Necrotising enterocolitis-A 15-year outcome report from a UK specialist centre.

AIMS: Necrotising enterocolitis (NEC) is a disease associated with high mortality and morbidity, low birthweight and prematurity are risk factors. This study reports outcomes of babies having emergency laparotomy for NEC, examining institutional trends and exploring impact of multiple variables on mortality at 30 days and 1 year post-operatively. METHODS: Case records of babies with ICD coding for NEC were examined from 2000 to 2015. After exclusions, 243 cases were identified-confirmed by operative findings and histology. Cohort demographics and trends in mortality were investigated, and the relationship of common variables to mortality was modelled with univariate and multivariate logistic regression to generate a mortality prediction tool. RESULTS: Mean gestational age was 28 + 4 weeks. A 30-day mortality was 18.9%. Gestation, birthweight and area of bowel affected were significant of outcome (mortality), and the presence of pre-operative pneumoperitoneum was strongly correlated. Year of surgery and congenital cardiac pathology requiring intervention were not significant. Using multivariate regression modelling, a mortality outcome prediction tool has been developed. CONCLUSION: Good survival following operation for NEC (>70%) is feasible, even in those babies born extremely premature (<28 weeks) and post-operatively re-located to tertiary NICUs. With increasing gestational age (>32 weeks), mortality is uncommon.

From Paris to Montreal: disease regression is common during long term follow-up of paediatric Crohn's disease.

Introduction: Paediatric Crohn's disease (PCD) often presents with extensive and a frequent pan-enteric phenotype at onset. However, its long term evolution into adulthood, especially since the widespread use of biological agents, is not well characterised. We conducted a single centre cohort study of all PCD patients transitioned to adult care to assess the long term disease evolution in the era of biologic therapy.Methods: We conducted a retrospective observational, study of all PCD patients who were subsequently transferred to the care of an adult gastroenterology unit and had a minimum follow up of 2 years. We examined the case notes for evolution of disease location and behaviour. Disease location and behaviour was characterised using Paris classification at diagnosis and Montreal classification at last follow-up. In addition, we examined variables associated with complicated disease behaviour and the need for CD related intestinal resection.Results: In total, 132 patients were included with a median age at diagnosis of 13 (IQR 11-14) and a median follow up of 11 years (range 4-14). At diagnosis, 23 (17.4%), 39 (29.6%) and 70 (53%) patients had ileal, colonic and ileocolonic disease respectively. In addition, 31 (23.5%) patients had L4a or L4b disease at diagnosis (proximal or distal to the ligament of treitz respectively) and 13 patients (9.8%) had both whilst 27 (20.4%) patients had perianal disease. At diagnosis, 27 (20.4%) patients had complicated disease behaviour but 83 (62.9)% of patients had an extensive 'pan-enteric' phenotype. Of these patients only 55 (66.3%) retained the pan-enteric phenotype at last follow-up (p = .0002). Disease extension was noted in 25 (18.9%) of patients and regression was noted in 47 (35.6%) of patients, whereas upper GI disease was noted in significantly fewer patients at last follow-up (21, 15.9%) (p = .0001). More patients had complicated disease behaviour (46 patients, 34.9%, p = .0018) at last follow-up. There was a high exposure to both thiopurines 121 (91.7%) and biologics 84 (63.6%). The cumulative probability (95% CI) of surgery was 0.05 (0.02, 0.11) at 1 year, 0.17 (0.11, 0.24) at 3 years and 0.22 (0.15, 0.30) at 5 years. Neither disease location nor behaviour were associated with the need for intestinal resectional surgery.Conclusions: Over the course of an extended follow-up period, there appeared to be changes in both disease location and behaviour in PCD. Interestingly, a significant proportion of patients had disease involution which may be related to a high rate of exposure to thiopurines and biologics. We were unable to identify any variables associated with complicated disease course or the need for intestinal surgery.

Evaluating the Implementation and Impact of a Motivational Interviewing Workshop on Medical Student Knowledge and Social Cognitions Towards Counseling Patients on Lifestyle Behaviors.

