TRANSIENT PSEUDOHYPOALDOSTERONISM SECONDARY TO URINARY TRACT INFECTION IN A MALE INFANT WITH UNILATERAL HYDRONEPHROSIS DUE TO PRIMARY OBSTRUCTIVE MEGAURETER: A CASE REPORT.

We present a case of transient form of type 1 pseudohypoaldosteronism (S-PHA) in a 1.5-month-old male infant who presented with lethargy, failure to thrive, severe hyponatremia (Na=118 mmol/L), hypochloremia (Cl=93 mmol/L) and fever due to urinary tract infection. Potassium levels were normal. Markedly elevated serum aldosterone level and elevated serum renin confirmed the diagnosis of pseudohypoaldosteronism. Renal ultrasound showed grade III hydronephrosis on the left kidney while contrast-enhanced voiding urosonography excluded the existence of vesicoureteral reflux, which raised suspicion of obstructive uropathy at the level of vesicoureteral junction. Serum sodium normalized after several days of intravenous fluids and antibiotic therapy, after which oral supplementation of sodium was introduced. The levels of 17-hydroxyprogesterone, adrenocorticotropic hormone, cortisol and thyroid-stimulating hormone were normal. Functional magnetic resonance urography conducted at the age of 3 months confirmed the diagnosis of primary congenital obstructive megaureter and the infant was referred to a pediatric surgeon. Although a rare occurrence, S-PHA can be a potentially life-threatening condition in infants if not recognized and treated appropriately. Therefore, serum concentrations of electrolytes should be obtained in every child diagnosed with obstructive anomaly of the urinary tract and/or acute cystopyelonephritis. On the other hand, every child diagnosed with S-PHA should be evaluated for obstructive anomaly of the urinary tract.

Melatonin as an alternative sedation method during magnetic resonance imaging in preschool children with musculoskeletal problems.

Magnetic resonance imaging (MRI) in preschool children is often challenging due to excessive motion artifacts. Sedation or general anesthesia (GA) is commonly used to prevent children from moving in the MRI scanner, with increased risk for cardiopulmonary complications and requirement for skilled personnel. Herein, we investigated whether oral melatonin, a natural hormone implicated in circadian rhythm regulation, could be used as an alternative sedation method prior to the MRI in preschool children with musculoskeletal problems. Fifteen children with suspected juvenile idiopathic arthritis underwent a total of 16 MRI examinations following administration of 10 mg of oral melatonin; satisfactory images were obtained in all but one case, with no adverse events. CONCLUSION: The use of melatonin before the musculoskeletal MRI in preschool children is an effective, safe, and inexpensive alternative to standard sedation and general anesthesia in preventing motion artifacts. What is Known: • Magnetic resonance imaging (MRI) is a well-recognized diagnostic method to visualize synovial inflammation and changes of cartilage and bone in juvenile idiopathic arthritis. • MRI examination requires sedation or general anesthesia to ensure immobility in children who are uncooperative. What is New: • Melatonin without sleep deprivation is efficacious and safe alternative to conventional sedation and general anesthesia before the musculoskeletal contrast-enhanced MRI in preschool children with JIA with timely insertion of intravenous cannula.

Correction to: Melatonin as an alternative sedation method during magnetic resonance imaging in preschool children with musculoskeletal problems.

AbstractMagnetic resonance imaging (MRI) in preschool children is often challenging due to excessive motion artifacts. Sedation or general anesthesia (GA) are commonly used to prevent children from moving in the MRI scanner, with increased risk for cardiopulmonary complications and requirement for skilled personnel. Herein we investigated whether oral melatonin, a natural hormone implicated in circadian rhythm regulation, could be used as an alternative sedation method prior to the MRI in preschool children with musculoskeletal problems. Fifteen children with suspected juvenile idiopathic arthritis underwent a total of 16 MRI examinations following administration of 10 mg of oral melatonin; satisfactory images were obtained in all but one case, with no adverse events.Conclusion: The use of melatonin before the musculoskeletal MRI in preschool children is an effective, safe and inexpensive alternative to standard sedation and general anesthesia in preventing motion artifacts. What is known: • Magnetic resonance imaging (MRI) is a well-recognized diagnostic method to visualize synovial inflammation and changes of cartilage and bone in juvenile idiopathic arthritis.• MRI examination requires sedation or general anesthesia to ensure immobility in children who are uncooperative. What is new: • Additional to previous published studies we were able to show that melatonin for sedation for an MRI of joints, even without sleep deprivation, in the studied population may provide an alternative in children without behavioral problems, in order to avoid sedation/GA.

