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Abstract. In neonates presenting with massive pericardial effusion and pericardial mass, liver herniation into the pericardium is a rare diagnosis. Echocardiogram and CT scan are useful investigations in the diagnosis [...]

Byline: D. Gupta (1), M. Srinivas (1), S. Agarwala (1), S. Dave (1), M. Arora (2), A. Gupta (3), C. Bal (4) Keywords: Esophageal atresia Tracheoesophageal fistula Esophageal replacement Gastric pull-up Abstract: Between 1991 and 1998, 28 out of 356 neonates with esophageal atresia and tracheoesophageal fistula (EATEF) required esophageal substitution. As only 8 returned (28%) for the esophageal replacement after initial esophagostomy and gastrostomy at our center, we were prompted to offer single-stage esophageal replacement when the primary repair had either failed or was not found feasible. Twelve full-term neonates (mean birth weight 2.32 kg) with EATEF who underwent esophageal replacement by gastric pull-up between 1998 and 2000 were reviewed. The indications were: major leak after primary repair (n=9) pure EA (n=2) and EATEF with a very wide gap (n=1). The average ages at presentation and gastric pull-up were 6.0 and 8.5 days, respectively. The patients were evaluated for gastric transit by a colloid radiopharmaceutical, for duodenogastric reflux (DGR) by hepatic immunodiacetic acid (HIDA) scan, and for gastric clearance and transit by contrast studies. Three patients had minimal leaks from the neck site, all of which healed well. Follow-up with nuclear scans and contrast studies to evaluate gastric emptying revealed obstruction in 1 case and DGR in 25% of cases. There were 2 deaths (16%), 1 due to complex congenital cardiac disease and the other due to septicemia. In view of the acceptable morbidity, mortality, and functional outcome following gastric pull-up, we recommend this procedure if it becomes inevitable in the neonatal period. Author Affiliation: (1) Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India (2) Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India (3) Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India (4) Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India Article History: Accepted Date: 10/07/2001 Article note: Electronic Publication

Byline: V. Chandrasekharam (1), M. Mathur (2), S. Agarwala (1), D. Mitra (1), V. Bhatnagar (1) Keywords: Acute jejunoileitis Bowel inflammation Bowel gangrene Short-bowel syndrome Acute necrotizing enteritis Abstract: We describe a variety of acute necrotizing enteritis that is endemic to the Indian subcontinent. During the period 1992--1998, 18 cases of acute jejunoileitis (AJI) were managed. Only those in whom the diagnosis was confirmed at laparotomy have been included in this study. The most common symptoms were abdominal pain (100%), fever (77%), and blood in the stool (100%). A stricture following conservative treatment was present in 1 case. The mean age at presentation was 6.5 years (range 6 months--12 years) the male:female ratio was 1.2:1. All cases were seen during May--October. Routine investigations and X-ray films were nonspecific. Stool cultures did not show any clostridia, shigella, or salmonella. The jejunum was involved most commonly 28% of patients did not require a bowel resection. Only 1 child presented with shock the mortality was less than 5%. Short-bowel syndrome resulted in 1 patient due to extensive disease. The histopathologic features that were characteristic of the disease were patchy transmural mucosal necrosis extending centrifugally with submucosal edema, interstitial hemorrhage, type III hypersensitivity reaction, and extensive neovascularization. This type of AJI seen in South/Southeast Asia does not seem to be due a to bacterial infective etiology immune mediation is suggested. The milder forms can be confused with dysentery. Mild forms of the disease can be managed conservatively, but carry the risk of developing strictures. This disease should be suspected in cases of prolonged dysentery during the summer and autumn months. Author Affiliation: (1) Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India (2) Department of Pathology, All India Institute of Medical Sciences, New Delhi-11029, India (3) Department of Pediatric Surgery, AIIMS, New Delhi-110029, India Article History: Accepted Date: 07/09/2001 Article note: Electronic Publication

