Unusual neonatal case of superior mesenteric artery syndrome with Meckel's diverticulum and literature review.

Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction which is characterized by compression of the duodenum due to narrowing of the space between the superior mesenteric artery and aorta. Incomplete duodenal obstruction due to SMAS in neonates is rarely reported in the literature. In this case, it is a full-term 2-day-old male with the complaint of recurrent vomiting starting soon after birth. The patient was diagnosed with SMAS and duodenoduodenostomy was performed. Accompanying Meckel's diverticulum was excised.

El síndrome de la arteria mesentérica superior (SMAS) es una causa rara de obstrucción duodenal que se caracteriza por la compresión del duodeno debido al estrechamiento del espacio entre la arteria mesentérica superior y la aorta. La obstrucción duodenal incompleta por SMAS en recién nacidos rara vez se informa en la literatura. En este caso se trata de un varón de 2 días nacido a término que presenta vómitos recurrentes desde poco después del nacimiento. El paciente fue diagnosticado de SMAS y se le realizó duodenoduodenostomía. Se extirpó el divertículo de Meckel que lo acompañaba.

Para-axillary subcutaneous endoscopic approach in torticollis: tips and tricks in the surgical technique.

AIM: An obvious scar on the neck may appear following the open surgery for congenital muscular torticollis (CMT). The cosmetic result may displease the patient and the family. In this study, we describe a minimally invasive technique, para-axillary subcutaneous endoscopic approach (PASEA) in CMT. PATIENTS AND METHODS: A total of 11 children (seven girls and four boys with the age range between 1 and 15 years) were operated for torticollis by PASEA. All patients had facial asymmetry and head and neck postural abnormality. Following an incision at the ipsilateral para-axillary region, a subcutaneous cavernous working space is formed toward sternocleidomastoid (SCM) muscle. The muscle and fascia are cut by cautery under endoscopic vision. The patients had postoperative 2nd-week and 3rd-month visits. The incision scar, inspection, and palpation findings of the region, head posture, and shoulder position of the affected side were considered in evaluation of the cosmetic outcome. Preoperative and postoperative range of motion of the head and neck were compared for functional outcome. RESULTS: We preferred single incision surgery in our last two patients; the rest had double para-axillary incision for port insertion. Incomplete transection of the muscle was not observed. There was no serious complication. Postoperatively, head posture and shoulder elevation were corrected significantly. Range of motion of the head was improved. Postoperatively, all the patients had rotation capacity with more than 30 degrees. The range of postoperative flexion and extension movements was between 45 and 60 degrees. CONCLUSIONS: The open surgery techniques of CMT causes visible lifelong incision scar on the neck. PASEA leaves a cosmetically hidden scar in the axillary region. A single incision surgery is also possible. A well-formed cavernous working space is needed. External manual palpation, delicate dissection, and cutting of SCM muscle with cautery are the important components of the procedure. Surgeons having experience in pediatric minimal invasive surgery may consider PASEA as an alternative to the open approach in CMT. The surgeon should be familiar with surgical anatomy of the neck and must be highly competent in management of possible complications in the region.

Effect of ketamine versus alfentanil following midazolam in preventing emergence agitation in children after sevoflurane anaesthesia: a prospective randomized clinical trial.

OBJECTIVE: To investigate the effect of intranasal ketamine versus alfentanil in addition to oral midazolam for the prevention of emergence agitation in children. METHODS: Children undergoing urological surgery with sevoflurane anaesthesia received oral midazolam 40 min before induction and were then randomly assigned to receive 2 mg/kg ketamine, 10 µg/kg alfentanil or 1 ml isotonic saline intranasally. Parental separation status and mask acceptance were assessed preoperatively. Emergence agitation was evaluated using a paediatric anaesthesia emergence delirium (PAED) score. RESULTS: Data from 78 children were evaluated in the study. There were no significant differences between the groups in demographic characteristics, recovery times or parental separation scores. Mask acceptance was significantly better in the ketamine group than in the saline group. The mean PAED score in the ketamine group was significantly better than in the other two groups, but was similar in the saline and alfentanil groups. The incidence of emergence agitation was 3.8%, 36.0% and 40.7% in the ketamine, alfentanil and saline groups, respectively. CONCLUSIONS: The addition of intranasal ketamine to oral midazolam significantly improved the quality of induction and reduced sevoflurane-induced emergence agitation, in children undergoing urological surgery.

