Endoscopic balloon dilatation of benign esophageal strictures in childhood: a 15-year experience.

The study aims to evaluate the effectiveness and safety of endoscopic balloon dilatation (EBD) in childhood benign esophageal strictures. The medical records of 38 patients who underwent EBD from 1999 to 2013 were retrospectively reviewed. Demographic features, diagnoses, features of strictures, frequency and number of EBD, complications, outcome, and recurrence data were recorded. Median age was 1.5 years (0-14), and female/male ratio was 17/21 (n = 38). Primary diagnoses were corrosive esophageal stricture (n = 19) and esophageal atresia (n = 19). The length of strictures were less than 5 cm in 78.9% (n = 30). No complication was seen in 86.8% (n = 33). Perforation was seen in 10.5% (n = 4), and recurrent fistula was seen in 2.7% (n = 1). Total treatment lasted for 1 year (1-11). Dysphagia was relieved in 60.5% (n = 23). Recurrence was seen in 31.6% (n = 12). Treatment effectiveness was higher, and complication rates were lower in strictures shorter than 5 cm compared with longer ones (70% vs. 25%, P < 0.05, and 3.4% vs. 37.5%, P < 0.05). Although there was no statistical difference, treatment effectiveness rates were lower and complication and recurrence rates were higher in corrosive strictures compared with anastomotic ones (P > 0.05). EBD is a safe and efficient treatment choice in esophageal strictures, especially in strictures shorter than 5 cm and anastomotic strictures.

Transinguinal laparoscopic evaluation of contralateral side during unilateral inguinal hernia repair for children.

BACKGROUND: Inguinal hernia repair is a common procedure in daily pediatric surgical practice. OBJECTIVES: The present study was planned to find out whether transinguinal laparoscopic exploration (TILE) of the contralateral groin is effective in reducing the need of operation for contralateral metachronous inguinal hernia (CMIH) in children. STUDY DESIGN: Charts of 1103 children who underwent inguinal hernia repair between 2006 and 2016 were retrospectively analyzed. Eighty-eight children with bilateral hernia at the presentation were excluded, and 705 patients whose parents could be contacted by phone to get the latest information about children's condition were included in the study. RESULTS: Of the 705 children with unilateral inguinal hernia repair, 362 (51.4%) and 343 (48.6%) of them had right-sided and left-sided inguinal hernia, respectively. Transinguinal laparoscopic exploration was performed in 479 of the 705 children with unilateral hernia and a hernia or contralateral patent processus vaginalis (PPV) was found and ligated in %28.3 (n = 136) of them. Mean follow-up time was 60 ± 36 months. Fifteen (4.3%) of 479 patients who had TILE and 31 (13.6%) of 226 the patients who did not have TILE developed CMIH. When the videos of 15 patients who developed CMIH were reviewed, overlooked PPV was found in 10 (3.3%) patients who had TILE during early phases of institutional learning curve. DISCUSSION AND CONCLUSIONS: TILE of the contralateral side during pediatric inguinal hernia repair is a simple and effective method to evaluate contralateral PPV. This approach clearly and significantly reduces the need of operation for a metachronous hernia at a later date.

Pretreatment of gastroschisis with transabdominal amniotic fluid exchange.

BACKGROUND: Intestinal thickening in gastroschisis results from prolonged exposure to amniotic fluid (AF). Experimental AF exchange has been shown to prevent intestinal thickening in gastroschisis. CASE: A 25-year-old primigravida was referred at 24 weeks' gestation with a prenatal diagnosis of gastroschisis. Transabdominal AF exchange was performed at 29 weeks. This pretreatment did not cause any complications and prevented intestinal thickening in our patient. Thus, we were able to perform primary fascial closure with an intra-abdominal pressure less than 5 mmHg. We began feeding the infant on the 5th day and discharged her on the 8th day. CONCLUSION: Evidence obtained from this initial case seems promising for the further application of the AF exchange for prevention of intestinal thickening in gastroschisis.

Experimental study investigating the feasibility of a new method for laparoscopic indirect inguinal hernia repair.

