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Injuries to male genitalia of infants due to bite of a pet pup are a rare occurrence. Few dog bite injuries to the genitalia of male infants have been reported, however, similar injuries have not been reported by the bite of pet puppies. Male genital injury in three male infants aged 8, 10, and 11 months, by the bite of pet puppies aged 1–2 months, ranged from avulsion of penile and part of scrotal skin with loss of both testes in case 1, a near circumferential laceration of penile skin at the base of penis with scrotal laceration in case 2, and laceration in mid penile shaft resulting in degloving and complete transaction of distal penile urethra with scrotal laceration in case 3. All these infants were appropriately managed surgically (case 1 and 3) and conservatively (case 2) and were given thorough toileting of wound, antibiotics, prophylaxis for tetanus and rabies. Some of these injuries may require complex surgical procedures to reconstruct the male genitalia. Timely management with aggressive intent and conserving the local tissue is the key to success. We describe a case series of injury to the external genitalia of three male infants by the bite of pet puppies, their possible predisposing factors, treatment, and follow-up. A case report and series like this have not been reported in literature so far to the best of our knowledge.

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Objective: There is an increasing trend of observational, nonsurgical management of abdominal injuries in children. We analyzed the feasibility and outcome of our management protocol in managing cases of the mesenteric injuries in blunt trauma abdomen in pediatric age group. Methods: Single-center retrospective analysis of pediatric trauma case records from July 2018 to March 2020 was performed. Results: Thirty-four cases of blunt abdominal trauma of whom 13 had mesenteric injuries were reviewed. The male-to-female ratio was 2.2:1, and the mean age was 9.11 ± 4.90 years. Mesentery of the small bowel was the most commonly injured segment and treatment consisted of repair of mesenteric tear, resection, and anastomosis with or without stoma formation. Conclusions: Isolated mesenteric injury of all grades should be managed either with diagnostic laparoscopy or laparotomy irrespective of hemodynamic status.

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Aim: The aim is to compare the diagnostic accuracy of laboratory investigations and ultrasonography (USG) in distinguishing complicated appendicitis (C-AA) from uncomplicated appendicitis (UC-AA). Materials and Methods: Forty-six children who underwent appendicectomy at our center between November 2018 and July 2020 were included. Based on intraoperative findings, they were divided into two groups – complicated (perforated, gangrenous, or associated with fecal peritonitis; n = 18) and UC-AA (n = 28). USG findings and inflammatory markers were compared in both groups at admission. Results: At admission, the mean values for total leukocyte count (TLC) (16090.56 vs. 11739.29 per mm³), high sensitivity C-reactive protein (hsCRP) (35.8 vs. 31.62 mg/L), and procalcitonin (PCT) (3.83 vs. 1.41 ng/mL) were significantly higher in C-AA. Visualization of a blind tubular aperistaltic structure was the only sonographic sign showing statistical significance – significantly lower in C-AA (50% vs. 90%). Independent predictors of C-AA were – duration of symptoms >48 h (odds ratio [OR] 6.3), free fluid/loculated collection in right iliac fossa (OR 3.75), TLC >11000/mm³ (OR 3.6), hsCRP >35 mg/L (OR 6.0), PCT >0.6 ng/mL (OR 4.02), and nonvisualization of appendix on USG (OR 8.33). Biochemical factors were sensitive (89%) and specific (55%) in differentiating C-AA from UC-AA but the addition of sonological parameters significantly improved the specificity of predicting complicated AA to 61% (P = 0.0036). Conclusion: Combining laboratory data with sonological findings significantly improves the predictive value for differentiating C-AA from UC-AA and can help decide operative approach and prognosticating.

