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Background: The falling of Umbilical stump occurs by 7-15 days of age. The healing of umbilical stump may be complicated by Umbilical Granuloma. It is often treated by chemical cauterisation which require repeated applications and may lead to local or systemic complications. Common salt by way of its dessicative property may help in treatment of Umbilical Granuloma. Objective: The objective of the study is to assess the role of common salt application in umbilical granuloma. Materials and Methods: This is retrospective study over 3 years from a pediatric surgery unit in Northern India. The study subjects were infants less than 10 weeks of age who presented with umbilical granuloma. The method of salt application was 1 pinch of common salt for 1 hour twice a day for 3 consecutive days. The babies were assessed at day 5th for resolution. The success was defined as thrice resolution after 3 cycles. The baseline demographic details were taken and the association of success of treatment was analyzed. Results: A total of 36 infants were given treatment in form of common salt application for treatment of umbilical granuloma. The success of around 96% and the cases which presented early responded well. Most of the cases resolved after 3 cycles of treatment. Conclusion: The common salt application is effective in treatment of granuloma without any side effects.

Endoscopic transmural drainage is the preferred method of drainage of pancreatic fluid collections (PFCs) in adults; however, there is scant literature in children. We analyzed our experience of 33 endoscopic cystogastrostomies done in 29 children to find its efficacy and safety.We retrospectively analyzed the prospectively collected database of 31 consecutive children (18 years) who underwent endoscopic cystogastrostomy from June 2013 to December 2017. The procedure was done using the standard technique with an adult duodenoscope. Data related to clinical details, technical success, complications and follow-up were collected.The median age was 14 (3-17) years (22 males). Indications were early satiety in 28 (90%), vomiting in 15 (48%), and duodenal obstruction and infected pseudocyst in 2 children each. Etiology includes acute pancreatitis 22, post-traumatic 4 and chronic pancreatitis 5. The procedure was successful in 29 of 31 (93.5%) children with no mortality. Adverse events happened in four cases (12.9%); two infections, another with bleeding and another with pneumoperitonium, both of which resolved spontaneously. Incidents (minor bleeding) were noted in 6 (19%). Stents were removed in 26 (90%) after 12 (7-20) weeks and got spontaneously migrated out in 3 (10%) cases. Over a median follow-up of 26 (5-48) months, 26 (90%) had no recurrence of pseudocyst and 3 (10%) had recurrence of a small, asymptomatic pseudocyst.Endoscopic cystogastrostomy is a safe and effective method of draining bulging PFCs in children. The procedure carries acceptable morbidity with minimal recurrence. In younger children it may be the preferred method of drainage of PFCs.

Background: Coronavirus disease Pandemic has affected the health-care delivery at all institutions worldwide. Analysis of multi-institutional data would reflect the impact and challenges of this pandemic in managing pediatric surgical cases. To assess the impact of lockdown due to coronavirus disease 2019 (COVID-19) on the pediatric surgical cases operated at four tertiary care institutions. Materials and Methods: Retrospective data of all patients operated at four tertiary care centers in North India in three different states during the imposition of lockdown due to COVID-19 were collected and compared to the immediate prelockdown period. The impact of following the guidelines for surgery during this period was studied. Results: All the institutions involved in the study showed a significant fall in the number and nature of patients treated during the lockdown period when compared to the prelockdown data. No elective cases were operated; 100 children were operated during this period of which neonates (56%) formed the major group; most of them were cases of congenital anomalies which could not be deferred; solid tumours (3/100) were operated on semi-emergency basis; number of trauma patients fell down drastically (1/100); one patient had bronchoscopic foreign body removal; other patients were operated for different causes of acute abdomen. Several measures in the outpatient, intraoperative, and in-patient care were adopted to lessen the spread of virus to the patient and health-care team. Conclusion: Corona pandemic severely impacted both the number and types of patients operated. Strict adherence to the protocol delayed emergency treatment and increased the cost of definitive management.

