Fiberoptic endoscopic evaluation of swallowing (FEES) study: the first report in children to evaluate the oropharyngeal dysphagia after esophageal atresia repair.

BACKGROUND: The aim of this study was to evaluate the swallowing problems by fiberoptic endoscopic evaluation of swallowing (FEES) study in both short- and long-gap patients after esophageal atresia (EA) repair. METHODS: Hospital records of patients who had undergone surgery for EA were reviewed retrospectively. Patients were divided into two groups as short-gap (SG) group (n:16) and long-gap (LG) group (n:10) to compare the swallowing problems. FEES study was performed, and the results were discussed in detail. RESULTS: There were twenty-six (16 M/10 F) patients with a mean age at evaluation was 7.52 ∓ 3.68 years. Mean follow-up period was 75.35 ∓ 44.48 months. In FEES study, pharyngeal phase abnormalities were detected in 10 patients (38.4%). Pharyngeal phase abnormalities were detected significantly higher in LG group (p:0.015). Laryngeal penetration/aspiration was seen in four patients on FEES study (15.3%). All of them was in LG group (40%). Laryngeal penetration/aspiration was seen significantly higher in LG group (p:0.014). CONCLUSION: This is the first study to conduct FEES study in children after esophageal atresia repair to evaluate their swallowing conditions. Even though our sample is small, swallowing problems are more common than expected in the cases of LG when compared to SG.

Long-term outcome and efficiency of symptom-selective approach to assess gastroesophageal reflux prior to gastrostomy in neurologically impaired children.

PURPOSE: To evaluate the necessity of preoperative screening for gastroesophageal reflux (GER) prior to gastrostomy in neurologically impaired children. METHODS: Medical records of neurologically impaired children, who have undergone laparoscopic gastrostomy between January, 2004 and June, 2018, were retrospectively reviewed. Before the year of 2014, all patients who required gastrostomy had been routinely screened for GER pre-operatively, but after the year of 2014, only the ones with GER-related symptoms were tested. The characteristics and outcomes of Routine Screening (RS) and Selective Screening (SS) periods were compared. RESULTS: There were 55 and 54 patients in the RS and SS periods, respectively. Demographics, primary pathologies, and mean follow-up durations (> 2 years) were similar. The rate of GER screening was significantly lower in the SS period (29.6% vs. 63.6%). The rate of Laparoscopic Nissen Fundoplication (LNF) combined with gastrostomy was significantly lower in the SS period (14.8% vs. 38.2%). During follow-up, the rates of new-onset GER symptoms (13% vs. 11.7%) and LNF requirement later on (6.5% vs. 8.8%) were statistically similar between the two periods. CONCLUSION: Routine screening for GER is not necessary prior to gastrostomy in neurologically impaired children. Symptom-selective screening algorithm is safe and efficient in the long term.

Thoracoscopic treatment of left-to-right shunt in a child with scimitar syndrome.

Scimitar syndrome represents a rare variant of partial anomalous pulmonary venous connection with right lung hypoplasia, dextrocardia, and concomitant airway-vessel abnormalities. Surgical correction is preferred in symptomatic patients or in patients with increased left-to-right shunt. In this report, the first case of scimitar syndrome with dual arterial supply and venous drainage to be treated with thoracoscopic approach is presented.

Acquired right diaphragmatic hernia following pediatric living donor orthotopic liver transplantation.

ADH following OLT is a rare entity. Herein, we report a case of Alagille syndrome who developed ADH secondary to OLT, and possible etiological causes are discussed in light of the literature.

Two-stage approach in the management of thoracic neuroenteric cyst with spinal extension: thoracoscopic excision following dorsal laminectomy.

BACKGROUND: Neuroenteric cysts (NC) are rare pathologies and localized generally in posterior mediastinum or abdomen where they may extend to spinal canal through a vertebral defect. Isolated spinal lesions require dorsal/ventral laminectomy and thoracic ones thoracotomy or thoracoscopy. Posterolateral approach via thoracotomy is generally performed for lesions with both thoracic and spinal components. Minimal invasive excision of a thoracic NC with spinal extension in an infant is presented herein. CASE REPORT: A term female newborn with an antenatal (26th week) diagnosis of congenital diaphragmatic hernia (CDH) was admitted. On physical examination, she was normal except mild dyspnea and CDH were excluded on radiogram. Left parenchymal opacity necessitated thorax tomography that revealed lobulated cystic lesion (6 × 3.5 × 4.5 cm) in posterior mediastinum. MRI showed intraspinal extension of the lesion through a hemivertebrae (6th). Two-stage procedure was planned for suspected neuroenteric cyst. First, intraspinal component was excised with dorsal laminectomy and the connection was closed. Then, the thoracic component was excised thoracoscopically. Histopathological evaluation confirmed the diagnosis. Total parenteral nutrition and high dose somatostatin analog was needed due to transient left chylothorax on postoperative course. She was well and symptom-free in postoperative period. CONCLUSION: Neuroenteric cysts may lead to misdiagnoses in antenatal period. MRI is critical to show spinal and vertebral pathologies in suspected cases. Thoracoscopy may safely be performed for thoracic lesions with spinal extension in two-stage approach following closure of the connection and excision of the spinal component.

