Congenital hiatus hernia: A case series.

OBJECTIVE: Hiatus hernia is frequent in adults and rare in children; congenital hiatus hernia is even rarer. In this study, we describe a group of infants with congenital hiatus hernia and discuss its management. METHODS: Records of patients (male: 3, female: 4) who were diagnosed with congenital hiatus hernia between 2010 and 2016 were extracted. Demographic data, presenting symptoms, diagnostic investigations, operative details, postoperative follow-up, and early and late postoperative complications were evaluated retrospectively. RESULTS: Four patients were female and three were male. One patient was diagnosed prenatally while the mean age at diagnosis for others was 18.6 months. Four patients had type IV hernia, 2 had type III hernia, and one had type I hernia. The diagnosis was confirmed by chest X-ray, computerized tomography (CT) and/or upper gastrointestinal series. The hiatal repair was done in all patients either by laparotomy or laparoscopy. During the procedure, 2 patients had Nissen fundoplication and 3 patients had Thal fundoplication. Recurrence of hernia occurred in the 2 patients who had Thal fundoplication. CONCLUSION: Recurrence of sliding hernias with Thal fundoplication seem more frequent in the series. If the esophagogastric junction is present in the thorax, mediastinal dissection of the esophagus may be required to achieve a good abdominal esophagus structure, which will prevent a recurrence.

Can mean platelet volume, Neutrophil-to-Lymphocyte, Lymphocyte-to-Monocyte, Platelet-to-Lymphocyte ratios be favourable predictors for the differential diagnosis of appendicitis?

OBJECTIVE: To investigate whether some ratios obtained from complete blood count could be favourable predictors in differentiating appendicitis from mesenteric lymphadenitis, appendicitis and familial Mediterranean fever. METHODS: The retrospective cross-sectional study was conducted at AfyonKocatepe University Medical Faculty, Afyonkarahisar, Turkey, from January 1, 2014, to December 31, 2016, and comprised data of patients who presented to the department of paediatric surgery and paediatrics with symptoms of acute abdomen. Mean platelet volume, neutrophil/lymphocyte ratio, lymphocyte/monocyte ratio, and platelet/lymphocyte ratio of the patients calculated at the time of admission were analysed. SPSS 20 was used for data analysis. RESULTS: Of the 301 patients, there were 139(46.2%) males and 162(53.8%) were females. The overall mean age was 11.5 } 4.33 years. Of the total, 137(45%) had appendicitis, 65(22%) familial Mediterranean fever, and 99(33%) had mesenteric lymphadenitis. Mean platelet volume was significantly different among the study groups (p<0.05). Neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were statistically significantly higher (p<0.05) while lymphocyte/monocyte ratio was significantly lower (p<0.05) in appendicitis cases compared to the others. CONCLUSIONS: Mean platelet volume, neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were found to be the potent predictors for the differential diagnosis of familial Mediterranean fever and mesenteric lymphadenitis which are mostly confused with appendicitis.

Examination of histopathological changes of scalpel, monopolar, bipolar, and thermocautery applications in rat experimental circumcision model.

This study endeavors to analyze the effects of thermocautery, bipolar cautery, monopolar cautery, and the scalpel to show that the thermocautery is a safe device to be used in circumcision. Twenty-four rats were assigned to 4 different groups: the scalpel, thermocautery, bipolar cautery, and monopolar cautery groups. Circumcisions were performed using the scalpel, thermocautery, bipolar cautery, or monopolar cautery devices. The circumcised foreskin was removed for histopathological analysis. The circumcision techniques were compared in terms of the depth of injury on the prepuce. Wound healing on the 5th day on the circumcision plane was evaluated by using a grading scale from 0-4 and by comparing re-epithelization, granulation tissue, and collagen deposition. Blood samples were taken 1st hour after the operation and the 5th day, prior to the necropsy. The totals of the oxidant/anti-oxidant levels were determined. For statistical analyses, the SPSS packet program was used. Statistical significance was determined as a P value <0.05. The least trauma was with the scalpel which was comparable with the thermocautery in regard to depth of injury, epithelization, granulation tissue formation, and collagen buildup. Thermocautery group showed superior collagen proliferation compared with the monopolar cautery group, while being superior in epithelization and injury depth when compared with the bipolar cautery group. The use of thermocautery for circumcision has shown to be safe and resulted in better wound healing in rats with no apparent complications, and, if used in the human population, it may be a safe and effective technique.