Introduction: Cystic Lymphangioma (CL) commonly involves head and neck region and axilla. Involvement of other sites like salivary glands is very rare. This study was done to assess the role of bleomycin sclerotherapy in salivary gland CL with relevant review of literature. Aim: To assess the outcome of intralesional bleomycin as sclerotherapy in CL of major salivary glands. Materials and Methods: This was an retrospective observational study, done in Department of Paediatric surgery and Plastic surgery from July 2013 to July 2017. All diagnosed cases of pure CL involving major salivary glands were included, where as those with venous or arterial component were excluded from the study. Patients having previous surgery or other treatment modalities were also excluded. Primary mode of treatment of CL at present center was sclerotherapy using aqueous bleomycin. As per our protocol sclerotheray was done under sedation for paediatric patients using dopler ultrasound. Relevant demographic and clinical data of all seven patients was collected in structured proforma and results were analysed. Results: Out of seven cases, four patient’s lesion responded well in a single session, two patients reported unfavourable response even after second session hence, were managed surgically and one patient responded partially after first session and managed surgically later on. Conclusion: Cystic lymphangioma should be included in the differential diagnosis of cystic lesion of parotid and submandibular gland though its involvement is rare. Bleomycin sclerotherapy can be used as a safe and low cost treatment modality for the management of this rare entity.

Introduction: Usually, the residual umbilical stump separates by 7-15 days postpartum and the umbilical ring closes with epithelisation. In few infants, the umbilicus ring does not get epithealialised completely it forms an umbilical polyp and disappears in 2-3 weeks. Umbilical polyp requires medical attention if it persists beyond 3 weeks. Application of common salt for management of umbilical granuloma is one of the known modality of treatment owing to its hygroscopic action, though literature is sparse on the topic. Aim: To observe the effect of common salt on umbilical granuloma. Materials and Methods: Common salt application for management of umbilical granuloma is a standard modality at the study Institute. This was a retrospective observational study from January 2015 to December 2018. All data on infants of diagnosed umbilical granuloma, managed with application of salt, were evaluated. A total of 76 cases were managed during this period. Detailed demographic and clinical data was retrieved and collected in structured proforma from the electronic and manual record system. Descriptive statistical analysis was done. Results: In all cases, the granuloma healed within a span of two weeks. Number of salt application ranged from 8 to 24 applications. Total time for which salt remained in contact of umbilicus ranged from 8 to 24 hours. The number of sessions of salt application from presentation of patient to cure ranged from 8 to 24; median for sessions of salt application for complete cure was 12. Median for 25 quartile and 75 quartile was 12. Parents did not report any behavioural changes, sleep disturbances, or irritability in the infants after the application. No other complication or recurrence was noted in follow-up of 1 year. Conclusion: Common salt can be an effective modality to treat umbilical granuloma.

Objective Surgery is still indicated as the treatment of choice in subset of patients with unilateral multicystic dysplastic kidney (UMCDK) because of its potential complications and malignant change. The purpose of this study is to present our observation that early nephrectomy may cure hypertension early in children with UMCDK and review the literature. Materials and Methods We report here four children (two males and two females) with antenatally diagnosed UMCDK with hypertension, treated in the past 4 years. All have antenatal diagnosis of UMCDK and referred to us after their birth. Diagnosis of hypertension (blood pressure > 95th percentile) was made after 3 months of follow-up in all patients. Nephrectomy was performed in all children in variable time duration. Hypertension, urinary tract infection, and desire of parents were the main indication of surgery. Results All children showed decrease in the size of their dysplastic kidney with time, but hypertension was persistent and needed antihypertensive drugs; even increase in the doses in successive follow-up. After nephrectomy, three children who were operated early got cured having normal blood pressure within variable time duration, while a child, operated late, still had high blood pressure and needed antihypertensive drugs. Conclusion Early nephrectomy in recently diagnosed hypertension in UMCDK is advisable and can cure hypertension early. Levels of Evidence The level of evidence is IV (case series with no comparison group).

Background: Constipation is a common problem after surgery for anorectal malformations (ARMs), especially in patients having preserved rectosigmoid after pull-down surgery. Here, we present our experience with patients having constipation after surgery for ARMs and briefly discuss its management. Materials and Methods: We retrospectively reviewed electronic operative and follow-up data from January 2015 to December 2019 of all patients having constipation after surgery for ARMs. Results: A total of 77 patients were included in the study. The median age was 60 months, and thirty patients were male. Primary diagnoses were rectourethral fistula (26; 33.77%), vestibular fistula (25; 32.47%), perineal fistula/ectopic anus (18; 23.38%), rectovaginal fistula (4; 5.19%) and imperforate anus without fistula (4; 5.19%). Anal stenosis was found in 20 (25.97%) patients, posterior ledge with an adequate anal opening in 5 (6.49%), displaced anus in 4 (5.19%) but no obvious problem found in 48 (62.34%) patients. Non-operative management was successful in 75.44% (43 out of 57) of patients. Surgery was performed in 32 out of 77 patients (41.56%) with no mortality. Forty-three (72.88%) patients are continent, stayed clean, but 16 (27.19%) patients still need some sort of laxative/bowel wash/enema intermittently (Grade I/II constipation). Incidence of constipation was higher in patients operated through anterior sagittal route (27.58%) than posterior sagittal route (23.94%), but it was not statistically significant (P = 0.479). Follow-up ranged from 3 months to 5 years. Conclusion: Constipation is a common problem after ARMs surgery, especially in patients having preserved rectosigmoid after pull-down surgery. It is advisable to create relatively larger neoanus after pull through with early practice of neoanus dilatation, especially in redo cases. Repeated counselling, laxatives and dietary manipulations should begin at the first sign of constipation.