Pulmonary arteriovenous malformation in children.

Although pulmonary arteriovenous malformations (PAVM) are relatively rare in children, they are important in the differential diagnosis of common pulmonary problems, such as hypoxemia, hemoptysis and dyspnea on exertion. We report the cases of two PAVM patients with different presentations and describe the treatment strategies.

Single-incision laparoscopy-assisted gastric transposition combined with thoracoscopic esophagectomy for esophageal replacement.

INTRODUCTION: We present a novel approach to single-incision laparoscopy-assisted gastric transposition combined with thoracoscopic esophagectomy in a child with long-segment corrosive esophageal stricture (CES). MATERIALS AND SURGICAL TECHNIQUE: A 2.5-year-old boy with a history of caustic ingestion underwent periodic esophageal dilatations at 3-week intervals, four sessions of topical mitomycin C application, and a strict antacid/H2 antagonist therapy for 8 months. The esophageal replacement was indicated because of persistent corrosive esophageal stricture. First, thoracoscopic native esophagus dissection was performed. After gastric mobilization with single-incision laparoscopy, esophagectomy and esophagogastric anastomosis were performed through the cervical incision. There was no complication, and the patient had gained weight by the end of the 12-month follow-up. DISCUSSION: Single-incision laparoscopy-assisted gastric transposition combined with thoracoscopic esophagectomy is feasible, safe, and effective in patients with corrosive esophageal stricture.

Radiological nodule behavior: A critical parameter in the surgical management of pediatric pulmonary metastases.

Divarci E, Arslan S, Dökümcü Z, Kantar M, Demirag B, Öniz H, Ertan Y, Alper H, Erdener A, Özcan C. Radiological nodule behavior: A critical parameter in the surgical management of pediatric pulmonary metastases. Turk J Pediatr 2018; 60: 372-379. Radiological nodule behavior (RNB) means the course of nodule appearance on consecutive CT scans. In this study, we aimed to discuss the effects of RNB on prognosis of patients with pulmonary metastasis. Retrospective analysis of patients who underwent pulmonary metastasectomy (PM) between 2005-2015 was performed. RNBs were grouped as stable, enlarging or new rising nodules. The effects of RNBs were analyzed on recurrence, 1- and 3-year event free survival (EFS) and mortality. Twenty-seven patients (18 male) underwent PM with a median age of 15 years (3-18 years). The diagnoses were listed as osteosarcoma (13), Wilms` tumor (7), Ewing`s sarcoma (3), synovial sarcoma (2), rabdomyosarcoma (1) and mixed germ cell tumor of testis (1). RNBs were new rising in 15 patients (55%), enlarging in seven patients (26%) and stable in five patients (19%). Vital tumor metastasis was detected in all of the patients with enlarging nodules (100%); in 10 of the 15 patients with new rising nodules (66%) and none of the patients with stable nodules. None of the patients with stable nodules developed recurrence or died after PM (p˂0.05). In patients with enlarging nodules, metastases recurred and they died in the postoperative period. These findings were similar in different types of tumors. RNB could be used as a critical parameter in deciding surgical management strategies of pulmonary metastases. Stabile nodules should be observed by close follow-up with serial CT scans without surgery. All of the suspected new rising nodules should undergo surgical sampling to avoid unnecessary chemotherapy. Nodule progression under chemotherapy is a poor prognostic criteria for overall survival.

Topical Mitomycin C Application Is Effective Even in Esophageal Strictures Resistant to Dilatation Therapy in Children.

