Ankyloglossia and effects on breast-feeding, speech problems and mechanical/social issues in children.

BACKGROUND: This aim of this study was to define the characteristics of the patients who underwent surgery for ankyloglossia. PATIENTS AND METHODS: The patients (n = 127) with ankyloglossia underwent surgery between 1987 and 2005. The patients were evaluated for age, gender, complaints, grade, and operative procedures. This study did not cover postoperative evaluation of the procedure. RESULTS: The ages of the children ranged from 20 days to 7 years, and 84% of them were under 1 year of age. Seventy-two percent were boys; 28% were girls. The most common complaint of the parents of infants under one year of age was breast-feeding (35/84). When the tongue movements of the patients were examined, 57 patients (of whom 18 were over one year of age) had limited tongue mobility. The mean frenulum length of the patients was grade 1 in 72 patients and grade 2 in 55 patients. Ankyloglossia was corrected by frenotomy. Three patients had bleeding from their frenotomy site which resolved with local pressure. General anaesthesia was preferred for 77 patients, and there was a need for suturing in 20 patients. CONCLUSION: The correction of ankyloglossia at an early age reduces the risk of latent complications. In addition, the early correction will mitigate the feeding- and speech-related concerns of parents and doctors alike.

Association of tumor necrosis factor, interleukin-6 and cyclooxygenase pathway with lipopolysaccharide-induced intussusception.

INTRODUCTION: Many factors and mechanisms have been proposed as causes for intussusception (IN); however, the etiology remains unclear. Inflammatory mediators such as tumor necrosis factor (TNF) and interleukin-6 (IL-6), which are elevated during infectious diseases, can significantly affect gastrointestinal motility. Motility changes caused by these agents might contribute to the development of IN. The aim of this experimental study was to determine the preventive effects of indomethacin on lipopolysaccharide (LPS)-induced IN in mice and to investigate the role of TNF and IL-6 on intussusception. MATERIALS AND METHODS: Seventy-eight mice were divided into five groups. In the Control group (n=6), no procedure was done. In the Sham group (n=6), 1 ml saline, in the Indomethacin group (n=6), 10 mg/kg of indomethacin, in the LPS group (n=30), 12 mg/kg of LPS was administered intraperitoneally (IP). In the Treatment group (n=30), 10 mg/kg of indomethacin was administered IP following 12 mg/kg of LPS. All animals were laparotomized 6 hours following IP injections. The existence of IN was noted and blood specimens were obtained. TNFalpha and IL-6 plasma level measurements were performed by standard ELISA for mice. The results were compared using the Mann-Whitney U test and one-way ANOVA test. A value of p<0.05 was considered significant. RESULTS: Five mice (1 in the control, 2 in the LPS, 2 in the Treatment group) were excluded from the study. IN was observed in 6 (20%) mice in the LPS group, whereas it was not found in any mice in the Treatment group. Mean TNFalpha and IL-6 levels were statistically higher in the LPS group (394.72+/-403.79; 195.18+/-218.37 pg/ml, respectively) compared to all other groups, including the Treatment group (p<0.05 for each comparison). Within the LPS group of mice, the levels were higher in animals with IN compared to the mice without IN. CONCLUSION: Increased TNFalpha and IL-6 levels induced by LPS correlated well with the occurrence of IN, and a decrease in these levels via cyclooxygenase (COX) inhibition by indomethacin prevented IN from forming in this experimental model.

Effect of melatonin on healing of colonic anastomosis in a rat model of peritonitis.