A comparison of preoperative and postoperative testicular volume and blood flow in patients with inguinal hernia, hydrocele, and cord cyst: A prospective cohort study.

OBJECTIVE: To evaluate the effect of inguinal operations performed with a modified Ferguson technique upon testicular volume and blood flow. METHODS: This study involved 23 children receiving surgery for inguinal hernia, hydrocele, and cord cyst. This was a prospective study performed between April 2016 and June 2016 in a medical faculty pediatric surgery unit. The color Doppler ultrasound (CDUS) was used to assess testicular volume and blood flow before and after a modified Ferguson technique surgery. The pre- and post operative testicular volume and blood flow were compared with the contralateral testes. SPSS software was used to statistically analyze the data arising; the Mann-Whitney U test and Friedman test were used to compare samples, and P<0.05 was accepted as statistically significant. RESULTS: Preoperative and postoperative testicular volumes were not statistically different when compared to contralateral testes. In patients with right sided inguinal pathology, testicular blood flow on the right side was significantly lower than that on the left side (P=0.023). The testicular blood flow was not statistically different compared with the contralateral testes during the first week evaluation and first month evaluation. The blood flow, probably reduced due to the pressure caused by inguinal pathology, was normalized through surgery. CONCLUSIONS: The modified Ferguson technique do not change the testes volume and blood flow.

Minimally Invasive Treatment of Mirizzi Syndrome, a Rare Cause of Cholestasis in Childhood.

Mirizzi syndrome is the compressive blockage of the cystic or choledochal duct caused by a biliary stone occupying the cystic canal or Hartmann's pouch. This occurrence is rare and, in English literature, three cases defined in children have been observed. In order to draw attention to this rare occurrence, we preferred a 14-year-old male patient with Mirizzi syndrome. In this case, ERCP was performed preoperatively and the diagnosis was carried out with the help of clear visualisation and identification of the tissue structures as well as the stent placed in bile duct; so we protected the patient from the possible iatrogenic injury occurring during surgery.

Benign Cystic Mesothelioma in a Child: Case Report and Review of the Literature.

BACKGROUND: Benign cystic mesothelioma (BCM) is a rare tumor with benign characteristic. There are only 8 child cases reported in the English literature. In this report, we present this rare entity a brief review of the literature. CASE REPORT: A two year-old boy presenting with abdominal swelling was hospitalized. Physical examination revealed a mass filling the abdomen. Laboratory findings were not specific. Abdominal computerized tomography showed a 15×13×11 cm cystic mass extending from the bladder to the liver with no solid components and no infiltration to adjacent organs. Operation revealed a cystic mass filled with yellow-green serous fluid which was attached to the right lobe of the liver with a 1 cm thick peduncle. Total excision of the mass was performed by clamping and cutting the narrow attachment. Recovery was uneventful. Pathology revealed multiple cysts lined with mesothelial cells. No recurrence was seen after 5 years of follow-up. CONCLUSION: BCM should be kept in mind as a rare cause of the abdominal mass in children, as it may lead to confusion in preoperative diagnosis. Although rare, patients should be followed throughout life because of the risk of recurrence and malignant degeneration.

Cystic lymphangiomatosis with severe intra-abdominal bleeding in a newborn: case report.

We report the case of a newborn girl with intestinal cystic lymphangiomatosis who presented with abdominal distension and intra-abdominal bleeding following a prenatal ultrasound diagnosis of intestinal anomaly. Postnatal abdominal ultrasound revealed disseminated submucosal and intramural cystic dilatations of various sizes in the bowel and intestinal lymphangiomatosis was diagnosed. The presence of severe bleeding diathesis and widespread disease led to conservative treatment. The patient died on postnatal day 7 and postmortem examination confirmed cystic lymphangiomatosis. Detection of intestinal hyperechogenicity and/or dilatation in prenatal ultrasonography and the persistence of these findings during pregnancy are suggestive for pathologies such as meconium ileus, meconium peritonitis, and intestinal atresia. Although rare, intestinal lymphangiomatosis should be kept in mind in patients whose prenatal sonographic findings persist until birth.

Laryngeal fracture due to blunt trauma presenting with pneumothorax and pneumomediastinum.

