Background:Diagnosis of duodenal perforation (DP) in children is often delayed. This worsens the clinical condition and complicates simple closure.Objectives:To explore the advantages of using T-tube in surgeries for DP in children.Patients and Methods:A retrospective study was conducted on all patients of DP managed in the Department of Paediatric surgery at a tertiary centre from January 2016 to December 2020. Clinical, operative and post-operative data were collected. Patients, with closure over a T-tube to ensure tension-free healing, were critically analysed.Results:A total of nine DP patients with ages ranging from 2 years to 9 years were managed. Five (55.6%) patients had blunt abdominal trauma; a 2-year-old male had perforation following accidental ingestion of lollypop-stick while a 3-year-old male had DP during endoscopic evaluation (iatrogenic) of bleeding duodenal ulcers; cause could not be found in other 2 (22.2%) patients. Of the five patients with blunt abdominal trauma, 4 (80%) had large perforation with oedematous bowel, necessitating repair over T-tube. Both patients with unknown causes had uneventful outcomes following primary repair with Graham's patch. Patients with lollypop-stick ingestion and iatrogenic perforation did well with repair over T-tube. The only trauma patient with primary repair leaked but subsequently had successful repair over a T-tube. One patient with complete transection of the third part of the duodenum and pancreatic injury who had repair over T-tube died due to secondary haemorrhage on the 10th post-operative day.Conclusion:Closure over a T-tube in DP, presenting late with oedematous bowel, ensures low pressure at the perforation site, forms a controlled fistula and promotes healing, thereby lessening post-operative complications.

Introduction Childhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality. Methods Prospective cohort study in 109 institutions in 41 countries. Inclusion criteria: children <18 years who were newly diagnosed with or undergoing active treatment for acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, retinoblastoma, Wilms tumour, glioma, osteosarcoma, Ewing sarcoma, rhabdomyosarcoma, medulloblastoma and neuroblastoma. Of 2327 cases, 2118 patients were included in the study. The primary outcome measure was all-cause mortality at 30 days, 90 days and 12 months. Results All-cause mortality was 3.4% (n=71/2084) at 30-day follow-up, 5.7% (n=113/1969) at 90-day follow-up and 13.0% (n=206/1581) at 12-month follow-up. The median time from diagnosis to multidisciplinary team (MDT) plan was longest in low-income countries (7 days, IQR 3-11). Multivariable analysis revealed several factors associated with 12-month mortality, including low-income (OR 6.99 (95% CI 2.49 to 19.68); p<0.001), lower middle income (OR 3.32 (95% CI 1.96 to 5.61); p<0.001) and upper middle income (OR 3.49 (95% CI 2.02 to 6.03); p<0.001) country status and chemotherapy (OR 0.55 (95% CI 0.36 to 0.86); p=0.008) and immunotherapy (OR 0.27 (95% CI 0.08 to 0.91); p=0.035) within 30 days from MDT plan. Multivariable analysis revealed laboratory-confirmed SARS-CoV-2 infection (OR 5.33 (95% CI 1.19 to 23.84); p=0.029) was associated with 30-day mortality. Conclusions Children with cancer are more likely to die within 30 days if infected with SARS-CoV-2. However, timely treatment reduced odds of death. This report provides crucial information to balance the benefits of providing anticancer therapy against the risks of SARS-CoV-2 infection in children with cancer.

Background: An association between rotavirus vaccination and intussusception has been documented in post-licensure studies in some countries. We evaluated the risk of intussusception associated with monovalent rotavirus vaccine (Rotavac) administered at 6, 10 and 14 weeks of age in India. Methods: Active prospective surveillance for intussusception was conducted at 22 hospitals across 16 states from April 2016 through September 2017. Data on demography, clinical features and vaccination were documented. Age-adjusted relative incidence for 1-7, 8-21, and 1-21 days after rotavirus vaccination in children aged 28-364 days at intussusception onset was estimated using the self-controlled caseseries (SCCS) method. Only Brighton Collaboration level 1 cases were included. Results: Out of 670 children aged 2-23 months with intussusception, 311 (46.4%) children were aged 28-364 days with confirmed vaccination status. Out of these, 52 intussusception cases with confirmed receipt of RVV were included in the SCCS analysis. No intussusception case was observed within 21 days of dose 1. Only one case occurred during 8-21 days after the dose 2. Post-dose 3, two cases in 1-7 days and 7 cases during 8-21 days period were observed. There was no increased risk of intussusception during 1-7 days after the doses 1 and 2 (zero cases observed) or dose 3 (relative incidence [RI], 1.71 [95% confidence interval {CI} 0.0-5.11]). Similarly, no increased risk during 8-21 days after the dose 1 (zero cases observed), dose 2 (RI, 0.71 [95% CI, 0.0-3.28]) or dose 3 (RI, 2.52 [95% CI, 0.78-5.61]). The results were similar for 1-21 day periods after the doses separately or pooled. Conclusions: The risk of intussusception during the first 21 days after any dose of rotavirus vaccine (Rotavac) was not higher among the Indian infants than the background risk, based on limited SCCS analysis of 52 children. (C) 2020 The Author(s). Published by Elsevier Ltd.

