Use of intraoperative microvascular Doppler during subinguinal microsurgical varicocelectomy in children reduces complications.

Background/Aim: This study assessed the impact of intraoperative microvascular Doppler ultrasonography (MDU) during microsurgical subinguinal varicocele correction in children. Materials and methods: Nineteen patients who underwent intraoperative MDU during subinguinal microsurgical varicocelectomy between 2021 and 2023 were included in this study. Each patient's age, varicocele side, clinical examination findings, preoperative ultrasonography results, intraoperative findings, spermatic artery counts and findings in terms of MDU use, postoperative complications, and results were evaluated. Results: All varicoceles were on the left side and the average age of the patients was 15.2 years. The indications for varicocelectomy were testicular hypotrophy (n = 10) and scrotal pain or fullness (n = 9). When a surgical microscope was used, testicular artery pulsation was detected in only five patients, whereas it was detected in all cases when MDU was used. In 16 cases, a single testicular artery was identified, and two arteries were identified in three cases. Additionally, in a case where a spermatic vein was suspected, it was not ligated due to the detection of pulsation with an arterial pattern using MDU. Two to three lymphatic channels were isolated and preserved, an average of 7.5 vessels were ligated, and five external spermatic veins were identified and ligated. There were no complications, and six of the patients with testicular hypotrophy showed signs of the catch-up growth phenomenon. Conclusion: The use of MDU during subinguinal microsurgical varicocelectomy in children not only increases the success rate but also minimizes complications such as hydrocele and recurrence.

Surgicel mimicking recurrent pelvic neuroblastoma in a 3-year-old boy.

INTRODUCTION: Surgicel is a hemostatic agent that consists of oxidized regenerated cellulose and used in surgical procedures as an aid to bleeding control. It is left in the operation site for hemostasis, could cause an operation by mimicking the recurrence of tumor, as in our patient. PATIENTS AND METHODS: A 3-year-old boy was operated by us at the age of 40 days and 2.5 years, respectively, due to pelvic neuroblastoma. He was re-operated for mimicking recurrence or residue tumor secondary to the prior placement of Surgicel within the peritoneal cavity. RESULTS: Re-laparotomy was performed and the mass approximately 2.8 × 2×1 cm in size in front of the right ureter and iliac vessels and behind the bladder was removed by blunt and sharp dissection without damaging these organs. While gelatinous content was evacuated from this mass, there was no apparent tumor appearance. Pathology report was reported as fibrotic tissue characterized by foreign body and foreign body giant cells. The postoperative period was uneventful and he was discharged on the 2nd postoperative day. CONCLUSIONS: In the light of our case, the use of hemostatic agents should be kept to a minimum and should not be left in the body unless it is difficult. Thus, unnecessary examination or recurrent surgery can be avoided.

Redo Hypospadias Repair: Comparison of Three Different Methods.

PURPOSE: To evaluate the clinical data and treatment outcomes of 3 different methods for redo hypospadias surgery. PATIENTS AND METHODS: We retrospectively reviewed the data of 39 patients with redo hypospadias surgery between January 2010 and April 2019 at our clinic. A ventral preputial onlay flap, a preputial tubular flap, and a full thickness skin tubular graft were used in redo hypospadias surgery. We evaluated these methods regarding age, number, and type of previous repairs, catheter time, chordee, length of the urethral defect, operation time, complications, and follow-up results. T tests and Fisher's exact tests were used to compare differences between groups. RESULTS: The mean operation age of the patients was 5.23 years. Sixteen patients had a single, 21 had 2, and 2 patients had 3 previous repairs. The position of the urethral meatus was perineal in 2, penoscrotal in 6, mid penile in 21, and distal penile in 10 patients. The initial repairs comprised 19 tubularized incised plates (TIP), 12 Mathieu procedures, 5 tubularized preputial flaps, 2 full thickness skin tubular grafts, and 1 onlay island flap repair. Eight full thickness skin tubular grafts, 18 onlay preputial island flaps, and 13 preputial tubular flaps were used for redo surgery. The success rate was 79.1%. Eight wound infections, 6 glans dehiscences, 13 fistulas, 12 meatal stenoses, and 5 urethral diverticulas were seen in the patients. The rates of these complications, Cystofix requirement, and reoperation were higher in the skin tubular graft group but this was not statistically significant (p > 0.05). One patient with graft contracture required a redo skin graft urethroplasty. The mean follow-up duration was18 months. CONCLUSION: Preputial tissue should be preferred in the presence of redo hypospadias surgery. In the absence of preputial tissue other tissues such as oral or buccal mucosa should be preferred instead of skin grafts.

Macrocystic Lymphangioma in Children Treated by Sclerotherapy With Bleomycin.