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Aims: This study aimed to evaluate the noninvasive methods to diagnose bladder bowel dysfunction (BBD) and its extrapolation on biofeedback therapy and pelvic floor exercises (PFE) to treat these children. Settings and Design: A retrospective cohort study at a tertiary care center was conducted between January 2010 and December 2020, on 204 children, aged 4–18 years, arbitrarily divided into two groups-4–12 and 13–18 years. Subjects and Methods: Details of lower urinary tract dysfunction were recorded as International Children's Continence Society nomenclature. Bowel habits were recorded and functional constipation was graded using ROME IV. The data recorded were urine analysis, a voiding diary, a dysfunctional voiding symptom score, and uroflowmetry with or without electromyography. Ultrasonography, voiding cystourethrogram, and magnetic resonance imaging were done in appropriate cases. Dysfunctional Voiding Severity Score was used to assist the evaluation and outcome. The treatment protocol included urotherapy, uroflow biofeedback, PFEs, prophylactic antibiotics, pharmacotherapy, and treatment of constipation. Statistical Analysis Used: Statistical analysis was done using SPSS version 26 and paired t-test was used for comparison and calculating P value. Results: There was a significant improvement in DVSS and uroflow parameters. However, the magnitude of change produced varied among the age groups. Patients who failed to show any clinical benefit were subjected to alternative therapies such as intrasphincteric Botulinum A toxin with or without neuromodulation. Conclusions: Integrated uroflow biofeedback (IUB) and PFE expedites the recovery by supplementing the effect of urotherapy; hence, this should be offered to all children with BBD.

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Introduction: Prostatic utricles (PUs) are the remnants of Mullerian ducts found in the male posterior urethra. Enlarged symptomatic utricles are known to be associated with hypospadias. There is a dearth of literature defining an enlarged utricle and also its clinical significance. Aims: The aim of this study was to describe anatomical difference of PUs of cases with severe hypospadias and also to find their clinical significance if any. Materials and Methods: A prospective study was carried out, and all patients with proximal hypospadias were enrolled. Cystoscopy was performed in all cases. Symptomatology, size, and location of PU were recorded. PU of >0.5 cm was considered enlarged. Results: In the present series, a total of 70 cases were included over a period of 2 years. Enlarged utricle was found in 47/70 (67.14%) on cystoscopy. They were wide-mouthed and negotiated 9 Fr/11 Fr cystoscope with ease. Recurrent epididymo-orchitis, recurrent urinary tract infection, and obstructive features were the most common complications requiring intervention. Conclusions: PUs in boys with hypospadias are enlarged as well as wide-mouthed. Most of these remain asymptomatic, but few of them carry the potential of complications. Cystoscopy helps in direct visualization of utricular anatomy, so it should be a preferred investigating modality for investigating a PU.

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Aim: This study aims to construct and validate a new score for diagnosis of complicated appendicitis in children, complicated appendicitis pediatric score (CoAPS), to guide residents' clinical decision-making on choosing the correct patients for immediate surgery, reducing the emergency negative surgeries. Methods: This prospective observational study enrolled two cohorts of patients 5–15 years old. Four hundred and seven consecutive patients were enrolled for the derivation cohort. Demographic data, clinical features, and histopathology data were collected. The outcome measure was the histological diagnosis of gangrenous appendicitis with or without perforation. The score was next validated in a separate cohort of 312 consecutive patients who were classified according to their risk of complicated appendicitis. The diagnostic performance of the score and the potential for the risk stratification to select patients for diagnostic imaging, emergency operative management, and reduce emergency negative operation rates were quantified. Results: A positive “jumping up” test, vomiting, white blood cell >13.5 × 10^3/ml, lymphocytes <18%, and C-reactive protein >50 mg/dl were independent predictors for complicated appendicitis. The final prediction model exhibited an area under the curve of 0.890 (95% confidence interval: 0.859–0.922). The low-risk group demonstrated high sensitivity (90.4%) for complicated appendicitis, while scores 6 or more were very specific (95%) for the disorder. Describing the potential utility of the score, emergency ultrasound imaging would have been postponed in 14.5% of patients (P = 0.0016), and emergency negative explorations would have been cut by 87%. Conclusion: The CoAPS score could guide residents in emergency management of children with complicated appendicitis reducing hospitalizations and urgent surgeries.

