Conjoined twin is an extremely rare condition and needs a thorough knowledge of anatomy and a multidisciplinary approach is essential to successfully separate, the twins. Thoracopagus are the twins attached by chest and umbilicus and are the commonest among all the varieties but carries a poor survival rate. We describe our approach and experience of management of thoracopagus twins who were separated at eighty-three day of life and are alive and well after 4 years of follow up. The most important decisive parameter for successful separation is the extent of sharing of organs between twins but the role of a motivated multidisciplinary team is also indispensable.

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Isolated renal mucormycosis is rare in children. A case of 3-month-old infant presenting with right-sided flank lump and fever is being reported. Investigations revealed a nonfunctioning right kidney with intrarenal abscesses and a low percent-frequency of T-cells. He made an uneventful recovery following surgery and systemic antifungal therapy. Compared to the other forms of deep mucormycosis, a review of literature suggests favorable prognosis in children with isolated renal involvement.

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We report a 4-month-old baby presenting with bilateral congenital lobar emphysema. A two-staged bilateral lobectomy was planned, but bilateral lobectomy had to be performed as a single-staged procedure. Data are scarce on the appropriate approach to children with bilateral involvement. Both single-staged and two-staged procedures have shown variable success.

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Aim: To determine the efficacy and outcome of pyeloplasty in poorly functioning kidneys in the pediatric population and whether pyeloplasty could be offered as an upfront procedure in such patient population, instead of nephrectomy. Materials and Methods: A retrospective data analysis of 83 patients who underwent pyeloplasty in poorly functioning kidneys from 2010 to 2015 was performed. Success was defined based on improvement in symptoms, stable or improved function, and better drainage on post-operative Tc-99m Diethylene Triamine Pentaacetic acid scan instead of DTPA scan renography done after 3 months and yearly thereafter. Results: Eighty-three patients with a mean age of 6.8 ± 2.88 years with poor function on isotope renogram (<30%) were included in the study. Three patients were excluded in view of postoperative outflow obstruction. Out of the remaining 80 patients, 56 were male and 24 were female. They were divided into two groups based on preoperative differential renal function (DRF), Group I (n = 26) having preoperative DRF of <10% and Group II (n = 54) having preoperative DRF of 10%–30%. All patients underwent laparoscopic dismembered pyeloplasty with ureteral stenting. The mean DRF improved from 7.58 ± 2.39 to 29.71 ± 5.16 postoperatively in Group I. However, in Group II, DRF improved from 20.81 ± 5.68 to 37.25 ± 7.11 postoperatively. At a follow-up of 24 months, the overall success rate was 98%. Conclusion: Pyeloplasty gives good intermediate-term results even in extremely poorly functioning kidneys and an upfront pyeloplasty instead of nephrectomy should be offered to all pediatric patients irrespective of preoperative function.

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Background: Choledochal cyst is a common congenital anomaly requiring surgical treatment. Nowadays, laparoscopic excision is the preferred approach. We studied a modification in the classical laparoscopic approach to facilitate the dissection of a cyst. Materials and Methods: A prospective comparative study was done on 42 Type I choledochal cyst children. One group was operated by classical laparoscopic technique, while the other group was operated by modification of classical technique by deliberately opening the cyst wall and dividing the cyst into two hemi-cups, followed by dissection and excision. The intraoperative and postoperative parameters were assessed in both the groups. Results: The age, gender ratio, clinical presentation, and cyst diameter were comparable in both the groups. There was a significantly higher success rate (95.7% vs. 73.7%, P = 0.042) and lesser time for cyst excision (96.43 ± 12.15 vs. 120.91 ± 17.38 min P < 0.001) in the modified technique when compared to the classical technique. Further in three patients, it was possible to convert the classical procedure to a modified technique and complete the cyst excision. The postoperative outcomes were similar in both the groups. Conclusion: The modified laparoscopic excision shortens the operative time with higher success rate and comparable short-term morbidity vis-a-vis classical laparoscopic technique.