Byline: V. Chandrasekharam (1), M. Srinivas (1), A. Charles (1), S. Agarwala (1), D. Mitra (1), C. Bal (2), V. Bhatnagar (1) Keywords: Hydronephrosis Ureteropelvic junction obstruction Somatic growth Urinary tract infection Abstract: To assess whether symptomatic unilateral ureteropelvic junction obstruction (SUUPJO) affects somatic growth and, if so, the parameters associated with it, 61 children (54 boys and 7 girls) who underwent pyeloplasty for SUUPJO without any other associated urological abnormalities were retrospectively studied. Height was compared with standard growth charts and was considered to be affected if it was below 2.00 Z-score. Such children were considered group B and the rest group A. Mean (+-SD) age at presentation and mean (+-SD) split renal function (SRF) (%) of the affected kidney were 6.0 +- 4.0 years and 27.3 +- 13.2, respectively, for the entire group. Somatic growth was affected in 16 (12 boys, 4 girls) children (26.2%). Urinary tract infection (UTI) was the presenting symptom in 11 (69%) and 5 (11%) children in groups B and A, respectively. Impaired somatic growth had no association with age at presentation or SRF, but a significant association (P &lt 0.001) was found with UTI. The mean post-surgery height percentile (2.92 +- 4.85) over a mean follow-up of 3.37 +- 1.86 years was significantly (P &lt 0.005) better compared with pre-surgery height percentile (0.67 +- 0.96) in group B, indicating catch-up growth after surgery. In SUUPJO, somatic growth is affected. Presentation with UTI has a significant association, and height significantly improves after surgery in these patients. Author Affiliation: (1) Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India (2) Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, 110029, India Article History: Received Date: 02/11/2001 Article note: Electronic Publication

Byline: A. Puri (1), V. Grover (1), S. Agarwala (1), D. Mitra (1), V. Bhatnagar (1) Keywords: Posterior urethral valves Urinary diversion Vesicostomy Ureterostomy Fulguration Urodynamics Abstract: Bladder function in patients with posterior urethral valves (PUV) has an immense impact on long-term continence and renal function. Bladder dysfunction was corelated with the initial surgical treatment in 67 patients with PUV treated between 1985 and 2000. Age at presentation, current age, duration of follow-up, initial surgical treatment (diversion or valve fulguration), trends of renal function tests, voiding disturbances, and changes in the upper tracts were recorded. Urodynamic studies were done in all patients to determine urine flow rates, residual volume, maximal cystometric capacity (MCC), bladder compliance, involuntary detrusor activity, and pressure-specific bladder volume (PSBV) at 30 cm water. The patients were divided into three groups depending on the initial treatment: fulguration (n = 38), vesicostomy (n = 25), and ureterostomy (n = 4). At the time of this study voiding symptoms persisted in 45 patients. Mean percent MCC (% MCC) was 62%, 96%, and 100% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively (P = 0.002). Large-capacity bladders were seen in 10.9% of patients, mostly in pubertal and post-pubertal boys who were treated initially by either fulguration or ureterostomy vesicostomy adversely affected bladder capacity and compliance (P = 0.007). PSBV was decreased in 48% of patients in the vesicostomy group and was significantly lower in the other groups (P = 0.01). Mean percent PSBV was 75%, 95%, and 96% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively. Uninhibited contractions were present in 21 patients (14 in the vesicostomy group) (P = 0.01). The highest incidence of upper-tract deterioration was seen with %MCC below 60% of normal (P = 0.001). The predominant urodynamic patterns were: (1) fulgurated group: good-capacity, compliant bladder (2) vesicostomy group: small-capacity, hyperreflexic bladder and (3) ureterostomy group: good capacity, compliant bladder. Primary valve ablation is associated with better bladder function than vesicostomy and should be the treatment of choice in PUV. Also, vesicostomy and ureterostomy have distinctly different effects on bladder function. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India Article History: Accepted Date: 18/09/2001 Article note: Electronic Publication

