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Biomedical subjects

K R Shankar

Publications and source records attributed to K R Shankar.

At least 19 recordsLinked to original sources
PubMed2004

Colonic transit time--what is normal?

BACKGROUND: Constipation is a common problem in childhood, and various radiologic methods have been advocated for investigation. Colonic transit time (CTT) has been used in adults to investigate colonic motility, but few studies evaluate this method in children. Data on CTT in the normal paediatric population are scarce. METHODS: The colonic transit time was measured in 22 healthy children (median age, 10 years; range, 4 to 15 years) by Abrahamsson's method. Children took bolus ingestions of radiopaque markers on 6 consecutive days, and on day 7 a single abdominal x-ray was performed. This was evaluated for total and segmental colonic transit time. RESULTS: The mean total CTT was 40 hours, and the upper limit of normal (95th percentile) was 84 hours. The upper limit of normal for segmental transit time was as follows: 14 hours for the ascending, 33 hours for the transverse, 21 hours for the descending, and 41 hours for the rectosigmoid colon. CONCLUSIONS: CTT provides an objective measure to assess childhood constipation. To date, 6 studies using 5 different methods have been published reporting values for healthy children. Comparing these, Abrahamson's method has low radiation exposure and is well tolerated. This study contributes additional normal values in children.

Adolescent↗
PubMed2003

Laparoscopic resection of type I choledochal cyst.

Type I choledochal cyst is a rare saccular or fusiform congenital dilatation of the extrahepatic biliary tract. It is usually treated by laparotomy at which the cyst is completely excised and a Roux-en-Y hepaticojejunostomy is performed to establish biliary enteric drainage. We report the laparoscopic excision and hepaticoduodenostomy of type I choledochal cyst in two girls aged 1 and 3 years. The entire procedure was performed laparoscopically using needlescopic instruments. A 7-mm telescope port was inserted at the umbilicus, a 3-mm port in the right upper quadrant, and a 6-mm port in left upper quadrant. An additional 3-mm fan-shaped liver retractor was passed through the abdominal wall without a trocar. The gallbladder and choledochal cyst was dissected and removed en bloc. The lower end of the common bile duct was closed with 5-0 polydioxanone. The duodenum was anastomosed to the common hepatic duct below the confluence of the right and left hepatic ducts. There were no intraoperative complications, and the children were asymptomatic with no episodes of cholangitis at 6 months follow-up. Pediatric surgeons trained in advanced laparoscopic techniques including intracorporeal suturing can perform laparoscopic repair of choledochal cyst safely.

Anastomosis, Surgical↗
PubMed2003

Reduction in visceral slide is a good sign of underlying postoperative viscero-parietal adhesions in children.

BACKGROUND/PURPOSE: Viscera stuck to the anterior abdominal wall from previous surgery risk injury during laparoscopic surgery. A prospective study was conducted to determine if these adhesions are detectable on ultrasound scan by showing a reduction in the normal visceral slide. METHODS: Patients undergoing laparoscopic procedure after a previous laparotomy underwent preoperative real-time ultrasound scan to observe if viscera slides freely under the abdominal wall. A reduction in slide was considered a positive sign of underlying adhesions. These findings were correlated with the operative findings. RESULTS: Anterior abdominal wall scans were performed on 17 children. Reduced visceral slide was seen in 10. Viscero-parietal adhesions were found in 9 of 10 patients. Visceral slide was reduced in a very localized area in 6 patients, and, in these, a loop of bowel (n = 3), liver and bowel (n = 2), or liver (n = 1) was adherent. In 4, reduced visceral slide was seen over a wide area. Extensive adhesions were found in 3 of 4. One renal transplant patient with peritonitis had a false-positive ultrasound scan. At laparotomy there were no adhesions. The peritonitis is thought to have prevented an adequate examination. Seven patients had normal visceral slide. Of these, 4 had no adhesions, but 3 children had flimsy omental adhesions. The sensitivity and specificity of visceral slide in predicting adhesions were 75% and 80%, respectively. CONCLUSIONS: Reduction in visceral slide is a good sign of underlying postoperative viscero-parietal adhesions. Ultrasonographic mapping of the abdominal wall may be useful in selecting an adhesion-free site for trocar insertion in children with previous operations requiring laparoscopic procedures.

