The authors report a patient who underwent elective cystogastrostomy for pancreatic pseduocyst and had three episodes of massive gastrointestinal bleeding postoperatively. The patient had bleeding vessels in the pseudocyst cavity of which conservative management of cold saline lavage and octreotide was instituted. Endoscopy was done after the 1st episode of bleeding and showed no active bleeding, no suture site bleeding and with blood clots inside the cavity. After the 2nd episode of gastrointestinal bleeding, there was a note of pinpoint hemorrhages on the pseudocyst wall. The plan was to do angiography but the patient succumbed to hypovolemic shock due to gastrointestinal bleeding hours after endoscopy. On retrospect, early angiography and possible embolization should have been done. Prompt surgical re-exploration is warranted among patients with hemodynamic instability.

Human ; Female ; Middle Aged ; Octreotide ; Therapeutic Irrigation ; Hypovolemia ; Gastrointestinal Hemorrhage ; Angiography ; Vascular Diseases ; Thrombosis ; Endoscopy ; Hemodynamics

Presented is a rare case of Wilms' Tumor (WT) in a 3-month old female with a palpable nontender left flank mass. In the early infancy period (<6 months), there is a low incidence of malignancy in renal masses, and congenital benign renal lesions (like congenital mesoblastic nephroma) predominate in this age group. We did nephroureterectomy and lymph node sampling. Histopathology revealed localized non-metastatic COG Stage I WT with favorable histologic features. The patient underwent adjuvant chemotherapy with dactinomycin and vincristine using an institution based protocol, which offers upfront surgery followed by chemotherapy. This approach is similar to the Children's Oncology Group (COG) protocol.
Nephrectomy

Reported here is the first documented laparoscopic repair of a rare partial diaphragmatic eventration in a pediatric patient. The case involves a three year old female who had recurrent cough. While a Morgagni hernia was the initial impression, an eventration of the left anterior diaphragm was instead found on laparoscopy. Repair was aided by using transcutaneous traction, with plication achieved by intracorporeal sutures. The patient recovered uneventfully and follow-up x-ray after six months demonstrated an intact repair.
Diaphragmatic Eventration ; Hernia, Diaphragmatic ; Laparoscopy

Reported here is the case of a 6 year old male child with a left Congenital Diaphragmatic Hernia who underwent thoracoscopic repair. The use of continuous low pressure CO2 insufflation pneumothorax during the procedure not only made manipulation during the reduction of bowel contents back into the abdomen easier, but also facilitated repair of the defect as it maintained bowel reduction during suturing. Although prolonged CO2 has been hypothesized to be hazardous leading to hypercapnea and aggravating pulmonary hypertension in Congenital Diaphragmatic Hernia patients. The authors found it to be a safe modification of the technique as long as pre-operative planning, patient selection and intra-operative maneuvers were proprely performed.
Hernias, Diaphragmatic, Congenital

Pancreaticoduodenectomy (Whipple's) procedure is indicated for complex  pancreatic  injuries,  with  immediate  reconstruction  for stable  patients  and  delayed  reconstruction  for  unstable  patients. This study aimed to review the authors' experience with trauma-related  Whipple's  procedure  at  the  East  Avenue  Medical  Center (EAMC).
METHODS: This study reviews cases where Whipple's procedure was performed from 2011 to 2015 at EAMC.  Data collected included age, gender, mechanism of injury, presentation, patient Injury Severity Score (ISS), time interval between injury to presentation, associated injury, surgical procedure, time and type of surgical reconstruction after resection complications and 30-day mortality.
RESULTS: During the 5 year period, 4 patients underwent Whipple's. All patients were male, mean age of 33.25 (range 29-48). Penetrating gunshot trauma was the predominant mechanism of injury (75% of cases) whereas peritonitis was the most common presentation (75% of cases). Mean ISS score is 29.5 (range 25-37).  Among them, 2 underwent  initial  resection  with  delayed  reconstruction  and  the other 2 underwent immediate reconstruction. Pancreaticojejunostomy was done for all pancreatic reconstruction. Cholecystojejunostomy (75%) and Choledochojejunostomy (25%) for biliary enteric conduit. Complications included pancreatic leak (50%), sepsis (25%) and pneumonia  (25%).  Overall,  30-day  mortality  rate  was  25%.Pancreatic leak was noted on all patients without stent placed on the pancreatic anastomosis.
CONCLUSION: Use of stents in pancreatic anastomosis in Whipple's for trauma may lessen the pancreatic leak rates, further studies are needed to prove this.  Cholecystojejunostomy can be an option for biliary enteric continuity, but further studies are needed to identify long tem patency rates.

Human ; Male ; Adult ; Pancreaticojejunostomy ; Pancreaticoduodenectomy ; Choledochostomy ; Pancreas ; Pancreatectomy ; Pancreatic Diseases ; Anastomosis, Surgical ; Peritonitis ; Sepsis