Although surgical operation is a commonly preferred method in lymphangiomas (LAs), there is a risk of vascular or nerve injury especially in macrocystic LA. Therefore, sclerotherapy would be more appropriate as the first treatment. The authors wanted to share the excellent results of intralesional bleomycin treatment in 3 patients with cervical macrocystic LA.

Conservative Treatment with Octreotide to Provide Early Recovery of Children with Esophageal Perforation.

BACKGROUND: The effectiveness of nonoperative treatment of esophageal perforation (EP) in children with octreotide is highlighted. METHODS: Records of nine patients (seven boys and two girls with an average age of 5.83 ± 5.35 years) with EP were reviewed. RESULTS: EP developed in six patients during dilation of esophageal stenosis (five of six caused by caustic burns). In the other three patients, EP developed after nasogastric placement, after endotracheal intubation, and during endoscopy for foreign body. The symptoms consisted of dyspnea in four patients, tachypnea in seven patients, fever in six patients, chest pain in two patients, and abdominal pain in one patient. Two patients had pneumomediastinum, four patients had pleural effusion, one patient had subcutaneous emphysema, four patients had pneumothorax, and two patients had severe sepsis. Eight of the perforations resolved spontaneously. Therapy included cessation of oral feedings, implementation of proper antibiosis, parenteral and/or enteral nutrition by gastrostomy, and drainage of pleural effusions or mediastinal abscesses if required. Though not recommended by literature, octreotide was administered to these patients. Only one patient was operated in another clinic and was lost during follow-up. The length of hospitalization stay had a median of 11 ± 6.59 days, ranging between 5 and 28 days. If the patient who was operated and did not receive octreotide therapy is excluded, the median hospitalization was only 8 days (5 to 12 days). All patients in our series (except patient 8) survived and still have their native esophagus. CONCLUSION: The initiation of octreotide treatment in the early period after diagnosis of EP without surgical intervention leads to early improvement in children.

The effect of alfuzosin on renal resistive index, urinary electrolytes and ß2 microglobulin levels and TGF ß-1 levels of kidney tissue in rats with unilateral ureteropelvic junction obstruction.

BACKGROUND: In this study, it was aimed to determine the effects of alfuzosin on experimentally generated unilateral partial ureteropelvic junction obstruction (UPO) in rats. MATERIALS AND METHODS: Thirty Long-Evans rats were randomly allocated into five groups. In control group (C), nothing was performed; in group Sham (S) only laparotomy was done; in Alfuzosin group (A) only alfuzosin was administered for two weeks (10 mg/kg/day p.o.) without any surgery; in UPO group, unilateral UP junction obstruction was produced; and in the Group UPT (ureteropelvic obstruction + treatment), alfuzosin was administered for two weeks (10 mg/kg/day p.o.) in addition to UPO production. Renal pelvic anteroposterior diameters were determined with ultrasonography (USG) and renal arterial resistivity indexes by color Doppler USG. Urine was collected both at the beginning and at the end of the experiment for 24 h in all the groups and at the end of the experiment, blood samples were obtained. Blood and urine electrolytes and TGF-ß1, urine density, urine ß2 microglobulin levels were determined. Renal tissue samples harvested from all of the rats were histopathologically evaluated. Results were determined using one-way ANOVA t-test; p < 0.05 was accepted as significant. RESULTS: Urine density in the UPT group was lower with respect to UPO group and blood electrolytes were preserved as close to normal (p < 0.05). In the UPT group, urine TGF-ß1 and blood TGF-ß1, blood ß2 microglobulin levels and histopathologic damage scores were lower compared to the UPO group (p < 0.05). CONCLUSION: It is shown in this experimental unilateral partial UPO model that alfuzosin treatment prevents obstructive renal damage.

Recurrent Sertoli-Leydig cell tumor of ovary in 8-year-old girl.

Sertoli-Leydig cell tumors are rare sex cord-stromal neoplasms that account for <0.2% of ovarian tumors. These tumors with a retiform pattern pose difficult diagnostic problems, with the majority of being misinterpreted as serous papillary cystadenocarcinoma and endodermal sinus tumor. We report an 8-year-old female patient presented to our institution with a huge mass and pain in the lower abdomen and recurrence in the 10th months following the first operation. Only four cases of Sertoli-Leydig cell tumors have been reported under age of the eight years in the literature so far. It is difficult to define the stage and the morphology of Sertoli-Leydig cell tumors with retiform pattern in children and chemotherapy or radiotherapy administration is contraversial. However, fertility sparing surgeries should be considered as a first treatment choice on the time of the diagnosis and the recurrence.

Lycopene has reduced renal damage histopathologically and biochemically in experimental renal ischemia-reperfusion injury.