Byline: L. Nambirajan (1), S. Agarwala (1), A.K. Dinda (2), D.K. Mitra (1) Keywords: Keywords Rats; Unilateral undescended testis; Ultrastructural changes; Contralateral descended testis Abstract: Fertility is decreased in rats with experimentally-created unilateral undescended testis (UUDT). Although light microscopy has shown changes in the UDT, it has consistently failed to demonstrate any significant damage in the contralateral descended testis (CDT) of these animals in previous experimental studies utilizing the same model. To study the ultrastructural details of the CDT and the ipsilateral UDT using transmission electron microscopy (TEM) in rats with experimentally-created UUDT, in Wistar albino rat pups UUDT was experimentally created in accordance with the model described previously. Ten rats with UUDT were compared with 10 control rats. The UDT and CDT were harvested at 135 days of age and sections from specimens studied by TEM for changes in the seminiferous tubules, Leydig cells, and extracellular matrix. All observations were graded and analyzed for statistical significance. TEM of the testes of control rats was normal, while both the ipsilateral UDT and the CDT showed significant changes. Significant changes in the CDT included thickening of the basement membrane (P=0.001), a decrease in spermatogenic cell lines (P=0.02), vacuolation (P=0.0001) and other features of degeneration (P=0.02), single cell apoptotic figures (P=0.02), and an increase in Sertoli-cell numbers (P=0.01), size (P=0.01), and endoplasmic reticulum (P=0.01). Another significant feature was the occurrence of morphologic sperm abnormalities in the form of tail denudation (P=0.02). The surgically-created UDT showed changes of gross degeneration and atrophy. TEM studies thus revealed gross ultrastructural damage to the UDT and similar subtle but significant changes in the CDT. These may explain the decrease in fertility in rats with UUDT. Author Affiliation: (1) Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India, IN (2) Department of Pathology, All India Institute of Medical Sciences, New Delhi-110029, India, IN Article note: Accepted: 18 April 2001

Byline: V. Bhatnagar (1), D. K. Mitra (1), S. Agarwala (1), R. Kumar (2), C. Patel (2), A. K. Malhotra (2), A. K. Gupta (3) Keywords: Keywords Urinary tract infection; Vesicoureteric reflux; Renal scarring; DMSA scans; Micturating cystourethrography Abstract: The correlation between urinary tract infection (UTI), vesicoureteric reflux (VUR) and renal scarring was studied in 89 patients (177 renal units 1 solitary kidney) during the period 1997--2000. There were 63 males and 26 females ages ranged from neonates to 14years. UTI was diagnosed on the basis of a positive urine culture, VUR was diagnosed and graded by micturating cystourethrogram (MCU), and renal scarring was assessed by technetium 99m Tc-dimercaptosuccinic acid (DMSA) scan. Ultrasonography (US) was done to evaluate renal tract dilatation and other structural abnormalities. A follow up DMSA scan was performed approximately 6months after the initial scan. VUR was present in 106 of the 171 renal units in which it was studied and absent in 65 units. The majority of the VUR was grade V. Renal scars were seen in 90 of 177 renal units at presentation and in 72 of the 163 renal units studied at follow-up. Some information was lacking in 31 patients hence, the correlation between UTI, VUR, and renal scarring was done in 58 patients. The majority of the suspected scars at presentation were not seen at follow-up, but most of the established scars persisted. Only 2 renal units showed scars for the first time on follow-up. On US, approximately 50% of normal kidneys showed either suspicious or established scars on DMSA scan, and patients with bilateral abnormality on US showed renal scars. Renal scars were seen in 15 of 23 children without VUR, 17 of 18 with unilateral VUR, and 16 of 17 with bilateral VUR. Thus, there is a cause-and-effect relationship between UTI and renal scarring that is made worse by VUR. DMSA scans have been shown to be the most reliable method of assessing renal scarring, and an abnormal US scan showing upper-tract dilatation or a structural abnormality may have a predictive value in the detection of renal scarring. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India, IN (2) Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi-110029, India, IN (3) Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi-110029, India, IN Article note: Accepted: 18 April 2001

