Treatment of lymphangiomas by means of sclerotherapy with OK-432 (Picibanil®) is safe and effective - A retrospective case series.

Introduction: Congenital cystic lymphangiomas (CCL) or lymphatic malformations (LMs) are benign malformations due to a developmental disorder of lymphatic vessels. Besides surgical excision, sclerosant therapy of these lesions by intracavitary injection of OK-432 (Picibanil®), a lyophilized mixture of group A Streptococcus pyogenes, is a common therapeutical option. Methods: In a single center retrospective study we analyzed 37 consecutive patients (30 children, 3 adolescents and 4 adults) who were diagnosed with lymphangioma and subsequently treated with OK-432 (Picibanil®) in a general hospital between October 2000 and November 2021. Results: The median follow-up period was 2.5 months (range 0.7-56.7 months). The lymphangiomas were localized in the head and neck region (n = 25), the thorax/abdomen (n = 6) and extremities (n = 6). The majority of patients had 1 injection with OK-432 (n = 28), five patients had 2 injections, three patients had 3 injections and one patient had more than 3 injections. The most common complications were swelling (89%), fever (81%), redness at the injection site (81%) and pain (73%). The response to therapy was excellent or good in 32 patients (86.4%), 2 patients had a medium response and 3 patients did not show any response. The clinical reaction after the instillation of OK-432 is not predictive for the quality of outcome. Conclusion: The application of Picibanil is safe and without serious side effects. Parents and patients prefer local sclerotherapy versus surgery as it has less complications. We therefore suggest that Picibanil sclerotherapy should be the first-line treatment for macrocystic and mixed type lymphangiomas.

Testicular cavernous hemangioma associated with testicular torsion - case report and review of literature.

INTRODUCTION: Testicular neoplasms that are derived from connective tissue, blood vessels and musculature are uncommon and intra-testicular tumors of vascular origin are extremely rare; both are benign in nature. Testicular hemangioma is exceedingly rare and typically occurs in patients younger than 20 years, the age in which a primary germ cell tumor of the testis may present, necessitating a radical approach to management with orchidectomy, although potential conservative focal partial surgical excision is desirable. Hemangiomas of the testis have a similar sonographic and magnetic resonance imaging appearance to that of malignant tumors of the testis, especially seminoma. The work has been reported in line with the SCARE criteria. PRESENTATION OF CASE: We present a case of testicular torsion in a 15-year-old male patient who had a painful left testis for 6 days, no vomiting, no fever or dysuria. With clinical suspicion of an old testicular torsion the patient was examined by ultrasound which confirmed the clinical diagnosis. The patient underwent emergency surgical exploration. The left testis was found to be necrotic after a 360° testicular torsion and an orchiectomy was performed. RESULTS: The postoperative course was uneventful. The patient was discharged on day 4 after surgery. Histology showed a complete ischemic infarction of the testicular parenchyma as part of a ruptured intratesticular cavernous hemangioma. DISCUSSION AND CONCLUSION: Cavernous hemangioma is a rare tumor of the testicle in either childhood or adult period. The particularity of the presented case is the possible association of a cavernous intratesticular hemangioma with the torsion of the testis in a teenager. Clinicians and pathologists must be aware of the rare entity of testicular hemangiomas, as clinical examination and imaging studies do not often suffice to arrive at a correct diagnosis.

The impact of clinical child protection programs.

PURPOSE: To follow up on child protection children after their discharge from hospital in order to assess efficiency of our child protection team (CPT) and collaboration of family and of Youth Welfare Agencies (YWA) with the clinical CPT. METHODS: Collaboration of the family considering treatment and controls was documented. Questionnaires were sent to the involved social worker and collaboration with the YWA was analyzed. RESULTS: From 2004 to 2008 57 children entered our child protection program. Clinical cooperation of the families and outcome was good overall. In 56 cases, an official information was sent to the YWA. In ten cases, the injuries were reported to the police which led to convictions in four cases. YWA installed further supervision and support in 53 patients. Cooperation of the families with the social workers was good in 50% of cases, ambivalent in 15% and not existent in 8%. Cooperation with the YWA was wearing. CONCLUSION: Measurements initiated to protect children were efficient in 98%. While cooperation with the families and the social workers was good, cooperation with the institution of the YWA was wearing caused by discrepancies in understanding data protection acts and act of information. Here clarification is required to improve and simplify collaboration between all involved groups.

OK-432 as a sclerosing agent to treat wound-healing impairment.

We report on the application of OK-432 (picibanil) in a patient with prolonged wound healing impairment. A 13-year-old girl had suffered a polytrauma with a displaced fracture of the sacrum which required neurosurgical decompression of the sacral plexus. Postoperatively, a seroma with recurrent fistulation was seen. Excision of the wound, prolonged suction drainage and the instillation of hypertonic glucose solution did not have any effect over a period of four months postoperatively. Relying on our personal experience of the treatment of lymphangiomas using OK-432 we instilled OK-432 into the wound. Leakage stopped immediately, there was a regression of fluid accumulation and four weeks later the ultrasound examination was normal. The patient is still asymptomatic four years after treatment. OK-432 can be used effectively for the treatment of chronic wound healing impairment.