Cystic hygromas, also known as lymphangiomas, are unusual congenital malformations of the lymphatic system and commonly involve the head and neck region or axilla. Involvement of other sites such as breasts is very rare. The preferred mode of treatment for lymphangioma of the breast in adults or children is surgery. We report a case of breast lymphangioma in a 3-month-old male child, which was managed successfully by intralesional bleomycin. Keywords: breast, bleomycin, intralesional sclerosing agent, macrocystic lymphangioma

Background: Bowel obstruction in early infancy may results from variety of congenital anomalies involving small and large bowel. Colonic stenosis (CS) congenital or acquired is among the rare causes of chronic bowel obstructions in early infancy. Methods: Medical record of 4 patients with colonic stenosis secondary to Hirschsprung’s disease was reviewed. Results: A total of 4 cases were included in the study. Age of presentation ranged from 25 days to 96 days. Most common presentation was gross abdominal distension with visible bowel loop, vomiting, difficulty in passing stool followed by history of passing recurrent loose stools and failure to thrive. In one case there was suspicion of bowel perforation and was operated in emergency. Initial operative findings and histopathology was not suggestive of Hirschsprung’s Disease, but a full thickness rectal biopsy confirmed HD in all 4 cases. Conclusion: Hirschsprung should be considered as underlying pathology in cases of colonic stricture/stenosis in children.

Background: Intralesional bleomycin scelro-therapy has become a favored line of treatment for macrocystic lymphatic malformations. However the need for multiple sessions is a drawback associated with this treatment modality. Our aim is to document whether multiple session of intra-lesional sclero-therapy is necessary for complete resolution of cystic lymphatic malformation. Method: Intralesional bleomycin under Ultrasound guidance was used for macrocystic lymphangioma at concentration of 3mg/ml but not exceeding the total dose (1mg/kg) body weight for single session or cumulative dose of 5mg/kg. In all cases intralesional sclerosant (ILS) was installed under proper aseptic precaution in operation theatre in general anesthesia or sedation depending on the site or size of lesion and age of the patient. Age of patients at the time of enrolment in study ranged from 3 months to 18 years. Clinical examination was the main stay of diagnosis which was supplemented by USG and/or computed tomography. Compression of the lesion site was done for few hours wherever it was possible after the ILS session. Result: A total of 21 patients included in our study. The age ranged from 3 months to 18 years. Male to female ratio was 8:13. The most common site of involvement was neck and axilla followed by anterior chest wall and nape of the neck. Complete resolution after single session was observed in 90.5% cases where as surgery was required in 9.5% case. Major complication was observed in one patient, who had intralesional bleeding which was managed conservatively. Transient pain and fever was observed in 23.8% of cases. Only two patient required surgical intervention where one had persistent subcutaneous fibrotic nodule and other one did not respond to ILS. Conclusion: Intralesional bleomycin is an effective treatment for macrocystic lesion, and complete resolution may be achieved by single session of ILS if proper principle are followed.

Pathologically elevated vasoactive intestinal polypeptide (VIP) plasma levels cause secretory diarrhea with excessive loss of water and electrolyte and is characterized by the typical symptoms of hypokalemia and metabolic acidosis. It rarely occurs in patients with non-pancreatic disease. Despite the clinical severity, diagnosis of a VIP-secreting tumor is often delayed. We herein present a 14-month-old boy having prolonged therapy-resistant secretory diarrhea, persistent hypokalemia with tissue diagnosis of ganglioneuroblastoma and raised plasma VIP-levels. How to cite this article Kumar B, Upadhyaya VD, Rao RN, Kumar S. Ganglioneuroblastoma as Vasoactive Intestinal Polypeptide-secreting Tumor: Rare Case Report in a Child. World J Endoc Surg 2015;7(2):47-50.