Byline: V. Bhatnagar (1), S. Dave (1), S. Agarwala (1), D. K. Mitra (1) Keywords: Keywords Bladder exstrophy; Bladder augmentation; Colocystoplasty; Bladder compliance; Incontinence Abstract: A good bladder capacity and adequate outlet resistance determine success after staged reconstruction of bladder exstrophy (BE). Augmentation cystoplasty (AC) is an established salvage procedure to treat the small, noncompliant bladders of some of these children. In a series of 89 patients with BE treated over the last 12 years, 19 underwent detubularized augmentation colocystoplasty (ACC) as an adjunctive procedure. Nine underwent ACC at the time of bladder-neck reconstruction (BNR) for small bladder capacity and poor compliance 10 underwent ACC as a secondary procedure after BNR for persistent urinary incontinence or poor bladder compliance and upper-tract deterioration. The follow-up period ranged between 6 months and 12 years (mean 41 months). Complications included symptomatic urinary-tract infection in 4 patients, recurrent epididymo-orchitis in 2, calculi in 3, colonic anastomotic dehiscence in 1, bladder-patch fistula in 2, and secondary coloureteric-junction obstruction in 1. There was no postoperative reservoir perforation or mortality. The upper tract remained normal or stable in all patients. Nine of the 19 patients are dry both day and night 4 others are dry during the day but have occasional nocturnal wetting. Three patients have nocturnal wetting with stress incontinence and 2 remain incontinent. Seven patients can void effectively using abdominal contractions and 12 require clean intermittent catherization to ensure complete voiding. The indications and results of AC in BE from other series are reviewed. AC is an important and safe adjunctive procedure in a subset of BE patients with small and poorly compliant bladders. Despite the known complications, more liberal use of AC in BE is warranted. Author Affiliation: (1) Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India, IN Article note: Accepted: 21 March 2001

Byline: V. V. S. S. Chandrasekharam (1), M. Srinivas (1), C. S. Bal (2), A. K. Gupta (3), S. Agarwala (1), D. K. Mitra (1), V. Bhatnagar (1) Keywords: Keywords Hydronephrosis; Ureteropelvic junction obstruction; Renal function; Pyeloplasty Abstract: The functional outcome and factors influencing improvement after pyeloplasty for ureteropelvic junction (UPJ) obstruction are still debated. This retrospective study was aimed at evaluating the factors associated with functional improvement in symptomatic unilateral hydronephrosis (HDN). Patients (n=68) who underwent successful pyeloplasty for unilateral symptomatic UPJ obstruction without any other associated urological abnormality were included. Preoperative evaluation included a diuretic renogram (DR) to confirm obstruction and assess the split renal function (SRF). A follow-up DR was obtained 3months and 1, 2, and 5years postoperatively. An absolute increase in the differential function of the operated kidney by over 5% was considered significant such kidneys were classified as improved (group A) and the others as unimproved (group B). The difference between the preoperative and 3-month SRF was highly significant (P&lt 0.001). Significant (P&lt 0.01) improvement in SRF continued until 1year after pyeloplasty. Patients who presented with a mass had significantly greater improvement (P&lt 0.05) than those who presented with other clinical features. In group A, a significantly higher number of patients presented with a mass. It was also evident that patients aged less than 1year showed significantly greater (P&lt 0.01) improvement in SRF than older patients. Thus, in unilateral symptomatic HDN with impaired function, patients who present with a mass or those in whom pyeloplasty was performed before 1year of age showed significantly greater improvement. Author Affiliation: (1) Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India, IN (2) Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India, IN (3) Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India, IN Article note: Accepted: 19 December 2000

Byline: A. Alladi (1), S. Agarwala (1), A. K. Gupta (2), C. S. Bal (3), D. K. Mitra (1), V. Bhatnagar (1) Keywords: Key words Antenatal hydronephrosis; Pelviureteric junction obstruction; Postnatal outcome Abstract: Routine maternal ultrasonography (US) has revealed a very high incidence of fetal hydronephrosis (HDN), the postnatal outcome and management protocols of which are replete with controversies. Pelviureteric junction (PUJ) obstruction is the commonest postnatal diagnosis, and its management has no consensus to date. This study was carried out to define the postnatal outcome and natural history of fetal HDN and to identify the mode of management to be adopted to the best advantage. All patients were subjected to US 48h postnatally or at first presentation and isotope renography (DTPA) with nuclear glomerular filtration rate (GFR) was carried out at 3--4 weeks of age or at presentation. Micturating cystourethrography (MCU) and/or direct radionuclide cystography (DRCG) were done in cases with bilateral HDN, nonobstructive HDN, dilated ureter on US, and recurrent urinary tract infection. Patients were then grouped for surgical intervention or conservative follow-up. Investigations were repeated periodically. A total of 56 patients were registered for the study (78 renal units) with a mean follow-up period of 14.6 months 37 renal units were operated upon or scheduled for surgery and 67 had some organic pathology, of which PUJ obstruction was the commonest. Among patients with PUJ obstruction, indications for surgery included symptoms, a palpable mass, poor or deteriorating function, and a solitary functioning kidney. Patients operated upon showed improvement in function and/or drainage, while those followed conservatively remained stable or improved. Controversy still exists as to the optimal management of PUJ obstruction detected antenatally. While it is the commonest postnatal diagnosis, many other pathologies are now being encountered. In antenatally-diagnosed HDN, there is a good scope for conservative management provided rigid follow-up can be ensured, especially because a good recovery potential exists followed surgery whenever indicated. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India, IN (2) Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi-110029, India, IN (3) Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi-110029, India, IN Article note: Accepted: 11 January 2000