BACKGROUND: The aim of this study is to determine the effect of melatonin on intestinal anastomosis in the presence of peritonitis. MATERIAL AND METHODS: 32 Wistar albino rats were randomized into four groups (n = 8): A (sham), B (control), C (melatonin 5 mg/kg), and D (melatonin 10 mg/kg). In group A, only cecal dissection was carried out. In the other groups, cecal ligation and puncture (CLP) followed cecal dissection in order to induce bacterial peritonitis. 24 h after the previous operation, cecal resection and ileocolic anastomosis were performed in the rats of all groups. In group C (5 mg/kg) and group D (10 mg/kg), melatonin was injected for 5 consecutive days starting after CLP. At the 48th hour of the CLP procedure, blood was drawn via the tail vein for tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) analysis, and on the 4th day of the experiment relaparotomy was carried out for bursting pressure (BP) measurements. The intestinal tissue containing the anastomotic line was then snap-frozen in liquid nitrogen and stored at -80 degrees C for determination of tissue levels of malondialdehyde (MDA) and glutathione (GSH). RESULTS: The tissue MDA level, blood TNF-alpha and IL-6 levels of group B were significantly higher than in the other groups, whereas the BP results and GSH levels of group B were found to be significantly lower than in the other groups. The results of groups C and D are statistically different from those of group B. When we compared the results of groups C and D, we found significantly higher results in terms of BP and GSH levels in group D and also significantly lower results in terms of MDA, blood TNF-alpha and IL-6 levels in group D. CONCLUSION: The findings of this experiment suggest that melatonin has a dose-independent positive effect on wound healing of colonic anastomosis.

A child with a giant omental cyst.

A case of giant omental cyst diagnosed preoperatively is described. A 4-year old girl presenting with abdominal distension and misdiagnosed as having ascites, was subsequently proved to have a giant omental cyst. This is a rather difficult diagnosis to reach and results in wrong treatment methods. A high index of suspicion is therefore required early in the course of the disorder to decrease the complication rate. This report describes the diagnostic modalities and our approach to the patient who was cured by total excision of the cyst and free of disease in the fourth year of follow-up.

Sequential cytokine levels in the diagnosis of appendicitis.

OBJECTIVE: To determine the diagnostic value of sequential white blood cell count (WBC), tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in patients with abdominal pain. MATERIAL AND METHODS: Tests were determined at hospital admission and 6 h later in 105 children. Patients who were non-operatively followed and had a normal histopathology were classified as the non-appendicitis (NA) group. Patients with symptoms consistent with appendicitis were classified as the appendicitis group (A). Data were analyzed as positive/negative predictive value, sensitivity, specificity and accuracy rate (AR). The global power of the variables in discriminating the patients between the two groups and advanced/simple appendicitis was assessed from the area under the receiver operating characteristic (ROC). RESULTS: Initial measurements showed WBC to be a valuable diagnostic tool in acute appendicitis (AR = 74 %), whereas IL-6 and TNF-alpha were found not to be valuable. The second measurements revealed higher values, and IL-6 reached its highest AR (89 %). When initial values were evaluated in combination, the highest AR of 73 % was observed with TNF-alpha + WBC. The highest AR (90 %) was seen with IL-6 + TNF-alpha in the second measurements. ROC analysis showed WBC to be the most valuable parameter of the three. The area under the curve (AUC) was 0.750 for the initial measurement and 0.779 for the repeat measurement of WBC (p = 0.001). The most useful diagnostic parameter in discriminating between the simple and the advanced cases was IL-6 as assessed with the ROC curve (p<0.01). CONCLUSIONS: WBC elevation in patients with suspected acute appendicitis is an important parameter supporting the diagnosis at initial admission, whereas IL-6 is a more valuable tool in diagnosing advanced appendicitis.

Surgical breast lesions in adolescent patients and a review of the literature.

BACKGROUND/PURPOSE: Breast disease in adolescence is uncommon, with most presenting lesions being benign. Breast lesions in adolescent patients are discussed in this article with a review of world literature. PATIENTS AND METHODS: The clinical records of 30 patients operated upon for breast lesions in our hospital during 18 years were reviewed. RESULTS: There were 25 female and five male patients, ranging in age from 16 years. Twenty-five female patients were operated on for breast mass and/or discharge, and five male adolescents were operated on for gynaecomastia. The most frequent (n = 27) complaint was palpation of mass in the breast. The most common histologies were fibro-adenoma (n = 14) and gynaecomastia (n = 5). The average duration of pre-operative symptoms was 2.9 months for fibro-adenoma, 1.6 years for gynaecomastia (extremes 2 days to 1 year). Nipple discharge was observed in three patients. Average diameters of palpable masses were 2.9 cm for fibro-adenomas and 5 cm for gynaecomastia. Lesions were excised surgically in all patients. Masses diagnosed as fibro-adenomas in the pre-operative period were reported upon pathological examination to be precancerous lesions such as cystosarcoma phylloiedes, juvenile fibro-adenoma, solitary intraductal papilloma, tubular adenoma and juvenile papilloma. One postoperative wound infection and one recurrence of fibro-adenoma was seen. CONCLUSION: The most frequently encountered breast masses were fibro-adenomas. These lesions are mostly benign in nature and can be treated conservatively but the possibility of precancerous lesion should be considered during follow-up.

