Chemotherapy-Induced Jejunal Perforations as an Atypical Presentation of Neutropenic Enterocolitis in an Acute Leukemia Patient.

Neutropenic enterocolitis (NE) is a potentially life-threatening condition, primarily affecting neutropenic patients with hematologic malignancies. The clinical manifestations of NE in patients receiving antineoplastic drugs range from fever, diarrhea, nausea, vomiting, and abdominal pain to intestinal perforation and shock. We report the case of a 12-year-old boy with acute myelogenous leukemia, undergoing chemotherapy, who presented with an atypical case of NE. Due to numerous jejunal perforations and severe rectal bleeding, he experienced abdominal distension without any accompanying tenderness and the unexpected rapid onset of shock. Surgery was performed, and his postoperative course was uneventful. However, seven days later, Pseudomonas aeruginosa-induced sepsis made his condition rapidly worse due to severe neutropenia and thrombocytopenia. Despite intensive supportive therapy, the patient unfortunately passed away. NE remains a life-threatening complication in pediatric immunosuppressed leukemic patients. A high index of suspicion, prompt diagnosis, aggressive treatment with broad-spectrum antibiotics, and correction of fluid-electrolyte imbalances are crucial in reducing morbidity and mortality.

Persistent Postoperative Chylothorax in a Neonate Undergoing Primary Esophageal Atresia Repair Successfully Treated by Open Thoracic Duct Ligation: A Case Report.

Chylothorax represents the accumulation of chyle in the pleural cavity due to leakage from the thoracic duct or its tributaries. Intraoperative intrathoracic lymphatic injury is a common cause, but it can also occur on its own. Management of chylothorax involves both medical therapy and, in some cases, surgery for postoperative patients and those who haven't responded to medical therapy. We describe a case of a one-month-old female infant with right-sided chylothorax following primary esophageal atresia repair, who underwent successful thoracic duct ligation by open thoracotomy after unsuccessful medical treatment. Minimally invasive radiology is now the standard treatment for traumatic chylothorax because it is safe and effective. However, surgical ligation of the thoracic duct remains an effective option for treating high-output or recurring chylothorax in countries with limited resources.

Clinical characteristics and outcome of children with acute cryptorchid testicular torsion: A single-center, retrospective case series study.

BACKGROUND: Cryptorchidism and testicular torsion (TT) are relatively common conditions in clinical practice; however, sparse information about cryptorchid TT is available in the current literature. METHODS: We retrospectively reviewed the clinical characteristics, treatment modalities, and long-term outcomes of pediatric patients treated for acute cryptorchid TT. RESULTS: We found eight patients with unilateral acute cryptorchid TT with a prevalence of 8.9% (8/90) among all TT cases. The left testis was affected in six patients. The median age of patients at the time of the surgery was 65 months (interquartile range (IQR) 4-136 months). The median duration of symptoms was 16 h (IQR 9-25 h), while the median time to treatment was 60 min (IQR 59-63 min). The most common symptoms were pain (abdominal and inguinal) and inguinal mass with no palpable testis in the ipsilateral hemiscrotum. Preoperative color Doppler ultrasonography revealed absent or decreased testicular blood flow in the affected testes in 7/8 of patients. Various degrees of testicular torsion (median 540°, min 360°, max 1260°) were found during surgery. A necrotic testis that led to orchidectomy was found in 4/8 of patients. The median follow-up period was 42.6 months (IQR 12.5-71.2 months), revealing only one patient with testicular atrophy. The final testicular salvage rate was 35%. CONCLUSIONS: Greater awareness among caregivers and primary care physicians about acute cryptorchid TT is required to improve their timely diagnosis and treatment. A physical examination of the external genitalia and inguinal regions should be mandatory to attain a proper diagnosis and treatment without delay.

The Predictive Value of Plasma Sodium and Other Laboratory Parameters in Determining Complicating Appendicitis in Children.