The role of transanal endorectal pull-through in the treatment of Hirschsprung's disease - a multicenter experience.

The transanal approach (TAA) is a new technique for surgery of Hirschsprung's disease (HD) that was introduced by de la Torre in 1998. The purpose of this multicenter study, including experience from three Austrian and one Italian departments of peadiatric surgery, was to evaluate the role of this approach in HD in 18 children aged 1-72 months. In 14 children the TAA only was performed; in 3 an additional laparoscopy was performed and in 1 conversion to a laparotomy was necessary. One complication (abscess) occurred after laparoscopic-assisted pull-through. The postoperative recovery was rapid, no severe long-term problems were observed. The transanal pull-through technique is generally possible in most classic cases of HD with extension of the disease to the sigmoid colon. If necessary, it can be combined with laparoscopy. Our preliminary results show that the technique is safe, less invasive, and gives excellent cosmetic results, and allows rapid recovery. Long-term results are still pending.

Gastroesophageal reflux and diaphragmatic motility after repair of congenital diaphragmatic hernia.

At the Department of Pediatric Surgery in Graz, 31 boys and 23 girls were operated on for congenital diaphragmatic hernia (CDH) from 1978 to 1994. In 49 patients the defect was on the left, in five on the right side. In 46 cases, the hernia was diagnosed within the first week of life; in eight children at a later date. 19 children (35%) died. 25 of the 35 survivors (71%) came to a follow-up examination on average 9.4 (1-17) years after the operation. 24 h pH-monitoring or manometry and Upper G.I. series revealed pathological gastroesophageal reflux (GER) in 16 patients. Nine children were treated conservatively; in seven patients an antireflux procedure was performed. A thoracic position of the stomach or left liver lobe, presence of a hernial sac, gestational age, prenatal diagnosis, use of a patch or severity of lung hypoplasia did not significantly influence the incidence of GER. In three patients, a hiatal hernia was found. The motility of the diaphragm was documented with M-mode sonography (n = 18); a restricted motility could be demonstrated in five patients. GER is very common in patients after repair of CDH. We recommend long-term follow-up with special interest in respect of GER.

[Dynamic splinting after flexor tendon injuries of the hand in childhood]. / Die dynamische Schienung nach Beugesehnenverletzungen der kindlichen Hand.

Ninety severed flexor tendons were repaired in 24 boys and 14 girls in a four-year-period at the Department of Pediatric Surgery in Graz. Mean age was 4.9 years. In 16 patients (42%) additional lesions were found. Direct repair was performed with modified techniques of Kirchmayr (23) or Kleinert (8). In four fingers, flexor tendon reconstructions were carried out. Postoperatively, the dynamic Kleinert splint was used for early nonresistive motion, beginning on average on the second postoperative day. Intensive training of motion was performed in physiotherapeutic sessions during a mean period of five months, postoperatively. In five cases tenolysis was performed; in one case a rupture of a sutured tendon had to be corrected. 27 patients (71%) with 42 injured fingers were followed-up on average 2.7 years after the operation. In accordance with the Buck-Gramcko classification, very good results were achieved in 37 cases (88%), and a poor result in one patient (2%). Atraumatic technique, dynamic splinting, consequent physiotherapeutic training by experienced physiotherapists, and well informed parents will yield excellent results after flexor tendon repair in the paediatric age group.

The effect of mode of delivery on outcome in fetuses with gastroschisis.

The postoperative course in neonates with gastroschisis after successful surgical repair is complicated by prolonged ileus. Elective cesarean section (CS) has been advocated to limit damage to the bowel due to labor and compression in the narrow birth canal and to prevent retrograde infection. We reviewed the records of 58 infants with gastroschisis treated between 1977 and 1993; 12 were delivered by CS for obstetrical reasons and 46 were delivered vaginally (V). Mortality was higher in the CS group (V = 1/46, CS = 4/12). Both groups differed significantly with respect to birth weight and gestational age; gestational age, however, had no influence on morbidity and mortality. Primary contamination was significantly lower in the CS group (V = 29/42, CS = 3/12). However, no difference was found regarding infectious complications. No complications could be attributed directly to the mode of delivery. Since these data do not show any significant advantages of CS on morbidity and mortality, we do not recommend CS for fetuses with gastroschisis diagnosed prenatally.

Late follow-up in patients with gastroschisis : Gastroesophageal reflux is common.