[CONTRAST ENHANCED VOIDING UROSONOGRAPHY (CEVUS) IN THE DIAGNOSIS OF VESICOURETERAL REFLUX]. / MIKCIJSKA UROSONOGRAFIJA POJACANA KONTRASTOM (CEVUS) U DIJAGNOSTICI VEZIKOURETERALNOG REFLUKSA.

Vesicoureteral reflux (VUR) is one of the most common urinary tract anomalies in children and can be associated with reflux nephropathy (RN). Some patients with RN develop chronic kidney disease, hypertension and a small number of patients progress to end-stage renal disease. Early detection of children with these clinical characteristics should be the goal of clinical, biochemical, and radiological evaluation of patients presenting with prenatal hydronephrosis or febrile urinary tract infection. The goals of imaging procedure in general are to confirm the diagnosis suspected with a high degree of sensitivity and specificity, to aid treatment and allow prognosis. The diagnosis of vesicoureteric reflux (VUR) is a relatively straightforward and well-established procedure. There is increasing awareness of the risks of radiation exposure and invasivness of VUR investigation which can be unpleasant experience for both child and parents. Currently, contrast enhanced voiding urosonography (ceVUS) is a radiation free, highly sensitive imaging modality for vesicoureteral reflux (VUR) and urethral imaging in children. It employs ultrasound technology (contrast-specific software) in combination with commercially available second generation ultrasound contrast administered intravesically via a bladder catheter.

An innovative diagnostic procedure in children: videourodynamics with contrast-enhanced voiding urosonography.

Contemporary videourodynamic (VUD) investigation combines voiding cystourethrography (VCUG) and urodynamics into one study, which allows simultaneous visualization of the urinary tract by ionizing radiation alongside the measurement of sensation, capacity, compliance, and detrusor pressure during bladder filling and voiding using one double lumen catheter. Today VUD is a benchmark for evaluating the lower urinary tract disorders in children because it evaluates urinary bladder and sphincter function and visualizes bladder morphology and vesicoureteral reflux (VUR) presence at the same time. Several previous studies of fluoroscopic videourodynamics issued concerns regarding radiation exposure. This technical report aims to describe a new modality of VUD in children by replacing fluoroscopic VCUG with contrast-enhanced voiding urosonography (ceVUS). ceVUS using second-generation contrast media and harmonic imaging is a radiation-free and highly sensitive imaging modality used to detect VUR in children. We simultaneously performed an infusion of ultrasound contrast through the double lumen urodynamic catheter during urodynamic evaluation. This article describes the advantages of this method compared with a conventional technique. In addition to being radiation-free, this procedure of advanced videourodynamics method can better detect vesicoureteral reflux and intrarenal reflux combined with urodynamic disorders associated with VUR.

Rehabilitation approach and results of using the biofeedback method (GIGER MD device) in children with neurogenic bladder.

Background: GIGER MD device applies a biofeedback method through stimulated coordinated rhythmic and dynamic movements of the trunk and extremities in an anti-gravity position, thus helping to regain lost motor functions. Methods: In this article, the performance of the GIGER MD device was evaluated in 36 children with neurogenic bladder measuring gait speed, voiding bladder capacity, deviation from the age-adjusted bladder capacity (measured using the Koff scale), and urinary incontinence. Results: Children using the GIGER MD device had an increase in voiding bladder capacity (33.79%, median volume increase of 50 ml) with a subsequent median decrease in median age-adjusted bladder capacity by 45.50% (median deviation before was 36% vs. 16% after treatment). The number of urinary incontinence episodes also reduced by 55.57% (7-3 episodes per day), and the 20-meter motor gait speed increased by 14.26% (from 23 to 19 s). Conclusion: Children who follow the GIGER MD therapy regularly for a period of 6 months show that CNS functional damage can be significantly improved.

Inherited Thrombophilia Associated With Ischemic Pediatric Stroke in Parent-Child Pairs.

