Using Immersive Technologies to Develop Medical Education Materials.

Principles of modern surgical education for clerkship and residency were established by the novel approaches of Sir William Osler, MD, Flexner report, and Halsted's principles. The evaluation of surgical education has continued to benefit from the wisdom of the past by harnessing technologies. Rapidly changing and improving the nature of the surgery fostered that evaluation and enforced the institutions to find new solutions for surgical education. In the present descriptive technical report, our aim was threefold: (1) to share acquired educational materials based on immersive technologies involving 3D-printing, Augmented Reality (AR), and 360-degree video recording to improve ongoing pediatric surgery student training at our faculty, (2) to describe workflow underlying the construction of the materials, and (3) to provide approaches that may help other students and lecturers to develop their educational materials. The educational materials, including 3D-printed models, AR hybrid student book, a hydrogel-based simulation model of the kidney, and Mirror World Simulation, were constructed. The authors, who are medical students, led the construction of the educational materials, so the educational materials were shaped by a collaboration between students and pediatric surgeons. The materials constructed enabled the students to practice surgical procedures and experience different surgical environments. We believe these educational materials can serve as a valuable resource for training in many medical specialties in the future. This work was presented at the American College of Surgeons (ACS) Quality and Safety Conference Virtual, August 21-24, 2020.

Expression of androgen, estrogen, and progesterone hormone receptors in the penile tissues of children with different types of hypospadias.

OBJECTIVE: Androgen (AR), Estrogen (ER) and Progesterone (PR) hormones play an important role in the prenatal and postnatal development of urogenital tract and especially the penis. The expressions of AR, ER and PR receptors in penile tissues in children with hypospadiases had also been shown previously. In this leading study, to demonstrate of the sex hormone receptor expression in cases with different types of hypospadias were aimed. METHODS: This study was designed in children operated due to hypospadiases without DSD. Biopsy samples of 3 mm's were obtained from three different sytes as the lateral parameatal tissue and the anterior corner of the prepuce, and inner layer of posterior prepuce. The presence of AR, ER and PR receptors was investigated immunehistochemically. RESULTS: Mean age was 5.4 years in 18 children with hypospadiases; in totally 33 specimens were taken in 5 subcoronal as 5 specimens, and 7 penile as 15 specimens, and 6 penoscrotal as 13 specimens. According to sytes of samples; 13 samples were from lateral para-meatal tissues, and 13 were from anterior corners of prepuces, and 7 were from inner layers of posterior prepuces. In regard to receptor expression; ER and AR receptors were positive in 29 (87.8%) and 12 (36.4%) respectively; PR receptors were negative. CONCLUSION: This study emphasized the dominant expression of estrogen receptors in penile tissues of children with hypospadias. Although there was not a manifest correlation of androgen receptors absence in regard to the severity of hypospadias patients, there was a marked estrogen receptors presence in penile tissues. These findings suggest that the disrupted androgen and estrogen receptor interaction and/or balance could play a role during the development of external genitalia in hypospadias patients. Progesterone receptor was not present and therefore the active role in the postnatal development of hypospadias is still debatable.

Which treatment modality for pediatric pilonidal sinus: Primary repair or secondary healing?

OBJECTIVE: To evaluate the outcome and characteristics of patients who were operated for sacrococcygeal pilonidal sinus (SPS) treatment using primary repair or secondary healing technique. METHODS: Forty-seven patients (female: 25, male: 22) diagnosed with pilonidal sinus operated between 2009 and 2015 were retrospectively analyzed. The cases were evaluated for age, gender, body mass index (BMI), surgical technique, hospital stay, recovery time and recurrence. Mainly two types of surgical techniques were applied: primary repair and secondary healing. RESULTS: Mean age of the patients was 15.6 (±1.2) years. Excision and primary repair was performed in 36, excision and secondary healing was in 11. There was no statistically significant difference between the groups regarding length of hospital stay and duration of postoperative pain (p > 0.05). There was a statistically significant difference between groups regarding recovery time (p < 0.05). Recurrence was detected in a total of 11 (23.4%) patients. CONCLUSION: We did not find any significant difference concerning length of hospitalization, duration of postoperative pain and recurrence rate. However we determined that the primary repair group recovery time is significantly shorter compared to our secondary healing group. Therefore we recommended primary repair in the treatment of primary repair PS in children.