Abdominal Wall↗
PubMed2003

After the honeymoon--medium-term outcome of antegrade continence enema procedure.

PURPOSE: The aim of this study was to determine medium-term outcomes of the antegrade continence enema (ACE) procedure. METHODS: A retrospective casenote review plus telephone questionnaire was conducted. The study was performed at a regional paediatric surgical centre. The subjects were consecutive children undergoing the ACE procedure over a 5 year period. Main outcome measures were use of the ACE; reversal rates; complications, ease of use, effectiveness, and satisfaction scores. Data are expressed as median (range). RESULTS: Thirty-two (52%) of 62 children undergoing the ACE procedure were girls. The age at the time of operation was 11.5 (3.8 to 17.6) years. Underlying diagnoses included spina bifida (n = 31), anorectal malformations (n = 15), slow-transit constipation (n = 9), Hirschsprung's disease (n = 2), sacral agenesis (n = 2), and trauma/tumour (n = 2). Median follow-up was 5.4 (3.25 to 8.25) years. Eleven of 62 (18%) children were no longer using the ACE (n = 5) or had it surgically reversed (n = 6; 14.1 +/- 9.3 months postprocedure). Reasons for disuse/reversal were lack of effectiveness (n = 4), complications (n = 2), noncompliance (n = 3), independent continence (n = 1), and pain (n = 1). Five (8%) children currently have a colostomy. Gender (P =.31; Fisher's Exact), age (Pearson), and underlying diagnoses (P =.07, Chi2) were not predictors of failure. Overall, stomal stenosis was the most common complication, affecting 26 of 62 (41%) children. Of 32 questionnaire respondents to linear scores, ease of use was rated as 2 (0 to 8, 0, very easy; 10, very difficult), discomfort on use as 3 (0 to 9; 0, no pain; 10, very painful), overall satisfaction as 9 (0 to 10; 0, completely dissatisfied; 10, completely satisfied). Eighty-four percent were completely continent or had soiling less than once a month. There was a significant correlation between the level of continence and satisfaction with the procedure (P =.04; Pearson). CONCLUSIONS: The ACE procedure offers significant benefits to some children with incontinence or intractable constipation. However, it is not universally successful, and other continence promoting strategies may need to be considered.

Adolescent↗
PubMed2002

Magnetic resonance venography in assessing venous patency after multiple venous catheters.

BACKGROUND/PURPOSE: Venous thrombosis is a well-recognised complication of central venous catheters (CVC). The aim of the study was to assess the value of magnetic resonance venography (MRV) in assessing venous patency in children with suspected venous thrombosis. METHODS: Contrast studies through the CVC (linogram) and Doppler ultrasonography were the initial investigations performed in children with suspected CVC-related thrombosis. Two-dimensional gated inflow and phase contrast MRV also was performed to assess the extent of venous thrombosis and to locate patent veins for replacement CVC. When the MRV identified a suitable patent vein, the CVC was reinserted by direct venous cut down or the percutaneous method under a general anaesthetic. RESULTS: A total of 25 children (median age, 5 years; range, 2 months to 17 years) who had multiple CVC insertions (median, 3; range, 1-9), underwent MRV for suspected venous thrombosis. Of 10 patients in whom the catheter was completely occluded, MRV identified extensive thrombosis of the central veins in 6. In 7 other children the linogram showed adherent thrombus at the tip of the CVC only. In 5 of these 7 children MRV showed extensive thrombosis of the vein in which the catheters were placed. Doppler ultrasonography diagnosed thrombotic occlusion of the neck veins in 7 children. The MRV studies showed more extensive thrombosis in 4 of these 7 patients. Additionally, MRV showed thrombosis of the intrathoracic veins in 11 patients who had patent neck veins on ultrasound scan. MRV identified a patent vein for reinsertion of CVC in 22 of 25 children. At operation, venous patency was confirmed in 20 patients (91%). CONCLUSION: MRV in children with suspected CVC-related thrombosis is more accurate than Doppler ultrasonography, and contrast studies for defining the extent of venous thrombosis. MRV correctly shows venous anatomy and patency for reinsertion of CVC.