Cystic lymphangioma of small bowel mesentery is rare with clinical features ranging from an asymptomatic abdominal lump to acute intestinal obstruction. We discuss two cases of lymphangioma of small bowel mesentery who presented to us as acute intestinal obstruction. In the first case exploratory laparotomy revealed a large multicystic lesion arising from small bowel mesentery just distal to the duodenojejunal junction having multiple small cysts filled with milky white fluid. The involved region of the bowel was excised. The second case had a large multicystic lesion involving the mesentery of proximal jejunum, dudenojejunal junction, encasing the entire superior mesenteric vessels. For this patient, debulking was done.

Infantile Choledochal Cysts (IFCC) usually present with jaundice, acholic stool and abdominal lump or abdominal distension. If the surgical intervention is delayed, they rapidly progress to liver fibrosis which is considered to be irreversible if progressed to cirrhosis. We present the data of four cases (aged one month to seven months) of IFCC presented with cholangitis managed in one surgical unit in last two years. In one case, cholangitis was treated with prolonged antibiotic course before definitive repair whereas in rest, external drainage of cyst was done in addition to intravenous antibiotic to treat cholangitis. All the infants had features of cholangitis at time of presentation. Total leucocyte count ranged from 18x1000/UL to 30.6x1000/UL. Total bilirubin level at presentation ranged from 8.2 mg/dl to 18 mg/dl and Prothrombin time (INR) ranged from 1.33 to 1.9. Hepatic fibrosis was observed in all cases but cirrhosis was observed in only one case. There was no mortality but one patient had postoperative complication with prolonged hospital stay. External drainage helps in early recovery from cholangitis and better optimization of liver function. It also delays further progression to liver fibrosis by relieving the biliary outflow obstruction while waiting for definitive repair.

Aim: Spontaneous perforation is a rare complication of a choledochal cyst that is difficult to diagnose because of its nonspecific clinical presentation. These patients usually present with an insidious course characterized by progressive abdominal distension, vomiting, and pain. Here, we present a series of three cases for clues for diagnosis. Materials and methods: All patients with spontaneous perforation of a choledochal cyst who were presented to our institute from January 2009 to December 2011 were included in the study and symptoms and signs at the time of presentation were analyzed. Results: All patients had clinical jaundice and acholic stools at the time of presentation; pain and vomiting was not a consistent feature. Abdominal paracentesis helped us diagnose these cases. Conclusion: Abdominal paracentesis is very useful in cases of suspected spontaneous perforation of the bile duct. Simple drainage with a T-tube, if possible, is safe, efficacious, has low morbidity, and aids in the establishment of the diagnosis as well as delineation of the anatomy of the concerned region for definitive surgery. Keywords: Choledochal Cyst, Spontaneous Perforation of Bile Duct, T-tube

Incomplete intestinal obstruction due to windsock web of the jejunum is uncommonly notice in neonates. We present a male neonate, prenatally suspected case of proximal bowel obstruction, who was found to have features of incomplete intestinal obstruction due to windsock deformity in jejunum. The difficulty in the diagnosis and management is discussed along with relevant literature review.

Gastrointestinal duplications can affect any part of the alimentary tract and are notorious for their variable presentation. Their association with malrotation and midgut volvulus is rare. We describe an 8-year old boy presented with episodes of abdominal pain. Radiological workup showed whirlpool sign and abnormal relationship of mesenteric vessels. At operation, malrotation with chronic volvulus were found. Incidentally, a jejunal communicating duplication cyst was also noted.

Neonatal surgery is the flagship and most challenging component of pediatric surgery, which is the youngest subspeciality of surgery. Neonatal surgery carried a survival rate of only 30% three decades ago. In the last decade there has been a significant change in the scenario. Earlier recognition and referral of these anomalies, availability of neonatal intensive care, better preoperative planning, decision, and techniques have lead to the change in the management. This is an audit into the outcome of neonatal surgery from one of the largest units in India over a ten year period. This audit reveals an across the board survival of 65-70% newborns after surgery on nearly two thousand case over a ten year period. It has an important message that while pediatric surgery units expand, risk stratification of surgical newborns and their treatment in suitable units is mandatory to maintain and improve these figures to match international standards over the next decade.