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Introduction: The etiopathogenesis of pelviureteric junction obstruction (PUJO) has been debated. Recently, the role of interstitial cells of Cajal-like cells (ICC-LC) has been studied and reported to be the cause of this functional obstruction. We studied the histopathology and ICC-LC density at PUJ and compared it with that of PUJ of the control group and distal ureteric margin of the study group. Methods: A prospective study was conducted which included PUJO patients in the study group and the renal tumor patients in the control group. Histopathological examination (muscle hypertrophy and fibrosis) and immunohistochemistry (ICC-LC density) were done. The muscle hypertrophy, fibrosis, and ICC-LC density at the PUJ in both the groups were compared. A similar comparison was performed between the findings at the PUJ and the distal margin in the study group. Results: The study and control groups included 37 PUJO patients and 13 Wilms tumor patients. The ICC-LC density at PUJ in the study group was significantly lower than that in the control group (P < 0.001) and that at the distal resected margin of the study group (P < 0.001). Significantly increased muscle hypertrophy (P < 0.001) and fibrosis (P = 0.002) were seen at PUJ in the study group compared to the control group. No significant association was noted between the ICC-LC density and muscle hypertrophy at PUJ and the distal resected margin in the study group. Conclusion: A significant decrease in the density of ICC-LC and increased fibrosis and muscle hypertrophy at PUJ in children with PUJO play a role in the etiopathogenesis of the disease.

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Background: A paradigm shift has occurred regarding the treatment of cutaneous hemangiomas over the last few years, from an open surgical approach to a conservative or minimally invasive approach. There are various treatment modalities described, and response to them is variable and unpredictable. This study was conducted to study the clinical profile of children with uncomplicated cutaneous hemangiomas, their response to oral propranolol, and compare intralesional bleomycin and intralesional triamcinolone among nonresponders to propranolol. Materials and Methods: A trial was conducted among 158 children <12 years with cutaneous hemangiomas from January 2019 to October 2020 in Kanpur, Uttar Pradesh. Based on the response to propranolol, partial/nonresponders were later assigned randomly to either receive intralesional bleomycin (n = 30) or intralesional triamcinolone (n = 29). Response to treatment and complications were assessed in two groups. All children were followed up for 6 months. Results: Of 158 children, complete response to propranolol was found in 99 (62.7% [95% confidence interval (CI): 54.6%–70.1%]) children. Partial and no response was found in 33 (20.9% [95% CI: 15.0%–28.2%]) and 26 (95% CI: 16.5% [11.2%–23.4%]) children, respectively. In the bleomycin group, 66.7%, 23.3%, and 10.0% of patients showed excellent, good, and poor response, respectively, and in the triamcinolone group, 27.6%, 24.1%, and 48.3% showed excellent, good, and poor response, respectively (P = 0.002). However, there was no significant difference between them in terms of complications. Conclusion: Intralesional bleomycin was found to be a better drug in terms of response compared to triamcinolone. There are no significant differences in complications between them. Further studies are needed to further evaluate the combined efficacy of bleomycin with triamcinolone and other treatment modalities.

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Aims: The study aimed to evaluate the presentation, management, and outcome of patients of sacrococcygeal malignant germ cell tumors (SC-MGCTs) with intraspinal extension. Materials and Methods: Case records of all cases of SC-MGCT were reviewed to identify cases with intraspinal extension. They were evaluated in terms of their presentation, response to therapy, extent of surgical resection, recovery of neurological symptoms if any, and outcome. Results: Of the three cases of SC-MGT, two had intraspinal extension. One had Altman Type 3 disease and another had Altman Type 4 disease; both had Stage 4 disease. The intraspinal extension in both patients was detected on contrast computed tomography scan and magnetic resonance imaging. One patient had bladder and bowel incontinence. All the tumors responded to preoperative chemotherapy. Gross complete local resection could be achieved in all patients. Neurological recovery was complete. All were alive with no recurrence on follow-up. Conclusions: Malignant sacrococcygeal GCTs with intraspinal extension are rare and can be managed with neoadjuvant chemotherapy which obviates the need for extensive exploration for excision and has got good neurological and oncological prognosis.