OBJECTIVE: Finding a reliable preoperative predictor of complicated acute appendicitis (AA) has been a challenging diagnostic problem. The present study aimed to identify potential factors that may predict complicated AA in the pediatric emergency department (ED) based on routine, widely available laboratory tests on admission to the ED, including plasma sodium concentration. METHODS: We retrospectively reviewed clinical and laboratory data of pediatric patients with AA who underwent emergency surgery at our department between January 2020 and December 2022. The patients were divided into two groups: histopathologically proven complicated AA (n = 80), and non-complicated AA (n = 155). RESULTS: Complicated AA was associated with reduced plasma sodium and chloride concentrations (p < 0.001, both), decreased values of lymphocytes (p = 0.002), elevated C-reactive protein (CRP) ( p < 0.001), elevated values of white blood cells (WBC) and neutrophils (p = 0.012 and 0.001, respectively). In binomial logistic regression, increased levels of CRP and WBC, and decreased levels of sodium were predictors of complicated AA. The area under the ROC curve was 0.825 (95% CI 0.764, 0.886). CONCLUSION: We identified mild hyponatremia and elevated CRP and WBC values as potential markers for distinguishing complicated from uncomplicated pediatric AA with implications for surgical approaches for treating complicated AA and conservative approaches for treating uncomplicated AA.

The Frequency, Severity, and Risk Factors of Hickman CatheterRelated Complications in Pediatric Cancer Patients: A Single-Center Experience from Bosnia and Herzegovina.

OBJECTIVE: This study aimed to identify the frequency, severity, and risk factors associated with Hickman catheter-related complications in children with hemato-oncological malignancies at the largest pediatric tertiary care unit in Bosnia and Herzegovina. MATERIALS AND METHODS: A cross-sectional study was conducted on a cohort of pediatric cancer patients who underwent Hickman central venous catheters (CVCs) between January 2019 and December 2022. Mechanical, infectious, and thrombotic Hickman catheter-related complications were evaluated and analyzed. We also investigated possible risk factors associated with these complications. RESULTS: Seventy-one Hickman CVCs were inserted in 68 children (44 boys and 24 girls) at a mean age of 6.9 ± 4.6. Forty (58.8%) children had hematological malignancies and 28 (41.2%) solid cancers. The median follow-up after Hickman CVC insertion was 190 days (95% CI [160-212]) for 12 644 catheter days. During follow-up, 10 (14.1%) mechanical, 7 (9.9%) infectious, and 1 (1.4%) thrombotic complications were recorded (0.8, 0.48, and 0.08 for mechanical, infectious, and thrombotic complications per 1000 catheter days, respectively). A slightly higher incidence of complications was recorded in children with hematological malignancies (1.59 per 1000 catheter days) compared with children with solid cancers (1.22 complications per 1000 catheter days). CONCLUSION: Using Hickman CVCs for long-term venous access in infusional chemotherapy for pediatric cancer patients is safe but is associated with significant morbidity.

The correlation between ureteric orifice morphology and primary vesicoureteral reflux grade and the impact on the effectiveness of endoscopic reflux correction.

INTRODUCTION: Early diagnosis and treatment of primary vesicoureteral reflux (VUR) are essential for preserving renal function. OBJECTIVES: The study explored whether preoperative cystoscopic grading of refluxing ureteric orifices (UO) correlated with their shape in an institution with non-performance of hydrodistention of the UO in the diagnosis and grading of VUR. We also assessed the relationship between the UO shape and VUR grade with the effectiveness of endoscopic correction of primary VUR in children. METHODS: This retrospective study included consecutive patients ≤15 years treated for primary VUR. The reflux grade was based on the results of preoperative voiding cystourethrography as mild, moderate, or severe. RESULTS: Fifty-one patients with 77 renal refluxing units (RRU) underwent endoscopic treatment with Deflux®. VUR was bilateral in 51 % of patients. VUR was mild in 13 %, moderate in 53 %, and severe in 34 % of cases. The patients with mild and moderate VUR had stadium-shaped UOs in 60 % and 54 % RRUs, respectively. Horseshoe-shaped UOs constituted 42 % of UOs in patients with severe VUR, followed by 31 % of golf-hole UOs. The reflux resolution rate after the first endoscopic injection was 84 %. The preoperative VUR grade correlated with UOs shape (p < 0.001). No significant correlation between UOs configuration and the outcome of endoscopic treatment was seen (p = 0.452). The preoperative VUR grade negatively correlated with a favorable endoscopic treatment (p = 0.043). DISCUSSION AND CONCLUSION: Our data indicate ureteral orifice shapes are closely related to preoperative VUR grade. There was no correlation between the UO configuration and the success rate of endoscopic treatment of VUR, in contrast to the significant negative correlation between the VUR grade and the success rate of endoscopic treatment.