Urethrocutaneous fistula is one of the most common complications after hypospadias surgery. The incidence of fistula development has varied from 4% to 20% in larger series. We sought to investigate the role of fibrin glue (Tisseel manufactured by Baxter India Pvt Ltd, Chennai, India) to reduce the chances of fistula formation in cases in proximal penile hypospadias.A total of 120 patients with proximal penile hypospadias (patients having urethral meatus at posterior third of penile shaft and at penoscrotal junction) were included in the present study. Patients were randomly allocated into 2 groups of 60 each by using Strata 9 software random number table. In group A, fibrin glue was used as a sealant after hypospadias surgery, whereas in group B, no sealant was used. All the operations were performed by single surgeon using transverse preputial tubularized island flap urethroplasty.Fistula formation occurred in 6 cases in group A (10%) and 19 cases in group B (32%) (P = .027). The fistulae observed in fibrin glue group A were single and small in size (1 mm). Multiple (or=2 fistulae) and larger fistulae (2 mm) were observed in group B. Overall complication was significantly higher in group B (P = .006).Fibrin glue in hypospadias repair does not eliminate fistula formation. However, it seems that it minimizes the incidence of fistula formation.

Necrotizing enterocolitis (NEC) is the most common gastrointestinal medical/surgical emergency in neonates. Non-operative support is needed in 70% of NEC cases, and surgical intervention in the rest 30%. Historically, pneumoperitoneum has been considered as an absolute indication for laparotomy. In the present study we emphasize that pneumoperitoneum is not an absolute indication for exploratory laparotomy in NEC cases.We prospectively studied 58 patients with severe NEC having pneumoperitoneum on abdominal X-ray in the last 5 years. At the time of admission, the patients were given intravenous fluid, total parental nutrition, blood transfusion and broad spectrum antibiotics followed by abdominal tapping (paracentesis). All the patients with pneumoperitoneum were closely monitored for 48 hours if abdominal tapping was repeated. When the disease seemed to worsen clinically, radiologically and laboratorially, the patient was subjected to exploratory laparotomy.Of the 58 patients, 40 were treated conservatively whereas 18 underwent surgical intervention. The overall mortality in the present study was 12.1%, including 5% of the patients managed conservatively and 27% of the patients undergoing surgery.Pneumoperitoneum is not an absolute indication for surgery in cases of neonatal NEC. Most of the patients can be treated conservatively.

The aim of this study was to characterize a successful approach for the management of infants with long-gap esophageal atresia (EA) with tracheoesophageal fistula (TEF). The goal was to preserve the native esophagus and minimize the incidence of esophageal anastomotic leaks using fibrin glue as a sealant over the esophageal anastomosis. A total of 52 patients were evaluated in this study. Only patients in whom, gap between the two ends of the esophagus was ≥ 2 cm were selected during January 2005 to January 2007. Patients were divided in two groups on the basis of block randomization. Group A comprised the patients in whom fibrin sealant was used as reinforcement on a primary end-to-end esophageal anastomosis; in group B, fibrin glue was not used. The two groups were compared in terms of esophageal anastomotic leak (EL), postoperative esophageal stricture (ES), and mortality. The statistical analysis was done using Fisher’s exact test and the chi-squared test. The number of anastomotic leaks in group A (glue group) was about one-fifth that in group B (no glue group). The incidence of ES was almost twice as high in group B as in group A. The mortality rate was almost threefold higher in group B (no-glue group). The higher incidence of EL and ES in group B compared to group A was statistically significant. Thus, fibrin glue when used as an adjunct to esophageal anastomosis for primary repair of long-gap EA with TEF appears safe in the clinical setting and may lower the chances of esophageal leak and anastomosis-site strictures. Hence, it can diminish the mortality and morbidity of these patients.

Jejuno-jejunal intussusception is a rare complication of feeding jejunostomy tube placement. A case of one year old child who underwent gastric pull-up for complicated tracheo-esophageal fistula had jejuno-jejunal intussusception induced by Witzel's feeding jejunostomy tube; is discussed with review of literature.

The thyroid gland, a highly vascular endocrine gland, is composed of two lateral lobes connected by a narrow median isthmus thus giving an ‘H’-shaped appearance to the gland. Congenital thyroid abnormalities mostly include unilateral lobar agenesis, with or without involving the isthmus. We are reporting a case rudimentary right lobe with absence of isthmus. The knowledge of various developmental anomalies of the gland and variations in neurovascular relations will help the surgeon in better planning of a safe and effective surgery. How to cite this article Sthapak E, Gajbe UL, Wanjari SP, Upadhyaya VD, Kumar B. Thyroid Agenesis: A Case Report with Review of Literature. World J Endoc Surg 2012;4(3): 99-101.

We are presenting two cases of congenital urethrocutaneous fistula on ventral penile shaft. Congenital urethral fistula is an extremely rare, but easily manageable anomaly that may be confused with hypospadias. Awareness of the entity will avoid complications. This condition may be associated with other anomalies like congenital hernias and anorectal malformations. Treatment of this entity is individualized according to site of fistula, associated anomalies and condition of the distal urethra. All the principles of hypospadias surgery should be strictly followed.