Byline: D. K. Gupta (1), M. Srinivas (1), S. Dave (1), S. Agarwala (1), M. Bajpai (1), D. K. Mitra (1) Keywords: Key words Teratoma; Stomach; Child Abstract: Gastric teratoma (GT) comprises less than 1% of all teratomas in children. Though GT in the presence of immature neuroepethelial elements is regarded as malignant, the prognosis is excellent after complete excision of the tumor. Because of its rarity the world literature lacks a large study. Clinical experience with ten cases of GT is presented and discussed. Only one patient was female the mean age at presentation was 3.2 months. Two cases were immature grade III GT one of these had infiltrated the left lobe of the liver and the transverse colon while the other had metastasized to the regional lymph nodes and omentum. All the patients underwent complete excision. There were no deaths, and after a mean follow-up period of 4.2 years, all the patients had no recurrence and were healthy. Both the mature and immature types of GT have an excellent prognosis after complete excision of the tumor. Even when the immature type infiltrates surrounding structures, complete excision offers recurrence-free survival without requiring chemo- or radiotherapy. Author Affiliation: (1) Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi -- 110029, India, IN Article note: Accepted: 8 November 1999

Byline: M. Srinivas (1), S. Agarwala (1), S. Datta Gupta (2), S. N. Das (3), C. Shaha (4), D. K. Mitra (1) Keywords: Key words Unilateral undescended testis; Rat; Testicular injury; DNA flowcytometry; Anti-sperm antibody Abstract: This study was designed to evaluate whether creation of a unilateral undescended testis (U/L UDT) in rats by direct fixation of the testis can lead to changes in the contralateral (C/L) descended testis, and if so, whether this inherent problem of the model could be eliminated by anchoring the divided gubernaculum to indirectly fix the testis. Thirty male newborn rats were divided into three groups of 10 each and the procedure done on the 2nd day of life to create U/L UDT according to the group allocated: group I: sham-operated group II: anchoring the gubernaculum after gubernaculectomy group III: Direct suture fixation of the testis. Fertility, C/L testicular weight (TW), Johnsen score, seminiferous tubular diameter (STD), DNA flowcytometry, and serum anti-sperm antibodies (ASA) were studied. Fertility, C/L TW, Johnsen score, STD, and haploid cell population were significantly reduced in group III compared to group II, while significantly higher titers of ASA were found in group III. Gubernaculectomy and anchoring the gubernaculum to the anterior abdominal wall is a better technique of creation of experimental UDT, as direct fixation of the testis is potentially detrimental to the C/L normal, descended testis. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India, IN (2) Department of Pathology, All India Institute of Medical Sciences, New Delhi, India, IN (3) Department of Biotechnology, All India Institute of Medical Sciences, New Delhi, India, IN (4) Sperm Biotechnology Laboratory, National Institute of Immunology, New Delhi, India, IN Article note: Accepted: 13 October 1998

