.640). Postoperative CRP level was significantly lower in the probiotics group (P = 0.020). There was more decline in total count of WBCs in postoperative period in the probiotic group. No statistical difference was seen between the groups in postoperative pyrexia, the total count of WBC, and neutrophil count. Conclusion: Use of probiotics along with traditional gut preparation as prophylaxis for postoperative infection in children showed no added benefit in comparison to the use of traditional gut preparation only.
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Fibromatosis colli: About 26 cases p. 534
Salsabil Mohamed Sabounji, Doudou Gueye, Mbaye Fall, Oumar Ndour, Gabriel Ngom
Aims: The aim is to identify the epidemiological, diagnostic, therapeutic, evolutionary aspects, and risk factors related to the occurrence of this condition. Subjects and Methods: It was a retrospective and descriptive study of a series of 26 cases of fibromatosis colli collected over a period of 3 years (from January 1, 2017 to December 31, 2019). We studied the following parameters: frequency, age, sex, delay of consultation, motive of consultation, gravidity, parity, type of delivery, notion of birth trauma, birth weight, examination findings, ultrasound results, type of treatment, and evolutionary modalities. The data were collected from patients' files. The analysis was done on Excel 2016. Results: The frequency was 6.5 cases/year. The mean age was 2.1 months. The average delay of consultation was 6.3 weeks. A notion of obstetrical trauma was found in 16 cases (61.5%). Primiparity was noted in 15 cases (57.5%). Associated torticollis was noted in 03 cases. Cervical ultrasonography was performed in all cases (n = 26/26) enabling diagnostic confirmation. Surveillance was the main treatment (84.6%). After a mean follow-up of 20.8 months, evolution was favorable in the majority of patients. The average time of complete regression of the mass was 3.8 months. Conclusions: Rare condition of the newborn and infant for which the diagnosis is clinical and the confirmation is based on ultrasound. The management is simple and based on surveillance. The evolution is most often toward spontaneous regression.
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Correlation of urinary biomarkers (Interleukin-6, Transforming growth factor-β, E-Cadherin, and MCP-1) with conventional parameters of disease progression in patients of posterior urethral valves: A comparative analysis p. 537
Priyanka Garg Mittal, Ram Samujh, Nitin James Peters, Sadhna Sharma
Aims: Posterior urethral valves (PUV) are the leading cause of end-stage renal disease in boys. The study aimed to look at the ongoing renal damage and profibrotic activity by measuring the levels of Interleukin-6 (IL-6), Transforming growth factor-β (TGF-β), E-cadherin, and Monocyte Chemoattractant Protein-1 (MCP-1) and observing trends in subsequent follow-ups and at the same time correlating them with the established parameters of disease progression. Materials and Methods: This prospective study included 36 consecutive patients of PUV, managed over a period of 18 months. IL-6, TGF-β, E-cadherin, and MCP-1 were measured in urine samples at the time of admission, pre-fulguration and 3 months' and 9 months' post fulguration. The observed values were correlated with the conventional parameters used in clinical practice. Results: All the biomarkers showed statistically significant trends when these values were compared on admission, postoptimization and 3 months' and 9 months' postfulguration. None of the biomarkers showed a significant correlation with renal function tests. E-Cadherin and TGF-β showed a positive and a negative correlation with ultrasonography (USG) kidney, ureter, and bladder (KUB) respectively. E-Cadherin showed a positive correlation, whereas IL-6 and TGFβ showed negative correlation respectively with micturating cystourethrogram (MCUG). IL-6 showed statistically a significant negative correlation with dimercapto succinic acid (DMSA). MCP-1 did not show any significant correlation with USG KUB, MCUG and DMSA. Conclusion: This study concludes that E-Cadherin, IL-6, TGF-β can be promising urinary biomarkers for early detection of the ongoing renal damage in patients of PUV following valve fulguration. MCP-1 may have more complex interactions, with inflammatory markers; which warrants further research.