Problem: Although motivational interviewing is an effective patient-centered counseling method that healthcare providers can adopt to promote positive behavior change among patients, motivational interviewing is not routinely taught in medical schools. Intervention: A 3.5-hour motivational interviewing workshop was delivered to second year students at a Canadian medical school. Students were first introduced to the concept of motivational interviewing, and then given an opportunity to apply this knowledge in smaller seminar groups to increase their competency within the context of lifestyle behaviors. Context: Using the Theory of Planned Behavior, this study sought to evaluate the impact of the workshop on medical students' motivational interviewing knowledge and social cognitions. Questionnaires were distributed to students pre- and immediately post-workshop to gather student demographics, previous motivational interviewing experience, current motivational interviewing knowledge and Theory of Planned Behavior social cognitions for using motivational interviewing. Repeated-measures ANOVAs assessed changes in motivational interviewing knowledge and social cognitions. During the workshop, a process evaluation assessing fidelity to and quality of motivational interviewing instruction was conducted. Outcome: The process evaluation indicated high fidelity and high quality of delivery of the workshop by all facilitators. Students (N = 27; Mage = 24 ± 2 years) reported significant increases in motivational interviewing knowledge from pre- to post-workshop (p = 0.001). Although not significant, small-to-moderate effect sizes in changes in social cognitions were reported from pre- to post-workshop. Lesson Learned: Medical students hold motivational interviewing in a high regard, as evidenced by the relatively high social cognitions observed prior to the commencement of the workshop. We learned that while a shorter, workshop-style approach is successful in increasing motivational interviewing knowledge, future workshops should allocate more time to skill acquisition to ensure proficiency in clinical use. Practice PointsMotivational interviewing (MI), an effective patient-centred counseling method that promotes positive patient behavior change, is not routinely taught in medical schools.The theory-based evaluation of the implementation and impact of an MI workshop for second year medical students revealed high quality of delivery and significant improvements in self-reported MI knowledge.While the workshop was implemented as intended and based on the Theory of Planned Behavior, no significant changes in students' social cognitions for using MI with future patients was seen from pre- to post-workshop.The fulsome workshop description and suggestions for future workshop modifications may be adopted by others interested in incorporating MI-specific training into the medical school curriculum.

Clinical Experience of Use of High-dose Intravenous Methylprednisolone in Children With Acute Moderate to Severe Colitis.

OBJECTIVES: Treatment of acute severe colitis (ASC) has been associated with high morbidity and high colectomy rate in children. In the prebiologics era, our centre used short-term high-dose intravenous corticosteroids (IVCS) at 2 to 30 mg ·â€Škg ·â€Šday. We conducted a retrospective review to compare efficacy of different dosing regimes of IVCS. METHODS: Thirty-four children treated with IVCS for ASC were included over 8 years. Patients were studied as 2 groups with similar pretreatment patient characteristics. Group 1 (standard dose) received IVCS at 2 mg ·â€Škg ·â€Šday and group 2 (high dose) received IVCS at 10 to 30 mg ·â€Škg ·â€Šday. Safety, efficacy, and follow-up of the entire cohort for >1 year were studied. The median IVCS dose in the standard- and high-dose cohort was 1.5 mg ·â€Škg ·â€Šday (maximum 60 mg ·â€Škg ·â€Šday) and 24.8 mg ·â€Škg ·â€Šday (maximum 1000 mg ·â€Škg ·â€Šday), respectively. RESULTS: Pediatric Ulcerative Colitis Activity Index scores at day 5 were significantly lower in high-dose (15, interquartile range 8.5-20) than in standard-dose IVCS (30, interquartile range 20-30). IVCS side effects were minor and reversible. Overall, medical salvage therapy was required in 5.8% (2 children) before discharge, and in 17% (6 children) at follow-up after 1 year. The colectomy rate of the entire cohort was remarkably low with 0% during admission and 11% (4 children) after 1 year, with a trend of less colectomies in high-dose (4.8%-1 child) than in standard-dose (23%-3 children). CONCLUSIONS: Our data show that in paediatric ASC, the short-term use of high-dose IVCS is safe and effective. Prospective studies are needed to define the role of IVCS within salvage therapy protocols.

Does time to theater matter in simple gastroschisis?