With the progress in laparoscopic techniques in recent years, there is an increased interest in laparoscopic hernia repair. The laparoscopic indirect inguinal hernia repair with simple closure of the internal ring seems feasible in childhood inguinal hernia repair; however, this technique carries the risk of postoperative patent processus vaginalis. In this-study we investigated the possibility of avoidance of this complication by chemical obliteration of processus vaginalis with 6% iodine solution in rats. The study population was comprised of three groups: simple suture of the internal ring, iodine application plus simple suture of the internal ring, and iodine application alone. While processus vaginalis was anatomically closed in 75% of the rats in the iodine plus simple suture of the internal ring group, it was closed in 10% of the iodine application alone group and was not closed in the simple suture of the internal ring alone group. No histopathologic injuries to the testis or cord were detected attributable to iodine. Our study showed that simple suture of the internal ring is not sufficient for hernia repair. Laparoscopic chemical agent application in addition to simple suture of the internal ring may be beneficial for successful laparoscopic indirect inguinal hernia repair in children.

A case of gastric cicatrization caused by ingestion of sulfuric acid, treated with Hunt-Lawrence jejunal pouch substitution for the stomach.

To the authors' knowledge, there had been no reported pediatric case of total cicatrization of the stomach owing to acid ingestion. The authors report a case caused by sulfuric acid ingestion. When admitted, the child did not have any oral intake and was fed through a jejunostomy, which had been placed in an other center. An upper gastrointestinal barium study showed a small gastric fundal pouch and no passage to the duodenum, but with passage to the jejunum through two fistulas. The modified Hunt-Lawrence pouch was created using the fistulous jejunal segment. After 6 months the patient is well.

The effect of amnio-allantoic fluid pH on the intestines: an experimental study in the chick embryo gastroschisis model.

BACKGROUND/PURPOSE: Prolonged exposure to amniotic fluid causes the intestinal changes such as serosal edema, thickening, fibrous coating, and adhesions in gastroschisis. The effect of amnio-allantoic fluid (AAF) pH on intestines was evaluated using a chick embryo gastroschisis model. METHODS: Seventy fertile eggs were divided into 5 groups: preliminary study (PS, n = 20), AAF control (AAC, n = 10), just gastroschisis (JG, n = 10), gastroschisis pretreated with placebo (GPP, n = 15), and gastroschisis pretreated with sodium bicarbonate (GPS, n = 15). The PS group was also divided into 2 subgroups to determine the biochemical differences between the amniotic and the allantoic fluid. Gastroschisis was created surgically at the 14th day of incubation. In GPS group, 8.4% NaHCO(3) solution (0.1 mL/100 mg/d) was instilled into the AAF for 4 days. RESULTS: A significant decrease in intestinal damage was observed both macroscopically and microscopically in the group GPS compared with the JG and GPP groups. CONCLUSIONS: Pretreatment with alkalization of AAF prevented intestinal damage because of gastroschisis. Alkalization could be a simple alternative for pretreatment with amniotic fluid exchange for human fetuses with gastroschisis.

Bilateral asynchronous perinatal testicular torsion: a case report.

Bilateral perinatal testicular torsion (PTT) is an extremely rare condition. A baby boy at the postnatal 28th hour presented with right scrotal erythema and swelling, and left hydrocele were detected. There were no systemic symptoms. Right hydrocele had been detected during prenatal ultrasonography at the 34th week of gestation. Emergency technetium Tc 99m pertechnetate scintigraphy showed hypoperfusion in both sides suggesting testicular torsion. The patient underwent surgery immediately. Right necrotic testis was removed, left testis was judged as viable, and thus was treated with detorsion. Bilateral PTT in the neonate is a true emergency because of the risk of anorchia. Controversy still exists regarding the treatment of unilateral PTT. Some investigators suggest delayed operation regarding the anesthetic risk imposed on the neonate and the reality that operative salvage of the prenatally torsed testicle is a remote possibility. However, although asynchronous bilateral PTT is rare, the patient with unilateral PTT is at risk of contralateral testicular torsion in the waiting period of delayed operation. Therefore, the authors recommend early surgical intervention.

Amnio-allantoic fluid exchange for the prevention of intestinal damage in gastroschisis: an experimental study on chick embryos.

In gastroschisis, the protruding intestine is usually shortened, thickened, and covered with a fibrous peel. Urine components, which are increased in the amniotic fluid with the onset of renal function, are responsible for these changes. In the chick embryo model of gastroschisis, the authors performed amnio-allantoic fluid exchange to reduce the effect of urinary products. There were three study groups: control, gastroschisis only, and gastroschisis plus exchange. There was a significant decrease in creatinine (P < .05) and a slight decrease in urea concentrations in the gastroschisis-plus-exchange group compared with the gastroschisis-only group. Whereas macroscopic and microscopic studies showed severe fibrosis and bowel-wall thickening in the latter group, the bowel was normal or slightly oedematous in the former. On the basis of this study, the authors suggest that antenatal amniotic fluid exchange might reduce the bowel damage in human foetuses.