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Evaluation of the outcome of pyeloplasty in children with poorly functioning kidneys due to unilateral ureteropelvic junction obstruction p. 544
Rohit Kapoor, Amit Gupta, Pooja Abbey, Ravinder Singh Sethi, Partap Singh Yadav, Subhasis Roy Choudhury, Rajiv Chadha
Aim: To analyze the outcome of upfront pyeloplasty in kidneys of children with unilateral ureteropelvic junction obstruction (UPJO). Materials and Methods: Thirty-three consecutive cases with split renal function (SRF) of ≤20% on dynamic renal scintigraphy (DRS) underwent upfront pyeloplasty with a nephrostomy tube and trans-anastomotic stent. Outcome was analyzed based on symptomatic relief, nephrostomy output, surgical complications and changes noted in pre-and post-operative findings on renal ultrasound (US), and DRS. Results: The most common symptom was abdominal lump in <5-year age group (79%) and abdominal pain in >5-year age group (93%). Postoperatively, symptoms were relieved in all (100%), parenchymal thickness (PT) on US improved in 82% and SRF improved significantly (>5%) in 75.8% of patients. The improvement was more significant in patients with abdominal lump and large kidneys. The mean nephrostomy output showed an inverse relationship with age at pyeloplasty and a direct correlation with the change in PT and SRF. The degree of improvement in SRF also was inversely related to the age at pyeloplasty with a significantly better outcome in <2-year-age. Although age at pyeloplasty, nephrostomy output and change in PT individually showed significant correlation with change in SRF, multiple regression analysis showed PT as the only significant factor. Conclusion: Upfront pyeloplasty should be the first option in children with poorly functioning kidneys as it has a favorable outcome in almost all the cases with a very low incidence of complications. The degree of improvement in SRF can be predicted by the nephrostomy output and improvement in PT on US.
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Novel coaxial technique of percutaneous nephrostomy in young children: A feasibility study p. 553
Krithika Rangarajan, Vishnu Prasad Pulappadi, Prabudh Goel, Manisha Jana, Raju Sharma, Shivanand Gamanagatti, Minu Bajpai, Devasenathipathy Kandasamy
Aims: The conventional Seldinger and trocar techniques of percutaneous nephrostomy (PCN) have inherent limitations in infants and younger children. We studied the role of a novel coaxial technique of PCN in children under the age of 5 years in comparison to the conventional techniques. Materials and Methods: This was a single-center feasibility trial based on 24 consecutive patients (n = 24 kidneys) under the age of 5 years, conducted over 12 months, substratified into Group I (n = 10): PCN with conventional Seldinger (n = 2) and trocar (n = 8) techniques and Group II (n = 14): PCN with proposed coaxial technique. In the proposed technique, catheter was inserted through the bore of a 14-G needle. The observation parameters included successful placement of PCN into the renal pelvis with free drainage of urine, number of needle punctures, duration of procedure, need for fluoroscopy, and procedural complications. Results: Proposed technique was successful in all cases with single-needle puncture, while conventional techniques were successful in 8/10 (80%) cases with multiple needle punctures required in 3/10 (33.3%) cases (P = 0.163 and 0.059, respectively). Proposed technique was associated with lower median procedure time (6 min vs. 10.5 min; P < 0.001) and lower incidence of fluoroscopy use (0/14, 0% vs. 5/10, 50%; P = 0.006) than the conventional techniques. No complications were seen with either technique. Conclusion: The proposed coaxial technique is a feasible alternative to the conventional techniques of PCN in young children. It reduces the procedure time and the need for fluoroscopy in these patients.