Objective: A recent publication has suggested that expedited time to theater in gastroschisis results in higher rates of primary closure and decreases the length of stay (LOS). This study primarily aims to assess the impact of time to first management of neonates with gastroschisis on the LOS. Methods: Neonates admitted between August 2013 and August 2020 with gastroschisis were included. Data were collected retrospectively, and neonates with complex gastroschisis were excluded. Variables including gestation, birth weight, time of first management, primary/delayed closure and use of patch were evaluated as possible confounding variables. The outcome measures were time to full feeds, time on parenteral nutrition (PN) and LOS. Univariate and multivariate linear regression analyses were performed. P<0.05 was regarded as significant. Results: Eighty-six neonates were identified, and 16 were then excluded (eight patients with complex gastroschisis, eight patients with time to first management not documented). The median LOS for those who underwent primary closure was 21 days (interquartile range (IQR) =16-29) and for those who underwent silo placement and delayed closure was 59 days (IQR=44-130). The mean time to first management was 473 min (standard deviation (SD) =146 min), with only 20% of these infants being operated on at less than 6 hours of age. Univariate and multivariate analyses demonstrated no relationship between time to first management and LOS (r2=0.00, p=0.82) but did demonstrate a consistent positive association between time to first feed and LOS and delayed closure, resulting in a longer time to full feeds and a longer time on PN. Conclusions: The time to first management was not associated with a change in LOS in these data. Further prospective evaluation of the impact of reducing the time to first feed on the LOS is recommended. Level of evidence: IV.

Histiocytic sarcoma presenting with chylous ascites in a 7-month-old infant: a case report.

We describe in this report what we believe to be the first report of a rare presentation of a very rare tumor, especially in this age group. We highlight the importance of early consideration of malignancy as a cause of chylous ascites in infancy and we discuss different causes of chylous ascites.

Role of Routine Dilatations after Anorectal Reconstruction-Comparison of Two Tertiary Centers.

AIM: Regular anal dilatations are commonly recommended in the postoperative management following posterior sagittal anorectoplasty (PSARP) in anorectal malformations (ARM). We hypothesized that routine postoperative dilatations may not affect surgical outcomes following PSARP. We compare surgical outcomes of routine postoperative dilatations versus no routine postoperative dilatations from two United Kingdom tertiary pediatric surgical centers. MATERIALS AND METHODS: This is retrospective records review of patients undergoing definitive surgery for ARM in two tertiary surgical centers in the UK over 5 years. Center A used a protocol of routine postoperative dilatations, and center B used a protocol, which used dilatations only for clinical indications of stricture. Data collected included ARM type, operative procedures, and postoperative interventions. All post-operative interventions under general anesthesia (GA) were compared between groups. RESULTS: From 2011 to 2015, 49 procedures (46 PSARPs) were performed in center A and 54 (52 PSARPs) in center B. Median follow up period was 31 months (interquartile range [IQR] 18-48). The first postoperative anal calibration under GA was documented for 43 (86%) patients in center A and for 42 (78%) patients in center B. Following this, center A followed routine postoperative dilatation (RPD) at home, and center B reserved further dilatations for specific indications. RPD was performed for 100% of patients in center A versus 8% in center B. Further anal dilatations under GA were performed in 19 (38%) children in center A and in 17 (34%) children in center B (p = 0.68). In center A, 10 patients (22%) needed further surgery versus 14 (28%) in center B (p = 0.48). CONCLUSION: The use of routine postoperative dilatations does not significantly improve surgical outcomes following PSARP in ARM.

Isolated cutaneous anaplastic large cell lymphoma progressing to severe systemic disease with myocardial involvement and central nervous system infiltration.

Anaplastic large cell lymphoma (ALCL) is a rare tumor comprising around 10-15% of childhood lymphomas. We describe the case of a female who initially presented with localized skin disease associated with an insect bite. However, she subsequently relapsed with widespread systemic ALK-positive ALCL that included lymphoma deposits in the myocardium, a very rare manifestation. Her disease responded well to chemotherapy but she later developed a fatal relapse in the CNS. We also present data on an immune response to ALK, demonstrating a fluctuation in the levels of circulating antibodies to ALK corresponding to the different phases of her illness.

Negative exploration for pyloric stenosis--is it preventable?