Minimally invasive coronary artery bypass (MICS CABG) in Bosnia and Herzegovina: a single centre, single surgeon cohort experience.

Aim This is the first research in Bosnia and Herzegovina presenting minimally invasive coronary artery bypass grafting surgery (MICS CABG) experience, advantages, and outcomes as compared to conventional surgery (OPEN CABG). Methods This retrospective cross-sectional study was conducted between January 2019 and November 2022 and included patients with indication for surgical revascularization. Results Among 237 patients, males predominated, 182 (76.7%), with a mean body mass index (BMI) of 28.4±3.9, median The Society of Thoracic Surgery Risk (STS) score of 1.55 (0.8, 4.0), short term STS score of 11.2 (6.8, 23.7), mean age of 64.8±8.7 (ranging 41-83) years, 122 (51.4%) underwent OPEN CABG and 115 (48.6%) MICS CABG. MICS CABG took less time (p<0.001; OPEN 3.5±0.8h; MICS 2.8±0.8h) and needed less mechanical ventilation (p<0.001, OPEN 17.3±11.9h; MICS 13.0±12.5h) than OPEN CABG. Even though there was no difference in hospitalization length between groups (OPEN (7.5±3.2), MICS (7.1±4.0)), patients receiving MICS (2.9±1.5) spent less time in the ICU (p=0.0013) than OPEN CABG (3.6±2.8). OPEN CABG used also more blood derivatives, red blood cells (OPEN 292 vs MICS 55), plasma (OPEN 270 vs MICS 86) and platelets (OPEN 71 vs MICS 28). Conclusion Patients undergoing MICS CABG in Bosnia and Herzegovina had less mechanical ventilation hours and less ICU duration compared to OPEN CABG even though the hospitalization duration was very similar. MICS CABG takes less time to be conducted, has fewer CPRs postoperatively, uses less blood derivatives including red blood cells, plasma and platelets.

A Long-Term Outcome of the Patients with Sacrococcygeal Teratoma: A Bosnian Cohort.

OBJECTIVE: Sacrococcygeal teratoma is an extragonadal germ cell tumor that develops during fetal and neonatal periods and is associated with significant perinatal morbidity and even mortality. This study aimed to determine the clinicopathologic characteristics, the clinical outcomes, and postoperative complications of sacrococcygeal teratoma cases in the low-volume pediatric surgery service in a developing country. MATERIALS AND METHODS: The study included data from all sacrococcygeal teratoma cases diagnosed from 2011 to 2020. All the relevant clinicopathologic data were recorded and analyzed. RESULTS: A total of 7 pediatric (5 females and 2 males) patients with sacrococcygeal teratoma were identified, ranging in age from 3 to 222 days. A prenatal diagnosis was made in 57.1% of cases. The mean gestational age for all cases was 37.1 weeks (34-38 weeks), and the mean birth weight was 3285 g (range, 2300-4700 g). Preoperative alpha-fetoprotein levels had a mean value of 24.327 ng/mL (range, 649.7-110.600 ng/mL). The surgery involved resection of the primary tumor and coccygectomy in all cases. Three (42.9%) tumors were classified as Altman type II lesions, 2 (28.6%) tumors were type IV, and 2 remaining cases were types I and III, respectively. Histology was benign in 4 (57.1%) and immature in 3 patients (42.9%). The mean follow-up time was 101.4 months (30-146 months), with 2 recurrences of high-grade immature teratomas at 11 and 30 months following the surgery. Three patients had postoperative bladder and rectal dysfunctions. CONCLUSION: Sacrococcygeal teratomas are rare tumors associated with frequent postoperative dysfunctions. Recurrences may also be seen, particularly in immature, high-grade forms of sacrococcygeal teratomas.