BACKGROUND: We aimed to examine inherited thrombophilia frequencies by extending genetic profile to previously rarely or not investigated polymorphisms in children with ischemic pediatric stroke (IPS) and their parents. METHODS: The study included 33 children: 23 with perinatal arterial ischemic stroke (PAIS), eight with childhood arterial ischemic stroke (CAIS), and two with sinovenous thrombosis and their parents (33 mother-child, 12 father-child, and 12 mother-father-child pairs). Genotyping of FV-Leiden, FV-H1299R, FII-G20210A, ß-fibrinogen-455G>A, FXIII-A-Val34Leu, PAI-1(4G/5G), HPA-1, MTHFR-C677T, MTHFR-A1298C, ACE(I/D), and APOE(ε2-4) was performed using CVD Strip assay (ViennaLab, Austria). RESULTS: At least one and up to seven simultaneously present polymorphisms were observed in all children with IPS, mothers, and fathers. More than five simultaneously present polymorphisms were identified threefold more frequently in children with IPS (10 of 33; 30%) compared with the child control group (17 of 150; 11%), yielding a statistically significant difference between the two groups (odds ratio [OR] = 3.40; 95% confidence interval [CI] = 1.39 to 8.35; P = 0.012). Stronger association was revealed for PAIS (OR = 4.17; 95% CI = 1.55 to 11.29; P = 0.008) and CAIS subgroups (OR = 7.82; 95% CI = 1.79 to 34.20; P = 0.012). Complete match of polymorphisms was not identified in any parent-child pair. A partial match (one to four mutual polymorphisms) was found in 11 of 12 parent-child pairs where until three mutual polymorphisms was present in 11 of 12 (91.7%) father-child compared with 21 of 33 (63.6%) mother-child pairs. CONCLUSIONS: According to obtained results the simultaneous presence of more than five polymorphisms is associated with a higher risk for IPS occurrence, suggesting the risk enhancement for PAIS in the presence of pregnancy complications or for CAIS in conjunction with maternal comorbidity and positive family history. The presence of up to three mutual polymorphisms more frequently in father-child than mother-child pairs suggests significant paternal contribution of inherited thrombophilia to increased risk of IPS.

Causal connection of non-specific low back pain and disc degeneration in children with transitional vertebra and/or Spina bifida occulta: role of magnetic resonance--prospective study.

The problem of low back pain (LBP) in children is very common and many specialists are dealing with it in everyday practice. The cause for low back pain often is not found and classified under the diagnosis of non specific low back pain. The objective of this prospective study is to determine wether children with non specific low back pain and existence of anomalies in LS spine (transitional vertebra- TV and/or Spina bifida occulta SBO) also have the degeneration of the intervertebral disc (DD) L4-L5 and/or L5-S1. This prospective study included 69 patients from 8 to 16 years of age (X 12.81) of whom 40 were male (57.97%), and 29 female (42.03%). They all were examinated in University of Zagreb, "Sestre milosrdnice" University Hospital Center, Zagreb Children's Hospital, Department of Orthopaedic, Zagreb, Croatia. The reason of their visit was non specific low back pain. Pain was measured by visual analog scale (VAS) and mean score was three, duration of pain was between two and four weeks. Also, pain was sporadic, during daytime and not connected with level of physical activity. They all have undergone an algorithm of radiological examinations. Standard AP and LL radiographs (RTG) were made, as well as magnetic resonance (MR) of LS spine and sacrum in sagittal and transversal plane in T1 and T2 weighted sequence. The anomalies of L5 and S1 were found in 65 patients: transitional vertebra classified according to Castellvi et al. and SBO. In MRI in T2 weighted sequence DD was found in 61 patients which was classified modified from Pearce. Data analysis and comparison showed that 56patients with TV and/or SBO have changes on vertebral dynamic segment L5-S1 (VDS) and that means DD. In 13 patients only DD or spinal anomaly (TV and/or SBO) were found. Correlation between anomalies and DD in those patients was established by McNemar analysis and has shown significant difference (p=0.581) in favour of the patients with anomaly and DD. This has established that all of 56 patients with spinal anomaly could have DD as known cause of LBP.

Contrast-enhanced voiding urosonography in the diagnosis of intrarenal reflux.