BACKGROUND: The present study aimed to investigate whether the inflammatory and antioxidant lycopene has a therapeutic effect against renal ischemia/reperfusion (I/R) injury. MATERIALS AND METHODS: In this study, 24 Wistar-Albino rats, weighing from 200 to 250 g, were divided into four groups. All rats underwent median laparotomy under anesthesia. No procedures were performed in the control group (Group C), whereas 100 mg/kg lycopene was administered by gavage in the lycopene group (Group L). The arteries of both kidneys were clamped for 45 min in the ischemia group (Group I), whereas 100 mg/kg lycopene was administered by gavage 30 min before clamping renal arteries, and ischemia was performed in the treatment group (Group T) rats. For all rats, blood samples and renal tissues were collected at 6 h of reperfusion. Samples were used to examine serum BUN, creatinine, MDA and GSH levels, and the renal tissues were used to examine MDA and GSH levels, and renal histopathologies. RESULTS: The treatment group had statistically significant lower serum MDA levels, histopathological tubular vacuolization, loss of brush border and tubular dilatation (p < 0.05), whereas serum BUN, creatinine, tissue MDA, and tissue and serum GSH levels were improved in favor of the treatment group, even though it was not statistically significant (p > 0.05). CONCLUSION: The present study demonstrated that lycopene, which was administered prior to renal I/R injury, prevented renal damage through biochemical and histopathological parameters.

Protective effects of lupeol in rats with renal ischemia­reperfusion injury.

Acute kidney injury (AKI) caused by ischemia and, exogenous or endogenous nephrotoxic agents poses a serious health issue. AKI is seen in 1% of all hospital admissions, 2-5% of hospitalizations and 67% of intensive care unit (ICU) patients. The in-hospital mortality rates for AKI is 40-50, and >50% for ICU patients. Ischemia-reperfusion (I/R) injury in the kidney can activate inflammatory responses and oxidative stress, resulting in AKI. The common endpoint in acute tubular necrosis is a cellular insult secondary to ischemia or direct toxins, which results in effacement of brush border, cell death and decreased function of tubular cells. The aim of the present study was to assess if the reported antioxidant and anti-inflammatory agent lupeol can exert any effects against renal I/R damage. In total, 24 Wistar Albino rats were randomly assigned into four groups of 6, namely Sham, lupeol, ischemia and therapy groups. In the lupeol group, intraperitoneal administration of 100 mg/kg lupeol was given 1 h before laparotomy, whilst only laparotomy was conducted in the sham group. The renal arteries of both kidneys were clamped for 45 min, 1 h after either intraperitoneal saline injection (in the ischemia group) or 100 mg/kg lupeol application (in the therapy group). The blood samples and renal tissues of all rats were collected after 24 h. In blood samples, blood urea nitrogen (BUN) was measured by the urease enzymatic method, and creatinine was measured by the kinetic Jaffe method. Using ELISA method, TNF-α and IL-6 levels were measured in the blood samples, whereas malondialdehyde (MDA), glutathione (GSH), caspase-3 levels were measured in kidney tissues. In addition, kidney histopathological analysis was performed by evaluating the degree of degeneration, tubular dilatation, interstitial lymphocyte infiltration, protein cylinders, necrosis and loss of brush borders. It was determined that renal damage occurred due to higher BUN, creatinine, MDA, TNF-α and caspase-3 values observed in the kidney tissues and blood samples of rats in ischemia group compared with the Sham group. Compared with those in the ischemia group, rats in the therapy group exhibited increased levels of GSH and reduced levels of BUN, TNF-α, MDA. Furthermore, the ischemia group also had reduced histopathological damage scores. Although differences in creatinine, IL-6 and caspase-3 levels were not statistically significant, they were markedly reduced in the treatment group. Taken together, these findings suggest that lupeol can prevent kidney damage as mainly evidenced by the reduced histopathological damage scores, decreased levels of oxidative stress and reduced levels of inflammatory markers. These properties may allow lupeol to be used in the treatment of AKI.

Protective Effect of Fasudil on Testicular Ischemia-Reperfusion Injury in Rats.

Background: Ischemia-reperfusion (I/R) injury to the testis can lead to organ damage, infertility, and subfertility. The goal of this study was to investigate the effects of fasudil on this devastating condition. Methods: Thirty male Long-Evans rats were divided into five groups: a control group (no torsion), rats administered fasudil (30 mg/kg, no torsion), rats subject to ischemia with no treatment (I) (I/R injury), injured rats that received treatment 1 (T1) (I/R with 30 mg/kg fasudil before detorsion), and injured rats that received treatment 2 (T2) (I/R with 30 mg/kg fasudil after detorsion). Serum levels of TNF-ɑ and IL-6, along with tissue levels of glutathione (GSH), malondialdehyde (MDA), caspase-3, and Johnsen Tubular Biopsy Score (JTBS), were measured. Results: Group I exhibited significantly higher levels of MDA and caspase-3 than all other groups except T2 (p ˂ 0.05). Although the difference was not statistically significant, Group T2 exhibited lower MDA and caspase-3 levels than Group I (p ˃ 0.05). Additionally, Group I displayed significantly higher TNF-ɑ and IL-6 levels, and lower GSH and JTBS values, than the other groups (p ˂ 0.05). Conclusion: Our findings indicate that fasudil protects the testis from I/R injury, particularly when administered early.