AIM: Injuries due to traffic accidents are frequent in childhood, and they have high mortality and morbidity. Laryngeal injury due to a traffic accident is a rare pathology and might be missed if not suspected. Here we present a laryngeal fracture in a child after a blunt chest trauma during a traffic accident that presented with pneumomediastinum and pneumothorax. CASE: A 14-year-old girl was referred for pneumomediastinum. Her physical examination was normal except subcutaneous emphysema, edema and tenderness in the cervical area, hoarseness, facial and extremity abrasions and ecchymoses. Chest tomography revealed pneumothorax and pneumomediastinum, and cranial tomography revealed maxillofacial fractures. Upper airway damage was suspected, flexible endoscopy revealed right vocal cord paralysis and cervical tomography revealed thyroid cartilage fracture. The fracture was repaired and tracheotomy was performed. She was discharged on postoperative day 6. Facial fractures were repaired in another center. Tracheotomy was removed on postoperative day 20. Her hoarseness, although decreased, still persists. CONCLUSION: Pneumomediastinum is a rare result of a laryngeal fracture and if not suspected, the fracture can easily be missed. It should be kept in mind after blunt cervical trauma with pneumomediastinum and/or pneumothorax. Direct endoscopy and cervical tomography may be necessary for the differential diagnosis.

A practical offer for hypospadias dressing: Allevyn®.

INTRODUCTION: An ideal hypospadias dressing material must be cheap and non-allergenic. It also must be easily and quickly applied, non-adherent to the incision, effectively absorb the leakages of the wound, pressurise the flaps and grafts effectively, without damaging the blood circulation, protect against infections, and must be easily and painlessly removable. We use a product that is produced for healing chronic wounds and burns, Allevyn Adhesive® , as a wound dressing after hypospadias surgery and circumcision. MATERIALS AND METHODS: We included 61 hypospadias and 85 circumcision cases operated in our clinic between November 2007 and August 2010, for the study. Allevyn Adhesive® dressing was used in all the cases. For approximately every 10 patients a sheet sized 22.5 x 22.5 cm was used. RESULTS: We did not meet any difficulty in application and removal of the dressings and the dressing could be performed easily even by inexperienced health personnel. The cost of the application is about $5 for each case. We did not encounter any complications with regard to the dressing during the follow-up. CONCLUSION: We did not encounter any of the complications with Allevyn Adhesive® that were seen with the use of traditional dressing products, such as, problems with removal of the dressing, development of maceration secondary to inadequate absorption of leakages from the wound, cohesions of the wound lips, and infections and necrosis of the flaps and grafts, secondary to erroneous locations of the dressings. There was no additional therapeutical cost due to the use of this product. For these reasons we thought that Allevyn Adhesive® is a good alternative for the dressing of hypospadias and circumcision.

Anal canal duplication.

INTRODUCTION: Anal canal duplication (ACD) is an extremely rare congenital intestinal anomaly. ACD is defined as a second anal orifice located posterior to the true anus ending blindly without connection to the rectum. Usually, there are no other accompanying hindgut pathologies. Patients are often asymptomatic and apply to clinics with their parent's attention. CASE 1: A 9-month-old girl was referred to our clinic because of a second orifice posterior to the true anus. On the physical examination, there was a 3 mm in diameter orifice, about 0.5 cm behind the anus, at 6 o'clock direction on the lithotomy position. Duplicated lumen was checked with a metal catheter; it was about 2 cm in length ending blindly without connection to the rectum. A prediagnosis of ACD was made and the patient was operated. Duplicated segment was excised totally. Postoperative course was uneventful. CASE 2: One-year-old girl was referred to our clinic because of the same complaint. On the physical examination, there was a 2 mm in diameter orifice, about 0.3 cm behind the anus, at 6 o'clock direction on lithotomy position. Duplicated lumen was checked with a metal catheter; it was about 1.5 cm in length ending blindly without connection to the rectum. CONCLUSION: ACD is a rare congenital intestinal anomaly located posterior to the anus. It can be confused with other types of anorectal pathologies, such as hemorrhoids, fistula-in-ano, and perianal abscess at the time of diagnosis. Although ACD is often asymptomatic, it should be removed surgically because of the risk of inflammatory complications and colloidal cancer.

Cross ectopic multicystic dysplastic kidney with ureterocele in nonectopic site.