PURPOSE: Although contrast-enhanced urosonography (ceVUS) has shown capable diagnostic accuracy for the diagnosis of vesicoureteral reflux (VUR) in children, the ability of ceVUS to detect intrarenal reflux (IRR) is considered limited. The purpose of our study is to assess the ability of ceVUS to detect IRR as well as its association with age, gender, and the grade of VUR. METHODS: This study included 5153 children who were referred to our clinic for ceVUS. All children underwent sonographic examinations, which were performed on a LOGIQ S8 machine equipped with dedicated software for contrast-enhanced studies with harmonic imaging. Standard ultrasound of the urinary tract was followed by bladder catheterisation and instillation of physiological normal saline and the US contrast medium (SonoVue®, Bracco). RESULTS: VUR was diagnosed by ceVUS in 1959 out of 5153 children (38%), of whom IRR was found in 233 of 1959 children (11.9%). A total of 285 ureteral units showing IRR were found. High grades of VUR (IV + V) with IRR were found in a total of 235 of 285 (82.81%) renal units. Bilateral IRR was found in 53 patients, usually with a high-grade VUR on both sides. Most children had VUR grade IV, predominantly those < 12 months. The younger the child, the higher the likelihood of higher-grade VUR (p = 0.02). CONCLUSION: ceVUS, combined with harmonic imaging and second-generation ultrasound contrast media, enabled IRR detection in almost 12% of our patients with VUR. IRR is most commonly found in children under 1 year of age with VUR grades IV and V.

Seroprevalence of SARS-CoV-2 infection among children in Children's Hospital Zagreb during the initial and second wave of COVID-19 pandemic in Croatia.

INTRODUCTION: The study aimed to investigate the prevalence and titres of anti-SARS-CoV-2 antibodies in children treated at the Children's Hospital Zagreb in the first and the second wave of the COVID-19 pandemic. Statistical significance of difference at two time points was done to determine how restrictive epidemiological measures and exposure of children to COVID-19 infection affect this prevalence in different age groups. MATERIALS AND METHODS: At the first time point (13th to 29th May 2020), 240 samples and in second time point (24th October to 23rd November 2020), 308 serum samples were tested for anti-SARS-CoV-2 antibodies by enzyme-linked immunosorbent assay (ELISA) and electrochemiluminescence immunoassay (ECLIA). Confirmation of results and titre determination was done using virus micro-neutralization test. Subjects were divided according to gender, age and epidemiological history. RESULTS: Seroprevalence of anti-SARS-CoV-2 antibodies differs significantly in two time points (P = 0.010). In first time point 2.9% of seropositive children were determined and in second time point 8.4%. Statistically significant difference (P = 0.007) of seroprevalence between two time points was found only in a group of children aged 11-19 years. At the first time point, all seropositive children were asymptomatic with titre < 8. At the second time point, 69.2% seropositive children were asymptomatic with titre ≥ 8. CONCLUSIONS: The prevalence of anti-SARS-CoV-2 antibodies was significantly lower at the first time point than at the second time point. Values of virus micro-neutralization test showed that low titre in asymptomatic children was not protective at the first time point but in second time point all seropositive children had protective titre of anti-SARS-CoV-2 antibodies.

Contraception-related deep venous thrombosis and pulmonary embolism in a 17-Year-old girl heterozygous for factor V leiden, prothrombin G20210A mutation, MTHFR C677T and homozygous for PAI-1 mutation: report of a family with multiple genetic risk factors and review of the literature.

We present the case of a 17-year-old girl who suddenly woke up with localized pain in the left groin and the inability to twist her leg. After comprehensive physician and laboratory examinations, deep venous thrombosis with consequent pulmonary embolism was ascertained. She had not experienced any recent trauma, but she had started to take oral contraceptives 6 months prior to the onset of the symptoms. Her parents and sisters had been asymptomatic throughout their lives, but the family history revealed a few thromboembolic accidents. Using DNA analysis, heterozygosity for factor V Leiden, prothrombin gene mutation G20210A and methylenetetrahydrofolate reductase C677T, as well as the homozygous 4G/4G genotype in the plasminogen activator inhibitor 1 were identified in our patient. Subsequently, DNA analysis was performed in all living family members, and multiple factors associated with thrombophilia were discovered. Our case confirms the multifactorial cause of thromboembolic events and emphasizes the importance of oral contraceptive use in the onset of venous thrombosis, especially in teenage females. In addition, this case indicates that teenage females with a family history of thrombosis who are making choices about contraception could most likely benefit from advanced thrombophilia testing.

Is axial magnetic resonance imaging useful in early juvenile spondyloarthritis-preliminary report.