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Aim: This study aims to determine the sequelae of corrosive ingestion in children. Methods: A retrospective study was conducted in the Department of Pediatric Surgery at a Tertiary Center. The children presenting between January 2015 and December 2020 with a history of ingestion of caustic agents were included in the study. Results: A total of 26 children were included in the study. The children with suicidal attempts were significantly older than those who ingested the corrosive agents accidentally (14.2 ± 1.9 years vs. 6 ± 3.3 years; P < 0.01; Student's t-test). Sixteen (62%) children had esophageal strictures, 8 (31%) had pyloric strictures, and a child (4%) had both esophageal and gastric strictures. Eight (31%) children required an initial feeding jejunostomy and 6 (23%) required a feeding gastrostomy as they had significant weight loss on presentation. Eleven (65%) esophageal strictures responded to the dilatation regimen and are symptom-free on follow-up. Three (18%) children with esophageal stricture underwent esophageal replacement. Eight (31%) children had a pyloric stricture and all of them were treated with a modified Billroth I gastro-duodenostomy. The children who presented after 2 months were found to have a significantly increased need for esophageal replacement (3/9 vs. 0/17; P = 0.03; Fischer's exact test). Conclusion: The corrosive ingestion in children is associated with higher morbidity. The sequelae include esophageal and antro-pyloric strictures. A feeding gastrostomy or jejunostomy was required in more than half of the patients. The children presenting after 2 months of ingestion were associated with an increased need for esophageal replacement.

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Aim: Working practices in pediatric surgery underwent enormous changes during the era of the COVID-19 pandemic. While certain surgical conditions in children can be managed temporarily with nonsurgical options, most neonates with congenital surgical malformations require emergent operations. We discuss the challenges faced; measures adopted in dealing with surgical emergencies and analyze the diagnoses and outcomes of patients with COVID-19 infection in our institute during the pandemic era. Materials and Methods: When the lockdown was imposed, it was mandated that all elective procedures should be put on hold. We formulated criteria for triaging procedures as emergent, urgent, and elective. A standard operating protocol was devised regarding admission, pre and postoperative management. Protocols for surgical procedures were established in a separate Covid-designated operation room including a specified sequence of donning and doffing personal protective equipment. Results: In the COVID era, from March 23, 2020 to mid-July 2021, 1282 surgeries have been done in our department, 344 emergencies and 461 planned procedures, which include 31 COVID-19 positive cases, with overall good outcomes. 103 emergency surgeries were done during the first wave (March-end to June 2020), and 103during the second wave (April to mid-June 2021). Moreover, not a single healthcare worker in the department has been infected. Conclusion: Pediatric Surgeons are adapting to the new guidelines to continue to provide emergency services with safe and effective care to their patients during the COVID-19 pandemic. Simultaneously, focus on personal and staff protection is ensured to keep the healthcare workers healthy and able to discharge their duties adequately.

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Introduction: While there is extensive literature investigating surgical outcomes in free flaps for adults, there is a dearth of information on the efficacy of flap use in the pediatric population. This study is the first to measure complication rates following pediatric free flap reconstruction on a national level. Methods: All pediatric free flap cases between 2012 and 2018 were identified and stratified by type of flap using current procedural terminology codes assigned to the primary procedure in the National Surgical Quality Improvement Program database. Each entry included the recipient location of the flap, postoperative complications, and demographics. Chi-square analysis was used to compare complication rates across various flap groupings. In addition, univariate and multivariate analyses were used to identify independent predictors of flap complications or failure. Results: Multivariate regression analysis demonstrated that compared to bone flaps, there is increased risk of nonbleeding complications in skin (Odds Ratio (OR) =7.7, P = 0.029), muscle (OR = 10.6, P = 0.012), and osteocutaneous flaps (OR = 10.8, P = 0.018). Flap of the trunk (OR = 40.9, P = 0.003) and upper extremities (OR = 32.9, P = 0.041) had a higher odds of bleeding complications compared to head-and-neck flaps. Regression analysis also showed that older age is associated with bleeding complications, with patients aged 5–11 years (OR = 38.5, P = 0.027) and 12–17 years (OR = 30.6, P = 0.038) having greater rates compared to patients under the age of 2. The pediatric flap reoperation rate was found to be 3.6%–4.7%, with the highest flap anastomotic complication rate in the head-and-neck region (6.9%–8.0%). Conclusion: Free flap reconstruction across flap type, anatomic location, and age ranges are safe and efficacious in the pediatric population.

