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The objective of this study is to compare the outcome of the children with vesical stones undergoing conventional open suprapubic cystolithotomy with those undergoing catheterless and drainless suprapubic cystolithotomy. The study included 176 children aged 1-15 years with bladder stones. It was a prospective study stretching over 14 years (1991-2003). In the initial years (1991-1994), 40 patients were used to put a urethral catheter for 5 days and retropubic drain for 48 h post-operatively, as has been recommended conventionally. From 1995 onwards we resorted to a catheterless-drainless (no suprapubic drain) suprapubic cystolithotomy in children with bladder stones. In all the patients, two-layered closure of bladder with absorbable sutures was done. The results of both protocols with regards to duration of hospitilisation and complications were compared. We observed that if the bladder is closed meticulously in two layers and complete haemostasis is achieved, bladder drainage by means of a catheter and drainage of retropubic space is not required. This approach allowed an early post-operative recovery without increasing the risks of complications. However, the catheterisation was required for patients with infected urine, recurrent stones and those operated earlier for ano-rectal malformations. The authors feel that for vesical stones, the catheterless-drainless suprapubic cystolithotomy in children is a safe procedure barring a few above-stated situations. The advantages of this procedure are a shorter hospital stay, early mobility and decreased morbidity.

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A 2-day-old male infant, born of a non-consanguineous marriage and uneventful pregnancy was found to have anomalies of vertebral, anal, cardiac, tracheo-esophageal, radial and limb (VACTERL) association. The striking feature was the simultaneous occurrence of two rare limb defects of right upper and lower limb in the baby who also had imperforate anus and ventricular septal defect. These limb defects were-meromelia of the right upper limb (due to transverse deficiency of right humerus and absence of all the bony elements distally), and a short right lower limb due to co-existence of proximal femoral hypoplasia and fibular hemimelia. We could not trace the co-existence of these rare skeletal defects in any case with VACTERL association in the existing English literature, as was observed by us. The simultaneous occurrence of the defects involving distant anatomic sites supports the hypothesis of 'axial mesodermal dysplasia' in our patient, rather than 'caudal regression syndrome', as is popularly held in patients with anorectal malformation (ARM). Further, it points to occurrence of an early embryonic insult, probably taking place at blastogenic stage, when the developing embryo can be considered a polytopic development field. However, in absence of antenatal history suggestive of exposure to a known teratogen and a chromosomal analysis, it appears that the spectrum of anomalies in this neonate might have resulted secondary to early amniotic leak and temporary oligohydramnios.

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A method to achieve distal fistula occlusion by inflating the balloon of a catheter placed at the gastroesophageal junction via a transgastric route was tried in seven consecutive neonates with esophageal atresia and wide distal fistula. Due to associated moderate or severe pneumonia, these infants were at poor anesthetic risk for the definitive repair. The procedure was done under local anesthesia with mild sedation and took an average of half an hour for completion. Another feeding tube was negotiated through another gastrotomy across the pylorus to allow early enteral feeds. Temporary transgastric fistula occlusion (TTFO) allowed better ventilation of the hypocompliant lungs (by increasing resistance at the fistulous end), prevented lung injury due to aspiration of the refluxing gastric juices, and facilitated optimal ventilation by preventing epigastric distension. All study subjects survived this procedure except for one of our earlier study subjects who died of massive pneumothorax that was a procedure-related complication. None of the remaining subjects required mechanical ventilation either after TTFO or after the definitive esophageal repair that was carried out 5-7 days subsequent to TTFO, except for one other neonate with right lung aplasia who began deteriorating 48 h after thoracotomy and died of cardiac failure. There were no anastomosis-related problems among the survivors over a 12-month follow-up. The gratifying results of our study prompt us to suggest that this procedure deserves attention, and its role should be explored for salvaging neonates with type C esophageal atresia with wide fistula and pneumonia in developing countries with few neonatal intensive care services.

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