Adolescent↗
PubMed2002

Trends in the management and outcome of jejuno-ileal atresia.

The aim of this study was to evaluate contemporary patterns of presentation and trends in the management and outcome of newborn infants with jejuno-ileal atresia at a regional paediatric surgical centre in the United Kingdom. The hospital neonatal surgical registry was used to identify patients with jejuno-ileal atresia (n = 83) admitted between 1976 - 1998, excluding those associated with gastroschisis. The clinical records were reviewed and antenatal information, patient demographics, associated anomalies, operative treatment, post-operative management and outcomes were analysed in three time periods to identify trends in management and survival: Group 1 1976 - 1982 (n = 32), Group 2 1983 - 1990 (n = 21), and Group 3 1991 - 1998 (n = 30). Overall survival was 90 %. The number of patients with associated anomalies were Group 1, 10 (31 %); Group 2, 7 (33 %); and Group 3, 11 (37 %). Cystic fibrosis was encountered in 4 (13 %), 1 (5 %) and 4 (13 %) patients, respectively. Resection with primary anastomosis was the definitive management in most of patients: Group 1, 25 (78 %); Group 2, 17 (81 %); and Group 3, 27 (90 %). Initial stoma followed by delayed primary anastomosis was performed in 14 infants; eight patients had divided stomas while 6 had Bishop-Koop stoma. Tapering was used in 10 patients (12 %) with proximal jejuno-ileal atresia. Parenteral nutrition was increasingly utilised over the three time periods studied. There were no deaths in Group 3 compared to 6 deaths in Group 1 and 2 in Group 2 (P = 0.02). Most of the deaths were due to overwhelming sepsis. Mortality did not correlate significantly with the TYPE of atresia, presence of associated anomalies or the need for long-term total parenteral nutrition. The overall complication rate in survivors was 18 %. In the infants undergoing Bishop-Koop operation the complication rate was 50 %. This study has shown a significant reduction in mortality from jejuno-ileal atresia, which may be attributed primarily to advances in perioperative management, including parenteral nutrition. Generous resection of the atretic segment with primary anastomosis is more frequently employed in preference to initial stoma formation. Cystic fibrosis remains an important co-morbid condition that must be excluded promptly in all newborns.

Case-Control Studies↗
PubMed2002

Management of severe hypospadias using Glassberg's modification of the Duckett repair.

OBJECTIVE: To assess the effectiveness of Glassberg's modification of Duckett's technique in the surgical correction of severe hypospadias. PATIENTS AND METHODS: The case notes of 24 boys who underwent hypospadias repair using this technique were reviewed, noting the severity of the lesion, the method of repair and the clinical outcome. RESULTS: One operation was required in 14 (58%) of patients; complications requiring further surgery occurred in 10 boys (42%). CONCLUSION: This technique allows a single-stage procedure when otherwise a two-stage procedure would be necessary.

Child, Preschool↗
PubMed2002

Outcome of hypospadias fistula repair.

