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Accessory scrotum is defined as extra scrotal tissue in the vicinity of the anatomically located normal scrotum. We report a case of 4-day full-term male neonate with a unilateral accessory scrotum. We have discussed clinical presentations and associated anomalies of an accessory scrotum thus guiding its evaluation and treatment.

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BACKGROUND: Hirschsprung disease is a notable cause of neonatal intestinal obstruction and constipation in older children. Transanal endorectal pull through (TEPT) is a newer technique of definitive management as against staged procedures. The aim of our study is to evaluate the feasibility and outcome of the procedure in selected children with Hirschsprung disease managed by this technique with review of the literature. MATERIALS AND METHODS: Medical records of 12 children who underwent single-stage TEPT in a tertiary care centre over a period of 3 years from 2015 to 2018 were reviewed and retrospectively analysed on the basis of age, investigations, intraoperative parameters, complications, functional outcome and hospital stay. RESULTS: The median age at surgery was 9 months. Nine patients were boys. The median weight of patients was 7.5 kg. The transition zone was observed at the level of the rectosigmoid in eight patients (66.6%) and sigmoid colon in four patients (33.3%). The mean length of muscle cuff was 3 cm, the mean length of resected bowel was 25 cm, the median operative time was 105 min and the mean hospital stay was 8 days. Perianal excoriation (n = 2) and enterocolitis (n = 1) were complications encountered postoperatively; however, no patient had cuff abscess, anastomotic leak or stricture. Stool frequency initially at 2 weeks was average of six to ten times a day, which gradually reduced to two to three times a day by 3 months postoperatively. None of the patients had faecal soiling or constipation on follow-up. CONCLUSION: Single-stage transanal endorectal pull through is an effective technique in the management of Hirschsprung disease with minimal complications.

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BACKGROUND: This prospective comparative study aims to assess the efficacy of fibrin sealant to improve outcomes in paediatric patients operated for hypospadias. MATERIALS AND METHODS: Forty consecutive patients with hypospadias were randomised into two groups of twenty patients each. The first group underwent hypospadias repair, technique depending on the type of hypospadias, whereas in the second group, fibrin sealant was used to reinforce the urethroplasty. Assessment was done with respect to the type of hypospadias, type of repair done, operative time, immediate post-operative complications (early ooze and skin flap-related complications), intermediate complications (urethra-cutaneous fistula) and delayed post-operative complications (penile torsion and poor cosmetic outcome) at follow-up. We also compared the overall improvement in outcome among the two groups. RESULTS: First Group: The mean operative time was 1 h and 45 min. Complications were seen in nine patients: Early ooze (n = 2); skin flap-related complications (n = 3); fistula (n = 7); poor cosmetic outcome (n = 7) and penile torsion (n = 4). Second Group (Fibrin Sealant): The mean operative time was 1 h and 30 min. Post-operative complications were observed in five patients: Coronal fistula (n = 3) and poor cosmetic outcome (n = 3). On comparing, the differences in outcomes of ooze, skin flap-related complications and torsion were found to be statistically significant with P < 0.05. The differences in the urethra-cutaneous fistula and cosmetic appearance were not found to be statistically significant. The difference in overall improvement in complications was found to be statistically significant. CONCLUSION: Fibrin sealant, when applied over the urethroplasty suture line as a waterproof cover, may help to improve the outcome in patients with hypospadias.

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BACKGROUND: Intussusception is a common cause of obstruction in paediatric patients. Rapid clinical recognition and treatment is important to prevent potentially fatal complications. The present study aims to derive a clinical scoring system for prediction of risk of operative intervention in patients with intussusception. MATERIALS AND METHODS: Data of 100 patients with intussusception were analyzed retrospectively, and a score was calculated based on clinical parameters - age, presence/absence of symptoms and signs such as abdominal distention, vomiting, lump abdomen, red currant jelly stools and duration of abdominal pain. The maximum score was 12, and the minimum score was 6. This score was then applied to other 50 consecutive patients with intussusception. RESULTS: Of 100, 13 patients required operative intervention; 87 patients were managed by hydrostatic reduction. In all, four patients with a score of 12 and five patients with a score of 11 required operative intervention. Seven patients had a score of 10, out of which four (57.14%) required operative intervention. A total of 87 patients who had a score of 10 or less were successfully managed non-operatively by ultrasound-guided hydrostatic reduction. In the next 50 patients, two patients with a score of 9 and all patients with scores of 10 and 11 required operative intervention. Thus, age less than 3 months and more than 2 years, presence of symptoms such as abdominal lump, red currant jelly stools and duration of abdominal pain of 2 or more days were strong predictors of operative intervention. CONCLUSION: This clinical score helps to predict the risk of operative intervention required in a child with a diagnosis of intussusceptions - duration of abdominal pain of 48 h or more, presence of abdominal distention and lump and red currant jelly stools are strong predictors of need of operative intervention in patients with intussusception. Higher the score (8 or more, as concluded by this study), more the probability of requiring operative intervention in these patients. Though limited, this study could serve as a pilot work to develop a user-friendly score for early surgical decision making in the management of paediatric intussusception.

