The incidence of inguinal complications after ventriculoperitoneal shunt for hydrocephalus.

AIM: This study outlines the incidence of acquired clinical inguinal manifestations (CIM) in infants undergoing ventriculoperitoneal (VP) shunt procedures, and the possible underlying mechanisms in the development of these pathologies. MATERIAL AND METHODS: The charts of children who had undergone VP shunt procedures for hydrocephalus between 1992 and 2002 were reviewed. All patients were contacted by a telephone interview, and they were invited to be examined in the outpatient clinic of paediatric surgery for the development of groin manifestation. RESULTS: Eighty-eight patients responded to the inquiry. Twenty-one (23.8%) patients developed a CIM. Three of them were premature infants. The mean interval between the shunt procedure and the diagnosis of CIM was 5.3 months (20 days to 48 months). Nineteen of the patients who developed a CIM were in the 0- to 12-month age group when the VP shunt procedures were initially performed. Ten CIM occurred on the right (47%), 7 on the left (33%) and 4 were bilateral (20%). The rate of bilateral patency as an operative finding was 76%. There was one recurrence (4.8%). CONCLUSION: The younger the age at which the VP shunt was performed, the higher the incidence of CIM. Bilateral manifestations were higher than in the normal population. Increased intra-abdominal pressure by accumulation of fluid in combination with the high patency rate of processus vaginalis possibly plays a role in the development of CIM in VP shunt patients. Bilateral repair should be considered even when CIM is unilateral. Special care should be given to repair procedures since the recurrence rate is relatively high.

Experience of the Izmir Pediatric Oncology Group on Neuroblastoma: IPOG-NBL-92 Protocol.

This multicentric study aimed to bring neuroblastoma patients together under IPOG-NBL-92 protocol and evaluate the results within the period between 1992 and 2001 in Izmir. Sixty-seven neuroblastoma patients from 4 pediatric oncology centers in Izmir were included in the study. IPOG-NBL-92 protocol modified from German Pediatric Oncology (GPO)-NB-90 protocol was applied: Patients in stage 1 received only surgery, while surgery plus 4 chemotherapy courses (cisplatin, vincristine, ifosfamide) were given in stage 2 and surgery plus 6 chemotherapy courses (cisplatin, vincristine, ifosfamide, epirubicin, cyclophosphamide) were given in stages 3 and 4 patients. In patients who were kept in complete remission (CR), a maintenance therapy of one year was applied. Radiotherapy was given to the primary site following induction chemotherapy plus surgery in stages 3 and 4 patients with partial remission (PR). The stages of the patients were as follows: 5% in stage 1, 39% in stage 3, 49% in stage 4, and 7% in stage 4S. Primary tumor site was abdomen in 88% of cases. CR rates were as 100% in stage 1, 76% in stage 3, 35% in stage 4, and 75% in stage 4S. Relapse was observed in 32% of patients in a median of 19 months. The median follow-up time for survivors was 33 (17-102) months. Five-year OS rate was 31% and the EFS rate was 30% in all patients. Five-year overall and event-free survival rates were 63 and 30% in stage 3, but 6 and 5%, respectively, in stage 4 patients. Univariate analysis established that the age, stage, primary tumor site, and high LDH and NSE levels conferred a significant difference. The IPOG-NBL-92 protocol has proved to be satisfactory with tolerable toxicity and reasonable CR and survival rates. However, more effective treatments suitable to Turkey's social and economic conditions are urgently needed for children over 1 year of age with advanced neuroblastoma.

Submucosal pressure-air insufflation facilitates endorectal mucosectomy in transanal endorectal pull-through procedure in patients with Hirschsprung's disease.