Introduction: Any surgical procedure which would restore the bilio-enteric continuity after excision of the choledochal cyst with minimal complications would be a feasible alternative to Hepaticojejunostomy using a Roux loop of jejunum. To determine the outcomes of Hepaticoduodenostomy done over T-Tube against Roux-en-Y Hepaticojejunostomy for bilio-enteric reconstruction after excision of choledochal cyst. Materials and Methods: This study was retrospectively done on all patients of choledochal cysts (Types 1 and 4) operated between January, 2014 and December, 2019. The clinical details, intra-operative and post-operative results of patients who underwent Roux-en-Y Hepatico-Jejunostomy (Group-1) and Hepatico-duodenostomy over T-Tube (Group -2) for establishing bilio-enteric continuity after excision of choledochal cyst were compared and analyzed statistically. Results: 78 patients of choledochal cysts were operated during this period with 31 patients in Group-1 and 47 in Group-2; there was no difference in the mean age or size of the cysts in the two groups; Type 1 cysts were the most common with female preponderance in both groups. Group-2 patients had lesser intra-operative time andfewer numbers of sutures were used during surgery. There was no difference in the incidence of anastomotic leaks, strictures, cholangitis or adhesive obstruction and reoperation rates between the two groups. Group 2 showed increased nasogastric bilious aspirates in 19.15% of cases which improved on conservative management. Conclusion: Bilio-enteric reconstruction using Hepaticoduodenostomy over T-Tube is a simpler, lower pressure and less time taking anastomotic technique with comparable complication rates when compared to Roux-en-Y Hepaticojejunostomy in the management of choledochal cysts.

Objectives The study aimed to document the association between intussusception in Indian children and meteorological parameters and examine regional variations. Design A bidirectional (retrospective and prospective) surveillance between July 2010 and September 2017. Setting At 20 hospitals in India, retrospective case record review during July 2010 and March 2016 and prospective surveillance during April 2016 and September 2017 were performed. Participants 2161 children aged 2–24 months with first intussusception episode were included. Interventions The monthly mean meteorological parameters (temperature, sunshine, rainfall, humidity and wind speed) for the study sites were collected. Methods The association between monthly intussusception cases and meteorological parameters was examined at pooled, regional and site levels using Pearson ( r ) and Spearman’s rank-order ( ρ ) correlation, factorial analysis of variance, and Poisson regression or negative binomial regression analyses. Results The intussusception cases were highest in summer and lowest in autumn seasons. Pearson correlation analysis showed that temperature ( r =0.056; p<0.05), wind speed ( r =0.134; p<0.01) and humidity ( r =0.075; p<0.01) were associated with monthly intussusception cases. Spearman’s rank-order correlation analysis found that temperature ( ρ =0.049; p<0.05), wind speed ( ρ =0.096; p<0.01) and sunshine ( ρ =0.051; p<0.05) were associated with monthly intussusception cases. Poisson regression analysis resulted that monthly intussusception case was associated with rising temperature (North region, p<0.01 and East region, p<0.05), sunshine (North region, p<0.01), humidity (East region, p<0.01) and wind speed (East region, p<0.01). Factorial analysis of variance revealed a significant seasonal difference in intussusception cases for pooled level (p<0.05), 2–6 months age group (p<0.05) and North region (p<0.01). Significant differences in intussusception cases between summer and autumn seasons were observed for pooled (p<0.01), children aged 2–6 months (p<0.05) and 7–12 months (p<0.05). Conclusions Significant correlations between intussusception cases and temperature, humidity, and wind speed were observed at pooled and regional level in India. A peak in summer months was noted, which may be used for prediction, early detection and referral for appropriate management of intussusception.