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True phimosis is overdiagnosed due to the failure to distinguish it from physiological phimosis, which is a normal developmental non retractability of the foreskin. The non-retractile prepuce in children is a cause of parental anxiety and concern. This leads to the majority of the children undergoing surgical procedures. Pathological phimosis needs to be differentiated from physiologic phimosis to avoid unnecessary circumcision. In recent years, topical steroid application use in cases of non-retractile prepuce has shown a good success rate and is well accepted by the parents. It has low risks, is cost effective and avoids anaesthetic and surgical complications. This is an observational study of 100 children with non-retractile foreskin who were managed by local application of topical steroid cream (0.1% Mometasone) over a period of 6 weeks. The non-retractibility was classified according to Kikiro's classification. These patients were analyzed on the basis of age at presentation, complaints at the first presentation, grade of phimosis at first presentation (as per Kikiro's classification), results of the topical steroid application as assessed at 6 weeks after starting application and after stopping of the steroid administered for 6 weeks. The results were analyzed on the basis of the resolution of symptoms and the decrease in Kikiro's grade. Those patients in whom there was no response to treatment or who developed recurrence after stopping steroid treatment underwent circumcision. A total of 19 patients required surgical intervention in the form of circumcision. The use of topical steroids yields satisfactory results in patients with a non-retractile prepuce. It could be a first-line treatment for management in such cases and is an effective alternative designed to avoid unnecessary circumcision.

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Colorectal carcinoma is a well-known malignancy in adults. However, it is rare in children. Besides, it also has different behaviour in paediatric age-group and usually presents with non-specific symptoms like abdominal pain, weight loss, and anaemia. This usually leads to delay in diagnosis. Adenocarcinoma in children has unfavourable tumour histology (mucinous subtype) and advanced disease stage at presentation which lead to poorer prognosis in children. Family history, genetic typing and sibling screening are essential components of management as this malignancy is frequently seen associated with hereditary syndromes. We describe a case of unusual presentation of rectal carcinoma in a 12-year-old girl.

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Gastrointestinal duplications are rare developmental anomalies that may occur at any level from the oral cavity to the rectum, with the ileum being the most common site. Gastric duplications are rare gastrointestinal duplications. Various theories have been proposed for the development of duplication cysts; however, there is no single theory that explains all types of duplications. Complete removal is the treatment of choice to avoid the risk of possible complications and malignant transformation. Most cases present within the first year of life. The clinical presentation of gastric duplications can be highly variable; however, they usually present with abdominal pain and a lump. Clinical presentation with hemoptysis is rare. Only one such case has been reported previously. We describe a three-year-old male with gastric duplication who presented with hemoptysis.

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OBJECTIVE: Ureteroceles are a great clinical challenge because of variations in anatomy and clinical presentations. We present our experience with primary transurethral incision of ureteroceles in children. MATERIAL AND METHODS: Data of thirteen children managed for ureterocele from 2009 to 2016 was retrospectively analyzed with respect to age, sex, clinical presentation and symptomatology, type and localization of ureterocele, investigations, surgical management and follow-up. RESULTS: A total of 13 patients with ureteroceles were managed. There were 7 males and 6 females. Six were neonates with antenatal diagnosis of ureteroceles. Five patients presented with urinary tract infection and two were diagnosed during ultrasound for abdominal pain. The ureteroceles were on the right side in 7 patients and left in 6 patients. Six patients had a duplex system-five on right side and bilateral in one. Two patients had ureteroceles in solitary kidney. Four patients had associated hydronephrosis and hydroureter and two had only hydronephrosis alone. One patient had bilateral grade III reflux in the bilateral lower moieties of the patient with bilateral duplex system. Two patients had poorly functioning kidney on radionuclide scan. All patients underwent cystoscopic incision of the ureteroceles. Eleven had intravesical ureteroceles and two had large caeco-ureteroceles. Two patients required ureteric reimplantation during follow-up. CONCLUSION: Though the approach of managing a patient with ureterocele should be individualized, transurethral incision remains valuable as a primary intervention with regular follow up. It may even prove to be the only intervention required in most of the patients.