Unusual localization of hydatid cyst.

We report a case of a single large echinococcal cyst that originated from the retroperitoneal space. Diagnosis was confirmed with serologic test and radiological examinations. Especially in the endemic areas hydatid cyst should be considered when evaluating cystic masses and it can be treated by extraperitoneal operation.

Treatment of Morgagni hernias by transabdominal approach / Tratamiento de las hernias de Morgagni mediante el abordaje transabdominal

BACKGROUND: Recently, the thoracic approach has been suggested in the surgical treatment of Morgagni hernias with some reported advantages over abdominal surgery. This manuscript reports the authors' experience with childhood Morgagni hernias repaired via laparotomy. SUBJECTS AND METHODS: Records of five cases of Morgagni hernias were evaluated with respect to age, presentation, operative data, complications, and outcome. RESULTS: The average age of four male and one female patients was 34 months (range 6 months to 8 years). Predominant presenting symptoms were related to the respiratory system. The diagnoses were made by posterior-anterior and lateral chest X-rays and confirmed by barium enema contrast radiographs. Associated anomalies were detected in three cases. All cases were managed by abdominal approach through upper midline incisions reducing the herniated viscera (transverse colon in all and including omentum in one patient) and excising the hernia sac which was present in all patients. The postoperative period was uneventful in this series and no recurrence was detected in an average of four years of follow-up. CONCLUSION: The transabdominal approach is appropriate in the surgical correction of paediatric Morgagni hernias.

Antecedentes: Recientemente, se ha sugerido el empleo del abordaje torácico en el tratamiento de las hernias de Morgagni, reportándose algunas ventajas del mismo sobre la cirugía abdominal. Este trabajo reporta la experiencia de los autores en relación con hernias de Morgagni en la infancia, reparadas mediante laparotomía. Sujetos y métodos: Las historias clínicas de cinco casos de hernias de Morgagni operadas en nuestro departamento, fueron evaluadas con respecto a edad, presentación, datos operatorios, complicaciones, y resultado. Resultados: La edad promedio de cuatro pacientes varones y una hembra fue de 34 meses (rango de 6 meses a 8 años). Los síntomas presentados estuvieron relacionados de forma predominante con el sistema respiratorio. Los diagnósticos se hicieron mediante rayos X posterior-anterior y lateral de tórax, y confirmados luego mediante estudio radiográfico de contraste con enema de bario. Se detectaron anomalías asociadas en tres casos. Todos los casos fueron manejados mediante abordaje abdominal a través de incisiones de la línea media superior, reduciendo así la víscera herniada (colon transversal en todos, incluyendo el omento en un paciente) y practicando la excisión del saco de la hernia, presente en todos los pacientes. El período post-operatorio no presento incidentes en esta serie, y no se detectó recurrencia durante el seguimiento, que duró un promedio de cuatro años. Conclusión: El abordaje transabdominal es apropiado en la corrección quirúrgica de las hernias pediátricas de Morgagni.

Omentum prevents intestinal adhesions to mesh graft in abdominal infections and serosal defects.