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Black ovary: Our experience with oophoropexy in all cases of pediatric ovarian torsion and review of relevant literature p. 558
R Sriram, MM Zameer, C Vinay, BS Giridhar
Introduction: Oophorectomy is the treatment of choice in ovarian torsion if after detorsion the ovary looks bluish black. Ovarian preservation is advocated by many studies in the pediatric age group quoting the ability of the ovary to recover despite the appearance after detorsion. Aims: This study aims to review the outcome of salvage surgery (detorsion) in the management of pediatric ovarian torsion. Materials and Methods: This is a retrospective study of girls under 18 years with ovarian torsion treated from January 2016 to June 2021. Data were collated from records and analyzed. Results: Ten girls with ovarian torsion were included (mean age of 11 years). Ultrasonography and Doppler confirmed ovarian torsion in all. Emergency laparoscopy with detorsion was done in all with the mean time lapse from onset to surgery being 35 h. All the ovaries were black initially and persisted to be bluish black after detorsion. All were conserved and fixed to the lateral abdominal wall. In one child with an associated ovarian cyst, the cyst excision was also done. All girls were asymptomatic on follow-up. Ultrasonography at 3-month follow-up showed a normal-sized ovary with good blood flow in 9 out of 10 girls (90% cases). Follicular changes were seen in five girls who had attained puberty. In one girl, the ovary was very small sized and flows were not well visualized. Conclusion: Detorsion and oophoropexy should be the procedure of choice in pediatric patients with ovarian torsion. The gross appearance of the ovary after detorsion should not be the sole determinant for oophorectomy.
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Perioperative course of COVID-19 in pediatric patients undergoing emergency surgeries p. 561
Raksha Kundal, Ranju Singh, Vishal Kant, Maitree Pandey, Yogesh Kumar Sarin
Objective: Adults with COVID-19 infection undergoing surgery have an increased risk of complications and mortality. However, literature mentioning the perioperative course and outcome of children with COVID-19 infection undergoing emergency surgery is still lacking. Therefore, we planned this study to observe the need for postoperative ventilation, oxygen requirements, and postoperative mortality in pediatric patients with COVID-19 infection scheduled for emergency surgery. Methods: After ethical committee approval, all the COVID-19-infected pediatric patients who underwent an emergency surgery from April 2020 to May 2021 were included. Data collected included details of COVID-19 disease, American Society of Anesthesiology (ASA) grading, comorbidities, perioperative details such as tachycardia or bradycardia, any oxygen desaturation (SpO2<90), need for postoperative oxygen therapy, postoperative ventilation, and recovery/death. Results: A total of 22 COVID-19-infected pediatric patients underwent emergency surgery in the study period. Fourteen (63.6%) were asymptomatic at the time of admission. Nineteen patients (86.4%) belonged to ASA grade IE and three (13.6%) patients belonged to ASA grade III E. Three patients (13.6%) had comorbidities. Only one patient had hypotension and tachycardia intraoperatively. The same patient needed postoperative ventilation and succumbed. Conclusion: Our study shows that pediatric surgical patients with COVID-19 infection do not exhibit an increased need for oxygen or postoperative ventilation, postoperative pulmonary complications, or high mortality unless there is associated comorbidity.
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A retrospective comparative study on the outcome of microscope-assisted technique and supra-auricular approach in preauricular sinus surgery in a Tertiary Care Hospital p. 565
Amit Bikram Maiti, Sakti Pada Dam, Saikat Samaddar, Sudip Kumar Das
Context: Preauricular sinus (PAS) can lead to severe complications such as facial paralysis, and squamous cell carcinoma may develop from this sinus later in life. Asymptomatic sinus needs no intervention, but symptomatic sinus needs surgical interventions. Aims: This study compares the surgical outcome of microscope-assisted sinus tract excision technique with the supra-auricular sinectomy technique. Settings and Design: This was a retrospective, observational study conducted at a tertiary care hospital in Purulia District, West Bengal, India. Subjects and Methods: Records of patients operated on for PAS were included following the proper inclusion and exclusion criteria. These patients were categorized and followed up based on disease pathology and the type of intervention received. Statistical Analysis Used: Data were collected, tabulated, and analyzed using the standard statistical software. Results: Fifty-two patients were included in our study. About 48.07% of patients were found in the age group of 11–15 years. In the microscope-assisted sinectomy category, recurrence of the disease was seen in 2 out of 15 operated patients compared to 1 patient among 13 in the supra-auricular sinectomy approach for uncomplicated cases. In complicated cases, the supra-auricular sinectomy approach had a nil recurrence rate compared to three patients out of ten operated in microscope-assisted technique (Fisher's exact test - 0.0593). Both the outcomes are not statistically significant. Conclusion: Supra-auricular sinectomy technique has the lowest recurrence rate for preauricular sinus surgery.