Epidemiologic and clinical characteristics of selected congenital anomalies at the largest Bosnian pediatric surgery tertiary center.

Congenital anomalies (CA) are any abnormality present at birth, either structural or functional, that may potentially affect an infant's health, development, and/or survival. There is a paucity of studies on clinical characteristics and outcomes of CA in Bosnia and Herzegovina, mainly due to the lack of a nationwide congenital malformations monitoring system. A 5-year hospital-based study was conducted to determine the prevalence at birth and clinical characteristics of selected major CA in Sarajevo Canton, Bosnia and Herzegovina. Ninety-one CA were observed from 2012 to 2016 (the overall prevalence was 39.6 cases/10,000 live births). The mean age of neonates at diagnosis was 3 days. The gastrointestinal tract was the most commonly affected system (76.9%), with esophageal atresia (EA) being the most frequent (17.6% of all CA). Major CA were more prevalent among preterm infants than term infants (P = .001), particularly in males (61.5% vs. 38.5%; P = .028; M:F ratio was 1.59). Multiple CA were seen in 37.4% of neonates. The overall mortality rate of neonates was 11%, and the median length of hospital stay was 19.8 days. Our study revealed the distribution and clinical patterns of common major CA in the largest tertiary care facility in Bosnia and Herzegovina. It also confirmed a relatively high mortality rate, which requires further efforts to improve the quality of neonatal care in the country.

Infantile hypertrophic pyloric stenosis in Bosnia and Herzegovina: A retrospective cohort study from the largest tertiary care facility.

BACKGROUND: Infantile hypertrophic pyloric stenosis (IHPS) is the most common condition requiring surgery in infancy, but the etiology of IHPS is still unclear. The study aimed to analyze the epidemiological and clinical features of the infants with IHPS in our setting and determine the yearly trends in IHPS incidence in the Sarajevo Canton between 2007 and 2016. METHODS: We retrospectively analyzed epidemiologic, clinical, and operative data of all infants undergoing pyloromyotomy for IHPS over ten years in the largest tertiary care facility in Bosnia and Herzegovina. RESULTS: Fifty-three IHPS patients were diagnosed, yielding an overall incidence of 1.17 per 1000 live births (1.25 and 1.09 cases in 2007-2011 and 2012-2016, respectively). IHPS was more prevalent among male infants (ratio 6.6:1, p < 0.001). The mean age at onset of symptoms was 39.6 days (range, 17-107 days). The estimated median time from symptoms onset to hospitalization was 11 days (range, 1-17 days). The mean age at diagnosis was significantly longer in premature infants compared with term infants (p = 0.003). Both first-born rank and bottle-feeding were significantly associated with IHPS (p = 0.001 and p = 0.04, respectively). No seasonal variation associated with IHPS was detected (p = 0.25). No evidence was found of differences in the incidence of IHPS related to maternal age (p = 0.24) and smoking (p = 0.59). CONCLUSION: Our data indicate a declining trend and provide insights into the clinical characteristics of IHPS in Bosnia and Herzegovina. Most of the obtained results are in line with the published data and could improve the quality of local pediatric services.

Duration of symptoms is the only predictor of testicular salvage following testicular torsion in children: A case-control study.

OBJECTIVE: Testicular torsion (TT) is an emergency requiring a prompt diagnosis and surgery to avoid irreversible changes and a complete loss of testis. The present study aimed to identify potential factors that may be predict a testicular salvage after TT in pediatric patients. METHODS: Consecutive medical records of all children ≤16 years old with surgically confirmed TT over a period of five years (2011-2016) were collected. Patients were divided into 2 groups according to testicular viability and the type of treatment: Orchidectomy and orchidopexy. The differences between the two groups and potential predictors of testicular salvage were analyzed. RESULTS: Thirty-one boys with TT met the inclusion criteria and were included in the study. The mean age was 13.6 years (range, 10 days - 15.8 years). Testicular salvage was possible in 18 (58.1%) patients. The duration of symptoms and a lesser degree of torsion indicated a testicular salvage in children and adolescents with testicular torsion, but in multivariate analysis only duration of symptoms (time to surgical detorsion) was significantly associated with the risk of non-salvage. At follow-up, testicular atrophy affected 73.3% of the patients treated with orchidopexy. CONCLUSION: Duration of symptoms is the only predictor of successful testicular salvage following testicular torsion in children. It is associated with a substantial risk of testicular loss and atrophy.