BACKGROUND: Most children with Hirschsprung's disease (HD) can be treated with a transanal endorectal pull-through (TEP) procedure. The authors have developed a simple technique of submucosal pressure-air insufflation (SI) to facilitate the submucosal dissection, which is one of the crucial parts of the operation. METHODS: Six patients with HD were treated by using TEP in one year. After adequate positioning and exposure, anal mucosa was incised 1 cm above the dentate line, and 4-quadrant SI with a simple system of scalp-vein needle connected to a 20-mL syringe was used in all of the patients. Submucosal proctectomy, aganglionic and dilated segment colectomy, and coloanal anastomosis were completed transanally, but, in 2 of the patients, laparoscopic assistance to release the colon was required. RESULTS: There were no intraoperative and postoperative complications related to SI. Submucosal dissections were completed smoothly in all of the patients with negligible amount of bleeding. The only complication during the submucosal dissection was mucosal perforation at the site of previous rectal biopsy in 2 patients. Average operating time was 2.7 hours (range, 90-180 min), and mean length of resected bowel was 22.5 cm (range, 12 to 42 cm). Follow-up is 8 to 14 months. Frequent bowel movements (>8 times per day) and perianal dermatitis were observed in 2 patients but returned to acceptable limits in 3 months. One patient had to undergo reoperation for adhesive intestinal obstruction. CONCLUSIONS: SI is simple, and offers a safe and faster dissection with minimum amount of bleeding during the endorectal mucosectomy in TEP procedure.

Sliding appendiceal inguinal hernia: preoperative sonographic diagnosis.

We report the case of a 3-month-old boy with a right-sided sliding appendiceal inguinal hernia that was diagnosed preoperatively with sonography. Surgery was performed, and intraoperative and histopathologic evaluations also revealed changes in the appendix that could have led to complications if left untreated. The infant's recovery was uneventful, and he was discharged on the second day after surgery. This condition is usually diagnosed intraoperatively, and to the best of our knowledge, this is only the second report in the English-language medical literature in which such a case was correctly diagnosed preoperatively with sonography. In our case, the early sonographic diagnosis led to early intervention and the avoidance of potential complications.

Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion.

BACKGROUND/PURPOSE: Adnexal torsion is a serious condition that frequently may result in ovarian removal, and there always is a risk of castration if the contralateral ovary undergo torsion as well. In this study, the authors present their experience with adnexal torsion in 15 children and describe a catastrophic event, asynchronous bilateral adnexal torsion, with review of the literature. METHODS: Between November 1993 and November 2000, 15 children under 15 years of age who had undergone operation because of torsion of uterine adnexal structures were evaluated. Two illustrative cases with asynchronous bilateral adnexal torsion are presented. RESULTS: Fourteen cases were associated with additional adnexal pathology, whereas in 1 case the torsion was of normal uterine adnexa. Sonographic studies improved the preoperative diagnosis. Hemorrhagic necrosis of the adnexa secondary to the torsion was found in all cases except 3 and necessitated adnexal resection. In only 3 cases preservation of the adnexa was possible. Asynchronous adnexal torsion occurred in 2 patients in the time course. Both were treated by laparotomy and adnexal untwisting and fixation by permanent multiple interrupted sutures. In their final evaluation at 40 and 8 months after the operation, they were found to have good ovarian function. CONCLUSION: Considering the risk of subsequent contralateral torsion and its impact on future fertility, the authors believe that conservative management (untwisting the ovary and pexing, both retained detorsed and contralateral, ovaries) should be considered in cases of ovarian torsion in children.

Stromal predominant type mesenchymal hamartoma of liver: CT and MR features.

Mesenchymal hamartoma is a rare pediatric liver tumor. The tumor is mainly cystic but occasionally a solid component is seen. Therefore the tumor can be divided into two forms: (a) cystic predominant, and (b) stromal predominant. In this report, CT and MR features of stromal predominant type mesenchymal hamartoma are presented.

A rare cause of gastric outlet obstruction in the newborn: Pyloric ectopic pancreas.

This report describes a case of symptomatic pyloric ectopic pancreas simulating infantile hypertrophic pyloric stenosis (IHPS) in an 1-month-old boy. There are few cases reported in the English-language literature with the same clinical presentation during the neonatal period. Rarely is the entity symptomatic, and it should be kept in mind in differential diagnosis of nonbilious vomiting, especially in neonates. The ectopic pancreas should be removed because of the late complications when found incidentally.