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Transcutaneous electrical nerve stimulation in management of neurogenic bladder secondary to spina bifida p. 570
Swapnil Pattanshetti, Jai Kumar Mahajan, Somya Saxena, Akshay Saxena
Aims: To assess the role of transcutaneous electrical nerve stimulation (TENS), alone or in combination with anticholinergic drugs in the management of neurogenic bladder (NB) in spina bifida (SB). Materials and Methods: All the consecutive patients, visiting outpatient clinic between July 2017 and December 2018, who were toilet trained and at least 1 year post-SB surgery with clinical and/or urodynamic evidence of NB, were included in the study. Out of 65 patients, 40 fulfilled the inclusion criteria and were randomised into: group A (ten patients, placebo TENS with anticholinergic agents), Group B (14 patients, TENS therapy with placebo medications) and Group C (16 patients, TENS therapy with anticholinergic medications). All the patients maintained a voiding diary and underwent assessment before and after the intervention. The study was approved by the Institutional Ethics Committee. Results: The presenting symptoms were urinary incontinence (100%), increased frequency (45%), straining during micturition (22.5%), urgency (22.5%), and hesitancy (30%). The demographic parameters were comparable in all the groups. After group specific intervention, the wet episodes/day significantly improved in Group C (P = 0.001). Similarly, the mean wet days/week also improved significantly in Group C (6.5–4.37 days/week, P = 0.01). Out of 40 patients, 29 had abnormal findings on ultrasonography before the start of the therapy. Following intervention, only two patients in Group C showed normalization of findings. On Urodynamic studies, detrusor pressure (Pdet max) decreased in all the groups; however, the patients in Group C, showed the maximum reduction (56.6 ± 11–30 ± 6.7 cm H2O). Similarly compliance (9.4 to 14.5 cm H2O, P = 0.02) and bladder capacity (68%–88% of EBC, P = 0.001) also improved significantly in Group C as compared to other 2 groups Overall, nine patients (Group A, B, and C = 1, 3, and five patients, respectively) showed detrusor instability, while post therapy, only one patient (Group B) had unstable bladder. Maximum decrease in postvoid residue (mean) was also observed in Group C (77–41 ml, P = 0.01). Conclusions: The application of TENS in NB secondary to SB is effective and its application led to improvement in symptoms, decrease in the wet episodes/day, maximum detrusor pressure, instability, bladder compliance, and capacity. TENS therapy in combination with anticholinergic agents had a better outcome as compared to monotherapy with either of the two modalities.
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Morbidity and mortality of necrotizing fasciitis and their prognostic factors in children p. 577
Dilip Kumar Singh, Rohit Kapoor, Partap Singh Yadav, Sonal Saxena, Kiran Agarwal, Ravi S Solanki, Amit Gupta, Subhasis Roy Choudhury, Rajiv Chadha
Background: This is a prospective study of the clinico-etiologic profile and factors affecting outcomes in 40 children managed for necrotizing fasciitis (NF). Materials and Methods: Demographic details, clinical characteristics, and laboratory parameters were recorded, and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated. Primary outcome (survival vs. nonsurvival) was noted, and prognostic factors were identified. Results: Initiating factors included boils (45%), i.v. cannula extravasations (22.5%), and blunt trauma (17.5%). Lesion (s) were predominantly on the lower limbs (35%) and trunk (25%). Twenty-two patients (55%) had <5% body surface area (BSA) involved. Severely deranged clinical and laboratory parameters were common. Ultrasound localized fluid collections. Pus cultures showed methicillin-resistant Staphylococcus aureus (52.5%), methicillin-sensitive S. aureus [27.5%], and polymicrobial growth (20%). Blood culture was positive in 24 patients (60%). Most isolates were sensitive to clindamycin and amoxy-clavulanate. Prognostic factors for mortality (n = 6; 15%) included categorization as “Sick,” BSA involvement >10%, thrombocytopenia, raised serum creatinine, late debridement, and polymicrobial blood culture isolates. All six nonsurvivors had a LRINEC score of ≥8 and positive blood cultures. Six patients (20.7%) developed unsightly scars and 5 (17.24%) contractures across joints. Conclusions: Pediatric NF has significant morbidity and mortality. Patients with adverse prognostic factors can benefit from early referral to a facility with a critical care unit. Adequate wound management is essential to minimize residual deformity.