BACKGROUND: The diagnosis of infantile hypertrophic pyloric stenosis (IHPS), although traditionally clinical, is now increasingly dependent on radiological corroboration. The rate of negative exploration in IHPS has been reported as 4%. The purpose of our study was to look at elements of supportive clinical evidence leading to positive diagnosis, and to review these with respect to misdiagnosed cases undergoing negative exploration. METHODS: All infants undergoing surgical exploration for IHPS between January 2000 and December 2004 were retrospectively analysed with regard to clinical symptoms, examination findings, investigations and operative findings. RESULTS: During the study period, 343 explorations were performed with a presumptive diagnosis of IHPS. Of these, 205 infants (60%) had a positive test feed, 269 (78%) had a positive ultrasound scan and 175 (55%) were alkalotic (pH >or=7.45 and/or base excess >or=2.5). The positive predictive value for an ultrasound (US) diagnosis was 99.1% for canal length >or=14 mm, and 98.7% for muscle thickness >or=4 mm. Four infants (1.1%) underwent a negative surgical exploration; Ultrasound was positive in 3, and negative in 1(who underwent surgery on the basis of a positive upper GI contrast). One US reported as positive had a muscle thickness <4 mm. Two false positive US were performed at peripheral hospitals. One infant had a false positive test feed following a positive ultrasound diagnosis. Two infants had negative test feeds. CONCLUSION: A 1% rate of negative exploration in IHPS compares favourably with other studies. However potential causes of error were identified in all 4 cases. Confident diagnosis comprises a combination of positive test feed and an 'in house US' in an alkalotic infant. UGI contrast study should not be used in isolation to diagnose IHPS. If the test feed is negative, strict diagnostic measurements should be observed on US and the pyloric 'tumour' palpated on table under anaesthetic before exploration.

Primary pull-through for Hirschsprung's disease: comparison of open and laparoscopic-assisted procedures.

Rectosigmoid Hirschsprung's disease is usually amenable to minimally invasive primary neonatal pull-through. This may be performed either entirely transanally or with laparoscopic assistance for biopsies with or without colonic mobilization. In our center, all dissection is performed transanally; laparoscopy is used for obtaining colonic biopsies and orientation of the pulled-through bowel segment. In this paper, we describe our initial experience of a consecutive cohort of 20 one-stage laparoscopic-assisted endorectal pull-through (LAEPT) procedures. A historic consecutive cohort of 22 infants who underwent the same open endorectal pull-through (OPT) with open transabdominal mobilization was used for comparison. Age at operation and mean theater time were not significantly different. The mean postoperative stay was significantly reduced in the laparoscopic group (LAEPT 3.8 days vs. OPT 9.5 days; P = 0.0002). Readmission and enterocolitis rates in the first postoperative year did not differ significantly. LAEPT permits early intraoperative biopsies with a visualization of the pull-through to prevent twisting of the bowel.

Physical activity interventions to promote positive youth development among indigenous youth: a RE-AIM review.

Physical activity (PA) programs are a promising strategy to promote positive youth development (PYD). It is not known if published reports provide sufficient information to promote the implementation of effective PYD in indigenous youth. The purpose of this study was to assess the extent to which published literature on PA programs that promote PYD in indigenous youth report on RE-AIM (reach, effectiveness, adoption, implementation, maintenance) indicators. A systematic literature search was conducted to identify articles reporting on PA programs that promote PYD in indigenous youth. The search yielded 8084 articles. A validated 21-item RE-AIM abstraction tool assessing internal and external validity factors was used to extract data from 10 articles meeting eligibility criteria. The most commonly reported dimensions were effectiveness (73 %), adoption (48 %), and maintenance (43 %). Reach (34 %) and implementation (30 %) were less often reported. Published research provides insufficient information to inform real-world implementation of PA programs to promote PYD in indigenous youth.

Malrotation: Age-Related Differences in Reoperation Rate.

OBJECTIVE: Intestinal malrotation classically presents in the neonatal period with bilious vomiting. However, population studies suggest that up to two-thirds of these patients are diagnosed later in childhood or in adulthood. Increased morbidity in the adult population has been reported. Local experience suggested that surgery was technically more difficult in older children and led to the hypothesis that it would be associated with increased morbidity. METHODS: A retrospective case note analysis was performed on all children presenting with intestinal malrotation to a tertiary referral center between January 2002 and November 2014. Case notes and operation records were reviewed and those who underwent laparotomy for confirmed malrotation were included. Children were grouped as infants (< 1 year) and older (> 1 year). The primary outcome was total emergency reoperation rate. Secondary outcomes were requirement for a bypass at reoperation and mortality. RESULTS: A total of 131 children with malrotation were identified (104 infants, 27 older children; 78 males; age range, 0-16 years). Overall, 13 patients had emergency reoperation following initial Ladd procedure (6 infants and 7 older children). Risk for reoperation was significantly higher in older children (p = 0.005) and additionally a bypass procedure was more often required in older children than infants (4 children, 2 infants, p = 0.016). Adhesiolysis was required on four occasions and redo Ladd procedure in two; these were evenly distributed between both groups. One child was found to have distal bowel obstruction at reoperation. There were three deaths (2.3%), all in the infant group. One was directly associated with malrotation with extensive bowel necrosis. The other two died of unrelated sepsis several months later. CONCLUSIONS: Malrotation surgery in older children is associated with a significantly higher emergency reoperation rate. The primary duodenal bypass procedure should always be considered with longstanding chronic intermittent obstruction associated with malrotation if the simple Ladd procedure is deemed inadequate.