A review of intussusception cases involving failed pneumatic reduction and re-intussusception.

BACKGROUND: The aim of the present study was to evaluate cases in which intussusception was unsuccessfully treated with pneumatic reduction (PR), and intussusception recurred following PR. METHODS: The medical records of 401 patients who presented with intussusception between 2003 and 2014 were retrospectively analyzed. Included were 61 patients, 20 of whom underwent unsuccessful PR (Group 1), and 41 of whom experienced intussusception recurrence following PR (Group 2). Treatment and outcome were summarized. RESULTS: In Group 1 (mean age: 14.2 months; range: 2.5 months-6 years) surgery was indicated due to PR failure in 15 patients, and perforation occurred during PR in 5. In these 5 patients, age was under 1 year (range 6-9 months) and mean time to presentation was 3 days (range 2-4). During laparotomy, pathologies were noted: mesenteric lymphadenopathy (LAP) and/or Peyer's patch hyperplasia was observed in 15 cases, Meckel's diverticulum in 5 cases. In Group 2 (mean age: 20 months; range: 3 months-6 years), intussusception developed after successful PR in 41 patients, most frequently within the first 24 hours (21.51%). Of the 41 patients, recurrent intussusception (RI) was treated with PR in 36, and laparotomy in 5. Operative findings were mesenteric LAP in 4 and polyp in 1. CONCLUSION: PR is effective for the treatment of intussusception and recurrences. Delayed presentation reduces the success rate. In the event of failure, a lead point is usually encountered at laparotomy.

Risk continues: Very late manifestation of helicobacter pylori at gastric augmented bladder.

Helicobacter Pylori was previously demonstrated at gastric patch after gastrocystoplasty and a possible relationship with acid-haematuria syndrome was established after symptomatic relief by medical treatment. We present the long term outcome of a male bladder exstrophy patient after gastrocystoplasty. There was past history of bladder perforation, acid haematuria syndrome and treatment of HP and recurrent urinary tract infections, noncompliance on regular follow-up and cadaveric renal transplantation. At the preoperative evaluation for renal transplantation HP was present in the biopsy samples collected during gastroscopy and cystoscopy. The significance of persistant HP after gastrocystoplasty in the long term follow-up was discussed.

[Duodenum perforations in children: case series]. / Çocuklarda duodenum perforasyonlari: Olgu serisi.

To analyse patients those admitted to our clinic due to perforation in duodenum. Fourteen patients those have been admitted to our center with perforation in duodenum between 1990 - 2014 analysed retrospectively. Ten patients (8M, 6F) those have been admitted to our clinic between 1990 - 2014 have a mean age of 6.2 years (25 days - 16 years). Two of cases admitted directly to our clinic and the rest referred from another hospitals. Mean time for appliance to our clinic was 3.2 days (1day - 1 week). Ulcer in duodenum was the cause of perforation in 10 cases while in 3 the cause was trauma and in 1 case was surgical complication of infantly persistant hyperinsulinism (IPHH). The case with hyperbilluribinemia after near total pancreatectomy due to IPHH had been explored and perforation in deuedenum diagnosed. Resection in first two parts of duodenum and pylor, choledochojejunostomy, gastrojejunostomy and jejunojejunostomy was performed. Primary repair was performed in the remaining patients. In one case with primary repair gastrostomy was performed, while in 9 cases omentoplasty were performed. In the follow-up 12 cases has no problems and doing well. Two patients died. Perforation in duedenum is a rare entity that pediatric surgeons should encounter and keep in mind. Primary repair (duodenoraphy ± omentoplasty) is safe and reliable surgical treatment modality.

Actinomycosis presenting as an abdominal mass in a child.