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Correlation between glans, meatus, shaft score, and penile perception after hypospadias repair p. 585
Vita Indriasari, Patricia Oktaviani Alimoeddin, Kurniawan Oki Pamungkas
Aims: The aim is to analyze the correlation between the degree of hypospadias based on the Glans-Urethral Meatus-Shaft (GMS) score and penile perception after hypospadias repair using pediatric penile perception score (PPPS). Settings and Design: Analytic observational study with a cross-sectional design. Subjects and Methods: Thirty-two children with hypospadias were included in this study. The severity of hypospadias was assessed using GMS score. Postoperatively, PPPS was rated by two external pediatric surgeons. Statistical Analysis Used: Correlation between GMS score and PPPS were analyzed using the Spearman test, P ≤ 0.05: Significant. Results: Mean-GMS was 8.69 ± 2.303 (mean-G 2.67 ± 0.858, mean-M 3.27 ± 0.942, mean-S 2.75 ± 1.055). Mean-PPPS was 10.19 ± 1.287. GMS score and PPPS had a very weak correlation (r = −0.227; P > 0.05). Conclusions: There was no correlation between GMS score and penile perception according to PPPS after hypospadias repair.
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An exploratory study on pediatric inguinal hernia videos on the youtube platform p. 588
Mehak Sehgal, Divya Jain, Prabudh Goel, Vishesh Jain, Devendra Kumar Yadav, Vivek Verma, Anjan Kumar Dhua
Aim: A study was conducted to explore the characteristics of the videos on pediatric inguinal hernia repair on YouTube and compare the most popular videos (MPV) with the least popular ones in terms of educative value vis-a-vis their popularity. Materials and Methods: The term “Pediatric inguinal hernia repair” was searched for on YouTube on August 15, 2021, with the filter set to “view rate.” Pertinent data were collected from the 50 MPV and the 50 least popular videos (LPV) and then compared. The h-index and affiliation of the surgeon were obtained from the Scopus database, and their affiliation was further categorized as academic or nonacademic. Results: One hundred and seventy-five videos were found with median views of MPV: LPV being 9270 (interquartile range [IQR] – 12099):127 (IQR – 194), respectively (P < 0.0001). Most of the videos in the MPV and LPV groups were uploaded from the United States of America (USA) (MPV – 17 and LPV – 13) and India (MPV – 15 and LPV – 15). The MPV were on YouTube for a median duration of 3.1 (IQR – 5.5) years as compared to 1.2 (IQR – 2.3) years for the LPV (P < 0.0001). Ninety-two surgeons were identified. The median h-index of the surgeons of MPV was 3 (IQR – 12) in comparison to 1 (IQR – 10) of LPV (P = 0.13). The ratio of academic versus nonacademic affiliation among MPV and LPV was almost equal in both the groups. Conclusions: On either end of the spectrum of popularity, the majority of the pediatric inguinal hernia videos on YouTube were surgical videos uploaded from the USA and India. The educative value of these videos was found to be low and widely dispersed. Surgeons from both academic and nonacademic affiliations had contributed similarly.
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Mortality prediction score for Hirschsprung's disease-associated enterocolitis: A novel mortality prediction model p. 594
Syed Asif Shah Harooni, GR Prasad, Gayatri Reddy Danda, Mahera Naureen
Introduction: Enterocolitis associated with Hirschsprung's disease is a fatal and serious complication. Number of scoring systems are in vogue to grade the severity of Hirschsprung's disease associated with enterocolitis (HDAEC), but none of these scoring systems help predict mortality. Hence, we attempt to develop a mortality prediction model (MPM) for HDAEC. Materials and Methods: A retrospective analysis of all cases of HDAEC encountered was analyzed. We also used the parameters of Elhalaby et al. for data collection. A total number of 71 cases were analyzed with regard to mortality in relation to each parameter. Sensitivity and specificity were calculated by statistician, and based on these values, a scoring model was proposed. All those with predicted mortality were given score 2 and those who did not were given score 1. Results: A total score of more than 16 predicted mortality, a score of <10 predicted survival, and a score between 11 and 15 predicted survival with morbidity. Conclusion: A MPM for HDAEC is being proposed.
