The multivariate analysis of indications of rigid bronchoscopy in suspected foreign body aspiration.

OBJECTIVE: Foreign body aspiration (FBA) could be a serious life-threatening condition in children. Patients usually underwent bronchoscopy with suspicious of FBA alone. In this study, we aimed to determine which patients need to go to bronchoscopy based on pre-operative findings. METHODS: Retrospective analysis of patients underwent bronchoscopy between 1999 and 2015 was performed. Clinical symptoms, witnessed aspiration event (WAE), physical examination findings (PEFs) and radiological findings (RFs) were analyzed by multivariate analysis to evaluate the indications of bronchoscopy. RESULTS: 431 patients (266M, 165F) underwent bronchoscopy with a median age of 2 years (7 months-16 years). A foreign body was detected in 68% of the patients. Univariate analysis demonstrated that wheeze was the sole distinctive clinical symptom for detection of FBA (p<0.001). The rates of positive WAE, PEFs and RFs were 83%, 71.7% and 36.9%, respectively. All of them were identified as independent predictive parameters in the detection of FBA by univariate analysis (p = 0.003&p<0.001&p = 0.015). Multivariate analysis was performed with considering the association between them. The rate of positive bronchoscopy was 91.3% in patients with positive WAE, PEFs and RFs together(84/92). In patients with a positive WAE alone who had not got PEFs and RFs, the rate of positive bronchoscopy was 34.2% (25/73). A foreign body was detected in 84% of the patients who had not got a WAE but positive PEFs and RFs together(21/25). Bronchial laceration was occurred in one patient during bronchoscopy. Pneumothorax was not seen in any of the other patients. The rate of mortality was 0.4% in the overall group (2 patients). CONCLUSION: The indications of bronchoscopy in suspected FBA are usually based on clinical suspicious. The definition of " suspicous" could be a WAE or positive PEFs and RFs. The association of these factors increase the rate of positive bronchoscopies. In the light of our study, the classical indication for suspected FBA is still valid as "suspicious requires bronchoscopy".

An unusual case of epigastric heteropagus: parasite with a rudimentary heart.

Parasitic or heterotopic conjoined twins are exceedingly rare, and these cases are referred to as "heteropagus" when there is a parasitic attachment in a nonduplicated fashion to any portion of the body. Epigastric heteropagus twinning refers to the attachment of the parasite to the epigastric region of the autosite. An unusual epigastric heteropagus case is presented with a rudimentary cardiopulmonary and also nearly complete gastrointestinal and genitourinary system of the parasite, and an organogenetic and vascular status of the previously reported cases are reviewed. The current case might be unique for the parasite having a cardiopulmonary development--although rudimentary--and this might be the reason that it has more complete organogenesis than the cases that have been presented previously in the literature.

Primary pancreatic hydatid disease in a child: case report and review of the literature.

A 9-year-old boy was admitted with acute abdomen, and a cystic mass in the pancreas was coincidentally detected by ultrasonography. Definitive diagnosis of hydatid disease of the pancreas could be made only at operation, and surgical therapy was effective.

Blood transfusion requirements in children with blunt spleen and liver injuries.

The records of 174 children sustaining blunt spleen and liver injuries in a 16-year period were analyzed retrospectively to determine blood transfusion requirements in surgically versus conservatively managed patients. The whole study group consisted of 97 spleen, 70 liver, and 7 combined spleen and liver injuries respectively. Seventy-eight patients were managed conservatively while 96 children had undergone various operative procedures. The hematocrit (Hct) values, transfused blood volumes (ml/kg), and length of hospital stay were compared between the non-operative and operative treatment groups. Although the initial Hct values were found to be similar in non-operative versus operative groups (26.7% +/- 2.7% vs. 24.8% +/- 3.5%), transfused blood volumes were significantly higher in the surgically treated group respectively (20.9 ml/kg vs. 39.5 ml/kg) (p < 0.05). Similarly, mean length of hospital stay was longer in the surgical groups. Associated injuries were seen in 105 (60.3%) patients distributed randomly among two study groups. Twelve patients in the series died of other system/organ involvement. There were no deaths in isolated spleen and/or liver injuries. Increased blood transfusion requirement in surgical groups may be due to excessive bleeding prior to the operation which virtually provides the indication for laparotomy. Manipulation and suturing enhances additional bleeding to elevate the total volume to be delivered. Operative choice should be spared for very selected cases, and conservative management is safe; procedures such as splenorrhaphy are not superior to observation therapy as a means of controlling intraabdominal bleeding.

Management of pneumothorax in children.