Byline: R. Lal (1), V. Bhatnagar (1), S. Agarwala (1), V. P. Grover (1), D. K. Mitra (1) Keywords: Key words Posterior urethral valves; Micturition abnormalities; Bladder function; Urinary incontinence; Urodynamics Abstract: This study describes the urodynamic findings in 22 patients with posterior urethral valves and discusses their association with urinary incontinence, age, mode of primary treatment, renal function, and changes in the upper tracts. The patients' ages ranged from 3 to 26 years and 27% were either adolescents or older. The urodynamic findings were categorized into 5 main patterns, although mixed patterns were also observed (1) normal capacity and compliance with normal detrusor contractility (2/22 patients, 9.1%) (2) small-capacity, hypocompliant bladder (8/22 patients, 36.4%) (3) unstable bladder (2/22 patients, 9.1%) (4) large-capacity, hypotonic bladder with decreased detrusor contractility (2/22 patients, 9.1%) and (5) normal capacity and compliance but with decreased detrusor contractility (8/22 patients, 36.4%). More than one-half of the patients (57.1%) evacuated their bladders incompletely, and this seemed to be associated with post-treatment episodes of urinary-tract infection. The commonest symptom was daytime frequency, urgency, and leak with nocturnal enuresis, which urodynamically correlated with a small-capacity, hypocompliant or unstable bladder or to incomplete evacuation of the bladder, leading to significant post-void residue. Significant detrusor dysfunction was identified in 2 asymptomatic patients as well, emphasizing the need to perform a routine urodynamic work-up on all valve patients. Urodynamic properties seemed to be associated with age. Small, hypocompliant, and unstable bladders were almost always seen in prepubertal boys and in the first 5 years following undiversion, whereas large, hypotonic bladders with impaired contractility were seen in post-pubertal boys. While the current policy is to avoid high diversion, data in this study suggest that disorders of detrusor capacity, compliance, and contractility exist in children treated by primary valve ablation and vesicostomy and that abnormal detrusor dynamics seem to be a reflection of inherent developmental detrusor dysfunction consequent to congenital infravesical obstruction. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India, IN Article note: Accepted: 5 January 1999

Byline: V. Bhatnagar (1), R. Lal (1), S. Agarwala (1), D. K. Mitra (1) Keywords: Key words Urinary bladder; Bladder exstrophy; Bladder neck; Continence Abstract: A simple modification of an existing technique for bladder-neck reconstruction in exstrophy of the urinary bladder is reported. The technique involves tubularization of the posterior urethra up to just below the ureteric orifices. It differs from other techniques in that no part of the bladder tissue is used for buttressing the repair, but all is utilized for enhancing the bladder volume. Only 2 of 20 patients remained incontinent after bladder-neck reconstruction the remaining 18 have achieved socially acceptable continence. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India, IN Article note: Accepted: 17 June 1998

Byline: M. Srinivas (1), S. Agarwala (1), A. K. Padhy (2), A. K. Gupta (3), M. Bajpai (1), V. Bhatnagar (1), D. K. Gupta (1), D. K. Mitra (1) Keywords: Key words Renal function; Nephrectomy; Wilms' tumor; Microalbuminuria; Hyperfiltration injury Abstract: Solitary kidneys in renal donors and patients who have undergone unilateral nephrectomy for malignant disease have been reported to undergo hyperfiltration injury. This study was undertaken to evaluate the somatic growth and development of followed-up patient after Wilms' tumor to evaluate their renal function and identify any evidence of injury in the remaining kidney. The growth and development of all the children was found to be normal, as was DTPA clearance. Microalbuminuria in 24-h urinary collections was detected in 84% of the patients, indicating evidence of hyperfiltration injury. This study highlights the need for close monitoring of the renal function of long-term follow-up patients after Wilms' tumor in addition to the routine monitoring for tumor recurrence. Author Affiliation: (1) Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India, IN (2) Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India, IN (3) Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India, IN Article note: Accepted: 26 May 1998