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Improvement in care and maintenance of Port-A-Cath following the introduction of care” bundle p. 600
Alex Tom, Akshath Ramesh Acharya, Anusha Kamath, Anand Venugopal, Harsha Prasada Lashakri
Background: Port-a-cath is a type of indwelling central venous catheter used to manage pediatric patients who require long-term intravenous therapy. Objectives: The objective of this study was to improve the care and maintenance of port-a-cath among the nursing staff by introducing a care bundle. Materials and Methods: Pretraining and posttraining designs using PDSA (Plan, Do, Study, Act.) model were followed. We observed two sets of 30 procedures for accessing of port-a-cath by the nursing staff. Following the initial 30 observations of port-a-cath handling, a “care bundle” was designed as per the set standards of the maintenance of port-a-cath. It involved education and training and live audio-visual sessions. Two months after the initiation of the care bundle, the second set of 30 procedures was observed. Results: Following the introduction of the care bundle, the observed efficacy on obtaining verbal consent improved to 100% from 83%, arrangement of drugs and instruments before insertion to 100% from 90%, not touching the needle while inserting from 60%, administration of adequate amount saline flush from 83.3% (25/30), heparin administration from 71.1%, and looking out for signs of extravasation to 100% from 80%. Two nursing staff involvement improved from 23% to 63%. A 100% efficacy in the management of nonbleeding back scenarios was observed. The cross-checking of drug expiry improved from an initial 26.6% to 89.3%. The port-a-cath infections have significantly come down (3 vs. 0) (P < 0.05). Conclusion: Implementation of a “care bundle” has significantly improved the quality of handling of port-a-cath and reduction in infections.
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How we made exstrophy bladder continent and preserved the renal functions p. 605
Uday Sankar Chatterjee
Purpose: Crucial requirement of exstrophy bladder repair is to make patients continent as well as to preserve kidney functions. We analyzed our patients' data retrospectively to study their continence and to find out the justification behind continence and preservation of renal functions. Patients and Methods: We selected files of 18 fully continent patients from 52 patients operated. Eleven out of 18 patients were presented from beginning and 7 were referred after around 8 to 14 years, as incontinent bladder following good repair of bladder neck and posterior urethra. Eleven were operated with complete primary repair of exstrophy along with pubic osteotomy minimal and were kept on cystostomy track (CT) till augmentation to vent out vesical pressure. In seven patients, we did reduction of caliber of posterior urethra and bladder neck along with CT followed by augmentation after 6 months. Results: All 18 patients are maintaining dry period for 24 h. Two patients had enuresis but are manageable with partial fluid restriction from evening. Seventeen out of 18 patients are maintaining their renal functions. Conclusion: No tension abdominal wall closure with rectus muscle apposition is essential to preserve repaired bladder exstrophy. Osteotomy prevents lateral drag to overcome failure of whole reconstruction. Increased “systolic” vesical pressure from contraction of small bladder might destroy the mechanism of continence and renal functions. Hence, venting of vesical pressure through CT is obligatory till augmentation which is of necessity to be done as early as possible to create a low-pressure continent system.
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Persistent urogenital sinus with ambiguous genitalia and urethral duplication in a pubertal female p. 610
Sunil Kumar, Rudra Prasad Ghorai, Shivcharan Navriya, Preeti Usha, Satish Kumar Ranjan
Urogenital sinus (UGS) and cloacal malformations are the spectra of disease affecting mainly females, resulting in an unusual confluence of the genital and urinary tract with or without the involvement of the gastrointestinal tract. Successful reconstruction of these anomalies depends on the accurate preoperative delineation of abnormal anatomy with the help of cross-sectional and other contrast studies like genitourogram along with cystourethroscopy wherever indicated. We hereby report a case of a 14-year-old female who presented with irregular cyclical hematuria and was diagnosed with persistent UGS with urethral duplication. After a thorough evaluation, the patient was successfully managed with surgical reconstruction, described in this study. Persistent UGS is a complex developmental anomaly. Complete characterization of anomaly requires a thorough evaluation such as hormonal assessment, endoscopy, cross-sectional, and radiological contrast study. Surgical reconstruction needs individualization and may need clitoroplasty, labioplasty, and urethral and vaginal mobilization. Morphological and functional outcome is satisfactory in a well-planned surgical reconstruction.