BACKGROUND: Many studies have evaluated the use of grafts in the reconstruction of abdominal wall defects. In this study, the effects resulting from the presence or absence of the omentum were evaluated in the setting of infection or serosal defects in the formation of adhesions in abdominal closures using mesh grafts. METHODS: For this study, 60 Wistar albino rats were divided into six groups. A circular 3.79-cm(2) fascioperitoneal defect was created. After group-specific procedures, defects were reconstructed using polypropylene mesh grafts. In group C (control group), only a mesh graft recontruction was performed, whereas group O (O for omentectomy) underwent an omentectomy plus mesh closure. In group SD (serosal defect group), the cecum was abrased with a brush before mesh closure. Group SDO underwent cecal abrasion plus an omentectomy. In group I (infection group), the intraabdominal space was filled with 1 ml of solution containing 100,000 colony-forming units (CFUs) of Escherichia coli per milliliter. Group IO received the same same amount of E. coli solution plus an omentectomy before mesh closure. After 28 days, the groups were evaluated by intraabdominal and blood cultures, grading of intraabdominal adhesions, graft-organ adhesions, proportion of adhesions to graft size, and histopathologic studies. The results were statistically evaluated using one-way variant analysis and Scheffe's and Fisher's definite chi-square tests. RESULTS: For the groups in which the greater omentum was preserved, intestinal adhesions to the graft surface were less frequently observed, especially in cases with intraabdominal infections and serosal defects (p < 0.05). CONCLUSIONS: Preservation of the greater omentum reduces the formation of intestinal adhesions, especially in cases with underlying infections and serosal defects in abdominal closures using mesh grafts. This could be beneficial in related clinical situations in lowering the rate of intestinal fistulas, erosions, and obstructions that can be attributed to the formation of adhesions.

Treatment of Morgagni hernias by transabdominal approach.

BACKGROUND: Recently, the thoracic approach has been suggested in the surgical treatment of Morgagni hernias with some reported advantages over abdominal surgery. This manuscript reports the authors' experience with childhood Morgagni hernias repaired via laparotomy. SUBJECTS AND METHODS: Records of five cases of Morgagni hernias were evaluated with respect to age, presentation, operative data, complications, and outcome. RESULTS: The average age of four male and one female patients was 34 months (range 6 months to 8 years). Predominant presenting symptoms were related to the respiratory system. The diagnoses were made by posterior-anterior and lateral chest X-rays and confirmed by barium enema contrast radiographs. Associated anomalies were detected in three cases. All cases were managed by abdominal approach through upper midline incisions reducing the herniated viscera (transverse colon in all and including omentum in one patient) and excising the hernia sac which was present in all patients. The postoperative period was uneventful in this series and no recurrence was detected in an average of four years of follow-up. CONCLUSION: The transabdominal approach is appropriate in the surgical correction of paediatric Morgagni hernias.

Postoperative intussusception in children.

Postoperative intussusception (POI) is an uncommon cause of postoperative mechanical bowel obstruction in children. Four cases of POI during a period of 15 years (1987-2001) were analysed retrospectively. Symptoms developed after a median period of 2.5 days following the operation. All cases were succesfully treated with operative manual reduction. POI occurs after a wide variety of surgical procedures and is often difficult to diagnose because the symptoms are often obscure. As a conclusion, we state that reaching a diagnose requires a high index of suspicion.

Massive ovarian oedema in adolescents.

Massive ovarian oedema is an unusual clinical entity occurring in teenage girls. It is a rare tumour-like condition of the ovary characterized by marked enlargement of one or both ovaries due to marked accumulation of oedema fluid in the ovarian stroma. Massive ovarian oedema may result from partial or intermittent torsion of the mesovary, interfering with venous and lymphatic drainage, but not with arterial blood flow. The patients most commonly present with lower abdominal pain and enlargement. This entity can clinically mimic a neoplasia. We report three cases with massive ovarian oedema.

Pancreas pseudocyst associated with L-asparaginase treatment: a case report.

A major complication of L-asparaginase used in the treatment of paediatric malignancies in children is pancreatitis (2%-16%). However, only seven paediatric cases of pancreatic pseudocyst caused by the utilization of the agent have been reported in literature. We present the case of a 5-year old girl who had abdominal pain and epigastric dullness after the third course of BMF-95 protocol with a diagnosis of ALL. A pancreatic pseudocyst of 10 x 10 cm size was found by abdominal tomography. The cyst was treated by percutaneous external drainage, total parenteral nutrition (TPN), administration of octreotide and antibiotherapy for one month. Percutaneous external drainage has proven to be an effective, noninvasive method in this special case with a systemic disorder and the high risk of mortality should a surgical intervention have been performed.