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INTRODUCTION: Liver abscess is common in pediatric population in India. Children have unique set of predisposing factors and clinical features. Liver abscesses are infectious, space-occupying lesions in the liver; the two most common abscesses being pyogenic and amebic. Its severity depends on the source of the infection and the underlying condition of the patient. MATERIALS AND METHODS: A total of 34 patients less than 12 years were assessed in a retrospective study from January 2012 to 2016. Patients were assessed in terms of age of presentation, etiology, bacteriology, diagnosis, and modality of treatment. RESULTS: The mean age of presentation was 6.3 years. Average volume of abscess was 164 cc. Nine patients (26.4%) underwent percutaneous needle aspiration under ultrasound guidance with wide bore needle (18 G disposable needle). Three patients required more than two sittings of aspiration. Patients with volume more than 80 cc were treated with catheter drainage. Twenty patients (58.8%) underwent ultrasound-guided percutaneous catheter drainage. Two patients required catheter drainage for large abscess and needle aspiration for the smaller abscess. CONCLUSION: Antimicrobial therapy along with percutaneous drainage constitutes the mainstay of treatment, whereas open surgical drainage should be reserved for selected cases.How to cite this article: Waghmare M, Shah H, Tiwari C, Khedkar K, Gandhi S. Management of Liver Abscess in Children: Our Experience. Euroasian J Hepato-Gastroenterol 2017;7(1):23-26.

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Posttraumatic major bile leak in children is uncommon, with few cases reported in the literature. These injuries are seen in high-grade liver trauma and are difficult to diagnose and manage. We describe a 7-year-old boy with grade IV hepatic trauma and bile leak following blunt abdominal trauma. The leak was successfully managed by percutaneous drainage and endoscopic retrograde cholangiopancreatography (ERCP) stenting of the injured hepatic duct. How to cite this article: Tiwari C, Shah H, Waghmare M, Khedkar K, Dwivedi P. Management of Traumatic Liver and Bile Duct Laceration. Euroasian J Hepato-Gastroenterol 2017;7(2):188-190.

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Duodenal injury following blunt abdominal trauma in children is extremely rare. It commonly has a delayed presentation, thus leading to increased mortality and morbidity. We report two cases of isolated duodenal injury following blunt abdominal trauma in children.

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A female neonate with two openings in the introitus and an absent anal opening at the anal site presents a diagnostic challenge. Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome associated with rectovestibular fistula, though rare, should be kept in mind as a differential diagnosis of this presentation. We present such a case in a one-year-old female child with MRKH syndrome and rectovestibular fistula.

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Type I intestinal atresias (webs) are rare causes of gastrointestinal obstruction in infants, the most common site being the second portion of the duodenum. According to the Louw and Barnard classification, type 1 atresia has been defined as an intra-luminal web which results in either complete (web with no perforation) or incomplete (web with central perforation) intestinal obstruction. The jejunum is a rare site of such webs. Diagnosis of an incompletely obstructing web due to central perforation is usually difficult and challenging. We present two cases of jejunal web with a central perforation in which the presentation was delayed. Both were managed by excision of the web.

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A vestibular fistula with a normal anus is a rare subtype of anorectal malformation seen more often in East Asia and India. Though mostly congenital, some authors have suggested acquired etiologies for this condition. Infants with retroviral infection have been reported to develop acquired rectovestibular fistulas. We report a case of an infant anovestibular fistula in a patient with retroviral infection.

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Yolk sac tumours are rare ovarian malignancies accounting for less than 1% of malignant ovarian germ cell tumours. They are mostly seen in adolescents and young women and are usually unilateral making fertility preservation imperative. Raised alpha-feto protein level is the hallmark of this tumour. We describe stage III yolk sac tumour in a girl child.

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PURPOSE: Abdominal cysts of gastrointestinal origin are rare. Their rarity and varied clinical presentations make their pre-operative diagnosis difficult. METHODS: Fourteen patients with histological diagnosis of cysts of gastrointestinal origin admitted between 2009 and 2015 were retrospectively analyzed with respect to age, sex, clinical presentation, diagnostic modality, site and type of cyst, management, outcome and follow-up. RESULTS: The mean age at presentation was 4 years and there were six males and eight females. Abdominal pain was the most common presenting symptom. Five patients had an acute presentation-three had distal ileal mesenteric cysts and two had ileal duplication cyst sharing a common wall with ileum. Six patients presented with chronic abdominal pain and lump-three patients had omental cysts and three had mesenteric cysts-two of these in distal ileum and one in sigmoid colon. Two patients presented with antenatally diagnosed palpable abdominal lump. One had a mesenteric cyst of the ileum and the other had a distal ileal duplication cyst which required excision with resection and anastomosis. One patient had an atypical presentation. He was a known case of sickle cell trait and had presented with vague abdominal pain, recurrent cough and multiple episodes of haemoptysis over a period of one year. At laparotomy, gastric duplication cyst was found which was excised completely. Histopathology confirmed the diagnosis. CONCLUSION: Cysts of gastrointestinal origin are rare and have varied presentation. Surgical excision is the mainstay of treatment. The results and prognosis are good.

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Vaginal cysts are rare, particularly in the newborn. They usually present as one of these three entities in the newborn: paraurethral cysts (Skene duct cysts), Gartner duct cysts (mesonephric ductal remnants) or a covered ectopic ureter. Abdominal ultrasound should always be included in the clinical evaluation in search of renal anomalies. We report two cases of Gartner cysts in neonates.

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