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Fetus in fetu (FIF) is a rare congenital anomaly. Anomalies of inferior vena cava (IVC) in the host are rare and not reported in the literature. In this case report, the surgical management and the findings of a rare vascular anomaly of IVC in a 10-month-old male child with FIF are discussed. This case highlights the importance of antenatal ultrasonogram in the detection of FIF and to diligently look for structural anomalies of IVC in the host in such cases.

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Background: With the global assimilation of “publish and perish” culture into institutional academics, there has been an exponential rise in the publication numbers. There are ~2500 PUBMED entries related to “anorectal malformation (ARM).” The young clinician in his pursuit to translate experimental research to bedside often finds himself lost “in the midst of plenty.” This bibliometric analysis has been conducted to codify the seminal work on ARM for future reference and pay tribute to the most impactful articles. Materials and Methods: Thomson Reuters Web of Science citation indexing database and research platform was used to retrieve the most cited articles in ARM using appropriate search strings. The characteristics (name of authors, the total number of authors, the title of publication, journal of publication, year of publication, etc.,) of the 50 top-cited articles were analyzed. Results: The analysis revealed that the Journal of Paediatric Surgery was leading the choice of journal for publication. While most of the publications originated from the United States of America, Alberto Pena was the most influential author. The most studied topic was on associated malformations, and the most common study design was cohort studies. Conclusion: The approach of citation analysis provided us an opportunity to retrieve the most influential articles on ARM. The trends in research in ARM have also been analyzed, spreading over five decades.

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Background: There is limited information on the impact of cytomegalovirus (CMV) infection on clinical outcomes and operative histopathology in children with biliary atresia (BA). We hypothesized that CMV infection is associated with greater histopathological damage and unfavorable short-term clinical outcomes. Materials and Methods: A prospective single-center study was conducted with effect from January 2011–July 2012 including all infants with BA who underwent surgery. Diagnosis of CMV infection was confirmed by serum immunoglobulin M (IgM) positivity or the presence of CMV-deoxyribonucleic acid (DNA) in the liver tissue. Four short-term outcome variables were observed. The cohort was divided into subgroups on the basis of seropositivity (IgM + or IgM−); the presence of CMV-DNA in the liver (polymerase chain reaction [PCR]+ or PCR−); and composite CMV groups (Group 1 – IgM+, PCR+; Group 2 – IgM+, PCR−; Group 3 –- IgM−, PCR+; and Group 4 – IgM−, PCR−). Outcomes and histopathology were compared in these subgroups. Results: A total of 32 infants with BA were operated at a mean age of 3.5 (range: 1–6) months. Serum IgM+ and PCR+ were observed in 50% and 37.5% of the patients. Unfavorable outcomes showed a significant association with IgM+ and not PCR+. Similarly, outcomes were poor for CMV Groups 1 and 2 at 1-month follow-up. Infants with IgM+ and PCR+ showed a greater degree of histopathological damage in terms of bile duct proliferation and severe bile duct fibrosis, respectively. Conclusion: In the present study, there was a high incidence of serum IgM+ (50%) and PCR+ of biopsy specimens (37.5%) in infants with BA. This CMV-infected subgroup was associated with greater histopathological damage and unfavorable short-term outcomes after surgery.

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Diaphragmatic defects involving the right side of the diaphragm are less common but represent a distinct entity. The clinical presentation, management, and prognosis differ significantly from a left-sided defect. We report a case of a term neonate who was diagnosed to have a congenital diaphragmatic hernia during the third trimester of pregnancy, operated at 36 h of life and subsequently found to have an associated mediastinal cyst in 1^st week of life.

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Intussusception of one or another type is frequently seen in children and is the most common cause of acute bowel obstruction. This pathology is usually promptly recognized and treated accordingly. But if untreated, this entity can have either of the two outcomes. The first one is death from peritonitis and resulting toxemia, which is the most common one. The second one is spontaneous elimination followed by auto-anastomosis and is extremely infrequent. We report one such case of this rare progression who was found to have old healed small bowel intussusception with luminal narrowing on exploration for acute bowel obstruction. We have also reviewed the world literature to understand the mechanism and circumstances under which this progression occurs.