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Salvage of injured lower limb and improvement of quality of life of a 1½-year-old child p. 613
Vishal Patil, AJ Praveen, Mohd Altaf Mir, Awaneesh Katiyar, Sourabh Kumar Sinha, Ankush Tambotra
We present a case of left proximal femoral artery transection injury in 1½-year-old male child due to a fall over a bike handle after sustaining a road traffic accident. He was presented to the emergency room with a cut proximal end of the left femoral artery and a fracture upper end of the shaft of the femur seen at the wound site. Following initial resuscitation, the patient was planned for wound exploration, fracture stabilization, and femoral artery repair which were executed, and salvage of the lower limb of 1½-year-old child was achieved. We conclude that teamwork, training, and experience in repairing pediatric vessels and timely pediatric vascular repair play a pivotal role in the salvage of a limb and improvement of the quality of life of a child.
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Yolk sac tumor of the parotid gland in a child and its differentials p. 617
Riddhi Jaiswal, Swati Agnihotri
Yolk sac tumors (YST) (or endodermal sinus tumors) are rare neoplasms of germ cell origin that have been reported in gonadal sites (testis and ovary). Extragonadal YST are uncommon and are extremely rare in the extracranial head-and-neck regions. Here, we present a rare case of a 1-year-old male with isolated YST of the right parotid gland initially diagnosed as malignant epithelial neoplasm with possibilities of mucoepidermoid carcinoma and epithelial–myoepithelial carcinoma.
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An unusual case of parapharyngeal desmoid fibromatosis - A rare case report p. 620
Chinmayee P Joshi, Nandini Jitendra Gupta
Desmoid fibromatosis (DF) is a rare locally aggressive, connective tissue malignancy developing in musculoaponeurotic tissues with an incidence of 2–4 per million population. We presented a case of a 3-year-old patient with a left parapharyngeal mass, histopathological examination suggesting DF, who underwent complete surgical excision without recurrence or requirement of cardiac resynchronization therapy.
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Extrarenal teratoid wilms tumor p. 623
Ashitha K Unny, Balagopal Subramanian, Arathi Srinivasan, Seyed Rabia
Teratoid Wilms tumor (TWT) is a variant of Wilms tumor. 30 cases have been reported so far. The extrarenal TWT variant has only been 5 in number. We are reporting a case of retroperitoneal TWT in a 6-year-old female child with diagnostic and therapeutic challenges.
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Congenital midline cervical cleft – A case report on a rare anomaly of the neck p. 627
CS Vidhya Annapoorni, Sam Varkey
Congenital midline cervical cleft is a rare congenital anomaly of the neck of uncertain embryological origin, with around 205 cases reported in literature. We report the case of an 8-year-old girl who presented with the same anomaly.
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Humero-pectoral band in poland syndrome p. 629
Manish Jagtap, Akshay Kapoor, Debarati Chattopadhyay
The humero-pectoral band in Poland syndrome is a rare presentation and needs urgent surgery because it restricts the shoulder abduction of the patient. In our case, instead of excising the band, we have made use of the tissue by including it in the Z-plasty flaps which make the flaps reliable even though they were supplied by a narrow base.
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Bilateral single-system ectopic ureter: When can we avoid bladder neck reconstruction? p. 631
Prashant Motiram Mulawkar, Parag Vijayrao Tapre, Pankaj N Maheshwari, Sumeet Gopal Agrawal, Giridhar Shivnarayan Panpaliya
Bilateral single-system ectopic ureter (BSSEU) is often associated with underdeveloped incompetent bladder neck; hence, to achieve continence, bladder neck reconstruction (BNR) is usually advocated with ureteric reimplantation. Presented here is a 14-year-old girl with BSSEU who achieved continence without BNR. An attempt is made to look at factors that could identify patients in whom BNR could be avoided.