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Pleuropulmonary blastomas (PPBs) are very rare, highly aggressive, dysembryonic neoplasms of thoracopulmonary mesenchyme. These have been reported in the pediatric population and account for only 0.5%–1% of all primary malignant lung cancers. They normally arise from lung tissue, however rarely the parietal pleura may be the tissue of origin (extra pulmonary PPB) which are extremely rare. Common age of presentation is three to 4 years. The prognosis is poor with distant metastasis to central nervous system and bone with survival rate of approximately 42.9% at 5 years. They are managed by aggressive multimodal therapies including surgery and chemotherapy. We report a case of a 3-year-old male child with Type 2 PPB of the left hemithorax, managed by surgical excision of the mass and adjuvant chemotherapy.

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Ectopic scrotum is a rare form of congenital scrotal anomaly that is rarely encountered in pediatric surgical practice. Herein, we report an infant with a unilateral ectopic suprainguinal scrotum associated with undescended testis and multicystic dysplastic kidney. The case is reported in view of rarity of this anomaly in the general pediatric population.

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Cowper's syringocele is a condition caused by dilatation of the main duct of Cowper's gland. It is a very uncommon cause of urethral obstruction. Closed type causes urinary obstruction. The aim of this article is to report a case of closed type syringocele causing new-onset urinary obstruction in a 10-year-old boy.

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Aims: Congenital colonic stenosis (CCS) is an extremely rare cause of low-intestinal obstruction in neonates/child. We report our experience with seven cases of CCS presenting with low-intestinal obstruction and diagnosed intraoperatively and also propose an algorithm for its appropriate treatment for the adequate outcome. Materials and Methods: It was a retrospective study of seven patients of CCS including two neonates (5-days and 15-days old), four infants (age range – 2–11 months), and one 24-month-old child admitted from 2014 to 2019. Information regarding the age of presentation, clinical presentation, physical findings, radiological and laboratory findings, details of surgery, and outcome was retrieved and analyzed. Results: The male-to-female ratio was 5:2. Patients were initially diagnosed as cases of Hirschsprung's disease in five and ileal atresia in two. A final diagnosis of CCS was made during surgery and histopathological examination of resected stenotic segment. The segment involved was ascending colon in three, transverse colon in two, and sigmoid colon and junction of descending and sigmoid colon each in one patient. Resection of stenotic colonic segment and primary end-to-end anastomosis was performed in two, divided stoma after resection of the stenotic segment and secondary anastomosis in three, and proximal loop terminal ileostomy followed by resection of the stenotic colonic segment and ileocolic anastomosis after 10–12 weeks in two. Conclusions: CCS is a rare but possible cause of large-bowel obstruction, in neonatal, infant, and children particularly when associated with a history of chronic constipation since birth. It should be kept in mind as a differential diagnosis while managing a case of neonatal and pediatric intestinal obstruction, particularly low-bowel obstruction along with a history of chronic constipation. Treatment should be individualized for each patient based on clinical status and associated anomalies to give the best results with less morbidity.

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Background: Primary gastrointestinal lymphomas (PGIL) are uncommon in children and account for <5% of all pediatric malignancies. The objective of our study was to analyze the prognostic factors of pediatric PGILs with reference to its histological subtypes, stage, and outcomes using immunohistochemistry. Materials and Methods: Twenty cases were studied over 11 years. Clinicopathological profiles, histological details, and immunohistochemical (IHC) profiles were analyzed. Results: The mean age at the presentation was 6 years. Using IHC stains (CD CD10, CD19, CD20, CD3, terminal deoxynucleotidyl transferase, BCL 2 and 6, PAX 5, and MUM1), diffuse large B-cell lymphoma (DLBCL) was most prevalent (45%), followed by Burkitt lymphoma (35%) and lymphoblastic lymphoma (20%). DLBCLs (9) were classified using the Han's algorithm. Six were activated B-cell and 3 were germinal center B-cell subtypes. The cases of lymphoblastic lymphoma and those in Stage I disease had the best prognosis. Conclusion: Pediatric PGILs have variable presentation, outcomes, and diverse treatment modalities depending on the histological subtypes. A panel of IHC stains can be a useful adjunct for the categorization and prognosis of pediatric PGILs.