PURPOSE: Several treatment techniques may be used in the treatment of esophageal strictures. The purpose of this study was to present the effects of topical mitomycin C (TMC) as an useful adjunct to dilatation therapy in esophageal strictures. MATERIALS AND METHODS: A retrospective analysis of patients who underwent TMC between February 2015 and July 2016 was performed. Dysphagia score, periodic dilatation index, and number of dilatations were compared before and after intervention to investigate the efficacy of TMC. RESULTS: TMC was performed on 20 patients with a median age of 3.5 years (2 to 17 y). The diagnosis was corrosive esophageal strictures in 14 patients, anastomotic strictures in 5 patients, and congenital esophageal stricture in 1 patient. The length of the stricture was long in 10 patients (50%). The median dysphagia score decreased from 2 (1 to 3) to 0 (0 to 2) after application (P<0.001). The median number of dilatation sessions decreased from 5 (1 to 41) to 1 (0 to 11) after intervention (P<0.001). The median periodic dilatation index decreased from 1 (0.66 to 1.34) to 0 (0 to 1.33) after TMC (P<0.001). Regular esophageal dilatation was not necessary in 16 patients after application (80%). The length of the stricture did not affect the efficacy of TMC. The success of treatment was lower in patients with a long treatment period before TMC (>3 y) (50%). No complications were seen in a median follow-up period of 16 months (7 to 22 mo). CONCLUSIONS: TMC application has a significant positive effect as an adjunct to dilatation therapy in most of the patients with different types of esophageal strictures. It should be performed as a safe and efficient treatment option even in patients who were resistant to dilatation therapy.

Thoracoscopic Treatment of Pulmonary Hydatid Cysts May Have a High Morbidity Risk in Children: Retrospective Analysis.

OBJECTIVE: Thoracoscopic treatment of pulmonary hydatid cyst (PHC) has been considered to be a good treatment option in both children and adults for nearly 25 years. However, there have been very few pediatric studies published during this period. Our goal is to review our results and evaluate the efficiency of thorascopy in pediatric patients. MATERIALS AND METHODS: The medical records of patients with PHC who were surgically treated between 2005 and 2015 were reviewed. As all cysts larger than 5 cm in diameter were surgically removed, cysts less than 5 cm in diameter were medically treated and were not included in the study. Demographics, cyst characteristics, and operative/postoperative data were compared between patients who underwent thorascopy (thoracoscopy group) and patients who underwent thoracotomy (thoracotomy group). Chi-square and t-test were used for statistical analysis where appropriate. RESULTS: There were 26 consecutive children (14 girls, 12 boys; mean age 9.4±2.7) included in the study. Except for 2 incidentally diagnosed patients, all were symptomatic, 4 had multifocal lesions, and multiorgan involvement was detected in 11 patients. Thoracoscopy was performed in 10 patients, and conversion was necessary in 2 patients due to unsuccessful fistula ligation attempts. The thoracoscopy group included 8 thoracoscopically treated patients, and remaining patients constituted the thoracotomy group (n=18). Comparison of preoperative characteristics of the groups was insignificant, whereas the overall complication rate (residual bronchial fistula, prolonged air leak, pneumothorax, and localized air cyst) and median hospital stay were significantly higher in the thoracoscopy group. There was no mortality and no recurrence at the postoperative follow-up after 37.4 months. CONCLUSION: The thoracoscopic approach to PHC may have a high risk of conversion and postoperative complication rate. Thoracotomy in children still seems to be the approach of choice for PHC larger than 5 cm. Routine thoracoscopic hydatid cyst treatment is yet far from being the gold standard, whereas thoracoscopy may be preferred in selected patients.

The Efficacy of Intralesional Steroid Injection in the Treatment of Corrosive Esophageal Strictures in Children.

PURPOSE OF THE STUDY: Esophageal dilatation can be insufficient in the treatment of severe corrosive esophageal strictures. In this study, we aimed to present the efficacy of intralesional steroid injection as an adjunct to dilatation therapy. MATERIALS AND METHODS: Retrospective analysis of children who underwent intralesional steroid injection between 2004 and 2014 was performed. Patients' age, type of corrosive substance, length of stricture, number of injection and dilatation sessions and complications were reviewed. The success was evaluated by the comparison of number, frequency, and requirement of dilatation therapy before and after injection. RESULTS: Intralesional steroid injection was performed to 32 children with a mean age of 3.6±2.5 years. The types of corrosive agents were alkali (24) or acid (8). Mean number of injection sessions was 2.5±1.1(1 to 6). Mean number of dilatation sessions was decreased from 10±8.8 to 5.4±4.6 after injection (P=0.003). Mean frequency of dilatations was extended from 3.6±0.9 weeks to 8.7±3.9 weeks (P=0.000). Dilatation treatment was successfully terminated in 25 of 27 children with short-segment strictures after injection (92%). Whereas all of the children with long-segment strictures could not resolved and finally required esophageal replacement (5 patients). One patient had transient cushingoid phenotype as a complication. There was not seen any major complication-like perforation. The mean follow-up period was 6±3 years. CONCLUSIONS: Intralesional steroid injection is an effective adjunct to dilatation in most of the children with short-segment strictures. It should be performed as a safe and efficient treatment option in patients with short-segment corrosive esophageal strictures resistant to dilatation therapy.