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A rare differential diagnosis of air under the diaphragm on abdominal X-ray – Chilaiditi's syndrome in a child with skin wrinkle syndrome p. 635
Sreekar Gundapaneni, Debashish Bhattacharya
Chilaiditi's syndrome is a rare disorder characterized by hepatodiaphragmatic interposition of the intestine. Only 30 cases of Chilaiditi's syndrome in children were reported in the literature and none in a child with skin wrinkle syndrome. Herein, we report a case of Chilaiditi's syndrome in a child with skin wrinkle syndrome.
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Concealed penile duplication – Presenting late p. 638
K Abhishek Reddy, Vinay Chandrashekar, Sanjay Rao, Ashley D'cruz
We report a case of concealed penile duplication without many symptoms and normally looking external genitalia in a 10-year-old boy. He was evaluated with appropriate imaging and had successful surgical reconstruction of his genitalia with good cosmesis and functional outcome.
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Escobar syndrome with monodactyly: A rare case report p. 641
Somnath Karad, Imran Ahmad, Sudhanshu Tripathi, Sheikh Sarfraz Ali
Escobar syndrome (nonlethal type of multiple pterygium syndrome) is a very rare genetic disorder. The central manifestations of Escobar syndrome are the presence of multiple pterygia, fixed joint contractures, and characteristic facies. Here, we report a case of Escobar syndrome with additional features such as monodactyly and hypoplastic pectoralis muscle.
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Anaplastic rhabdomyosarcoma of upper lip in a 3-year-old girl p. 644
Arti Khatri, Nidhi Mahajan, Mamta Senger, Niyaz Ahmed Khan
Rhabdomyosarcoma is an aggressive malignant striated muscle neoplasm commonly seen in children involving orbit, paranasal sinuses, cheek, tongue, and rarely upper lip. The anaplastic subtype is further rare and associated with poor prognosis. Herein, we report a 3-year-old female with this uncommon variant at an uncommon site.
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Doxorubicin extravasation from a port-a-cath into pleural space in a young girl: A case report and review of literature p. 648
Alex Tom, Jayatheerth Joshi, Manoj Kumar Golla, Harsha Prasada Lashkari
Extravasation of chemotherapeutic agents from a peripheral cannula is a known problem, and to prevent that, oncology units use central vein access with indwelling catheters such as port-a-cath or Hickman catheter. The intrapleural extravasation of chemotherapeutic agents is a rare event. We describe a 9-year-old girl with newly diagnosed Ewing's sarcoma of the left upper humerus receiving neoadjuvant chemotherapy through a newly inserted port-a-cath device. The patient developed tachypnea and right-sided chest pain on day 2 of chemotherapy. The radiological investigations confirmed the extravasation of doxorubicin into the pleural space. The surgical washout with chest-drain insertion was done, and we continued flushing with normal saline until the drain fluid became clear. She has completed neoadjuvant therapy. This case report shines light into scenarios where extravasation of anthracycline into the pleural cavity or thorax can be managed conservatively and in settings where dexrazoxane is unavailable without causing much delay in restarting the chemotherapy.
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Congenital chylothorax: Conservative management counts p. 652
Smriti Bhagiratha, Prathik Bandiya, Niranjan Shivanna, Naveen Benakappa
Nonimmune hydrops is a common cause of hydrops fetalis. Here, we report a rare case of congenital chylothorax which presented with nonimmune hydrops and was effectively managed by conservative measures.
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Pancreatic divisum causing recurrent pancreatitis in an 8-year-old child p. 655
Charu Tiwari, Syamantak Basu, Apoorva Makan, Hemanshi Shah
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Post congenital pulmonary airway malformation excision thymic growth: An unusual postoperative sequel p. 657
Kanika Sharma, Anjan Kumar Dhua, Devasenathipathy Kandasamy, Devendra Kumar Yadav, Prabudh Goel, Minu Bajpai
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Multisystem inflammatory syndrome in children: How to live with COVID-19? p. 659
Uday Sankar Chatterjee
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  2005 - Journal of Indian Association of Pediatric Surgeons | Published by Wolters Kluwer - Medknow 

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