Surgical strategies in paediatric inflammatory bowel disease.

Inflammatory bowel disease (IBD) comprises two distinct but related chronic relapsing inflammatory conditions affecting different parts of the gastrointestinal tract. Crohn's disease is characterised by a patchy transmural inflammation affecting both small and large bowel segments with several distinct phenotypic presentations. Ulcerative colitis classically presents as mucosal inflammation of the rectosigmoid (distal colitis), variably extending in a contiguous manner more proximally through the colon but not beyond the caecum (pancolitis). This article highlights aspects of the presentation, diagnosis, and management of IBD that have relevance for paediatric practice with particular emphasis on surgical considerations. Since 25% of IBD cases present in childhood or teenage years, the unique considerations and challenges of paediatric management should be widely appreciated. Conversely, we argue that the organizational separation of the paediatric and adult healthcare worlds has often resulted in late adoption of new approaches particularly in paediatric surgical practice.

Kabuki Syndrome and Anorectal Malformations: Implications for Diagnosis and Treatment.

Kabuki syndrome (KS) is a rare genetic condition characterized by a distinctive facies, intellectual disability, growth delay, and a variety of skeletal, visceral, and other anomalies, including anorectal malformations (ARMs). We present two cases of female patients with KS, diagnosed and successfully managed at our institution, one with a perineal fistula and one with a rectovestibular fistula. Our report, along with a literature review, shows that the syndrome is usually associated with "low" anomalies, with a potential for a good prognosis. Management of the anorectal anomaly in patients with KS is not essentially different from that in other nonsyndromic patients, taking into account the frequent association of the syndrome with serious congenital heart disease, which might affect the decision-making and timing of the stages of anorectal reconstruction. The frequent occurrence of learning and feeding difficulties makes establishment of toilet training and bowel management rather more challenging, requiring the expertise of a multidisciplinary team. The finding of ARMs in female patients with other characteristics of KS, although inconstant, could support the clinical suspicion for the syndrome until genetic confirmation is available, and should alert the physician for the potential of severe cardiac defects.

Evaluating the theoretical content of online physical activity information for people with multiple sclerosis.

BACKGROUND: Physical activity can aid people with multiple sclerosis (MS) in managing symptoms and maintaining functional abilities. The Internet is a preferred source of physical activity information for people with MS and, therefore, a method for the dissemination of behavior change techniques. The purpose of this study was to examine the coverage and quality of physical activity behavior change techniques delivered on the Internet for adults with MS using Abraham and Michie's taxonomy of behavior change techniques. METHODS: Using the taxonomy, 20 websites were coded for quality (ie, accuracy of information) and coverage (ie, completeness of information) of theoretical behavior change techniques. RESULTS: RESULTS indicated that most websites covered a mean of 8.05 (SD 3.86, range 3-16) techniques out of a possible 20. Only one of the techniques, provide information on behavior-health link and consequences, was delivered on all websites. The websites demonstrated low mean coverage and quality across all behavior change techniques, with means of 0.64 (SD 0.67) and 0.62 (SD 0.37) on a scale of 0 to 2, respectively. However, coverage and quality improved when websites were examined solely for the techniques that they covered, as opposed to all 20 techniques. CONCLUSIONS: This study, which examined quality and coverage of physical activity behavior change techniques described online for people with MS, illustrated that the dissemination of these techniques requires improvement.

Gastrointestinal surgery in cystic fibrosis: a 20-year review.