Objectives To examine the long-term results of hypospadias fistula repair, the factors involved in recurrence and the outcome in cases where this has occurred. Patients and methods The study comprised 113 children undergoing urethrocutaneous fistula repair between 1984 and 1996. Most of the fistulae were closed in two to three layers, with or without a transpositional skin flap. Tunica vaginalis or a scrotal dartos flap was used in patients with inadequate vascularized tissue adjacent to the fistula. Success rates were calculated for each attempt at fistula repair until the patient was cured. Results The median (range) age at primary fistula repair was 40 (18-169) months and the median follow-up after the most recent repair 7.5 (2.3-17) years. The overall success rate of primary fistula repair was 71%. Fistulae which were >2 mm (11 of 21, 52%) were more likely to recur than were those < or = 2 mm (22 of 92, 24%). Recurrence did not relate to the initial form of hypospadias repair, to the means of skin closure nor, with the exception of multiple lesions, to the location of the fistula. The success rates of subsequent repairs were 70% at the second and 50% at the third, fourth and fifth repairs. One child was cured at the sixth attempt. The use of tunica vaginalis or scrotal dartos as a 'waterproofing' layer was limited to the third or subsequent repairs and was successful in five of six cases. Conclusion A simple layered closure with or with no transpositional skin flap is effective in 71% of repairs. For recurrent fistulae, tissues from an unscarred area (tunica vaginalis or scrotal dartos layer) should be used to cover the fistula.

Adolescent↗
PubMed2001

Cystic retroperitoneal lymphangioma: treatment by image-guided percutaneous catheter drainage and sclerotherapy.

Retroperitoneal cystic lymphangiomas are extremely rare and the majority are symptomatic during childhood. Although benign, they can compress and infiltrate vital structures. Surgery is curative but is associated with a high complication rate. An alternative treatment strategy is image-guided percutaneous catheter drainage of the lymphangioma followed by sclerotherapy. Resolution of a large retroperitoneal cystic lymphangioma in a 4-year-old child treated by this technique is reported. To our knowledge, this technique has not been previously described in this condition and we believe that it offers significant advantages over surgery.

Child, Preschool↗
PubMed2001

Classification and risk-factor analysis of infections in a surgical neonatal unit.

BACKGROUND/PURPOSE: Nosocomial infection may result in significant morbidity in surgical neonates. Traditionally, nosocomial infections are classified using time cut-off points. Gastrointestinal carriage of microorganisms has not been used as a criterion for classifying infection in surgical neonates. The aims of the study were to (1) determine the overall infection rate, (2) distinguish between nosocomial and community acquired infections using a 48-hour postadmission cutoff and the carrier state criterion, and (3) determine risk factors for clinical infection. METHODS: A 1-year prospective observational cohort study was undertaken in a regional neonatal surgical unit between 1997 and 1998. All infants residing for >/=3 days in the unit were included in the study (n = 167). Patient demographics, including illness severity (PRISM score), were recorded for all infants. Surveillance throat and rectal swabs were obtained on admission and twice weekly thereafter to determine carrier status. Carriage was defined as isolation of the same microorganism from at least 2 consecutive surveillance samples. Infective episodes were diagnosed if a clinical diagnosis of local or general inflammation was microbiologically proven. RESULTS: A total of 167 infants responsible for 174 admissions were studied. Median gestational age was 38 weeks (range, 24 to 42), median birth weight was 3 kg (range, 1 to 3.6), median age on admission was 8 days (range, 0 to 142), median length of hospital stay was 8 days (range, 3 to 95). The diagnoses were gastrointestinal disorders (n = 96), abdominal wall defects (n = 22), neural tube defects and hydrocephalus (n = 17), thoracic disorders (n = 16), urologic disorders (n = 12), and abdominal tumours (n = 4). Twenty-five infants had 33 episodes of infection giving an overall infection rate of 14.9%. The predominant infecting organism was Stapylococcus aureus (n = 11); others were enterococcus, coagulase negative staphylococcus, Candida spp, Gram-negative bacilli, and anaerobes. A total of 27 of 33 infective episodes were caused by microorganisms carried by the infants on admission (primary endogenous). Only 6 children had "true" nosocomial infections. Using a traditional 48 hour cutoff, 87% of the infections were classed as nosocomial. Birth weight, presence of central venous line, PRISM score, and length of stay were identified as significant risk factors for developing clinical infection. CONCLUSIONS: (1) Carriage allowed us to identify the true nosocomial infection rate (microorganisms acquired in the unit), which was only 18%. In contrast, using a traditional 48 hour cutoff, 87% of the infections would have been classed as nosocomial and warranted unnecessary cross-infection investigations. (2) The results of this study confirm that birth weight, illness severity (PRISM score), presence of central venous catheter, and length of hospital stay were independent risk factors associated with clinical infection in surgical neonates.