Congenital esophageal stenosis owing to tracheobronchial remnants: a case report.

A 3.5-year-old girl who had congenital esophageal stenosis caused by tracheobronchial remnants without esophageal atresia or tracheoesophageal fistula is presented. The diagnostic difficulties are discussed.

The effects of intraamniotic human neonatal urine and meconium on the intestines of the chick embryo with gastroschisis.

BACKGROUND/PURPOSE: Urinary waste products in the amniotic fluid has been implicated as a cause of intestinal damage (ID) in gastroschisis based on the fact that fetus urinates physiologically into the amniotic cavity. However, experimental and clinical data suggest that intrauterine defecation is a physiological event, thus gastrointestinal waste products also may be responsible for ID in gastroschisis. An experimental study was performed to investigate the effects of intraamniotic human neonatal urine and diluted meconium on the intestines of chick embryo with gastroschisis. METHODS: Five-day-old fertilized chick eggs (Gallus domesticus) were used. Gastroschisis was created through amniotic cavity without opening the allantoic cavity. Sterile urine and meconium were obtained from newborn humans, and 1% meconium suspension was prepared. The eggs were divided in to 3 groups. In the first group, gastroschisis was created, and amniotic fluid was reinstilled without changing its composition (control group). Equal amounts of amniotic fluid and urine mixture was instilled into the amniotic cavity in second group (urine group) and 1% meconium suspension was instilled in similar fashion in the third group after creation of gastroschisis (meconium group). RESULTS: Histopathologic features of the intestines of the urine group did not differ from the intestines of the control group. The meconium group's bowel showed serosal thickening, inflammation, focal fibrin, and collagen deposits. Histopathologic changes of intestines induced by intraamniotic diluted meconium are consistent with the ones described for human gastroschisis specimens. CONCLUSION: Gastrointestinal waste products seem responsible for the ID in gastroschisis rather than urinary waste products.

Nitric oxide synthase inhibition prevents intestinal damage in gastroschisis: a morphological evaluation in chick embryos.

PURPOSE: Increased small bowel nitric oxide (NO) synthase activity accused for postnatal intestinal dysmotility in gastroschisis. The purpose of this study is to evaluate the effect of prenatal NO synthase inhibition on intestinal damage in gastroschisis. METHODS: Sixteen-day-old fertilized chick eggs were divided into 4 groups. In the control group, the allantoic and amniotic membranes were opened to create a common cavity. In the gastroschisis group, a defect in the abdominal wall was made, and intestinal loops were exteriorized. In the gastroschisis pretreated with L-NAME group, gastroschisis was created, and L-NAME was administered into the amnioallantoic cavity for 4 days. In the gastroschisis sham pretreated group, after the same surgical procedure as the previous group, same amount of saline was given beside L-NAME. At the end of 20th day of incubation, intestinal morphological changes were investigated macroscopically and microscopically. RESULTS: Macroscopic changes such as shortening, thickening, and fibrous adhesions were found in the exteriorized bowels of the just gastroschisis group and the gastroschisis pretreated saline group. However, there was only mild thickening in the gastroschisis pretreated with L-NAME group. Microscopically, compared with the gastroschisis group, serosal thickness, muscular thickness, and bowel wall thickness were found to be significantly lower in the gastroschisis pretreated with L-NAME group (128.0 +/- 19.3 microm and 239.5 +/- 3.0 microm v 57.0 +/- 8.2 microm and 145.0 +/- 9.7 microm). CONCLUSION: It is possible to decrease intrauterine intestinal morphological changes in gastroschisis by inhibiting NO synthase.

Laparoscopic appendectomy in children performed using single endoscopic GIA stapler for both mesoappendix and base of appendix.

BACKGROUND/PURPOSE: Similar to open appendectomy (OA), most of the methods described for laparoscopic appendectomy (LA) require two steps: (1) dissection and division of mesoappendix and (2) excision of appendix. Dissection of mesoappendix requires more skill and experience during LA. In single endoscopic GIA stapler laparoscopic appendectomy technique (SESLAT), both mesoappendix and base of appendix may be divided in one step with the application of a single endoscopic GIA stapler. METHODS: LA was attempted in 18 patients who had acute appendicitis and was successfully performed in 16 patients. RESULTS: In two patients, the operation was converted to OA. The authors did not need conversion to OA because of complication resulting from the use of the stapler. CONCLUSIONS: SESLAT is a quick, easy, and versatile method for LA in children that obviates dissection of mesoappendix and related complications. Thus, it enables LA to be performed by inexperienced beginners.