Effects of hyperosmolar agents--lactulose, lactitol, sodium phosphate and polyethylene glycol--on cecal coliform bacteria during traditional bowel cleansing: an experimental study in rats.

Mechanical bowel cleansing is considered to be necessary prior to colorectal surgery, some radiological or endoscopic procedures, and for fecal disimpaction. Traditional bowel cleansing (TBC) with cathartics and enemas is a method of mechanical bowel cleansing for patients who have restrictive factors for whole-bowel irrigation (WBI), such as excessive fecal impaction, cardiac, hepatic or renal disorders. In this experimental study, TBC with hyperosmolar agents was evaluated in terms of their effects on colonic flora and bacterial translocation (BT). Sprague-Dawley rats were divided into 6 groups. The animals, except controls, were not fed for 72 h but received tap water ad libitum. During this period, lactulose, lactitol, sodium phosphate (NaP), polyethylene glycol 3350 (PEG3350) and physiological saline gavages were administered to the rats in groups 1-5, respectively, once a day. All animals except controls (group 6) received enemas with 15 ml of warm saline twice a day. The cecum, mesenteric lymph nodes (MLNs) and portal vein blood were sampled for microbiological and histopathological analysis. The highest level of coliform bacterial overgrowth and BT to MLNs were observed in the lactulose group, although the others, except the saline and control groups, also caused some degree of BT. Portal vein cultures were negative for all groups. Histopathological damage was not associated with cecal bacterial count and BT. As a result of this study, PEG3350 seems to be safer and more effective than lactulose, lactitol and NaP during TBC.

Diagnostic value of plain abdominal radiographs in acute appendicitis in children.

OBJECTIVE: The plain film of the abdomen (PAX) is still utilised in the diagnosis of acute appendicitis (Aap). Aim of this study was to evaluate the value of PAX in the diagnosis of Aap in children, since it continues to be a controversial subject. DESIGN: A retrospective study. SETTING: Department of Paediatric Surgery, Gazi University Medical School. PATIENTS: The histopathological diagnoses and PAX of 213 children (mean age 9-6 years) operated for acute right-lower quadrant pain were evaluated retrospectively. There were 181 patients with Aap and 32 with normal appendix. METHODS: The rate of detection of overall thirteen roentgenographic criteria defined in various reports in medical literature as indicating appendicitis were noted and compared with histopathological diagnoses. The PAX which revealed one or more of these signs in combination was considered to be positive for Aap. Data was analysed statistically and sensitivity, specificity and positive and negative predictive values of PAX in the diagnosis of Aap were determined. RESULTS: Roentgenographic sign(s) were detected in 170 (79%) cases, 18 without Aap. The most frequent were lumbar scoliosis with left-sided convexity (50%) and small intestinal air-fluid levels (32%). In 39 cases, 25 with Aap, no sign(s) was detected. In all of the perforated cases, at least one of the determined criteria was seen. The percentage of roentgenographic signs found in cases with and without appendicitis was different significantly (p<0.01). The negative predictive value of PAX in the diagnosis of acute appendicitis was 32.5% and positive predictive value was 89%. CONCLUSION: PAX could he helpful in diagnosis in children with suspected acute appendicitis.

Effects of amrinone on bilateral renal ischemia/reperfusion injury.