Carrier State↗
PubMed2001

Ovarian adenocarcinoma in premenarchal girls.

Ovarian neoplasms are unusual in the paediatric age group; the majority of them are of germ cell origin. Malignant epithelial tumours of the ovary occur infrequently in adolescent girls. Ovarian carcinoma in particular is extremely rare before puberty. The authors describe 3 cases of adenocarcinoma of the ovary in premenarchal girls and highlight the unique characteristics of this tumour in this age group.

Adenocarcinoma↗
PubMed2001

Use of the gonadal vein in children with difficult central venous access: a novel technique.

In children who require multiple central venous catheterization, the commonly used veins can become thrombosed making central venous access a challenging problem. The authors report on a patient with a rare metabolic disorder who had extensive thrombosis of the superior vena cava and iliofemoral veins, in whom the right ovarian vein was cannulated using a retroperitoneal approach for the placement of a SILASTIC((R)) (Dow Corning, Midland, MI) catheter with an implantable port. This is a useful and reliable technique in children who have difficult venous access.

Catheterization, Central Venous↗
PubMed2001

Phenotypic presentation and outcome of esophageal atresia in the era of the Spitz classification.

PURPOSE: The aim of this study was to investigate contemporary patterns of presentation and outcome in newborns with esophageal atresia with or without tracheoesophageal fistula (OA) using modern prognostic criteria to appraise survival. METHODS: Over a 12-year period (1986 through 1997), 134 patients with OA were admitted to a single institution. Patient demographics, the presence of cardiac defects, other associated abnormalities (VACTERL), surgical intervention, and patient outcome were recorded. To identify and evaluate changes in the pattern of clinical presentation, frequency of associated anomalies and outcome, patients were analyzed during 4 consecutive time periods, 1986 to 1988, 1989 to 1991, 1992 to 1994, and 1995 to 1997. RESULTS: A primary repair or delayed primary repair was performed in 113 (84%) patients, with a staged procedure in 19 (14%). Two babies with trisomy 18 did not undergo surgery. Thirty-eight newborns (28%) had a major cardiac malformation (excluding patent ductus arteriosus, unless needing ligation), and 25 (19%) had recognized VACTERL associations. There was a significant increase in the proportion of infants with major cardiac defects diagnosed over the study period, 5 of 34 patients between 1986 and 1988 to 19 of 41 patients between 1995 and 1997 (chi(2) test, P <.001), but the incidence of VACTERL associations remained unchanged. Overall survival rate was 86% in those who underwent surgery. The relative risk of mortality in patients with major cardiac disease and VACTERL associations was 3.47 (95% CI; 1.51 to 7.96) and 2.54 (95% CI; 1.14 to 4.86), respectively. Birth weight was significantly higher in infants who survived (2.68 kg) compared with those who died (2.16 kg, P =.003). Thirty percent of infants with more than one system abnormality died compared with 8% of infants with 1, system abnormality (P =.004). CONCLUSIONS: This study has found a significant increase in the frequency of cardiac abnormalities encountered in a cohort of OA patients during the period under review. Cardiac disease and multiple abnormalities carried a substantial increased risk of mortality. In the era of the Spitz classification, the phenotypic presentation is important to accurately assess caseload severity and prognosis.

Abnormalities, Multiple↗
PubMed2001

Umbilical pyloromyotomy--an alternative to laparoscopy?