Abdominal actinomycosis in childhood period is very rare and a relation to trauma is not well established. Herein we report a case that appeared subsequent to abdominal trauma. A 17 years old boy presented with left lower quadrant abdominal mass and signs of acute abdomen. The symptoms of abdominal discomfort began after a fall from height 3 months before admission. There were signs of acute abdomen at physical examination. Ultrasound of abdomen demonstrated a mass; CT scan findings pointed to a suspicious "internal hernia". An emergency laparotomy was performed. During surgery, a mass located over sigmoid colon and infiltrating the lateral abdominal wall was found. It was removed en bloc with the adjacent omentum. Except for the thickened sigmoid colon, no other pathologies were present at laparotomy. The pathology specimen revealed the actinomyces infection. The patient was treated with oral penicillin after discharge and the follow-up was uneventful. We advocate, keeping the actinomyces infection in mind in cases presenting with abdominal mass of unknown origin in childhood period.

Intestinal volvulus and perforation caused by multiple magnet ingestion: report of a case.

Ingested magnets can cause intestinal fistulas, perforation, and obstruction. There have been reports of magnet ingestion causing intestinal volvulus, but multiple magnet ingestion causing perforation and intestinal volvulus in a child is very unusual. We report the case of a 4-year-old girl, who ingested four magnets she acquired as toys, which caused intestinal volvulus and perforation as a result of pressure necrosis, several days after ingestion. At surgery we repaired two perforations, but additional bowel resection was not required. The patient was discharged on postoperative day 10. If multiple magnet ingestion is suspected in a child, the child must be monitored carefully. If there are signs of obstruction, emergency surgery is mandatory.

The missing hazelnut.

This report describes a case of esophageal perforation caused by a hazelnut which became stuck in the upper esophagus but was not detected. We outline the pitfalls in diagnosis, complications and treatment in the pediatric population.

Neonatal gastric perforation: review of 23 years' experience.

PURPOSE: To review our experience of treating 13 neonates with gastric perforation (GP) over the past 23 years. METHODS: The records of all 13 patients were reviewed, noting gender, weight, gestational age, age at admission, associated anomalies, site of perforation, type of operation, and clinical outcome. RESULTS: There were 11 boys and 2 girls, with a mean body weight of 2 375 g, including 4 (45%) preterm infants. The mean age at admission was 3.2 days. Three (23%) infants had associated anomalies. Perforation occurred in the lesser curvature and anterior wall in 3 (23%) infants, at the greater curvature and anterior wall in 2 (15.4%), in necrosis of anterior wall in 1 (7.7%), at the esophageal junction and posterior wall in 2 (15.4%), at the lesser curvature and posterior wall in 1 (7.7%), at the lesser curvature and esophageal junction in 1 (7.7%), and the site was not specified in 3 (23%). Twelve patients were treated with gastrorrhaphy and drainage, and 1 was treated with gastrorrhaphy alone. Three patients required additional gastrostomy. Mortality was 53.8% (n = 7). Early diagnosis and management before clinical deterioration of the metabolic status improved the prognosis. CONCLUSION: The pattern of presentation and surgical findings should be investigated comparatively in premature and full-term neonates, as the etiology of this condition is likely to differ in these two gestational groups.

Intestinal rotation anomalies in childhood: review of 22 years' experience.

PURPOSE: We review our experience of treating intestinal rotation anomalies in infants and children in the 22-year period between 1978 and 2000. METHODS: The type of operation performed, postoperative complications, and mortality were compared in three age groups. Group 1 consisted of neonates <1 month old, Group 2 consisted of infants aged <1 year old, and Group 3 consisted of children aged >1 year old. RESULTS: There were 101 infants and children, with a female : male ratio of 2 : 1. Of the 101 patients, 72 (71%) were neonates, with a mean age of 11.8 days (range 1-28 days); 20 (19.8%) were under the age of 1 year, with a mean age of 6.7 months (range 1-12 months); and 9 (8.9%) were >1 year of age, with a mean age of 6 years (range 1-9 years). Eighty-five (84%) patients underwent emergency procedures. Ladd's operation was performed in all patients, with various additional procedures. The most frequent postoperative complications were adhesive intestinal obstruction, stoma necrosis, evisceration, and short bowel syndrome. The mortality rate was 36% in Group 1, 20% in Group 2, and 0% in Group 3. CONCLUSIONS: In this series surgery was usually performed as an emergency procedure, with higher morbidity and mortality in newborns than in older infants and children.

Pyloric atresia: 15-year review from a single institution.