A case of mediastinal cystic hygroma whose only symptom was hoarseness.

Hoarseness caused by mediastinal cystic hygroma has not been reported before. The authors report a case of mediastinal cystic hygroma in which the patient's only symptom was hoarseness. A 6-year-old girl had hoarseness. Physical examination findings were normal except for indirect laryngoscopy, which showed unilateral vocal cord paralysis. The chest radiograph showed an opacification 3 cm wide in the left side of the superior mediastinum. Through a median sternotomy, a large multicystic mass was resected. During resection, left laryngeal recurrent nerve was seen to be intact, and its integrity was preserved. Six months later the left vocal cord was moving to a limited extent. A chest radiograph should be considered in a case of hoarseness caused by a peripheral nerve lesion to detect a mediastinal mass without any cervical component.

The effect of allopurinol pretreatment on intestinal hypoperfusion encountered after correction of intestinal volvulus.

After reversal of blood flow following a prolonged period of ischemia, blood flow returns for a few seconds and is reduced afterward. This is called "no-reflow phenomenon." Antioxidants such as allopurinol have been shown to prevent the occurrence of this phenomenon in organs other than the intestine. An experimental study was conducted to investigate the effect of allopurinol pretreatment on intestinal blood flow after correction of intestinal volvulus in rabbits. In group 1, baseline intestinal blood flow (IBF) was evaluated using radiolabeled red blood cells. In group 2, 720 degrees intestinal volvulus was created and IBF was evaluated 6 hours later. In group 3, intestinal volvulus was created and devolvulus was performed 6 hours later. Intraperitoneal isotonic saline was injected 60 minutes before correction of the volvulus. IBF was evaluated after correction of the volvulus. Group 4 had the same procedures as group 3, but allopurinol (200 mg/kg) was injected in place of the isotonic saline. IBF stopped 6 hours after volvulus. Compared with the baseline group, IBF was significantly lower in the group with volvulus + devolvulus (P < .01). The IBF of the allopurinol-treated group was significantly higher than that of the isotonic saline group (P < .01) and it did not differ significantly from that of the baseline group. Histopathological examination showed that intestinal volvulus leads to histological injury. The histological injury was more pronounced in the devolvulus group and was less severe in the allopurinol group in comparison to the isotonic saline pretreatment group (P < .01). It is concluded that allopurinol pretreatment prevents the intestinal hypoperfusion (no-reflow phenomenon) and histological injury encountered after correction of intestinal volvulus of 6 hours' duration.

Sacrococcygeal extraspinal ependymomas: the role of coccygectomy.

BACKGROUND: Ependymomas, the common glial tumors of the spinal cord, occur occasionally outside the central nervous system and are called exstraspinal ependymomas (EEP). EEPs are found primarily in sacrococcygeal region during childhood. The pathogenesis and the treatment of the sacrococcygeal (SC) ependymomas are still controversial. Therefore, we present our case with metaanalysis of other case reports to determine the optimal treatment modality for SC EEPs. METHODS: A metaanalysis of case reports of SC EEPs, including the current case, was conducted. Also all available case reports of EEPs, without age limit, were analyzed to determine the distribution of EEPs localization. RESULTS: EEPs usually are found in teratoma localizations such as the SC area, ovary, paraovarian structures, and medastinum. The distribution of EEPs localization differs with age. Local recurrence rate of EEPs after coccyx excision is zero, however, it increases to 71% when the coccyx was left behind. CONCLUSION: The identical clinical characteristics of the SC teratomas and EEPs imply that the SC EEPs may be monophasic teratomas as their ovarian counterparts are named. Coccyx excision is an important part of the surgical treatment of these tumors, with an apparent decrease in the recurrence rate.

A case of split notochord syndrome: presence of dorsal enteric diverticulum adjacent to the dorsal enteric fistula.

Like umblical enteric remnants (eg, umblical sinus and omphalomesenteric fistula), enteric remnants can be seen on the dorsal aspect of the body (dorsal enteric sinus, dorsal enteric fistula IDEF], dorsal enteric diverticulum) in conjunction with complete cleft of the vertebral column. Complete cleft of the vertebral column associated with gastrointestinal tract and central nervous system anomalies is known as "split notochord syndrome" (SNS). The authors present an unreported variant of SNS having dorsal enteric diverticulum adjacent to the DEF. The patient died 17 days after surgical repair.