INTRODUCTION/OBJECTIVES: Magnetic resonance imaging (MRI) is recommended for evaluation of changes in juvenile spondyloarthropathies (JSpA). To our knowledge, there is no previous prospective study analysing early changes on axial MRI. The objective is to investigate incidence of reparable changes on axial MRI in patients with established JSpA, lasting for less than 6 months. MATERIALS AND METHODS: The pilot study included 27 patients with confirmed diagnosis of JSpA examined within 2 years. Prior to imaging, basic demographic and laboratory data and HLA-B27 were collected. Patients filled out a visual analogue scale for pain and a childhood health assessment questionnaire. A paediatric rheumatologist and a paediatric physiatrist examined patients and measured indices of flexion, extension and sagittal flexibility. Contrast-enhanced axial MRI examination and cervical x-ray were performed. Three experienced paediatric radiologists independently reviewed x-ray and MRI images of all patients. RESULTS: There was no significant correlation between early changes detected on MRI and other parameters. The study revealed early changes of the cervical spine to be the most common finding. More patients had positive cervical MRI than positive sacroiliac joint (SIJ) MRI. Cervical x-ray and MRI were equally useful for diagnosis regardless of other parameters. CONCLUSION: Study showed new information on axial involvement, striking cervical spine as the most involved part. The biggest study limitation is the small number of patients. Establishing early JSpA diagnosis is of utmost importance, especially in the light of novel therapy introduced in every day practice. It seems that cervical spine involvement is more represented than previously described in literature, especially in comparison with SIJ. Key Points • Contrast-enhanced MRI is considered the gold standard for detection early changes in JSpA. • Standardization of diagnostic criteria and better classification of changes using the unique scoring system for children are necessary. • It seems that cervical spine involvement is more represented than previously described in the literature, especially in comparison with SIJ involvement.

Atherosclerotic lesions of supra-aortic arteries in diabetic patients.

The aim of this prospective study was to determine the prevalence and localization of stenotic atherosclerotic lesions of supra-aortic arteries in diabetic patients according to age and sex. Angiograms obtained by digital subtraction angiography were analyzed in 150 diabetic patients (study group) and 150 non-diabetic patients (control group) with symptoms of cerebral ischemia. Diabetic patients were found to have a significantly higher prevalence of stenotic atherosclerotic lesions of the internal carotid artery. Lesions of the large supra-aortic arteries were significantly more common in the left than in the right side of the neck (p < 0.001), but the difference between the diabetic and the non-diabetic group did not reach statistical significance. Hemodynamic conditions were found to be more important than diabetes for the occurrence of atherosclerotic lesions in these arteries. Changes in the proximal segment of the left common carotid artery were the most common finding in diabetic patients, hence attention should be paid to this localization on control examinations.

[Laparoscopic decapsulation of congenital splenic cyst]. / Laparoskopska dekapsulacija prirodene ciste slezene.

Nonparasitic splenic cysts are uncommon and may be congenital or post-traumatic in origin. Complications may include enlargement with pain, rupture, and infection. The laparoscopy is widely accepted method in the treatment of this condition with numerous approaches. A technique of partial decapsulation-fenestration designed to minimize the risk of splenic loss and cyst recurrence is presented.

Ataxia Telangiectasia and Juvenile Idiopathic Arthritis.

We report, to the best of our knowledge, the first case of a child with typical ataxia telangiectasia (A-T) who developed juvenile idiopathic arthritis (JIA). The patient was a 15-year-old boy with A-T who presented with noninfectious polyarthritis. A-T is a rare, autosomal recessive disorder characterized by cerebellar atrophy, oculocutaneous telangiectasia, immunodeficiency, radiosensitivity, and predisposition to cancer. The gene responsible for A-T is the A-T mutated (ATM) gene. Clinical manifestations of the disorder are the result of lacking ATM protein, which is involved in DNA repair, apoptosis, various checkpoints in the cell cycle, gene regulation, translation, initiation, and telomere maintenance. There are a few articles that describe deficiency of the DNA repair enzyme, ATM, in rheumatoid arthritis, but the connection between the absence of ATM protein and JIA has not been presented or studied yet. JIA is a heterogeneous group of diseases characterized by arthritis of unknown origin with onset before the age of 16 years. It is the most common childhood chronic rheumatic disease and causes significant disability. Because immunodeficiency can be part of A-T, infectious arthritis can occur, but chronic autoimmune arthritis in these patients is rare. We report a rare case of a 15-year-old boy with A-T and JIA. This case shows a possible relationship between altered function of ATM protein and the pathogenesis of JIA.