BACKGROUND: Pyloric atresia (PA) is a rare pathology. Calder presented the first pyloric atresia case in 1749 and Touroff, Sussman, Meltz, and their colleagues presented the first successful operation in 1940. PA has 3 types of anatomic variations: (1) type A, pyloric membrane or web; (2) type B, the pyloric channel is a solid cord; and (3) type C, in which there is a gap between the stomach and duodenum. Associated anomalies also have been described. Epidermolysis bullosa (EB) and intestinal anomalies occur most often with this condition. METHODS: Charts of 16 cases of congenital PA, aged 1 to 30 days and admitted to our department between 1986 and 2001, were studied retrospectively in regard to sex, prenatal diagnosis, presence of polyhydramnios, time of admission, pathology, type of operation, associated anomalies, and mortality rate. RESULTS: In the study group, the male to female ratio was 5:3, the mean birth weight was 2,312 g and the mean age of admission was 6.5 days. The distribution of the anatomic variations was type A in 9 (56.3%) and type B in 7 (43.7%) of cases. Associated anomalies were present in 7 cases (43.8%). Familial occurrence was a prominent feature of our series. Seven of 16 cases occurred in 3 families. We performed 9 web excisions together with Heineke Mikulicz (H-M) pyloroplasty, 5 atresia excisions and gastro-duodenostomy, and 2 H-M pyloroplasties alone. Stamm gastrostomy was supplemented in 3 cases. The overall mortality rate (n = 9) was 56.3%. CONCLUSIONS: Pyloric atresia can be managed successfully if it is diagnosed early. In this group of patients, congenital anomalies or septicemia are the main causes of mortality.

Effects of different sex hormones on male rabbit urodynamics: an experimental study.

BACKGROUND: The effects of different sex hormones on urodynamics in female rabbits have been investigated previously. Estrogen induces an increase in bladder capacity and compliance, whereas testosterone and progesterone reduced bladder capacity and compliance. OBJECTIVE: The aim of this study was to investigate the effects of sex hormones on bladder urodynamics in male rabbits. METHODS: 5 groups were set up for the study: group I, low midline laparotomy (LML) + 0.9% NaCl; group II, LML + testosterone; group III, LML + bilateral orchiectomy (BO) + testosterone; group IV, LML + BO + progesterone, and group V, LML + BO + estrogen. Baseline urodynamic records and blood sex hormone levels were measured. In the follow-up all rabbits from each group underwent urodynamics 5, 10 and 30 days after injection. Estrogen, progesterone and testosterone levels were also measured during the follow-up period. For statistical verification Mann-Whitney U and Kruskal-Wallis chi(2) tests were used. RESULTS: Hormone levels: Testosterone levels were found to be increased in groups II and III 5 and 10 days after the injection. Testosterone declined thereafter and returned to baseline levels on day 30. In groups IV and V progesterone and estrogen levels increased after the injection and returned to baseline levels on day 30. Urodynamics: In groups II and III testosterone increased the bladder capacity and compliance on days 5 and 10. In these groups, capacity and compliance decreased thereafter and returned to the baseline levels on day 30. These urodynamic findings correlated with the alterations in blood testosterone levels. In groups I and IV no changes were observed in bladder capacity and compliance. In group V capacity and compliance were found to be increased on day 5 after the injection and returned to baseline levels on day 30. The changes in bladder capacity were found to be statistically significant in groups II, III and V. CONCLUSION: In this study, after the injection of testosterone, bladder capacity and compliance increased with high blood testosterone levels in male rabbits. The most interesting finding was observed in the estrogen group, questioning the role of estrogens in males. These findings allow us to reconsider the role of sex hormones in bladder functions.

Which patients are at risk? Evaluation of the morbility and mortality in newborn pneumothorax.