Objectives: Lymphatic malformations (LMs) are aberrant proliferation of sequestrated lymphatic vessels during early embryogenesis and do not communicate directly with the general lymphatic system. The absence of vascular flow is the hallmark of LMs and is usually symptomless apart from painless disfiguring mass with concerns regarding cosmesis. Design: Sclerotherapy has gained prominence as a preferred treatment modality for macrocystic lesions. Here, we present our experience with use of aqueous bleomycin as intralesional sclerosing agent, an economical first-line treatment for macrocystic variant of LMs in children and adults. While bleomycin microsphere in oil has been commonly used in many previous studies, we have used aqueous bleomycin solution as the sclerosing modality which is easily available and economical. Materials and Methods: Twenty-seven patients of macrocystic LM including adults and children underwent bleomycin sclerotherapy under ultrasonography guidance. Number of sessions, dose administered, and the response to therapy along with all side effects were noted. Results: Sixteen patients received 3 or less sessions while rest needed 4–6 sessions of sclerotherapy for desired response. The response was excellent in 22 patients while 5 patients showed good response. Eleven patients developed minor side effects in form of fever, local infection, intracystic bleed, and local skin discoloration. Postsclerotherapy, surgery was performed in two patients. Conclusion: The better response in the present study can be attributed to targeting of individual cysts in multiloculated lesion, ultrasound-guided aspiration of the cysts content before drug delivery, and postprocedure compression which increases the contact time between cyst wall and bleomycin reducing the chances of postprocedure seroma formation. Since the drug acts on the endothelial lining of the cyst, volume of the cyst is the major determinant in response. Aqueous bleomycin had comparable results with oil-based microsphere establishing it as an economical alternative treatment modality.

Background: Spontaneous biliary peritonitis is a rare cause of acute abdomen. In spontaneous biliary peritonitis there is perforation in the wall of the extra-hepatic or intra-hepatic duct occurs without any traumatic or iatrogenic injury and have been described more often in neonates. The symptoms may be acute or insidious delaying the diagnosis. Presentmanuscript deals with diagnosis and management of these cases. Materials and Methods: This is a prospective study and all patients of suspected biliary peritonitis presented during Dec 2010 to Feb 2012 wereincluded in the study. After preliminary investigations in all patients abdominal paracentesis was done and in cases where intra-abdominal fl uid bilirubin level was several fold higher than serum bilirubin level were subjected to exploratory laparotomy. Further investigation like T-tube cholangiogram and magnetic resonance cholangiopancreatography (MRCP) was done to rule out choledochal cyst before leveling these cases as SPBD. Results: A total of 6 patients were included in present series commonest presenting symptom was progressive abdominal distension without signs of overt peritonitis followed by progressive jaundice, fever and abdominal pain. On exploration site of perforation was observed in 50% of cases and in 50% of cases bile duct was not dilated. Second surgery was not required in 34% of cases. There was no mortality or signifi cant morbidity in our series.Conclusion: Spontaneous perforation of bile duct is rare disease and high index of suspicion is required for diagnosis. Simple bed side test can help in diagnosis but T tube cholangiogram or MRCP are must to rule out choledochal cyst.Key words: Bile duct, choledochal cyst, perforation, peritoneal drain

Introduction: Gastrointestinal tuberculosis often involves the ileocecal region. Duodenal and gastric tuberculosis found in only 1% of patients suffering from pulmonary tuberculosis with associated HIV infection in non-endemic areas. Duodenal obstruction due to tuberculosis is very rare and needs high index of suspicions for diagnosis. Mostly this entity is suspected on intraoperative findings. In this manuscript we emphasized on ways and means for establishing histopathological diagnosis before starting anti-tubercular treatment in such cases.Method and Material: All patients of suspected gastroduodenal tuberculosis presented with feature of gastric-outlet obstruction managed during Jan 2009 to June 2011 were included in the study. After proper evaluation (routine hematological and biochemical examination, microbiological examination, serological and endoscopic evaluation) exploratory laparotomy was done and if there is no mesenteric lymphadenopathy or it is not safe to take biopsy form the diseased duodenum, multiple FNAC were taken from the diseased portion for histopathological and microbiological diagnosis. Result: A total of five patients were treated during this period. The most common presentation was vomiting followed by failure to thrive and weight loss; two patients had abdominal pain. Biopsy of mesenteric lymph node was possible in two cases. FNAC from diseases portion was taken in all cases. FNAC showed granulomas in four cases. Cases where even FNAC fi nding was non-conclusive on HPE/Microbiology was not subjected to antitubercular drug.Conclusion: Multiple intra-operative FNAC may be taken from the diseased portion of the duodenum to establish the histopathological diagnosis if diagnosis is not established by any other mean.Key words: Duodenum, fi ne needle cytology, tuberculosis