Initial oxygenation response to inhaled nitric oxide predicts improved outcome in congenital diaphragmatic hernia.

BACKGROUND: Pulmonary hypertension (PH) is the most important complication of congenital diaphragmatic hernia (CDH) and still has a high mortality rate. The aim of this study was to evaluate the effectiveness of inhaled nitric oxide therapy in PH due to CDH. METHODS: Hospital records of children who had undergone inhaled nitric oxide therapy for PH due to CDH between June 2009 and December 2011 were reviewed. RESULTS: Twenty-nine patients had a diagnosis of CDH at the time of study, and eight of these patients underwent nitric oxide therapy because of failure of conventional ventilation techniques, which was successful in five of these patients. Patients who had a good overall outcome of nitric oxide therapy experienced rapid improvement (pretreatment, mean PaO2 = 44.8 mmHg; after the first hour of therapy, mean PaO2 = 96.8 mmHg), whereas patients with no response did not have a similar course (pretreatment, PaO2 = 37 mmHg; after the first hour, PaO2 = 54.6 mmHg). CONCLUSION: Inhaled nitric oxide therapy seems to increase survival in PH due to CDH. No predictive parameters to orient patient selection could be identified; however, the early response seemed to predict the overall outcome. Good results in our series were attributed to routine use of sildenafil and dopamine, along with the nitric oxide inhalation.

Postoperative recurrent tracheoesophageal fistula: an unusual complication of oxidized regenerated cellulose (Surgicel®).

Oxidized regenerated cellulose (Surgicel(®)) is a commonly used material in Pediatric Surgery. We present a case of recurrent tracheoesophageal fistula (RTEF) repaired by Surgicel(®). In this case, tracheoesophageal fistula (TEF) recurred due to migration of Surgicel into the tracheal and esophageal lumen.

Enteral resveratrol supplementation attenuates intestinal epithelial inducible nitric oxide synthase activity and mucosal damage in experimental necrotizing enterocolitis.

BACKGROUND/PURPOSE: The release of various enzymes including inducible nitric oxide synthase (iNOS) leads to enterocyte apoptosis through free nitrogen radicals, which in turn leads to impaired mucosal barrier and bacterial translocation with resultant sepsis in necrotizing enterocolitis (NEC). Resveratrol, a polyphenol compound from phytoalexins with antioxidant and scavenger properties, also play a critical role in modulating key enzymes in cell cycle including iNOS. We therefore hypothesized that resveratrol would prevent mucosal damage in experimental NEC in rats. METHODS: Newborn rats were randomized into 3 groups: group 1 was left to breast-feed (BF), whereas group 2 (NEC) was induced by enteral formula feedings twice daily and by being subjected to hypoxia thrice. The third group (R) received the same treatment as the NEC group but the enteral feeds were supplemented with resveratrol. Rats were killed on day 4, and their terminal ileal samples were harvested for histopathologic analysis. Expression of iNOS was assessed by sodium dodecyl sulfate polyacrylamide-gel electrophoresis analysis and immunohistochemistry. Band densities were quantified by using the software NIH image. RESULTS: The epithelial structure in group BF was normal. In the NEC group, there were marked loss of the brush border, vacuolization, and necrosis. The epithelial structure was found to be preserved in group R. Western blot analysis revealed marked elevation in the expression of iNOS protein at 130 kD molecular weight (band densities in groups BF, NEC, and R were 0.3 +/- 3.5, 3.7 +/- 2.9, and 0.6 +/- 5.1, respectively; P < .01). Immunohistochemical analysis revealed that iNOS staining was significantly increased in the NEC group, whereas it remained minimal for the BF and R groups. Ileal tissue nitrate/nitrite levels for groups BF, NEC, and R were 178.3 +/- 7, 191.4 +/- 4.1, and 181 +/- 3.6 micromol/(L x g), respectively (P < .01). CONCLUSIONS: These findings may provide insights for the beneficial effect of enteral resveratrol supplementation on inflammatory conditions of the bowel including NEC through attenuating the release of iNOS and preservation of mucosal integrity.

Long-term results of conservative management of adnexal torsion in children.