Renal ischemia/reperfusion injury could arise as a consequence of clinical conditions such as renal transplantation, shock, cardiac arrest, hemorrhage and renal artery surgery. In this experimental study, we aimed to determine the preventive effects of amrinone on bilateral renal ischemia/reperfusion injury in rats. A total of 60 Wistar-albino rats were divided into six groups ( n=10). Midline laparotomies were made under ketamine anesthesia. In the sham, amrinone1 and amrinone2 without ischemia (AWI1 and AWI2) groups saline, 5 and 10 mg/kg of amrinone was infused, respectively. In the ischemia, ischemia plus amrinone1 (IPA1) and ischemia plus amrinone2 (IPA2) groups, saline and 5 and 10 mg/kg of amrinone was infused, respectively, at the beginning of reperfusion, subsequent to 45 min of bilateral renal artery occlusion. Following 6 h of reperfusion, blood was drawn to study serum BUN and creatinine and a bilateral nephrectomy was done to determine tissue malonyldialdehyde ( MDA) and myeloperoxidase (MPO) levels. The results were analysed by Mann-Whitney U-test. The parameters studied were statistically higher in the ischemia group compared with the other groups ( P<0.05 for each comparison), indicating renal I/R injury. These parameters were lower in the amrinone without ischemia groups (AWI1 and AWI2) than in the sham group, however there were no significant differences between the groups ( P>0.05, for each comparison). The treatment groups IPA1 and IPA2 had statistically similar results compared with the sham group, showing the preventive effect of amrinone on renal I/R injury at the given doses. We conclude that amrinone prevented experimental renal ischemia/reperfusion injury in rats, independently of the administered doses. This preventive effect of the agent could depend on its effect of regulating the microcirculation, in decreasing intracellular calcium and in preventing neutrophil activation. We propose that this preventive effect of amrinone - which has gained clinical application especially in cases of cardiac insufficiency - could also be exploited in clinical conditions related with renal ischemia/reperfusion.

Effect of bilirubin in ischemia/reperfusion injury on rat small intestine.

PURPOSE: The aim of this study was to determine the effects of bilirubin in experimental small intestinal ischemia/reperfusion (I/R) injury in rats. METHODS: Thirty rats were divided into 5 groups (n = 6). In group S, saline and in group B, bilirubin, 20 mg/kg were infused via the jugular vein without an additional procedure. In groups S-IR, saline, B(1)-IR and B(2)-IR, 10 and 20 mg/kg/h of bilirubin were infused for 2 hours, respectively. In these groups, an I/R procedure was done after infusions by occluding the superior mesenteric artery for 45 minutes followed by 1 hour of reperfusion. After reperfusion, the small intestines were resected for histopathologic and malondialdehyde (MDA) assessments. Mucosal lesions were scored between 0 and 5. Malondialdehyde levels and histopathologic grades were analyzed statistically. RESULTS: Mucosal injury was severe in S-IR (grade 4 to 5), mild in B(1)-IR (grade 0 to 3) and none in B(2)-IR group (grade 0). Grades of group S-IR were higher than those of B(1)-IR and B(2)-IR statistically (P <.05). Tissue MDA levels of the S-IR group were significantly higher than those of B(1)-IR and B(2)-IR groups (U = 36, P <.05). Bilirubin levels correlated inversely with MDA levels (r = -0.94). CONCLUSIONS: Bilirubin effectively prevents intestinal I/R injury in rat. This observation is consistent with the hypotheses regarding bilirubin as an antioxidant, having a role in the body defense. J Pediatr Surg 36:1764-1767.

Colon interposition for esophageal stenosis in a patient with epidermolysis bullosa.

Epidermolysis bullosa (EB) is a disease with 3 forms, most hereditary, characterized by spontaneous blistering lesions. The autosomally inherited form, epidermolysis bullosa dystrophica recessive (EBDR), is responsible for esophageal lesions consisting of web or stenosis. The authors could find only 9 cases treated by various esophageal replacement procedures in the literature, and the experience with 1 case treated by colon interposition is presented. J Pediatr Surg 36:1861-1863.

Diffuse fibrous proliferation of tunica vaginalis associated with testicular infarction: a case report.

Fibrous pseudotumor of the tunica vaginalis testis is an uncommon lesion of unknown pathogenesis. Although this reactive process of testicular tunics is benign, this usually is diagnosed after radical orchiectomy. The authors describe a case of fibrous pseudotumor of the tunica vaginalis testis associated with testicular infarction. To our knowledge, this is the first case presented with similar association, second case consisting predominantly of myofibroblasts and the fourth reported case encountered in childhood.

Postoperative necrotizing enterocolitis following incarcerated inguinal hernia repair: report of a case.

The postoperative development of necrotizing enterocolitis (NEC) following major surgery in neonates has often been described. We report herein the case of an older infant in whom postoperative NEC developed following emergency repair of an incarcerated inguinal hernia.