Esophageal atresia with tracheoesophageal fistula (TEF with EA) is a common disease which is associated with many other congenital abnormalities. The most common association is with VACTERL syndrome.. Various types of ear malformations have been reported in CHARGE syndrome associated with EA and TEF. However, absence of external ear has not been described which is being reported in this article. We could not found this association even on extensive search of literature.

OBJECTIVE: Advanced and inoperable solid tumours in children have high mortality despite aggressive multimodal treatment. Intravenous chemotherapy is abandoned at times because of systemic toxicity. This study investigated intratumoural chemotherapy and compared it with intravenous chemotherapy. METHODS: Forty children with advanced inoperable solid tumours (Wilms’ tumour and neuroblastoma) were randomly allocated into two groups of 20. Group A was given intratumoural chemotherapy and group B was given intravenous chemotherapy. Both groups were compared for reduction in tumour size and volume, tumour resectability, histopathological changes and drug side effects. RESULTS: Intratumoural chemotherapy was superior to intravenous chemotherapy in terms of reducing tumour size and volume (63% in group A vs. 22% in group B). The resectability was 70% in the intratumoural group compared with 40% in the intravenous group. The overall good histopathological response was 71% in group A as opposed to 0% in group B. Moreover, the incidence and severity of drug side effects and morbidity were less with intratumoural chemotherapy. Mortality was also low in group A (5%) compared to group B (20%). CONCLUSION: Intratumoural chemotherapy can be offered as an effective and safe alternative treatment modality for advanced and inoperable Wilms’ tumour and neuroblastoma. [Asian J Surg 2008; 31(4):225–9]

Background A 21 day old male child presented with non bilious vomiting and abdominal mass. Case presentation This case is reported because pyloroduodenal duplication cysts are an extremely rare congenital anomaly, whose clinical presentation often mimics those of hypertrophic pyloric stenosis. Ultrasound examination showed cystic mass at pyloric region and barium study was suggestive of extrinsic mass compressing the pyloric region. A laparotomy, a tense cystic mass was present at the pyloroduodenal junction (PDC) which was resected and end to end anastomosis was done. Patients followed an uneventful recovery and doing well. Conclusion The clinical and radiological analysis can reveal configurational changes consistent with a large extrinsic mass rather than muscular hypertrophy and can lead to accurate preoperative diagnosis.

Ileostomy is usually performed for patients of typhoid intestinal perforation with poor general condition, but it is associated with significant morbidity. We have used the T-tube in such patients as an alternative to ileostomy.This is a prospective evaluation of a cohort of children with proven typhoid intestinal perforation. Patients with multiple perforations and poor general condition were managed with a T-tube inserted into the bowel lumen after closing all distal perforations (group 3). They were compared with patients who had primary closure of perforation (group 1) or bowel resection (group 2) to determine the efficacy of the use of T-tube.The total number of patients for groups 1, 2, and 3 was 51, 4, and 12 (n = 67). The mean number of perforations for the three groups was 1, 3.5 +/- 0.58, and 4.25 +/- 0.97. The operation time for the three groups was 37.29 +/- 3.24, 59.25 +/- 3.09, and 59.17 +/- 4.17 minutes, respectively. The T-tube was removed after 13.17 days. The mean duration of fistula at T-tube site to heal was 8.58 +/- 2.11 days. The overall follow-up period was 10.94 +/- 1.15 months and none of the patients with T-tube placement had features of intestinal obstruction.In children with multiple typhoid intestinal perforations and poor general condition, the use of T-tube may be an effective management option.

The ascariasis is one of the most cosmopolitan intestinal parasite infections and it can be in inhospitable regions inhabited by human being, but its biggest prevalence is observed in the tropical and subtropical areas. Intestinal obstruction has been estimated to occur in 2 per 1000 ascaris-infected children per year. We are presenting a study emphasizing the conservative treatment for complete intestinal obstruction due to roundworms without sign and symptom of peritonitis and perforation.A total of 22 patients of roundworm obstruction partial or complete without signs of and symptoms of peritonitis were admitted in the Department of Pediatric Surgery IMS, BHU Varanasi India in the period form 2003-2005. Patients were put nil by mouth, intravenous fluid, antibiotics, piperazine salt through nasogastric tube and glycerine + liquid paraffin emulsion enemas and were evaluated for duration of hospital stay, rate of conversion to surgical treatment and complications.19 (86%) patients were treated successfully with conservative line of management. Only 3 patients required surgical intervention. No mortality, complication and mean hospital stay was 4.1 days (range 4-5 days).Round worm intestinal obstruction can be effectively treated by conservative line of management.