Byline: M. Srinivas (1), S. Agarwala (1), S. Datta Gupta (2), S. N. Das (3), P. Jha (4), M. M. Misro (5), D. K. Mitra (1) Keywords: Key words Cyclosporine; Male fertility; DNA flowcytometry; Rats Abstract: The effect of cyclosporine (CsA) on fertility has assumed greater importance with the increasing numbers of pediatric transplantations being performed all over the world. Conflicting reports on the effects of CsA on sex hormones are available. This experimental animal study was designed to examine the effect of CsA on testicular weight, sperm counts, seminiferous tubular diameter (STD), testicular morphology, DNA flowcytometry, sex hormone levels, and fertility in male rats. Those rats who received CsA (20mg/kg per day) showed significant reductions in testicular weight (P&lt 0.05), sperm count (P&lt 0.01), Johnsen score (P&lt 0.05), STD (P&lt 0.01), serum testosterone levels (P&lt 0.05), haploid cell population (P&lt 0.001) in the testis, and fertility (P&lt 0.001) compared to those receiving CsA 10mg/kg per day and control rats. These findings will have an important bearing for children receiving cyclosporine for long periods to guide the physician in optimally adjusting long-term treatment. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India, IN (2) Department of Pathology, All India Institute of Medical Sciences, New Delhi, India, IN (3) Department of Biotechnology, All India Institute of Medical Sciences, New Delhi, India, IN (4) Department of Reproductive Biology, All India Institute of Medical Sciences, New Delhi, India, IN (5) National Institute of Health and Family Welfare, New Delhi, India, IN Article note: Accepted: 6 November 1997

Byline: M. Srinivas (1), S. Agarwala (1), S. Datta Gupta (2), S. N. Das (3), C. Shaha (4), D. K. Mitra (1) Keywords: Key words Fertility; Unilateral undescended testis; DNA flowcytometry; Anti-sperm antibodies; Rats Abstract: Continuing experimental work on the effect of experimentally created unilateral undescended testis (UL-UDT) in neonatal rats, this study examined the fertility and correlated it to contralateral (CL) testicular morphology, seminiferous tubular diameter (STD), DNA flowcytometry, and the presence of serum anti-sperm antibodies (ASA) at 120--135 days of age. In our previous reported work, the fertility of rats with UL-UDT at 65--80days of age was the same as that of controls. In the present study the rats with UL-UDT had significantly reduced fertility (P&lt 0.01) compared to controls, even though the Johnsen scores and mean STD of the CL testicular tissue were comparable. DNA flowcytometry demonstrated a significant decrease (P&lt 0.001) in haploid cell population in the CL testicular tissue of rats with UL-UDT. Furthermore, the rats with UL-UDT who either received an immunosuppressive or in whom the UDT was excised early showed almost normal fertility and DNA histograms like those of controls. Significantly high titres of serum ASA were detected only in the group with UL-UDT when tested at 135 days of age. From these results, in combination with earlier results on similar work, it may be inferred that UL-UDT causes immunologically-mediated, progressive damage to the CL descended testis, leading to a decrease in fertility in rats. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India, IN (2) Department of Pathology, All India Institute of Medical Sciences, New Delhi, India, IN (3) Department of Biotechnology, All India Institute of Medical Sciences, New Delhi, India, IN (4) Sperm Biotechnology Laboratory, National Institute of Immunology, New Delhi, India, IN Article note: Accepted: 14 October 1997

Byline: N. A. Bhat (1), S. Agarwala (1), S. Wadhwa (2), A. K. Gupta (3), V. Bhatnagar (1) Keywords: Keywords Thoracoabdominal intestinal duplication; Absent inferior vena cava; Azygos vein; APGastrointestinal bleeding; Diaphragmatic hernia Abstract: We report a rare case of thoracoabdominal intestinal duplication with absent inferior vena cava (IVC). The patient was initially explored with a mistaken diagnosis of diaphragmatic hernia on the basis of a chest radiograph and barium meal. However, a subsequent computed tomography scan revealed a mediastinal mass with an air--fluid level, a hugely dilated azygos vein, and an absent IVC. Thoracoabdominal exploration was required to excise the duplication cyst arising from the jejunum. We believe that this is the first report of this association. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi -- 110029, India, IN (2) Department of Anatomy, All India Institute of Medical Sciences, New Delhi -- 110029, India, IN (3) Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi -- 110029, India, IN Article note: Accepted: 27 October 2000