Clinical course and short-term outcome of postsplenectomy reactive thrombocytosis in children without myeloproliferative disorders: A single institutional experience from a developing country.

OBJECTIVES: To evaluate the clinical outcome and complications in the pediatric population who had splenectomy at our institution, emphasizing the incidence of postplenectomy reactive thrombocytosis (RT) and its clinical significance in children without underlying hematological malignancies. MATERIALS AND METHODS: The medical records of pediatric patients undergoing splenectomy were retrospectively reviewed for the period 1999-2018. The following variables were analyzed: Demographic parameters (age, sex), indications for surgery, operative procedures, preoperative and postoperative platelet count (postplenectomy RT), the use of anticoagulant therapy, and postoperative complications. The patients were divided into two groups according to indications for splenectomy: The non-neoplastic hematology group and the non-hematology group (splenectomy for trauma or other spleen non-hematological pathology). RESULTS: Fifty-two pediatric (37 male and 15 female) patients who underwent splenectomy at our institution were reviewed. Thirty-four patients (65%) were in the non-hematological group (splenic rupture, cysts, and abscess) and 18 patients (35%) in the non-neoplastic hematological group (hereditary spherocytosis and immune thrombocytopenia). The two groups did not differ significantly in regards to the patients' age, sex, and preoperative platelet count (P>0.05 for all variables). Forty-nine patients (94.2%) developed postplenectomy RT. The percentages of mild, moderate and extreme thrombocytosis were 48.9%, 30.7%, and 20.4%, respectively. The comparisons of RT patients between the non-neoplastic hematology and the non-hematology group revealed no significant differences in regards to the patients' age, sex, preoperative and postoperative platelet counts, preoperative and postoperative leukocyte counts, and the average length of hospital stay (P>0.05 for all variables). None of the patients from the cohort was affected by any thrombotic or hemorrhagic complications. CONCLUSIONS: We confirm that RT is a very common event following splenectomy, but in this study it was not associated with clinically evident thrombotic or hemorrhagic complications in children undergoing splenectomy for trauma, structural lesions or non-neoplastic hematological disorders.

Changing Trends in the Referral and Timing of Treatment for Congenital Cryptorchidism: A Single-Center Experience from Bosnia and Herzegovina.

BACKGROUND: Cryptorchidism is the most common male urogenital tract disorder identified at birth. Treatment delays of cryptorchidism may be associated with significant complications such as subfertility and testicular cancer. The currently recommended age for performing orchidopexy is between 6 and 12 months of age and no later than 18 months. The aim of this study was to investigate the trends in the pattern of referral and age of boys at the time of operative treatment of congenital cryptorchidism at the largest tertiary care center in Bosnia and Herzegovina. METHODS: The study included all boys who underwent orchidopexy for congenital cryptorchidism during two equivalents periods: 2008-2010 and 2015-2017. We assessed the referral age of patients, the age of patients at the time of orchidopexy, laterality of cryptorchidism, position of cryptorchidic testes palpated before surgery, the intraoperative position of cryptorchidic testis, a clinical position of the testis at follow up, and risk factors for late orchidopexy. RESULTS: In total, 324 patients with 386 testes underwent orchidopexy for congenital cryptorchidism during the study periods. Of these patients, 62 received a bilateral orchidopexy (19.1%). Total referral age of patients with congenital cryptorchidism was 23 months (range, 4-74.5 months). Total median age at surgery was 24 months (range, 6-74 months). One hundred and eleven patients (28.8%) underwent surgery at less than the age of 12 months, 136 (35.2%) at less than the age of 18 months, and 250 (64.8%) patients underwent surgery after the age of 18 months. The analysis of the observed two periods (2008-2010 and 2015-2017) showed a statistically significant decrease in the mean referral age and the mean age at surgery over the last 5 years (2015-2017) (p = 0.007 and p = 0.003, respectively). CONCLUSIONS: Current guidelines for timely operative treatment for congenital cryptorchidism have not been fully implemented in Bosnia and Herzegovina but a gradual improvement is evident. The main factor contributing to delays in orchidopexy was delayed or neglected referral by referring physicians. Optimizing the time of orchidopexy will require an improved coordination at all levels of pediatric health care to diminish the long-term consequences of cryptorchidism. TYPE OF STUDY: Retrospective. LEVEL OF EVIDENCE: III.