Background Anorectal malformations are one of the most common congenital defects. This study is conducted to demonstrate new technique for treatment of rectovaginal fistula without disturbing the fourchette through posterior sagittal approach. Method All the patients of rectovestibular fistula admitted after the neonatal age were treated with posterior sagittal anorectoplasty without opening the fourchette. The results were evaluated for cosmetic appearance and anal continence. Result A total of 40 patients were included in our study. All patients were more than 1 month old. Operative time ranges from 70 to 150 minutes. The cosmetic appearance was good. Anal continence was good in 72% cases and fair in 20% cases. Fifteen percent of patients had minimal constipation and 7.5% patients had mucosal prolapse. Conclusion Single-stage repair for vestibular anus through posterior sagittal anorectoplasty without opening fourchette has a good cosmetic appearance and good anal continence.

Wandering spleen is a rare clinical entity that accounts for only 0.1-0.2% of all splenectomies. Early diagnosis and intervention is necessary for the preservation of the spleen, especially in children. However, most of the times in acute settings a precise clinical diagnosis is difficult because of its similarity of presentation with other causes of acute abdomen resulting in delayed diagnosis. We present a 12-year-old boy with left-sided abdominal pain following a fall from a bed. His abdominal examination revealed an enlarged tender spleen. Abdominal ultrasound and computed tomography showed enlarged spleen with multiple areas of infarction and thrombosis of the splenic vein. At laparotomy a diagnosis of torsion of a wandering spleen with infarction was confirmed and splenectomy done. We present the management of the patient with wandering spleen that presented as acute abdomen with lower abdominal mass and briefly review the literature.

Morgagni's Hernia is the direct herniation of the intra-abdominal organs through the anterior retrocostoxiphoid diaphragmatic defect. We are presenting a case of obstructed Morgagni's hernia in a five-year-old child. Who presented with colicky abdominal pain, distention of upper abdomen, vomiting with constipation of three days duration.. Morgagni hernia is a rare disease even rarer in pediatric age group, and is usually diagnosed incidentally; presentation of this disease with obstruction had been reported in adult but not in children.

Aim: Report of a series of 12 cases of juvenile polyposis coli. Methods: The study period was from 1995 to 2005. All the patients were treated by total colectomy with rectal mucosectomy and endorectal ileoanal pullthrough with or without ileal pouch formation. Covering ileostomy was avoided in all the cases. Time taken for the surgery, postoperative complications and continence were documented. Results: The mean operating time was 4.2 h (range: 4-5 h). The mean duration of hospital stay was 16.3 days (range: 15-18 days). The most common postoperative complication was pouchitis and perianal excoriation. Initially, all the patients were passing stools at an interval of 2 h, and after 3 weeks, the frequency has reduced to 6-8 stools per day. In the follow-up after 3 months, the frequency was 3-5 per day with minimal soiling. Conclusions: Single-stage total colectomy with rectal mucosectomy and endorectal ileoanal pull-through without covering ileostomy and pouch formation is a safe and definitive treatment for juvenile polyposis coli if the patient selection is appropriate.

OBJECTIVE Until recently, surgeons have been posed with a dilemma—whether or not they should preserve the terminal end of the distal rectal pouch and the fistula region in anorectal malformations (ARMs). A detailed histological study of this region was conducted to establish a consensus for preserving or excising this region for reconstruction of ARMs. METHODS Histopathological examination using haematoxylin and eosin-stained sections of the terminal portion of the distal rectal pouch and proximal portion of the rectourogenital or rectoperineal connection was performed in 60 cases of high, intermediate and low ARMs. RESULTS Distorted internal sphincter was present in 93.3% of high, 90% of intermediate and 100% of low ARMs. The proximal fistula region was lined by transitional epithelium in 50% of cases, and anal glands were present in 83.3% and anal crypts in 68.3% of cases. The rectal pouch in the region of the internal sphincter and fistula was aganglionic in all cases. CONCLUSION This study shows that the terminal end of the distal rectal pouch and proximal fistula region possess distorted anal features with aganglionosis, and contradicts the recommendation that this region should be reconstructed in patients with malformations.