This study was conducted to evaluate the morbidity and mortality among the newborns hospitalized for pneumothorax. The data of 83 cases were analysed retrospectively according to gestational age, weight, underlying primary lung pathology, age of admittance, side of pneumothorax, drainage time, need for mechanical ventilation and mortality. Male: Female ratio was 1.6:1. Mean duration of admission was 63.8 hours (2 hours-20 days). 51 patients (61.4%) weighed les than 2500g and 41 patients (49.4%) were preterms. The mean weight was 2280 g (640-5170). Fifty one patients (61.4%) needed mechanical ventilation. The pnemothorax was on the right in 44 (53%), left in 21 (25.7%) and bilateral in 18 patients (21.7%). Overall 32 babies died. Among the non-survivors, 22 (68%) were preterm and there was a defined underlying lung pathology in 24 (75%). Twenty nine (90.6%) of them needed mechanical ventilation. The difference in mortality was significant in the presence of primary lung disease, low birth weight, prematurity and use of mechanical ventilation (P <005).

Is there a "bladder sex"? The relation of different sex hormones and sex hormone receptors in bladder in childhood.

The aim of this study was to review the classical concept of bladder physiology in regard to sex hormone effects and to focus on a new concept. Sex hormones affect bladder functions and the classical concept tries to explain these effects via alpha and beta adrenoreceptors. The effects of hormones had been investigated in this understanding. To obtain a biological response to steroids in target tissues, specific proteins--so-called receptors--are warranted. After the demonstration of the sex hormone receptors in bladder first in adults and in children urge questioning the effects of hormones in this regard. The hypothesis is based on the fact that, if a special receptor is present, the direct (via sex hormone receptors) effect is more likely to occur as an indirect effect (via alpha and beta adrenoreceptors). There is evidence that there is a sex difference and the sex receptors and hormones play an important role in some bladder disorders. Therefore we stress the importance of investigating especially the pediatric patients with bladder problems in regard to sex hormone receptors and hormonal status.

Tracheostomy in childhood: 20 years experience from a pediatric surgery clinic.

BACKGROUND: There is a limited indication for tracheostomy procedures in pediatric surgery. It is rarely applied to the pediatric patient because they can be kept intubated for a longer duration compared with adults. Problems and complications can occur after tracheostomy, even during the childhood period. PURPOSE: The purpose of this study is to evaluate our experience with tracheostomy procedure. METHODS: Records of 17 children treated over a 20-year period (1978-99) were reviewed retrospectively in the aspects of indication, complication and mortality. RESULTS: There were 13 boys and four girls with a mean age 30.3 months (range: 1 week-13 years). Indications for tracheostomy were prolonged intubation (n = 5), subglottic stenosis (n = 3), general body trauma (n = 2), tracheomalasia (n = 2), tracheoesophageal cleft (n = 1), cervical tumor pressing trachea and larynx (n = 1), congenital myotonic dystrophy plus respiratory failure (n = 1), burn injury of trachea and esophagus (n = 1), and foreign body aspiration (n = 1). In the last decade the number of cases with tracheotomy increased due to the development of new intensive care units, the use of mechanical ventilation and the increasing number of patients needing prolonged ventilation support. In this group, tracheostomies were mainly performed electively. The overall complication rate was 29%. Mortality was 59% and there was one death related to the tracheostomy procedure. CONCLUSION: Tracheostomy is a life saving procedure when performed with an appropriate indication and surgical technique. Therefore, the pediatric surgeons dealing with this procedure should be aware of the tracheostomy care problems, fatal complications and the need for reconstructive surgery. With strict indications and experience of the procedure, this should be enough effort to minimize its complications and related care problems.

The role of surgery in the treatment of instussusception in celiac disease.

Small bowel intussusceptions comprise fewer than 10% of all pediatric patients with intussusceptions and most of them are secondary to another pathology. In this report, we discuss the role of surgery in the treatment of intussusception in celiac disease. A 13-month-old girl was admitted with a three day history of progressive abdominal distention and vomiting of bile. There were air-fluid levels on supine abdominal X-ray and ultrasonographic examination demonstrated an intussusception. At surgery, two separate small bowel intussusceptions were encountered. The postoperative course was uneventful. Due to a history of frequent diarrhea and mild abdominal distention developing after the age of seven months, further studies for celiac disease were initiated. Antigliadin and antiendomysium antibodies were found to be strongly positive. Celiac disease was also confirmed by endoscopic small bowel biopsy. Children who present with chronic or transient intestinal obstruction should also be evaluated for underlying celiac disease. Nevertheless, the surgical decision should be based upon clinical observation in this group of patients.