AIMS: To evaluate the utility of umbilical pyloromyotomy for infantile hypertrophic pyloric stenosis (IHPS) compared to published series promoting laparoscopy. METHODS: Eighty-six babies with IHPS had pyloromyotomy using an umbilical skin fold incision. Operating times, post-operative hospital stay and cosmetic appearance of the umbilical wound were studied. Data extracted from recent series promoting laparoscopy were identified using a MEDLINE search strategy and used for comparative analysis. RESULTS: Mean operating time for umbilical pyloromyotomy was 30 min (range 15-50 min). All patients went home at an average period of 58 h (range 48-72 h) following surgery. The umbilical scar was barely visible in the post-operative period. Laparoscopic pyloromyotomy operating times ranging from 18-41 min (mean overall 30 min) are recorded in the literature. Post-operative stay following laparoscopy has been variable (23-91 h), where reported. In contrast with umbilical pyloromyotomy, "pox" marks observed following port insertions for laparoscopy can give an unsightly scar. CONCLUSIONS: This study has found that umbilical pyloromyotomy can be performed with minimal morbidity and equivalent operating times to laparoscopy. The shorter hospital stay reported in some series promoting laparoscopy must be balanced against local practice influencing hospital stay, the financial implications of offering a laparoscopic service, the skills needed for laparoscopy, and the short learning curve required by paediatric surgical trainees to become proficient at umbilical pyloromyotomy. The cosmesis of the umbilical incision is excellent. These findings suggest that umbilical pyloromyotomy is a reliable alternative to laparoscopy.

Humans↗
PubMed2001

Outcome of patients with prenatally detected duplex system ureterocele; natural history of those managed expectantly.

PURPOSE: We assessed the outcome of patients treated for prenatally detected duplex system ureterocele with particular reference to those treated expectantly. MATERIALS AND METHODS: We reviewed the records of 52 consecutive patients treated between 1984 and 1999 with a median followup of 8 years (range 1 to 16.2). RESULTS: Of the 38 patients who underwent surgical treatment 13 subsequently required unplanned secondary procedures. A total of 14 cases satisfying currently defined criteria, including less than 10% upper renal pole function, an unobstructed lower pole (absent nonrefluxing hydroureteronephrosis), lower pole vesicoureteral reflux not exceeding grade III and unobstructed bladder outflow, were managed expectantly with a median followup of 8 years (range 1.6 to 12.8). In this group of patients prophylactic antibiotics were routinely prescribed until the completion of toilet training or age 5 years in those with persistent reflux on repeat cystography. None has required surgery or had symptoms or urinary infection. In 6 cases followup ultrasonography showed substantial resolution of upper pole hydronephrosis with a collapsed ureterocele. Furthermore, 7 of the 38 patients who underwent surgical treatment early in our series would have been treated expectantly had the current criteria been applied. CONCLUSIONS: In 14 of the 52 patients (approximately 27%) with prenatally detected duplex system ureterocele the natural history of the complaint is essentially benign within the currently available followup.

Animals↗
PubMed2000

Immunogenicity of plasma-derived hepatitis B vaccine in preterm infants.

The objective was to determine whether plasma-derived hepatitis B vaccine is immunogenic in preterm appropriate for gestation babies when administered at birth and to compare the immunogenicity between 5 micrograms and 10 micrograms doses of the vaccine in these babies. Fifty preterm neonates (31-36 weeks gestation) were randomized to receive 5 micrograms or 10 micrograms doses of plasma-derived hepatitis B vaccine at birth, with subsequent doses 1 and 6 months later. Serum specimens were obtained a month after each dose of the vaccine and were tested for antibody to hepatitis B surface antigen (anti-HBs). Thirty six babies (gestation 31-36 weeks), 18 from each group competed the study. While 89.2% of the babies seroconverted, 82.1% achieved seroprotective titres of anti-HBS (> 10 mIU/ml). There was no difference between weight, gestational age, age of administration of vaccine and age of estimation of anti-HBs between 5 micrograms and 10 micrograms groups. The difference in the seroprotective rates were not statistically different between the groups (5 micrograms 78.5%; 10 micrograms--85.7%). Although immune response to plasma derived hepatitis B vaccine in preterm babies is suboptimal when the first dose is administered at birth, the full course achieves adequate seroprotective levels.

Female↗