Crossed renal ectopy (CRE) is the second most common fusion anomaly of the kidney, with an incidence of 1 in 7000 autopsies; it comes in second after horseshoe kidney. Crossed renal ectopy is associated with an ectopic ureter and generally an ectopic kidney fused with a normal kidney. A 7-month-old boy who had left-to-right crossed non-fused renal ectopy and multicystic renal dysplasia with ureterocele in nonectopic kidney was reported in English language literature. In this article, we present the first case of CRE where surgical intervention has been performed.

Increasing tendency in caustic esophageal burns and long-term polytetrafluorethylene stenting in severe cases: 10 years experience.

In recent years, lye products have come into common household use in Turkey. Unfortunately, we have noted more cases of serious corrosive esophagitis owing to accidental caustic agent ingestion. The aims of this study were to (1) evaluate our experience with these cases and (2) investigate the effects of long-term intraesophageal polytetrafluorethylene stenting on esophageal remodeling and its impact upon the need for esophageal replacement. Between 1997 and 2006, 68 patients (44 males and 22 females) with accidental caustic agent ingestion were admitted to our department, the only tertiary care referral center for the Turkish Army. Once stabilized, esophagoscopy was performed for injury grading (grades 0, 1, 2a, 3b, 3a, or 3b) as described by Millar and Cywes (Pediatric Surgery. 1998;969-979). Esophagogram was performed 3 weeks after injury to assess healing. At presentation, the injury grade for 24, 31, 11, and 1 cases were 0 or 1, 2a, 2b, and 3a, respectively. One case had gastric outlet obstruction. All cases of grade 0 or 1 injuries had a normal esophagogram at 3 weeks postinjury. For the remaining 44 patients, several treatment modalities have been applied, including antegrade and retrograde dilatations in 31 grade 2a patients, intraluminal stenting in 11 grade 2b patients, esophageal reconstruction in 1 grade 3a patient, and gastroenterostomy in 1. Of the 11 patients with esophageal stenting, 8 patients have resumed a normal diet after 9 to 14 months of stenting. Mean follow up duration is 3.5 years (1-6 years) after stent removal. In the remaining 3 cases, treatment is still ongoing. Esophagitis and esophageal structuring because of caustic agent ingestion is a major public health problem in Turkey. Our small uncontrolled pilot series suggests that intraluminal polytetrafluorethylene stenting may be an effective treatment method to reduce the need for major surgical reconstruction of recalcitrant esophageal strictures.

Postoperative anorectal manometric evaluation of patients with anorectal malformation.

BACKGROUND: Fecal incontinence is a common problem after reconstructive surgery for anorectal malformations. The aim of this study was to investigate the effectiveness of clinical scores and anorectal manometry in patients, who have been operated on for anorectal malformations. METHODS: In total, 18 patients who underwent surgery for anorectal malformation between 1999 and 2004 were investigated for anal continence. For the assessment of the patients' continence, Kelly's clinical scoring, Kiesewetter-Chang scoring, and anorectal manometry were used. RESULTS: In the intermediate level anorectal malformations, average anal resting pressure was found as 58.16 +/- 8.14 cmH(2)O and in high level anorectal malformations was found as 40.16 +/- 17.4 cmH(2)O. In the continence score, good according to Kelly and Kiesewetter-Chang scoring systems was an average anal resting pressure value of 57.92 +/- 8.57 cmH(2)O and in fair or bad was found as 32 +/- 12.83 cmH(2)O. There were significant differences between the scoring systems anorectal malformation level, and average anal resting pressure values (P < 0.05). CONCLUSIONS: Anorectal manometric evaluation of the patients in postoperative period with anorectal malformation can give more realistic information about the patient continence status in anorectal malformations.

Bilateral cervical chondrocutaneous remnants: a case report and review of the literature.

Cervical chondrocutaneous remnants are less common lesions, which are encountered at the lateral neck. They are similar in appearance to preauricular tags, which are more frequent. Bilateral appearance of this pathology is quite uncommon. The lesions always present at birth, and are located in the middle or lower third of the lateral neck with a significant prevalence of location anterior to the sternocleidomastoid muscle. The overlying skin is similar to the surrounding neck skin and the lesion is painless, lacking any inflammation or discharge. Surgically there is no connection with deep underlying structures. The therapy of choice should be complete surgical removal. Several associated anomalies may accompany cervical chondrocutaneous remnants. Thus these patients must be evaluated carefully in order to detect any additional anomaly. We herein report a four-year-old patient with bilateral cervical chondrocutaneous remnant located at the inferior third of the lateral neck anterior to the sternocleidomastoid muscle. We also review the literature for patients with bilateral cervical chondrocutaneous remnants and discuss embryologic and diagnostic aspects.