Using magnetic resonance imaging to identify the lumbosacral segment in children.

Identification of the lumbosacral (L-S) segment on magnetic resonance (MR) images is important for appropriate treatment of disease in the lumbosacral (L-S) area. In the study, data obtained from plain A-P radiographs of the L-S spine and sagittal MR imaging scans (sagittal T1- and T2-weighted sequences) of the L-S spine and sacrum with the coccygeal bone, are analyzed. Twenty-six children aged 10 to 14 years were examined for back pain. On the standard A-P radiographs of the L-S spine, a L-S transitional vertebra as classified according to the method of Castellvi et al. was found in 17 subjects. The problem arose as to whether this was lumbalisation or sacralisation, and how to determine which vertebra was L5 wich S1. On the sagittal MR imaging studies the same question applied. A need emerged for a simple method which would identify the L-S segment on the sagittal MR imaging studies of the L-S spine in children so that in case of a tumor, inflammation, spondilolystesis, or protrusion of a disc, the level in the L-S spine where the problem is localized can be accurately identified. To this objective we selected the method using detection of the S1 vertebra. This involved that, in addition to the sagittal MR imaging scans of the L-S spine, sagittal images of the sacrum and coccygeal bone be also obtained. on the T2-weighted sequence, the sacrum can be clearly distinquished from the coccygeal bone. By counting from the S5 up, the S1 vertebra can be accurately identified. Determination of the S1 vertebra enables detection of the L5 vertebra and, in turn, of all other lumbar vertebrae. In patients in whom a T2-weighted MR studies were done S1 could be precisely determined and so could the L5 vertebra. In this process, whether the patient had a transitional vertebra or whether there was lumbarisation or sacralisation was irrelevant.

Lung ultrasound in the diagnosis of pediatric pneumonia: Are we ready for routine use?

No abstract available.

Efficacy and safety of propofol sedation during urgent upper gastrointestinal endoscopy--a prospective study.

The aim of this study was to investigate both the efficacy and safety of sedation with propofol during urgent therapeutic gastroscopy in patients with upper gastrointestinal bleeding. This prospective study included a total of 110 patients. Propofol was administered intravenously at the starting dose of 1 mg/kg body weight and was followed by repeated doses. Oxygen saturation and heart rate were monitored by pulse oxymetry. The mean dose of propofol administered was 161 +/- 49 mg. Urgent upper GI endoscopy under propofol sedation was successful in 98% of cases. Endoscopists rated the sedation as good in 83.6%, satisfactory in 14.5%, and poor in 1.8% of patients. Potentially harmful drop in oxygen saturation below 85% was observed in 5.5% of patients, whereas a temporary drop in heart rate below 50 beats/min was observed in 11.8%, not requiring any intervention. Almost 93% of patients could not remember the beginning or the end of the intervention. This data demonstrates that sedation with propofol is suitable for use in patients with upper gastrointestinal bleeding undergoing urgent endoscopy.

Klatskin tumor--results of surgical therapy.

Between January 1st 1990 and December 31st 1999, 24 patients affected by Klatskin tumor underwent operation in our department of surgery. According to Bismuth's classification, there were 0 (0%) type I, 5 (21%) type II, 6 (25%) type IIIa, 4 (17%) type IIIb and 9 (37%) type IV tumors. Five patients (21%) were treated by curative resection (group I) while in 14 patients (58%) palliative surgical procedure was performed (group II). In 5 cases (21%) the extension of malignancy did not allowed any procedure (group III). Curative resection for malignant tumors of the hepatic duct bifurcation included wide tumor excision and bile duct resection at the liver hilum (with wedge hepatic resection in one patient) and creation of biliary-enteric anastomosis. Palliative surgical procedure included stent insertion. Jaundice was completely relieved in all patients undergoing resection, since 3 patients (21%) after stenting hadn't satisfactory biliary drainage. There was 1 (20%) perioperative death in the group 1, while in group 2, 5 patients (36%) died postoperatively. In this series, the mean postoperative survival of all patients was 16 months. The mean postoperative survival of patients undergoing localized tumor resection with curative intent was 38 months, in contrast to 10 months for those undergoing operative stent insertion. in addition, only 1 patient from group III, in whom only exploratory surgery were performed survived 7 months, while other 4 patients died in the hospital. This retrospective review suggests that aggressive surgical treatment could improve survival and quality of life in patients suffering from Klatskin tumor.