Our experience in repairs using the native esophagus such as the Foker and Gazi methods in the management of patients with long-gap esophageal atresia.

This study aimed to share our experience with infants with repaired long-gap esophageal atresia (LGEA) using the native esophagus and Foker and Gazi methods. We retrospectively analyzed the medical records of 10 patients with LGEA (six with pure esophageal atresia [EA], and four with distal trachea-esophageal fistula [TEF] + EA). The mean length between the esophageal pouches was 5.9 cm (4-9 cm). Five Foker methods, three Gazi methods, and two delayed primary repairs after a daily bougie were performed an average of 19.3 days after the first surgery and 26.4 days after the final esophageal anastomosis. For the Foker technique, it was 36.1 days. Their first oral intake was 10.2 days, and their transition to full enteral food was 26.2 days. An esophageal leak was detected in six patients. Fundoplication and dilatations were performed for three and four patients, respectively. For good results, LGEA patients should be operated on at least under the supervision of an experienced surgeon in specialized centers, and the team should be familiar with the techniques for using the native esophagus.

A Classification for Gastric Outlet Obstruction in Childhood: Extending Beyond Infantile Hypertrophic Pyloric Stenosis.

BACKGROUND/AIMS:  Gastric outlet obstruction (GOO) is a rare condition in childhood, with the exception of infantile hypertrophic pyloric stenosis (IHPS). However, no classification exists from a pediatric gastroenterologist's perspective. MATERIALS AND METHODS:  The patients with a diagnosis of GOO between 2009 and 2020 were reviewed retrospectively. We classified the patients according to GOO: presence of clinical findings accompanied by radiological and/or endoscopic findings; clinical status: intractable nonbilious postprandial vomiting alone or with abdominal pain, early satiety, weight loss, postprandial abdominal distension, and malnutrition; radiology: delayed gastric emptying and dilated stomach; endoscopy: nonbilious gastric contents after 6-8 hours of emptying and/or failed pyloric intubation; physical examination: visible gastric peristalsis. RESULTS:  A total of 30 GOO patients (15 patients with IHPS, 1 patient with annular pancreas, 4 patients with gastric volvulus, 2 patients with duodenal atresia, 2 patients with antral web, 1 patient with late-onset hypertrophic pyloric stenosis (LHPS) had surgical treatment, and remaining 5 patients had medical treatment) were enrolled to the study. The median age was 8 months (range: 3 months-16 years), and 14 patients were female. Mitochondrial disorders, LHPS, metabolic disorders, and eosinophilic gastrointestinal system diseases were added to Sharma's GOO classification, and the classification has been expanded. CONCLUSION:  This is the first and largest study of GOO in children. From the perspective of pediatric gastroenterology, new diseases will be addressed, and definitions will be highlighted with our classification for GOO in childhood.

An interesting and rare cause of post-operative intussusception: Roux limb intussusception.

Intussusception is a common disease in children. Most intussusception is idiopathic and approximately 1% develops postoperatively. We present a case of a 6-year-old male patient who underwent surgery for a type 1 common bile duct cyst. In his post-operative 2nd month, the patient presented with a complaint of abdominal pain after eating, but his pain was not accompanied by nausea or vomiting. No pathological findings were evident in the examination or an abdominal X-ray of the patient. Intussusception was detected by ultrasonography and computed tomography. We wanted to introduce this interesting intussusception that originated from the Roux limb that was not seen before.

Observations and experiences of pediatric surgeons working on the field in the first 7 days of the Kahramanmaras earthquake.

Purpose: This study aims to share our experiences and problems, and to suggest solutions as pediatric surgeons who took part in the teams that went voluntarily to the region hit by the Kahramanmaras earthquake during the first 7 days after the disaster. Methods: This study conveys our observations made at Kahramanmaras Sütçüimam University Faculty of Medicine Hospital, where we worked as a volunteer team between February 7 and 14, 2023. Results: During the first few days, there were registration problems due to lack of electricity, water, and internet, as well as issues with sterile surgical environments. In the following days, a lack of auxiliary health personnel was revealed as the main difficulty. Conclusion: Since coordination is important when working as a team in the aftermath of an earthquake, staff from the same center should be deployed together if possible, and a team leader should be selected. Alternative recording systems should be established in case of power outages and computer problems. Secretaries, auxiliary health staff, and technicians should be included in the team in addition to doctors and nurses.