BACKGROUND/PURPOSE: Adnexal torsion is a condition that may result in serious morbidity including adnexal removal. However, conservative management with preserving the torsed adnexa is not justified, and long-term outcomes remain unclear. METHODS: The records of 14 girls with ovarian torsion whose adnexal structures were preserved after detorsion were reviewed to evaluate the long-term results of conservative management. Data including age, previous history, duration of complaints, surgical findings and type of intervention, color Doppler ultrasound findings performed in the early and late postoperative periods, and final outcomes were collected. RESULTS: Mean age of patients was 11.5 +/- 2.8 (range 6 to 15) years. Time interval between the onset of pain to surgery was 46.78 +/- 35.5 (range 12 to 126) hours. Seven patients had a benign solitary cyst as an underlying cause for adnexal torsion. The intervention performed by open surgery in 9 and by laparoscopy in 5 patients included detorsion, simple cyst aspiration, unroofing and/or cystectomy in 7 patients with ovarian cysts, and oophoropexy in 9 of 14 patients. Follow-up ranged from 3 to 66 (mean 21.9 +/- 20.1) months. Thirteen patients resumed normal size and folliculogenesis, whereas in 1 patient, the involved ovary atrophied. No recurrence or contralateral adnexal torsion was observed on follow-up. CONCLUSIONS: Conservative management with untwisting the ovary and pexing both retained detorsed and contralateral ovaries especially in idiopathic torsions should be considered in cases of ovarian torsion in children.

A new variant of esophageal atresia associated with esophageal heterotopic pancreas.

An infant with esophageal atresia (EA) and absence of gas on abdominal radiographs was found to have an obliterated distal tracheoesophageal fistula (TEF). Preoperative bronchoscopy and surgical exploration found that the reason for gasless abdomen was the atresia of the distal portion of lower esophagus, which also contained heterotopic pancreatic tissue. The type of trachea/esophageal anomaly found in this patient, with the association of esophageal heterotopic pancreas (EHP), has not yet been reported in the literature.

Does colonization of Helicobacter pylori in the heterotopic gastric mucosa play a role in bleeding of Meckel's diverticulum?

BACKGROUND/PURPOSE: Helicobacter pylori is a microorganism known to colonize in gastric type of mucosa and is associated with gastritis and peptic ulceration. The aim of the study was to determine whether colonization of H pylori in heterotopic gastric mucosa plays a role in bleeding of Meckel's diverticulum. METHODS: Histopathologic slides of patients who had undergone resection of Meckel's diverticulum in recent 5 years were reexamined for the presence of H pylori in heterotopic gastric mucosa. Polimerase chain reaction (PCR) test was used to trace the genetic material of urease gene and 16s rDNA amplifications for H pylori. RESULTS: Thirteen of the 30 histopathologic slides of Meckel's diverticula had heterotopic gastric mucosa. Ten of the 13 patients presented with acute bleeding of the diverticula, whereas 3 of them were asymptomatic. None of the 13 gastric mucosa bearing diverticula were colonized with H pylori. PCR was unable to show any trace of genetic material for H pylori. CONCLUSION: Although the role of H pylori is well established in the gastric mucosal ulceration, its presence is not essentially required to induce "heterotopic gastritis" that may result in bleeding of the Meckel's diverticulum. .

Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion.

BACKGROUND/PURPOSE: Adnexal torsion is a serious condition that frequently may result in ovarian removal, and there always is a risk of castration if the contralateral ovary undergo torsion as well. In this study, the authors present their experience with adnexal torsion in 15 children and describe a catastrophic event, asynchronous bilateral adnexal torsion, with review of the literature. METHODS: Between November 1993 and November 2000, 15 children under 15 years of age who had undergone operation because of torsion of uterine adnexal structures were evaluated. Two illustrative cases with asynchronous bilateral adnexal torsion are presented. RESULTS: Fourteen cases were associated with additional adnexal pathology, whereas in 1 case the torsion was of normal uterine adnexa. Sonographic studies improved the preoperative diagnosis. Hemorrhagic necrosis of the adnexa secondary to the torsion was found in all cases except 3 and necessitated adnexal resection. In only 3 cases preservation of the adnexa was possible. Asynchronous adnexal torsion occurred in 2 patients in the time course. Both were treated by laparotomy and adnexal untwisting and fixation by permanent multiple interrupted sutures. In their final evaluation at 40 and 8 months after the operation, they were found to have good ovarian function. CONCLUSION: Considering the risk of subsequent contralateral torsion and its impact on future fertility, the authors believe that conservative management (untwisting the ovary and pexing, both retained detorsed and contralateral, ovaries) should be considered in cases of ovarian torsion in children.