BACKGROUND: The efficacy of tube thoracostomies inserted at the sixth intercostal space at midaxillary line was evaluated retrospectively in children. METHODS: Ninety-seven children with pneumothorax, treated by tube thoracostomy were taken into the study. There were 67 male and 30 female patients with a mean age of 6.5 years (range 1 days to 15 years) RESULTS: Pneumothorax was located at the right side in 50 (51.5%), and at the left in 38 (39.1%) of the cases. Bilateral pneumothorax was found in 9 additional patients (9.2%). All patients were treated with tube thoracostomy placed in the pleural cavity at the sixth intercostal space at the mid-axillary line. Postoperative course was uneventful and no complication was encountered at any of the patients. CONCLUSIONS: On the basis of these data we suggest that all thoracostomy tubes should be inserted on the sixth intercostal space where both air and the accumulating fluid can be reached. The insertion of the thoracostomy tube at the second intercostal space must be avoided since it carries a high risk of subclavian vein injury in small children, and also a secondary tube is frequently required to drain the accompanying intrapleural fluid.

Characteristics of multisystem organ failure in neonates.

The records of 45 neonatal deaths in a four year period were reviewed retrospectively. Sixteen patients (35.5%) developed multisystem organ failure (MSOF). The criteria for pulmonary, hepatic, renal, hematologic, cardiac and microvascular failures were established. The onset of the first organ involvement was calculated in days prior to death. The earliest organ involved was kidney (14.2 +/- 15.1) followed by microvascular (9.4 +/- 7.6), hematologic (84. +/- 10.1), liver (6.8 +/- 6.7), lung (6.3 +/- 6.6) and cardiac (6.0 +/- 8.7) failure. Blood culture analyses revealed 5 patients with culture-positive sepsis. Yeast was the leading septic agent (n = 3) followed by Klebsiella pneumoniae (n = 2), Pseudomonas sp. (n = 1) and E. coli (n = 1). The first organ involvement was noted at 17.6 +/- 23.2 days. We concluded that the sequence of neonatal MSOF is different from that of adults, yet the inciting events are not clear-cut. Lung, which is the first organ involved in adults, seems to be a lately involved organ in neonates.

Effects of H2 receptor blocking agents on bacterial translocation in burn injury.

We experimentally studied the effects of H2 receptor blockers (ranitidine) on bacterial translocation (BT) in 42 male albino rats. Sham group (Group I, n = 12 rats) were exposed to 21 degrees C water while Burn group (Group II, n = 15 rats) and Ranitidine group (Group III, n = 15 rats) were exposed to 95 degrees C hot water for 10 seconds to produce a full thickness burn in 30% of total body surface area. 300 mg/kg ranitidine was administered to Group III starting immediately after the burn injury. Rats were sacrificed on the fifth postburn day. Sham group gained weight while groups II and III had significant weight loss. Gastric pH increased with the administration of ranitidine. Both gram negative and total number of bacteria were found to be reduced in cecal stool cultures in ranitidine group. Significant increase in BT was observed in Group III, and translocating bacteria were found to be different in burn and ranitidine groups with a final conclusion that administration of ranitidine changes intestinal ecological equilibrium and promotes BT.

Evaluation of the lower urinary tract function in caudal duplication (dipygus) anomaly.

Caudal duplication is a rare anomaly with less than 30 reported cases. For those patients who also have double bladders, there are not enough data regarding the function of the lower urinary tract. A boy with caudal duplication anomaly was evaluated fluoroscopically and urodynamically. The results of the evaluation showed that the bladders were filling and emptying synchronously with normal and almost identical detrusor pressures. The child did not require either or both bladders to be resected. Because the level of the duplication in dipygus cases varies, thorough evaluation of the lower urinary tract, including urodynamics, should be considered for every case.

Gastrointestinal perforations in children: a continuing challenge to nonoperative treatment of blunt abdominal trauma.

The present trend towards conservative management of hemodynamically stable pediatric trauma patients may be increasing the risk of delay in the diagnosis of traumatic hollow viscus perforations (HVP). The purpose of this study is to determine whether there is a delay in the diagnosis of HVP because of expectant management. A survey of factors leading to diagnostic delay was also made and the value of current diagnostic tools were reevaluated. In 1,283 trauma admissions between 1980-1994, 34 patients were operated for HVP caused by blunt abdominal trauma. Sites of perforation were; stomach (four), duodenum (five), jejunum (12), ileum (nine), and jejunum/ileum (four). Signs of peritoneal irritation were positive in 32 of 34 patients. There was free air in only six of 24 abdominal roentgenograms. Free peritoneal fluid without solid organ injury was detected in only four out of 13 patients with ultrasound. Peritoneal lavage was diagnostic in eight of nine patients. Time from admission to operating room averaged 24 +/- 4.1 (mean +/- standard deviation) hours. Eleven patients died after the operation mostly because of accompanying head injury. Only two of the deaths were the result of sepsis originating from the perforated bowel. There is an apparent delay in the diagnosis of traumatic HVP in this series. Signs of peritoneal irritation are the most consistent findings of HVP after blunt abdominal trauma in children. Persistence of abdominal signs indicates peritoneal lavage, which has a high diagnostic sensitivity for HVP compared to other diagnostic modalities.

Accumulation of 99Tcm-polyclonal immunoglobulin in different stages of infection: an experimental study.