During a 16-year period, 60 neonates with gastroschisis were treated at the Department of Pediatric Surgery in Graz; 6 died and 54 (90%) survived. A questionnaire was sent to 45 patients, who were called for a medical examination; 31 patients (69%) came to follow-up, 26 of whom reported minor abdominal problems that could be related to gastroesophageal reflux (GER). Fifteen agreed to 24-h esophageal pH monitoring and/or upper gastrointestinal series; in 7 pathological GER could be demonstrated. Manometric studies in 6 patients revealed a motility disorder of the esophagus. Only 4 children were concerned by a disfiguring scar or the absence of a navel. Heigtt and weight were within normal limits and the children had developed normally.

[Experiences with using the soft cast in injuries of the fibular ligament of the upper ankle joint]. / Erfahrungen mit der Softcastanwendung bei fibularen Bandverletzungen des oberen Sprunggelenks.

From June 1993 until October 1994, 75 persons with recent ruptures in the region of the fibular ligament at the ankle joint were treated with a Softcast at our hospital. The patients were divided into a surgical and a conservative group: 33 patients were operated on and 42 were treated conservatively; 49 persons were male, 26 female. Both groups were initially treated with a conventional cast, and after the first week a Softcast was used. Surgery was performed whenever X-ray examination showed a difference of more than 10 degrees in supinatory subluxation between the unstable ankle and the intact one or anterior instability of more than 10 mm. In 55 of these patients follow up by clinical and X-ray examination was possible after an average period of 14.5 months after trauma and treatment. For the clinical follow-up the 100-point Pförringer-Stolz score was used (6), and the X-ray examination was performed under constant conditions by means of these standardized conditions, excellent and good results were achieved in more than 95% of the patients. The authors recommend the semi-rigid immobilization with Softcast in both operatively and conservatively treated patients with ruptures of the lateral ankle ligaments.

Surgical strategies in very-low-birthweight neonates with necrotizing enterocolitis.

Very-low-birthweight (VLBW) neonates are more prone to complications and death than term infants are. In a 15-year period, 19 neonates with VLBW were operated on for necrotizing enterocolitis (NEC). Indications for operation were pneumoperitoneum in 12 and deterioration of general condition in 7. Bowel resection and intestinal diversion was performed in 12, a lateral enterostomy at the site of perforation was created in 5, and 2 neonates with necrosis of the whole bowel underwent an exploratory laparotomy without any further surgical treatment. Surgical complications were found in one-third of the patients. The mortality rate was significantly higher when the ileum was affected. The survival rate was 68%. Prior to 1984 the survival rate was 37% (3/8); subsequently, it has improved to 91% (10/11) as a result of improved intensive therapy.

Preservation of the ileocecal valve and right colon in total colonic aganglionosis.

A new surgical technique for the treatment of total colonic aganglionosis is described. Preservation of the right colon and the ileocecal valve is possible by performing an end-to-back anastomosis between a prececal short ileum segment and the uneffected ileum, and by creating a side-to-side anastomosis between an isolated ileal loop and the right colon. The ileorectal anastomosis is performed with a curved EEA 21 circular stapler (USSC, Norwalk, CT). After a neonatal ileostomy, the operation is performed as a one-stage procedure. The advantage of preserving the right colon and the ileocecal valve is discussed.

Course of pubic tubercle--centre of testicle distance in children with and without testicular maldescent.

The aim of this study was to establish whether a more precise classification of the different types of testicular maldescent could be made by using the measurement of pubic tubercle-centre of testicle distance. The pubic tubercle-centre of testicle distance was determined in 77 healthy children. The results were obtained in children aged 1 month to 15 years. The results were compared to the distances obtained in 47 children with testicular maldescent. The distance between pubic tubercle and centre of testicle represents an objective parameter in the examination of testicular maldescent. It is used to determine the testicular position precisely, and by comparing it to our graphs of normal values, it is possible to find pathological results. Our graphs of normal values for pubic tubercle-centre of testicle distance for different age groups, weight groups and body length groups in children can also be used to record the effect of hormonal or surgical therapy. Surprisingly there exists no obvious growth of the pubic tubercle-centre of testicle distance within the first seven years of life. By comparing the measurement of the pubic tubercle-centre of testicle distance of a child with testicular maldescent to our graphs of normal values, it is easy to find an objective parameter for the initiation of therapy, or for the decision to wait and see. By comparing a series of measurements of one case to our graphs of normal values, it is possible to set ideal intervals for consultations.

[Effect of surgery on inflammation parameters]. / Einfluss von Operationen auf Entzündungsparameter.

Of 27 patients undergoing major surgical procedures--mainly orthopaedic ones--we took the temperature, blood sedimentation rate, total white blood cell count, fraction of immature to total neutrophils (I:T proportion) and C-reactive protein. With the exception of the I:T proportion all unspecific indicators of inflammation showed an increase after the operation. Therefore, the I:T proportion is the most reliable parameter for the postoperative control of infections, since it is not subject to surgical trauma.