Byline: V. Bhatnagar (1), K. Das (1), S. Agarwala (1), D. K. Mitra (1) Keywords: KeywordsaOmphalocele; Gastroschisis; Abdominal-wall defects; Primary closure; Silo Abstract: aA simple technique of constructing a silo for the treatment of gastroschisis (GS) and omphalocele (OMP) is described. A polypropylene mesh covered on both sides with a sterile transparent adhesive film (incise drape) was used both these items are freely available in the operating room. The resultant silo is sterile, soft, flexible, sturdy, internally smooth, provides a reasonable barrier, and allows enough visibility of the bowel. This silo was used in the treatment of 25 cases of GS and 13 cases of OMP with acceptable results. Survival was better in patients in whom primary closure could be achieved in both OMP and GS. Silo treatment was associated with higher mortality from septic causes. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India, IN Article note: Accepted: 24 August 2000

Byline: V. Bhatnagar (1), S. Agarwala (1), R. Lal (1), D. K. Mitra (1) Keywords: Key words Posterior urethral valves; Endoscopic treatment; Nd:YAG laser Abstract: Endoscopic management is the accepted form of treatment for posterior urethral valves (PUV) . The Nd:YAG laser has been in clinical use for many decades, but has been used only sporadically for ablating PUV. In this study, PUV were diagnosed by micturating cystourethrogram (MCU). In the 9-month period beginning March 1997, 23 boys 3 months to 9 years of age underwent endoscopic Nd:YAG laser surgery for PUV using a 600 quartz bare fibre through the catheter channel of an 8.5F cystoscope. The laser power and total energy delivered ranged from 20 to 50W and 50--1085J, respectively. Type I PUV were present in 20 boys 1 had type III, and in 1 boy each there were residual valves and a urethral stricture from a previous electrocautery ablation. All operations were done with the patient under general anaesthesia supplemented by caudal morphine. Routine postoperative cystoscopy was done in the first 5 cases only. All patients had a good stream of urine without bleeding or any other complication after valve ablation. Mucosal tags seen on follow-up cystoscopy in 5 patients were fulgurated by laser. In 4 other patients recystoscopy was required for deterioration of the urinary stream and persistent posterior urethral dilatation on MCU residual valves were refulgurated by laser. An indwelling catheter was left in only 4 patients, 2 of whom were primarily operated and 2 following refulguration. All except the first 2 were treated as out-patients. Application of the Nd:YAG laser has added a new dimension for treating PUV. The initial experience has been very encouraging: the destruction of valves is precise, there are no complications, and it can be practised on a day-care basis without indwelling catheterisation. The bare fibre can be used repeatedly, thus reducing the cost of treatment. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India, IN Article note: Accepted: 26 April 1999

Byline: S. Agarwala (1), J. K. Goswami (1), D. K. Mitra (1) Keywords: Key words Pyloric atresia; Epidermolysis bullosa; Malrotation; High anorectal malformation Abstract: Pyloric atresia (PA) is an uncommon anomaly that may be associated with many other congenital anomalies, the commonest of which is junctional epidermolysis bullosa (JEB). Most of the cases of PA associated with JEB (Herlitz syndrome) reported have been fatal. A case of PA associated with JEB, malrotation, and a high anorectal malformation with a rectourethral fistula, which was hitherto undescribed, was successfully managed at our institution. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India, IN Article note: Accepted: 26 May 1998

Byline: S. Agarwala (1), S. Dave (1), A. K. Gupta (2), D. K. Mitra (1) Keywords: Key words Nasogastric tube; Duodeno-renal fistula; Iatrogenic Abstract: Major complications due to nasogastric tubes (NGT) are uncommon. Esophageal and duodenal perforations have been described. We describe a newborn in whom a NGT led to a duodenal perforation, causing duodeno-renal fistula. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India, IN (2) Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India, IN Article note: Accepted: 6 November 1997

Byline: V. Bhatnagar (1), S. Agarwala (1), D. K. Mitra (1) Keywords: Key words Hydrometrocolpos; Vaginal atresia; Neonate; Vaginostomy Abstract: The preferred treatment of neonatal hydrometrocolpos has been vaginal drainage onto the perineum. However, in some situations a temporary vaginostomy is required, for which an indwelling catheter is used. This report describes an operative procedure that avoids the use of any indwelling catheter and at the same time provides excellent drainage and an easy access for performing dye studies to outline the pathological anatomy of the condition. This procedure has been performed in two patients, found ready acceptance, and gave gratifying results. Author Affiliation: (1) Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India, IN Article note: Accepted: 8 October 1997