Pulmonary sequestrations (PSs) are rare anatomical aberrations of pulmonary development. We describe an unusual case of intradiaphragmatic extralobar PSs associated with eventration of the diaphragm on the left side. This association complicated the clinical presentation and intraoperative management of the patient.

Background: Duplications of the alimentary tract are known for their embryonic, anatomical, clinical, and pathologic variations. Summarizing the features of these lesions would reveal these characteristics and guide appropriate management. The objectives of this study are to describe the clinical features and characteristics of all cases of duplication of alimentary tract managed at a tertiary center.Materials and Methods: A retrospective study on all cases of duplications of the alimentary tract managed at a tertiary center from July 2015 to June 2020 (5 years) was conducted after approval from the Institutional Ethics Committee. Data regarding history, demographic details, symptoms, clinical features and investigation results, and intraoperative and histopathologic findings were collected from the hospital records and analyzed.Results: Twenty-eight cases of duplication were managed during this period. They had different locations (esophageal-5 [cervical-2 and thoracic-3], gastric-1, jejunal-3, ileal – 11, cecal-3, appendicular-2, colorectal-1, rectal-1, and posterior anal canal-1) and site-specific symptoms but definite histopathology with evidence of adjacent gastrointestinal tissue on microscopic examination. Unique cases included cervical esophageal duplication, bleeding ileal duplication (ID) with heterotopic mucosa, ID with bezoar, jejunal duplication with malrotation, appendicular duplication with type 2 pouch colon and anorectal malformation, rectal duplication, and posterior anal duplication. Case-specific management ensured minimal complication without any mortality.Conclusion: Variable location and site-specific symptoms necessitate individualized case-specific management of duplication anomalies. Histopathology confirms both native and heterotopic gastrointestinal tissues and is indispensable for the diagnosis.

The Journal is the primary organ of Continuing Paediatric Medical Education in Sri Lanka. The journal also has a website. Free full text access is available for all readers.The Sri Lanka Journal of Child Health is now indexed in SciVerse Scopus (Source Record ID 19900193609), Index Medicus for South-East Asia Region (IMSEAR), CABI (Centre for Agriculture and Bioscience International Global Health Database), DOAJ and is available in Google, as well as Google Scholar.The policies of the journal are modelled on the Committee on Publication Ethics (COPE) Guidelines on Principles of Transparency and Best Practice in Scholarly Publishing. Sri Lanka Journal of Child Health is recognised by the International Committee of Medical Journal Editors (ICMJE) as a publication following the ICMJE Recommendations.

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.

Esophageal atresia (EA) with tracheoesophageal fistula (TEF) is one of the common neonatal surgical emergencies presenting with excessive salivation, and inability to swallow or pass a firm cathether into the stomach. The present report describes an unusual case of EA-TEF with a long upper esophageal pouch that overlaps the lower esophageal pouch reaching just above the dome of diaphragm. The lower pouch fistula was present at the usual site (Kluth type IIIb6). The redundant upper pouch was excised and TEF was ligated and divided, and an end-to-end esophageal anastomosis was performed. In the post-operative period baby developed sepsis and could not be revived. However, the case was described due to rarity of presentation.

Introduction: Anorectal malformation [ARM] can be treated either by staged procedures or by a single stage procedure. In the present study we have performed single stage surgery of ARM in male neonates. Materials and Methods: Retrospective review of cases of ARM operated over 4 years at Indira Gandhi Institute of Medical Sciences, Patna, and Bihar from January 2015 to December 2018 were undertaken. In this study we have compared the results of single stage repair of Anorectal malformation with that of staged procedures performed earlier. Fifty four patients of Anorectal malformation were operated by single stage procedure (category 1) this was compared with staged procedures (category 2). Forty three patients underwent primary PSARP (posterior sagittal anorectoplasty) and the remaining 11 primary APP (abdomino-perineal pull through) procedure. The result of these single stage procedures were compared with that of staged procedures (category 2) in which a total of 39 cases were operated from 2012 to 2014. Result: Mean post-operative hospital stay in category 1 was 11 days and 32 days in category 2. In category 1, 20 patients were analysed. In which PSARP procedure was done in 15 and in 5 patients APP procedure was performed. The Rest of the patients are in follow up. Kelly score was good to fair in 17 patients (85%) and poor in 3 (15%) patients. In category 2 it was good to fair in 28 (71.7%) cases and poor in 11 cases (28%). Conclusion: Single stage surgical repair of anorectal malformation in male neonates is reliable and can be safely performed. Early results are encouraging; however, a long term follow-up is required to get any definite conclusion.