Is there a correlation between intravaginal ejaculatory latency time and enuresis? An exploratory study.

INTRODUCTION: Premature ejaculation (PE) is the most common male sexual dysfunction. Monosymptomatic enuresis (ME) is nocturnal bed wetting, without any daytime symptoms. Recent clinical studies report an association between lifelong PE and ME. The purpose of this study was to compare the intravaginal ejaculatory time (IELT) between lifelong PE in men with and without ME. The goal was to determine if there is an association between the severity of ME and of IELT. MATERIAL AND METHODS: A total of 137 men with lifelong PE were included in this study. Subjects were asked if they had childhood ME. The characteristics and mean IELTs of patients with and without ME were compared using the student's t-test, and the correlation between severity of ME and IELT was assessed with trend test. RESULTS: Of the 137 lifelong PE patients, 57 reported ME. There was a strong negative correlation in patients with ME between the severity of enuresis and IELT, with IELT being shorter in patients with severe ME. CONCLUSIONS: A strong correlation between IELT and the severity of ME suggests a common underlying mechanism. Further studies are required to confirm these findings and elucidate the exact pathophysiology.

A rare complication of an ingested foreign body: gallbladder perforation.

We present a 13-year-old child who admitted with a dull right upper quadrant pain that started 3 weeks before her referral. Several medications were given but they did not change the intensity and the frequency of the pain. Her physical examination was nonspecific except for slight right upper quadrant tenderness. The imaging studies revealed a sewing pin perforating the stomach and gallbladder. The patient was treated with a successful operation, and no postoperative complications were observed. To our knowledge, this is the first case of a sharp foreign body gallbladder perforation in a child.

A comparison of two different doses of bupivacaine in caudal anesthesia for neonatal circumcision. A randomized clinical trial.

BACKGROUND: We aimed to compare the analgesia quality of caudal block of low volume, high concentration bupivacaine to the conventionally used volumes and concentrations of the drug in neonates undergoing circumcision with sole caudal anesthesia. METHODS: Fifty neonates, undergoing circumcision were randomly assigned to low volume high concentration (group LVHC, n=25) and control groups (group C, n=25). Both groups received a caudal injection: Group LVHC 0.5 ml/kg bupivacaine 0.375% (1.875 mg/kg) and group C 1 ml/ kg bupivacaine 0.25% (2.5 mg/kg). Hemodynamic parameters, block onsets and analgesia periods were compared among the groups. Pain scores were evaluated hourly for 3 hours postoperatively with NIPS (neonatal infant pain score). Statistical analyses were performed with Student's t-test for continuous variables. X(2) and Mann-Whitney U-tests were used for nominal and/or categorical variables. RESULTS: Demographic, hemodynamic data, block onset time (group LVHC and C values were 4.9 +/- 1 vs 5.2 +/- 2 mins, respectively; p=0.53) was similar and postoperative median NIPS (a median value of 0 at postoperative 1, 2, and 3. hours) were identical among the groups (p=0.7, p=0.9, p=1). None of the neonates required additional analgesic for the first 24 hours following the surgery; therefore postoperative analgesic requirement was similar among the groups (p>0.1). CONCLUSIONS: Low volume high concentration caudal bupivacaine provided a similar perioperative analgesia quality, time and safety profile compared to conventional bupivacaine doses in awake neonates undergoing circumcision. Low volume, high concentration bupivacaine may be used to reduce the risk of local anesthetic toxicity in outpatient neonates.

Amyand's hernias in childhood (a report on 21 patients): a single-centre experience.