In this experimental study, the utility of 99Tc(m)-polyclonal human immunoglobulin (99Tcm-HIG) for localizing acute and chronic phases of inflammatory lesions was investigated. Three groups of rats were inoculated with Staphylococcus aureus in the right thigh. Then, 24 h (group I, n = 12), 48 h (group II, n = 12) and 72 h (group III, n = 12) post-inoculation, the rats received 40 MBq 99Tcm-HIG into the jugular vein. In addition, two control rats were studied at 24 h after inoculation of sterile saline. Both visual and quantitative evaluations were undertaken. The acute and chronic stages of inflammation were determined by pathological examination. The mean ( +/- S.D.) lesion/contralateral uptake ratios at 4 and 24 h after 99Tcm-HIG injection were: group I, 1.22 +/- 0.1 and 2.12 +/- 0.16; group II, 1.15 +/- 0.08 and 2.25 +/- 0.16; group III, 1.06 +/- 0.09 and 2.08 +/- 0.14. In conclusion, the acute and chronic phases of infection showed non-significant differences in 99Tcm-HIG uptake ratios.

Microphthalmos associated with esophageal atresia.

The authors report on a neonate who had esophageal atresia and tracheoesophageal fistula associated with unilateral microphthalmos and glandular hypospadias. Primary repair of the esophageal defect was accomplished in the first week of life. This is the first report of such a combination of congenital anomalies.

Unilateral inguinal hernia in girls: is routine contralateral exploration justified?

To determine the incidence of contralateral hernia development after unilateral inguinal hernia repair in girls, collected case series from two large hospitals were analyzed retrospectively. Among the 294 girls who had analyzed repair of a unilateral inguinal hernia (during a 15-year period), 245 could be traced; the mean follow-up period was 8.4 years. In 25 (10.2%) of the patients, contralateral hernia developed, mostly within one year (4 months to 6.5 years). The incidence of contralateral hernia development with respect to the original side of the inguinal hernia was significantly higher (19%) for the originally left-sided hernias than for the right-sided ones (6%) (P < .01). Although the incidence of contralateral hernia development for girls with a left inguinal hernia decreased as age increased, it was still 14.9% for the girls age 3 and up. Contralateral exploration should not be routine for girls who have a right-sided hernia, at any age. For left-sided hernias, it may be performed routinely for girls up to 2 years of age, and selectively for older patients.

Traumatic rupture of mesenteric cyst: a life-threatening complication of a rare lesion.

Mesenteric cysts are very rare. Most of the cases are asymptomatic except when complicated. A mesenteric cyst ruptured due to trauma in a 3-year-old boy is described. It was diagnosed intraoperatively and treated surgically.

Microcolon-intestinal hypoperistalsis without megacystis: uncommon form of neonatal intestinal pseudoobstruction.

Two cases of microcolon-intestinal hypoperistalsis without megacystis are reported. They had dilated proximal small bowel and narrowed distal small bowel and malrotated microcolon. No organic obstructive intestinal lesion was found and double-barrel ileostomy was performed. The biopsy specimens showed ganglion cells to be normal in number and appearance in the entire intestinal wall. The ileostomy did not function postoperatively and drugs stimulating bowel movement failed to induce peristalsis. We have suggested that microcolon-intestinal hypoperistalsis without megacystis may be the cause of functional intestinal obstruction in neonates and it is a variant of megacystis-microcolon-hypoperistalsis syndrome.

Pulmonary hydatidosis in children.

In the years 1963-1991 inclusive, 88 patients were operated on with a diagnosis of pulmonary hydatid disease. The cysts were intact in 69 and infected in 19 cases. It was possible to use a surgical technique that preserved the pulmonary parenchyma in 67 patients. In this technique, the cavity after removal of the mother membrane is left open and only the air leaks are sutured. Continuous postoperative drainage of the residual cavity and the ipsilateral hemithorax always resulted in complete inflation of the affected lung. Enucleation of the endocyst and extended resection of the sclerotic pulmonary parenchyma were performed in 15, enucleation and obliteration in three, lobectomy in two and Barrett's method was applicable in one patient. A bronchopleural fistula developed in 11 patients postoperatively and in four of these cases a second thoracotomy was necessary. Postoperative empyema developed in four cases. There were two postoperative deaths in the series. Eighty-six patients were symptom-free in the long-term postoperative follow-up. We conclude that in the surgical management of the disease it should not be necessary to obliterate the residual cavity with extensive suturing which always leads to extra fibrosis with loss of viable pulmonary parenchyma.

Jugular phlebectasia in children.

Jugular phlebectasia is a congenital dilatation of jugular vein which appears as a soft, compressible mass in the neck only during straining or crying. It should be differentiated from laryngocele, cysts and tumors of neck which may also appear during straining. Comparable ultrasonography (US) and computerized tomography (CT) are diagnostic methods to distinguish the pathology. Four children with jugular phlebectasia diagnosed by venography, US and CT are reported. Surgical excision of the dilated segment was performed in each case. The inevitability of surgical intervention is discussed.