Malrotation with midgut volvulus often results in gangrene of midgut with relative sparing of duodenum. An extremely unusual case of Malrotation with isolated necrosis of distal duodenum is described with brief review of literature. Isolated duodenal necrosis in association with malrotation is very rare; it increases the complexity of surgery and prolongs hospital stay.

Background: Any criteria (clinical, pathologic, microbiological or histo-pathologic) attributing a case of Paediatric gastrointestinal perforation to Typhoid would be of help in reaching a proper diagnosis to guide appropriate management. Aims and Objectives: To review all cases of Typhoid perforation for their clinical, pathologic and intra-operative findings. Materials and Methods: A retrospective study was conducted on all cases of typhoid perforation (gastrointestinal perforation with positive Widal test) operated at a tertiary care centre from September 2015 to September 2018. Data regarding their clinical findings, investigation results, intraoperative findings, nature of the surgical intervention, postoperative results and histopathological findings were collected from their records and analysed. Results: A total of 13 patients were operated during this period with positive Widal’s test at presentation. 6/13 had single ileal perforation; two patients had multiple ileal perforations; perforation at atypical sites were found in four patients (one each at gastric, duodenal, caecal and rectal); one patient presented with Meckel’s band obstruction with multiple ulcers – this patient was sick and died despite a diverting ileostomy in the postoperative period. While 8/13 patients had primary closure of the perforation site, diversion through ileostomy was performed in five patients. All patients did well in the post-operative period except one patient of multiple ulcers and obstructing Meckel’s band who died in the post-operative period. Conclusion: On encountering a gastrointestinal perforation, no definite symptomatology or its pattern, no clinical examination findings, no intraoperative characteristics of the perforation and no biopsy can definitively point towards Typhoid as the cause. Therefore, we still have to depend on serological tests in correlation with clinical features to reach a conclusive diagnosis. Cultures and PCR, although sensitive are either time-taking or expensive to guide management. Typhoid perforation can have vivid and atypical presentation depending on the number and site of perforation.

Background: Large wounds following surgery for neural tube defects are difficult to close; physical wound characteristics such as position and dimension would serve as a guide for their surgical closure. Aim: To study how wound dimension determines the choice between primary and rhomboid flap closure of skin defects following surgery for neural tube defects. Materials And Methods: A retrospective study was carried out on cases of neural tube defects operated in the department of paediatric surgery at a tertiary center for 3 years from January 2015 to December 2017. Data regarding clinical features, location, wound dimensions following surgery, any bony deformity, method of closure used, distance of wound from anus, and postoperative complications were collected and analyzed. Results: A total of 114 cases were operated during this period; 86/114 had primary closure, whereas 28/114 needed rhomboid flap for tension-free cover. Primarily closed wounds had a biphasic distribution of (long axis)/(short axis) ratio (with values either >1.65 or <0.63), whereas those covered by rhomboid flaps had a mean ratio of 1.25 (range, 0.71–1.45). All six cases with bony deformity needed rhomboid flaps. Although all lipomeningomyelocele defects could be primarily closed, all rachischisis needed flap cover. Infected lesions had a mean wound distance of 5.3cm from posterior anal margin. Conclusion: Defect’s position, its size and shape, and any bony deformity determine the choice of closure of postoperative wound. The versatile, safe, and universal rhomboid flap is an aesthetic solution to the large skin defects in patients of neural tube defects.