OBJECTIVES: The purpose of this study was to evaluate outcomes of the surgical management for meconium ileus (MI) and Distal Intestinal Obstruction Syndrome (DIOS) in Cystic Fibrosis (CF). METHODS: Children born between 1990 and 2010 were identified using a regional CF database. Retrospective case note analysis was performed. Outcome measures for MI were mortality, relaparotomy rate, length of stay (LOS), time on parental nutrition (TP), and time to full feeds (TFF). Outcome measures for DIOS were: age of onset, number of episodes, and need for laparotomy. RESULTS: Seventy-five of 376 neonates presented with MI. Fifty-four (92%) required laparotomy. Contrast enema decompression was attempted in nineteen. There were no post-operative deaths. Thirty-nine (72%) neonates with MI were managed with stomas. LOS was longer in those managed with stomas (p=0.001) and in complex MI (p=0.002). Thirty-five patients were treated for DIOS. Twenty-five patients were managed with gastrograffin. Ten patients underwent surgical management of DIOS. Overall, MI did not predispose to later development of DIOS. There was a significantly greater incidence of laparotomy for DIOS in children who had MI. CONCLUSION: The proportion of neonates with complex meconium ileus was high (49%) and may explain the infrequent utilisation of radiological decompression. Complex MI or management with stomas both significantly increase LOS. Re-laparotomy rate is high (22%) in MI irrespective of the type of management. DIOS is not a benign condition, particularly when the child has had previous abdominal surgery. Early referral to a surgical team is essential in these children.

Crohn's disease presenting as enterovesical fistula.

Enterovesical fistulae in Crohn's disease are relatively rare. We present the first report of a child presenting with an enterovesical fistula as the initial presentation of Crohn's disease. Management comprises of timely diagnosis, and treatment involving surgical resection with adjunctive medical management including immunomodulators. This case highlights the need to be aware of the rare but important occurrence of Crohn's enterovesical fistula as a cause for urinary symptoms in a child with inadequate weight gain.

Potential benefits of fast-track concepts in paediatric colorectal surgery.

BACKGROUND: Structured care pathways optimising peri-operative care have been shown to significantly enhance post-operative recovery. We aim to determine if enhanced recovery after surgery (ERAS) principles could provide benefit for paediatric patients undergoing major colorectal resection for inflammatory bowel disease (IBD). METHODS: Children undergoing elective bowel resection for IBD at a regional paediatric unit using standard methods of peri-operative care were matched to adult cases from an associated tertiary referral university hospital already using an ERAS program. Cases were matched for disease type, gender, operative procedure, and ASA grade. RESULTS: Forty-four children undergoing fifty procedures were identified. Thirty-four were matched to adult cases. Total length of stay in the paediatric group was significantly longer than in the adult group (6 vs. 9 days; P=0.001). Paediatric patients were slower to start solid diet (1 vs. 4 days; P<0.0001) and were slower to mobilize post-operatively (1 vs. 4 days; P<0.0001). No difference was seen in time to restoration of bowel function (2 vs. 3 days; P=0.49). Thirty day readmissions and total in-hospital morbidity were not significantly different between the groups. CONCLUSION: Potentially, application of ERAS in paediatric surgery could accelerate recovery and reduce length of post-operative stay thereby improving quality and efficiency of care.

The testicular regression syndrome--do remnants require routine excision?

AIM: Excision of testicular remnants is debatable in the scenario where hypoplastic vas and vessels can be seen entering a closed internal ring during laparoscopy for impalpable testes. We aimed to establish how frequently excised remnants have identifiable testicular tissue and, hence, malignant potential. METHODS: This study is a retrospective review of all excised testicular remnants in children with impalpable testis. Specimens that were excised for indications other than testicular regression syndrome were excluded. Pathology reports of excised specimens were reviewed, and the presence of multiple histologic features was noted. Histologic confirmation of testicular/paratesticular tissue required the presence of 1 or more of the following: seminiferous tubules, germ cells, Sertoli cells, Leydig cells, vas deferens, or epididymal structures. Malignancy potential was defined by the presence of germ cells or seminiferous tubules. All patients with seminiferous tubules were further examined by a single histopathologist. RESULTS: A total of 208 testicular remnants from 206 children were excised over the 11-year period (1999-2009). Histologic evidence confirmed excision of testicular/paratesticular tissue in 180 cases (87%). Seminiferous tubules were noted in 27 (15%), and germ cells were present in 19 (11%) cases. CONCLUSION: Viable germ cells were found in 11% of examined remnants, which, in our opinion, justifies their removal.