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Context: Adnexal masses in girls represent a wide pathological spectrum. We performed a retrospective analysis of clinical and diagnostic aspects of adnexal masses in girls. Aims: To analyze the clinical characteristics and surgical management of adnexal masses in children and adolescents. Settings and Design: Retrospective observational analysis from 2000 to 2020. Subjects and Methods: This analysis was performed on 28 children under the age of 17 years with adnexal masses who were managed by us at tertiary care centers of Delhi-NCR. Patients were analyzed based on their age at the time of admission, their presenting complaints, clinical and radiological findings, tumor markers, management, and follow-up. Results: The age ranged between newborn and 17 years. Abdominal pain, nausea with vomiting, and abdominal lump was the most common presenting complaints. Pelvic ultrasound with or without color Doppler done in all patients and computed tomography, magnetic resonance imaging was performed in seven patients preoperatively. Adnexal masses were unilateral in 26 (92.85%) patients and bilateral in 2 (7.15%) patients. Five babies had antenatal diagnosis of ovarian cysts. Serum alpha fetoprotein (AFP) and beta-human chorionic gonadotropin (b-HCG) were normal in all 19 tested patients. Cancer antigen 125 (CA-125) was raised in three ovarian tumors out of 9 tested patients. Laparoscopy was performed in 23 out of 28 patients (30 ovaries). Ovarian cyst torsion was present in 50% patients. Ovarian cystectomy was done in 10 (33.3%) patients. Six (20%) ovaries were saved by detorsion of the ovary and deroofing of the cyst with or without ovarian biopsy. Oophorectomy was done in five (16.7%) patients. Salpingo-oopherectomy had to be done in seven (23.3%) patients. Histopathology revealed functional nonneoplastic lesions in 18 cases (66.7%), benign neoplastic lesions in 8 cases (29.6%), and malignant neoplastic lesion in 1 case (3.7%). Conclusions: Adnexal masses in children are generally benign. AFP, b-HCG, and CA-125 in ovarian torsion are within normal limits. Urgent surgery is required if torsion is established. The ovary should be preserved wherever possible.

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Background: Mortality in surgical neonates contributes to neonatal mortality rates. The study was conceptualized to study clinical and nonclinical factors affecting mortality in surgical neonates so that timely intervention could result in improved survival of the neonates. Materials and Methods: The study was initiated after approval from the institutional ethics committee and included 120 surgical neonates over a period of 18 months after obtaining consent from the parents/caregivers. Predesigned pro forma was used to record the details of antenatal care received, place of birth, travel history, maternal education and gestational age, and clinical condition at the time of admission. Values of biochemical tests such as serum electrolytes, serum creatinine, and arterial blood gasses were recorded. The need of inotrope support, blood or blood product transfusion, and postoperative ventilator support and intensive care unit (ICU) care was recorded. The results of the two groups, i.e., survivals and mortality, were compared. Outcome was recorded as mortality at 30 days or earlier. Results: Irrespective of the surgical condition, the survival rate was significantly better in those babies who weighed more than 2.5 kg at the time of admission, had capillary refill time of <3 s, had serum ionized calcium levels more than 1 mmol/L, and did not require inotropes, blood or blood product transfusion, and postoperative ICU care and ventilator support. The place of birth, educational status of the mother, gestational age, and distance traveled for care had no statistically significant effect on survival. Conclusion: There is a statistically significant correlation between the survival of the babies who weighed more than 2.5 kg and are more physiologically preserved at the time of admission. Mortality rates can be decreased by timely interventions to reduce the need of inotropes, blood or blood products, and ICU care and ventilator support during their postoperative recovery.