Background : Anorectal malformations [ARM] are common neonatal surgical emergencies. They can be treated either by staged procedure or by single-stage procedure. In the present study, we have performed single-stage surgery of ARM in both male and female. Materials and Method: Retrospective review of cases of ARM operated over 3 years in the Department of Paediatric surgery at a tertiary care centre from January 2015 to December 2018 was done. In this study, we compared the results of single stage repair of Anorectal malformation (category1) with that of staged procedure performed earlier (category 2).In male babies 43 patients were operated by primary PSARP (posterior sagittal anorectoplasty) and remaining 11 by primary APP (abdomino-perineal pull through) procedure. Out of 65 female patients, PSARP was performed in 39 (60%) cases of recto vestibular fistula, ASARP in 23 (29.2%), Primary Abdomino-perineal pull-through in 4 (6.1%) cases of common cloaca. The result of this procedure was compared with that of staged procedure. (Category 2) Result : Mean post- operative hospital stay in category 1 was 11 days and 32 days in category 2. Mean duration of surgery in category 1 was 1hour and 15 minutes and 3 and half hours in category 2 that included initial colostomy, PASRP or APP and colostomy closure. In category 1, 41 (75.9%) cases had stool frequency 3- 5 per day while in category 2, 20 (51%) patients had the same frequency at the age of three years which was found to be statistically significant (P value? 0.001). Similar findings were observed in female patients. Conclusion : Single-stage surgical repair of Anorectal malformation in both male and female patient are reliable and can be safely performed with advancement of surgical expertise and better anaesthetic support with few exceptions. Early results are encouraging. However, long term study is required for its justification.

Introduction: Several studies have addressed the unique management challenges in poorly functioning kidneys of patients with ureteropelvic junction obstruction. Trial with percutaneous drainage of such kidneys as a guide to choose the type of surgical management would be a solution to this dilemma. We aimed to evaluate the role of percutaneous nephrostomy in treatment of poorly functioning kidneys in pediatric patients with UPJO. Materials and Methods: A prospective study was performed on patients with poorly functioning kidneys (split renal function<10% on renal dynamic scan) and unilateral ureteropelvic junction obstruction from August 2016 to January 2018. Ultrasound-guided nephrostomy was inserted for these patients. Data regarding the differential renal function and glomerular function rate (GFR) was collected before and after nephrostomy insertion. Decision regarding pyeloplasty or nephrectomy of the involved kidney was made based on changes seen in differential function and Glomerular filtration rate following the drainage. Results: Thirty three patients with unilateral UPJO with poorly functioning kidneys were treated during this period. Thirty patients had significant increase in differential function and glomerular filtration rate. These patients underwent pyeloplasty. In 2 patients, these parameters did not increase much and they underwent nephrectomy. One patient had an infected kidney which did not improve significantly on drainage and had to be removed. Of the 30 patients who had pyeloplasty, two developed obstruction after 3 months of removal of double-J stent and needed reoperation. Conclusion: Percutaneous nephrostomy in poorly functioning kidneys with ureteropelvic junction obstruction helps to identify potentially salvageable kidneys which merit pyeloplasty. Kidneys which do not improve with nephrostomy are unlikely to improve with pyeloplasty and therefore nephrectomy is done in such cases.

Background: With increasing survival of patients suffering from necrotizing enterocolitis (NEC) colonic strictures, as its late sequelae, is increasingly being seen and most of these patients present with chronic constipation. Case Series: Five patients of acquired colonic stricture presenting with abdominal distension and constipation are being reported here. All five patients varied in clinical features, age at presentation and surgical manage-ment. Three of them had abdominal distension and constipation with poor nutritional status. Primary resection with anastomosis could be done in only one while stoma was made initially in other patients. One patient pre-sented with sealed perforation and fistula between jejunum and colon. All, except one patient, had stricture at splenic flexure. Histopathology of colon reported normal ganglion cells in all patients. Conclusion: All survivors of necrotizing enterocolitis, should be followed for the development of colonic stricture; It should be kept as important differential diagnoses of chronic constipation in children.

Chilaiditi syndrome is the interposition of the right colon between the liver and the right hemi diaphragm. Generally, the patients are asymptomatic but can present symptoms mimicking intestinal obstruction. Although, there are many complications related to colostomy in the patients of anorectal malformation, appearance of Chilaiditi syndrome is unusual Further, hypokalemia can be a precipitating factor for the development of Chilaiditi syndrome.

H-type anorectal malformation characterized by a fistulous communication between urethra and rectum with patency of both epithelial tracts is a rare abnormality in male children. We recently managed a 15-year old male child with on and off passage of urine per rectum. We present the clinical details and the difficulties encounterd in managing this extremely rare malformation in a grown-up male patient.