PURPOSE: Amyand's hernia is a very rare type of hernia and is characterised by the presence of a vermiform appendix in the inguinal hernia sac. It may present as a tender inguinal or inguinoscrotal swelling, and is usually misdiagnosed as an irreducible or strangulated inguinal hernia. This is a presentation of our experiences with these unusual hernias. METHODS: This study conducted a retrospective analysis of 21 patients with Amyand's hernias operated on at our institution between April 2007 and February 2011. The age and sex distributions of the patients, the types of hernias, and preoperative diagnostic tests were evaluated. RESULTS: Twenty patients were male (95.3 %) and one was female (4.7 %). The median age was 20.3 months (ranging from 2 months to 10 years). In nine patients, the conditions were diagnosed using ultrasonographic (USG) imaging preoperatively. Nine of the 21 patients underwent emergency operations. The 12 remaining patients were operated on after preparations were completed. The operative findings included 12 normal appendixes, five inflamed appendixes, one perforated appendix, and three hernias whose inner hernia sac surface was adhered to the appendix. Nine patients underwent inguinal hernia repair with appendectomy, and 12 patients had hernia repair without an appendectomy. Recurring hernias and appendicitis were not detected in any patients within the follow-up time. CONCLUSIONS: Although a routine appendectomy is not required for a normal-looking appendix, in a case where the inflammatory status of the appendix adheres to the surface of the hernia sac, an appendectomy is required. We believe that USG examination in the diagnosis of Amyand's hernias can provide additional contribution.

Subsequent alterations in the contractile property of the vas deferens according to duration of spermatic cord torsion.

OBJECTIVE: To determine whether twisting of the ipsilateral vas deferens results in alteration of its contractility. DESIGN: Experimental study. SETTING: University animal lab. ANIMAL(S): 24 male Wistar rats. INTERVENTION(S): All the rats in the experimental groups underwent spermatic cord torsion. Durations of torsion were 45 minutes, 3 hours, and 24 hours in groups 2, 3, and 4, respectively. In groups 2 and 3, subgroups b were created to evaluate late effects using in vitro pharmacological techniques. MAIN OUTCOME MEASURE(S): The contractility of the vas deferens was evaluated in groups 1, 2a, 3a, and 4 right after and in groups 2b and 3b 48 hours after the initial operation. RESULT(S): Group 4 and subgroups 2b and 3a had significantly diminished responses compared with the control group, whereas in subgroups 2a and 3b, the responses to noradrenaline and to single-pulse field stimulation were not significantly different. CONCLUSION(S): The impairment of contractility with the twisting of the vas deferens might be another factor responsible for subfertility, particularly that related to sperm transport. The unfavorable late change in short duration of torsion may be the result of either ischemia and reperfusion injury or sympathetic overactivation in the acute period of torsion.

Management of a rare cause of neonatal airway obstruction: cervical teratoma.

Cervical teratomas are rare tumors during the prenatal period. Cervical teratomas account for 1.5-5.5% of all pediatric teratomas. Both mortality and morbidity are significantly high because of airway obstruction due to a mass effect of the tumor although good results are achieved with total excision of the mass. Antenatal diagnosis by routine ultrasound (US) screening helps in preparing a team to provide airway support and surgery. We present two cases of cervical teratomas with total excision and cure and a postmortem study from our pathology laboratory. The third case, the female infant who died soon after birth, demonstrates the paramount importance of antenatal diagnosis.

Foreign body aspiration: a four-years experience.

BACKGROUND: Foreign bodies (FB) in the airway require prompt removal in children. We reviewed our experience in patients with suspected airway FB. METHODS: A retrospective study was conducted in 189 consecutive children who admitted to the Department of Pediatric Surgery, SSK Tepecik Training Hospital between 1997-2001. Patients data on presentation, bronchoscopy findings and results were obtained. Of the 189 bronchoscopies, 127 (67.2%) showed FB which are commonly located in the right mainstem bronchus. Most of FB were nonradiopaque. Pips and hazelnuts were the most common FB. Mean hospital stay was 2.5 days. Many patients (151 out of 189; 79.9%) had transient stridor or fever that ceased within 24 hours after bronchoscopy. No mortality was observed rin relation with bronchoscopy. CONCLUSION: Chest radiographs of the children with FB in the airways are inconclusive. Children with a history of small particles in their mouths and subsequently showing wheezing, or choking episode should undergo prompt bronchoscopy. Complications related to bronchoscopy are uncommon.