Long-term effects of elevated intra-abdominal pressure on testes an experimental model of laparoscopy.

PURPOSE: To determine the long-term outcomes of pneumoperitoneum on the testes in an experimental laparoscopy model. MATERIALS AND METHODS: Twenty-four rats were divided into three groups: Group A, the control group; Group B, exposed to a 10 mmHg intra-abdominal pressure (IAP); and Group C, exposed to a 20 mmHg IAP with CO2 pneumoperitoneum for 60 minutes. After 6 weeks, the testes were removed, and testicular injury score and Johnson score were examined histologically. Germ cell apoptosis was also detected using flow cytometry. RESULTS: A significant difference was determined between all groups in terms of testicular injury scores, Johnson scores, and germ cell apoptosis percentages. For the testicular injury score, there were significant differences between the groups for the right testis (group A versus B, P = .009; group A versus C, P < .0001; and group B versus C, P = .001) and for the left testis (group A versus B, P = .001; group A versus C, P < .0001; and group B versus C, P = .002). Significant differences were determined in the Johnson scores for the right testis between all groups (group A versus B, P= .001; group A versus C, P < .0001; and group B versus C, P = .008, respectively). Percentage of apoptotic testis cells were significantly differed between all groups (P = .001 for each). CONCLUSION: This study shows that increased IAP during pneumoperitoneum causes histopathology and apoptotically-evident damage to the testes in the long-term, depending on the magnitude of IAP increase, which may cause sub/infertility. Considering the experimental nature of this study,further clinical studies are needed for a more decisive conclusion.

Bloody nipple discharge in children: possible etiologies and selection of appropriate therapy.

An understanding of underlying causes of bloody nipple discharge (BND) is necessary to be able to advise treatment guidelines of this rare symptom in the pediatric age group. Of 11 patients with 14 breasts that had BND, data regarding age, sex, side and duration of BND, physical examination findings, laboratory values, culture reports, ultrasonography (US) findings, treatment approach, histopathologic details, and outcomes were obtained, and also, literature was reviewed. The patients were between 3 months and 12 years of age. There were six males and five females. The BND was located in the right breast in six patients, in the left in two, and it was bilateral in three. On physical examinations, seven patients had palpable cystic nodules located at the areolar area and three had a diffuse breast enlargement without skin findings. Laboratory investigations showed normal hormone levels in all patients. At US examinations, seven breasts had cystic lesions, three had hypoechoic tissue in the subareolar region, and others had normal US findings. In a girl with positive culture for Staphylococcus aureus, BND resolved after oral antibiotics. Two cases resolved spontaneously, with 6 months and 4 months follow-up periods, respectively. Surgical intervention was performed for the remaining eight patients, and mean time to operation after onset of symptoms was 10 months (range = 1-34 months). Histopathologic findings showed that the underlying cause of BND was duct ectasia in five breasts, gynecomastia in three, and fibrocystic change in two. Their follow-up periods ranged between 3 months and 6 years, and no recurrences were observed. Classification of breasts with BND for selecting appropriate therapy on the basis of results of careful physical examination, with an US evaluation in selected cases, is effective, and prevents unnecessary investigations.

Congenital paraesophageal hiatal hernia: pitfalls in the diagnosis and treatment.

PURPOSE: The aim of this study was to analyze pitfalls in the diagnosis and treatment of congenital paraesophageal hiatal hernia (PEHH). METHODS: Between 1992 and 2004, the records of 5 infants with PEHH were retrospectively reviewed for age, sex, presenting symptoms, radiological studies, operative findings and approaches, and outcomes. RESULTS: All cases (3 male, 2 female) had right-sided hernias. They had clinical features of recurrent chest infections and intermittent vomiting that were present since birth in 3. Three presented acutely ill with findings of respiratory distress and vomiting. Three were referred with misdiagnoses of reflux disease, thoracic mass, and bronchopneumonia. On the chest x-rays of 3 cases, there were paracardiac opacities suggesting a mass lesion. According to the upper gastrointestinal series and/or computed tomography findings, 4 cases had a combination of sliding and paraesophageal hernia, and the remainder one had pure rolling hiatus hernia. Three had obstruction owing to organoaxial volvulus and required an emergency operation. All cases had a large hernia orifice. Four had gastroesophageal junction (GEJ) displaced into the thorax, and in 3, the stomach was found to be twisted, and transverse colon with omentum was also in the thorax in 2. In the remainder, the GEJ was in its normal position with herniated stomach. None of the cases had normal gastrosplenic and gastrocolic ligaments. Surgical repair included resection of the sac, closure of the hiatal defect, and Thal procedure. Two had intestinal malrotation, with right ovarian torsion and ventricular septal defect, respectively. Postoperative ventilation was required in one who later died. At a mean follow-up of 2 years, the other 4 had no symptoms related to the disease, and no evidence of recurrence or reflux was noted on control upper gastrointestinal series. CONCLUSION: Congenital PEHH may be difficult to diagnose. It is frequently complicated and associated with morbidity and even mortality. If the defect is large and associated with displacement of GEJ into the thorax, adding an antireflux procedure to the repair is appropriate.