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Background: Abdomino-perineal pull through procedure needs perineal dissection and for that swap of supine to prone may be necessary. To avoid that as well as to avoid neuro-muscular damage; we are describing a simple minimal invasive procedure with help of Alken's telescopic dilators. Patients & Methods: We created abdomino-perineal tunnel with Alken's telescopic dilators to bring down the lumen of intestine in perineum in eight patients. Results: Operative time happened to be less and procedure found to be less traumatic. All the eight patients had satisfactory outcome Conclusions: Actually, we have repurposed the Alken's dilator for creation of abdomino-perineal tunnel or track to get benefit of minimal dissection of perineum during pull-through procedure as well as to avoid neuro-muscular damage.

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Pyoscrotum is rarely encountered in neonates and is secondary to a local pathology such as neglected torsion or epididymo-orchitis. Pyoscrotum from an intra-abdominal pathology is possible in the presence of a patent processus vaginalis and has been rarely reported in the context of acute appendicitis. We report our experience with a case of antenatal bowel perforation presenting postnatally after an absolutely asymptomatic “honeymoon” period.

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We report the case of a 4-year-old boy with protein-losing enteropathy, leading to severe malnutrition. Associated thrombotic microangiopathic features made diagnosis difficult and challenging.

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Objectives: The aim of this study was to review the clinical profile, management, and outcome of solid tumors in the head-and-neck region in children at our institute. Methods: We retrospectively reviewed children with head-and-neck solid tumors who were treated jointly under the departments of Pediatric Surgery and Otorhinolaryngology at our institute between 2016 and 2019. Results: In the study period, 10 children (6 males, 4 females) with a median age of 9.5 years (range 5 days–16 years) were treated by our unit. The patients had four tumors arising from the parotid, 2 from nose/naso-pharynx, 1 each from the tongue, submandibular gland, para-pharyngeal space, and infratemporal fossa. A majority (90%) of the patients underwent complete surgical excision of the tumor, preserving the loco-regional neurovascular structures to minimize postoperative morbidity. Malignant lesions were seen in 4 patients (2 rhabdomyosarcoma, 1 primitive neuro-ectodermal tumor, 1 mucoepidermoid carcinoma) and 6 patients had benign pathology (3 pleomorphic adenoma, 2 mature teratoma, 1 schwanomma). Additional therapy with chemotherapy and local radiotherapy was required in 3 out of 4 patients with malignant pathology. The median follow-up duration is 15 months. At last follow-up, all patients are alive and 9 out of 10 patients (90%) are disease-free. Conclusion: Our experience highlights rare and difficult tumors in the head-and-neck region in children. These tumors are not commonly managed by the pediatric surgeon in routine practice. The paper outlines the multi-modality management of these tumors, which is essential for an optimal outcome.

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Context: Postoperative fever is known to occur after all surgical procedures irrespective of the type of anesthesia. Thermometry devices that work without touching or disturbing the child seem to be appreciated more than the conventional skin contact thermometers. However, whether this technology is reliable to be adapted for routine pediatric surgical care is debatable. Aims: The aim of this study was to study the accuracy of infrared nonskin contact digital thermometer (IRT) compared to the skin contact digital thermometer (DT) and mercury in glass thermometer (MT). Settings and Design: A prospective cross-sectional study was done in postoperative patients at a pediatric surgical center over a period of 3 months. Subjects and Methods: The forehead temperature was recorded with IRT. This was followed by recording the temperature in one armpit by DT and the other armpit by MT. Readings were promptly documented. Statistical Analysis Used: A sample t-test was done which gave the P value and mean. Linear regression analysis was carried out to find correlation coefficients. Bland–Altman test was used to access the concordance between all readings. Results: We found a strong correlation between temperature readings taken by DT (mean = −0.03, r = 0.07, slope = −0.04) and IRT (mean = 0.89, r = 0.091, slope = −0.14). However, on comparison of results with the MT, there are wider limits of agreement with the IRT (−0.31–2.09) in comparison to DT (−0.66–0.59). Conclusion: Skin contact digital thermometer are more accurate and suitable for checking body temperature as compared to infrared nonskin contact digital thermometer in postoperative pediatric patients.

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