Safe removal of upper esophageal coins by using Magill forceps: two centers' experience.

Coin ingestion with subsequent esophageal coin impaction is common in children. Considerable debate surrounds the choice of technique for the removal of esophageal coins. This study demonstrates a minimally invasive technique for upper esophageal coin extraction. A retrospective review was conducted of 165 children who had upper esophageal coins extracted by using a Magill forceps. One hundred fifty-six coins (96.4%) were successfully removed without any complications. The average time taken to remove the coin was 33 seconds. Use of the Magill forceps technique minimizes instrumentation of the esophagus and is an easy, safe technique for removing coins from the upper end of the esophagus.

Bronchial tear in a child after a liquid petroleum gas tank explosion.

Humans have been exposed to blast effects since the invention of gunpowder and explosives. Bronchial injury because of an explosion is a rare but lethal injury that requires prompt recognition and treatment. In this article, we present a case of a bronchial tear after an explosion.

Comparison of hyaluronate/carboxymethylcellulose membrane and melatonin for prevention of adhesion formation in a rat model.

BACKGROUND: To investigate the effectiveness of melatonin in preventing post-operative adhesion formation and to compare it with the efficacy of hyaluronate/carboxymethylcellulose membrane in a rat model. MATERIALS AND METHODS: Following pilot studies, 35 rats were operated on in the full study. In 15 animals (group one), 10 standard lesions were inflicted in each uterine horn (total 30 horns) and melatonin was applied before closure of the abdomen. In the second group, 20 animals were operated on and one of the uterine horns (total 20 horns) with standard lesions was treated with hyaluronate/carboxymethylcellulose membrane and the other uterine horn served as a control. Second-look operations were performed 1 week later and adhesion scores were compared. RESULTS: The adhesion scores of uterine horns treated with melatonin and of uterine horns treated with hyaluronate/carboxymethylcellulose membrane were significantly lower than the scores of the controls (P < 0.001). There was no statistically significant difference between the adhesion scores of uterine horns treated with melatonin and of uterine horns treated with hyaluronate/carboxymethylcellulose membrane (P > 0.05). CONCLUSIONS: Both melatonin and hyaluronate/carboxymethylcellulose membrane were effective in prevention of adhesion formation in a rat uterine horn model.

Topical nitric oxide treatment after pull through operations for Hirschsprung disease.

AIM: The diagnosis and treatment of Hirschsprung disease are well standardized. Symptoms of obstruction after surgery for Hirschsprung disease may result from residual spasticity of the internal anal sphincter. Nitric oxide (NO) is the chemical messenger mediating relaxation of the internal anal sphincter and its exogenous application results in a relaxation response in smooth muscle. The purpose of this study was to investigate topical NO application for obstructive symptoms after surgery for Hirschsprung disease and to correlate the symptoms with manometric findings with a view to directing further management. MATERIALS AND METHODS: The authors reviewed application of topical NO on six symptomatic children who were operated for Hirschsprung disease. Eighteen patients older than 3 years of age were evaluated for anorectal manometric, functional and clinical outcome. The symptoms included enterocolitis in three patients and constipation in three patients. NO ointment was applied twice daily for 6 weeks in symptomatic patients and manometry was repeated. RESULTS: Anorectal manometric evaluation of six patients showed high internal anal sphincter tone without reflex relaxation on applying distending pressure to the rectum. Marked improvement of symptoms was noted after 6-week application of topical NO and maximal internal anal resting pressure decreased significantly (35% reduction). After ceasing application of topical ointment, increased maximal anal resting pressure was seen again. CONCLUSION: Although anal sphincter hypertonicity is not thought to be the only cause of post-operative obstructive symptoms, relaxation of the internal anal sphincter may improve the symptoms. Topical NO can be used for treatment of obstructive symptoms in Hirschsprung disease. We managed our symptomatic patients successfully with local NO application with a reversible chemical sphincterotomy. NO could be used as a therapeutic modality.