We review a single surgeon and surgical centre's experience with congenital cystic adenomatoid malformation of the lung (CCAML) in relation to clinical spectrum, operative experience, and postoperative course. A retrospective hospital record review was done on surgically treated cases of CCAML over a 10-year period, focusing on number with antenatal diagnosis, spectrum of postnatal presentation, type of surgery performed, and outcome. Forty-seven patients from birth to 14 years of age underwent surgery for CCAML. Antenatal diagnosis (ante) was made in 30 cases. Of these, 10 became symptomatic before surgery. Six of the 17 postnatally-diagnosed (pnd) cases were an asymptomatic incidental finding. Overall, 16 were symptomatic in the 1st year of life, and five were symptomatic beyond 1 year of age. Symptoms varied from respiratory distress (seven ante, six pnd) to chronic cough (three, and recurrent chest infection (three ante, two pnd). All preoperative diagnoses were confirmed with chest CT. Most patients (25) were operated on before 3 months of age. Eleven were operated on in the first 2 weeks of life as emergency surgery for respiratory distress. The most common lobe involved was the right upper lobe (16), and lobectomy was performed in 42 cases, segmentectomy in four, and pneumonectomy in one. Seventeen cases were extubated immediately postoperatively; 29 required postoperative ventilation overnight, and nine needed more prolonged ventilation. Early postoperative complications included pneumothorax (two), pleural effusion (one), and chylous effusion (one). Late complications included recurrence in three cases (all segmentectomy), who then subsequently underwent lobectomy. There was one death from respiratory failure. Because there is an increasing trend in the detection of asymptomatic antenatally-diagnosed CCAML, consideration of early surgical excision to prevent complications is suggested by our series. CT scanning is mandatory for postnatal evaluation because chest x-ray could be normal. Safe elective excision after 3 months is supported by our low morbidity and less need for postoperative ventilation. Lobectomy is the procedure of choice to prevent recurrence.

A Meckel diverticulum is a well-recognized source of intestinal bleeding in children. A Meckel diverticulum occurs in about 2% of the population and haemorrhage is the presenting feature in approximately onethird of children with a symptomatic lesion. Almost all such cases have ectopic gastric mucosa in the diverticulum and the ulceration occurs in the adjacent ileal mucosa [1]. Normally the episode of bleeding has no demonstratable triggering factor. It is well known that non-steroidal anti-inflammatory drugs (NSAIDs) can cause erosions in gastric mucosa in the stomach. We would like to report a case of a child who bled from ulceration in the gastric mucosa in a Meckel diverticulum while on a non-steroidal anti-inflammatory drug.A previously fit and healthy 6-year-old boy underwent an umbilical herniorraphy and right hydrocele correction as a day procedure. He was discharged home with paracetamol and Ibuprofen. Postoperatively the boy took two tablets of 200 mg Ibuprofen at an interval of 8 h apart. He was presented on third postoperative day with four episodes of dark tarry stools which progressed to bright red blood per rectum. On presentation he was pale, although haemodynamically stable. His haemoglobin was 8.5 g/dl and he had a normal coagulation profile. A 99Tc Meckel's scan was organized which was positive for functional gastric mucosa. The patient underwent a mini-laparotomy through the umbilical hernia repair site and a Meckel diverticulum was resected. The patient made an uneventful recovery. The histology confirmed the presence of ulcerated gastric mucosa in the Meckel diverticulum.Non-steroidal anti-inflammatory drugs induce their gastric mucosal injury by inhibition of endogenous prostaglandin synthesis. This in turn leads to decrease in epithelial mucus, secretion of bicarbonate, mucosal blood flow, epithelial proliferation and mucosal resistance to injury. The impairment in mucosal resistance permits injury by endogenous factors, including pepsin, acid and bile salts, as well as by exogenous factors such as NSAIDs [2]. A similar case of a 27-year-old man with bleeding from ulceration in the ectopic gastric mucosa of a Meckel diverticulum while taking a NSAID has been reported [3]. A study of adult population which analysed surgical specimens of Meckel diverticulum, found 10 out of 58 specimens had heterotrophic gastric mucosa. Four out of ten with heterotropic gastric mucosa had acute intestinal haemorrhage, and a history of previous oral administration of NSAIDs was positive in three [4].Although rare it should be remembered a shortterm use of NSAIDs even in small amounts can play a major role in causing acute bleeding from a Meckel diverticulum.

No abstract

No abstract