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Over the last one-decade, endoscopic ultrasound (EUS)-guided drainage has evolved as a preferred modality for treating pseudocyst over conventional surgical or radiological procedures among adults using plastic stents or lumen opposing stents; however, studies on EUS-guided pancreatic of pseudocyst among children are mainly in the form of case reports or small case series. Therefore, we aimed to describe four pediatric cases of the pseudo-pancreatic cyst treated successfully with EUS-guided cysto-gastrostomy using plastic stents. In all four cases, EUS-guided drainage was successful using plastic stent with no major complications, and none of them required any follow-up endoscopic or surgical intervention. EUS-guided cysto-gastrostomy offers an excellent and safe alternative to surgery for treating pancreatic pseudocysts in children.

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The association of exomphalos major, congenital liver cysts, and an accessory lobe of the liver is very rare. There are only two previously reported cases in the literature, both describing surgical excision of the accessory lobe with liver cysts during primary closure of the exomphalos defect. We report a case of this rare association, managed by delayed primary closure, where the cysts underwent spontaneous regression. This case, along with those previously reported, supports the etiopathogenesis theory of a malformative sequence of exomphalos and hepatic trauma within the sac of this rare association. Spontaneous regression of these cysts would favor a delayed primary closure in such cases.

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Bronchial carcinoid is the most common primary malignant lung tumor in children; however, it remains a very rare diagnosis due to the overall low incidence of childhood lung malignancies. We report a case of a 17-year-old girl with respiratory symptoms who was initially misdiagnosed as a case of COVID pneumonia. She was later detected to have a right mainstem bronchial carcinoid which was managed successfully by a multi-disciplinary team.

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Objective: To study the possibility of creating mucosal valve mechanism at ureteric orifice without obstructing the urine outflow but preventing the urine backflow into the ureters. Materials and Methods: Ethical waiver was obtained from the institutional ethical committee. Prospective experimental study was conducted on the post-mortem specimen of intact bladder with urethra and bilateral ureters retrieved from the already slaughtered lamb available in the meat market. Feeding tube inserted via urethral opening into the bladder lumen and bladder inflated with saline demonstrated no reflux of urine via transverse cut opening of ureters. Bladder lumen opened, ureteric orifices incised backwards to eliminate the obliquity. After closing the bladder opening, saline inflation test demonstrated bilateral reflux of saline via cut openings of bilateral ureters. Bladder was re-opened. The upper limb of horizontal U started 10 mm lateral and 8 mm above the refluxing ureteric orifice. Distal most curvature of horizontal U was kept 5 mm medial to ureteric orifice continuing along the lower limb of horizontal U terminating 10 mm lateral and 8 mm below the refluxing ureteric orifice, mucosal flaps from superior and inferior incision mobilized and edges joined to cover the ureteric orifice creating a flap valve mechanism. Influx of saline via cut end of ureters demonstrated no obstruction. Bladder was closed. Saline inflation test and contrast study demonstrated abolition of reflux on flap side and persistence of reflux on another side. Results: Five such experiments were conducted. On the side where the valve was created, Vesicoureteral reflux was abolished in four but in one minimal reflux still persisted. Conclusion: Creating a mucosal flap valve around the ureteric orifice can prevent reflux in 80% of cases without obstruction and without the necessity of ureteric mobilization or creating submucosal tunnel.

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One of the uncommon urogenital malformations in males, which presents late in the second or third decades of life, is the congenital malformation of the seminal vesicle. Zinner syndrome is a rare condition comprising a triad of unilateral renal agenesis, ipsilateral seminal vesicle obstruction, and ipsilateral ejaculatory duct obstruction. Very few cases in the literature describe the malignant change in seminal vesicle cyst in Zinner syndrome. To the best of our knowledge, this is the first report of a papillary neoplasm of the seminal vesicle cyst developed in a patient with Zinner syndrome.

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Jejunal intramural hematoma (JIH) is rare. A 5-year-old girl, a known attention-deficit hyperactivity disorder child with paraneoplastic symptoms, on imaging showed a suspicion of Jejunal intramural mass with internal bleeding. Laparotomy showed a JIH. Evacuation of hematoma and Histopathological Examination (HPE) ruled out tumor. Possible explanation of the manifestation is suggested.

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We present two infants with postoperative intussusception following stoma formation for stricture bowel due to necrotizing enterocolitis. They had unusual clinical features which need a high index of suspicion to diagnose.

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