The value of peritoneal fluid hypoxanthine besides lactic acid in detection of the vascular compromise of intestine.

Hypoxanthine has been shown to be a sensitive and more specific measure of hypoxia than lactate in several body fluids other than peritoneal fluid. An experimental study was conducted to determine the value of peritoneal fluid hypoxanthine besides lactic acid levels in detecting vascular compromise of the intestine. Thirty male guinea pigs were divided in 3 groups each containing 10 animals. Groups comprised of sham operation control, simple intestinal obstruction and intestinal obstruction with vascular compromise. Lactic acid and hypoxanthine levels were determined in peritoneal lavage effluents. Peritoneal fluid lactic acid levels increased after 4 hours of intestinal obstruction with vascular compromise (p < 0.01) but not in simple intestinal obstruction and sham operation control groups. No detectable amount of hypoxanthine could be found in any of the fluid samples. It is concluded that unlike in other body fluids hypoxanthine is not present in peritoneal fluid and does not become evident after vascular compromise of the intestine.

Outpatient catheterless Mathieu repair: how to cover ventral penile skin defect.

A modification of the Mathieu repair eliminating stenting has been described by Rabinowitz which makes the method more convenient for outpatient performance. We report on our experience with this modification with special emphasis on coverage of ventral penile skin defect. To cover the raw area formed on the ventral aspect of penis with the creation of meatal based flap Rabinowitz used Byar's flap. Two different flaps prepared from prepuce were used in this series. In some patients an island flap was used. In others the prepuce was incised transversally on its dorsal aspect and transferred to the ventral surface as a bipedicle visor flap, as described by Ombrédanne and popularized by Nesbit. Twenty-two patients ranging in age from one to twelve years (mean +/- 1SD = 6 +/- 3.28) were operated on using the technique. The meatus was glandular in two, coronal in twelve and distal penile in eight patients. Preputial flap was not used in one patient because the defect was small. Island flap was used in three and Ombrédanne-Nesbit's flap in 18 patients. Complete disruption of the repair occurred in one of the patients in whom an island flap was used. Among 18 patients in whom Ombrédanne-Nesbit's flap was used, one partial necrosis of the preputial flap was encountered which required revision and two urethrocutaneus fistulae occurred which healed spontaneously. The use of the present technique yields a good cosmetic result, a high success rate with minimal complications, and eliminates catheterization; hence, hospitalization is recommended.

Amnio-allantoic fluid exchange for prevention of intestinal damage in gastroschisis II: Effects of exchange performed by using two different solutions.

The prevention of intestinal damage in gastroschisis was reported after amnio-allantoic fluid (AAF) exchange using serum saline. However it is not clear why AAF exchange prevents intestinal damage. Are some harmful chemicals withdrawn from AAF by exchange or sodium content of AAF is merely increased? A study was planned to find the end results of AAF exchange performed by using two different solutions in the chicken embryo gastroschisis model. After creation of gastroschisis, three groups were studied. In the first group AAF exchange was not performed. In the second group AAF exchange was performed using 0.075% NaCl solution (physiologic saline for chicken). In the third group AAF exchange was performed using 0.054% NaCl plus 1% dextrose solution. Exchange with two different solutions prevented cellular infiltration and fibrous peel formation in intestines which are observed in the non-treatment group. In the third group, intestinal edema was an additional pathologic finding. This study shows that in gastroschisis, the intestines outside the abdominal cavity are very sensitive to the quality of the fluid in which they are bathed. The intestinal damage resembling that encountered in human gastroschisis can be prevented by removing the harmful chemicals from AAF by exchange.

Colonic atresia associated with Hirschsprung's disease: it is not a diagnostic challenge.

Colonic atresia Hirschsprung's disease association (CAHDA) is usually diagnosed after several failures of intestinal anastomoses. Having previously reported one of the cases of CAHDA, we established the diagnosis in a patient before attempting intestinal anastomosis for stoma closure. We herein report the first patient with CAHDA in the literature diagnosed before a therapeutic challenge. We recommend a biopsy of the distal colonic segment either during initial laparotomy or before attempting intestinal anastomosis for closure of colostomy to prevent therapeutic challenge in the patients with colonic atresia.