Short-term changes in renal function in children and adolescents undergoing extracorporeal shock wave lithotripsy.

Aim To identify short-term effects of extracorporeal shock wave lithotripsy (ESWL) on renal function in children and adolescents with single kidney stones. Methods In a 4-year period 30 children (15 boys and 15 girls) from 10 to 18 years of age were treated for unilateral renal stones with ESWL. Inclusion criteria were: up to 18 years of age, kidney stone (from 4 to 20 mm in diameter) visible on X-ray, first ESWL treatment, unilateral lithotripsy treatment without previous kidney surgery, patients without infravesical obstruction, patients without proven urinary infection, repeated use of one (the same) analgesic, patients without anticoagulant and antihypertensive therapy, patients without use of nephrotoxic drugs prior to and during the treatment, normal blood pressure, non-pregnancy patients with normal renal function. Serum enzymes (alkaline phosphatase, lactate dehydrogenase), cystatin C, serum and urine electrolytes (sodium, potassium, chloride), and urine neutrophil gelatinase-associated lipocalin (uNGAL) were tested before, on the first and fifth day after the treatment. Results An increase of alkaline phosphatase and lactate dehydrogenase was statistically significant on day 1 (p<0.05) and values returned to normal on day 5. Serum cystatin C level was also significantly increased during the first four days after ESWL treatment (p<0.05) and returned to baseline on post-treatment day 5. There was a statistically significant difference in the level of uNGAL in urine before and 24 hours after ESWL treatment (p<0.05). Conclusion The ESWL is a safe and curative procedure for the treatment of kidney stones in children and adolescents with no evidence of serious adverse effects on renal function.

Laparoscopic Extirpation of Adrenal Gland Ganglioneuroma Incidentally Diagnosed during Evaluation for Patchy Alopecia Areata in an Adolescent Boy.

OBJECTIVE: We present a 17-year-old boy with an incidentally diagnosed left adrenal ganglioneuroma during the diagnostic workup of alopecia areata. CLINICAL PRESENTATION AND INTERVENTION: Laboratory investigations revealed vitamin D deficiency. Laparoscopic adrenalectomy was performed and ganglioneuroma was confirmed histologically. At follow-up, the vitamin D supplements improved the vitamin D levels followed by a gradual regression of alopecia areata. However, it recurred 18 months later despite the normal levels of serum vitamin D and no tumor recurrence. CONCLUSION: Further studies should reveal the relationship between alopecia areata and ganglioneuroma as well as the role of vitamin D in alopecia areata.

Gastric Necrosis and Perforation Following Massive Gastric Dilatation in an Adolescent Girl: A Rare Cause of Acute Abdomen.

Gastric necrosis with perforation is a rare and potentially life-threatening condition in childhood beyond the neonatal period. We report a case of gastric necrosis and perforation of a portion of the great curvature due to a massive gastric dilatation caused by pathological aerophagia in a 13-years-old, mentally impaired adolescent girl. Despite the successful surgical treatment, the patient's condition rapidly deteriorated post-operatively and she died due to the multisystem organ failure and multiple infections. In addition, we surveyed the literature on this rare condition and assessed the preventive actions to reduce this life-treating condition.

Female Epispadias Presenting as Urinary Incontinence.

Isolated female epispadias without bladder exstrophy is a rare congenital anomaly affecting 1 in 484,000 females. The presenting features of female epispadias are urinary incontinence and abnormal anatomical features. A 6-year-old girl presented with primary urinary incontinence who on physical examination had a bifid clitoris and labia minora. The vagina and hymen were normal. Voiding cystourethrogram showed no reflux and a funnel shaped proximal urethra. With the diagnosis of isolated female epispadias, one-stage reconstruction of the urethra, bladder neck, labia minora and clitoris was performed.