A novel technique for laparoscopic inguinal hernia repair in children: single-port laparoscopic percutaneous extraperitoneal closure assisted by an optical forceps.

AIM: The aim of this study was to describe and report the results of our new pediatric inguinal hernia repair technique, in which single-port laparoscopic percutaneous extraperitoneal closure (SPEC) technique was modified by using optical foreign-body forceps (OFF) of the rigid bronchoscope. MATERIALS AND METHODS: Between January 2012 and January 2014, a total of 79 children who were operated using SPEC assisted with OFF (SPEC-OFF) were included in this study. Demographic and clinical features of the children were obtained and reviewed retrospectively. RESULTS: Ninety-nine hernia repairs were performed on a total of 79 children (51 boys, 28 girls). All of the patients were operated by SPEC-OFF without the need of introducing extra forceps, with or without an additional trocar. The mean operating time was 17.6 ± 5.5 min. The mean follow-up period was 17.5 ± 7.1 months. There were six recurrences (two boys, four girls). No wound infection, hydroceles or testicular atrophy occurred in any patients during post-surgery follow-up. The technique left a very small scar with excellent cosmesis in the umbilicus and groin area. CONCLUSIONS: SPEC-OFF is a simple, safe and effective technique for laparoscopic inguinal hernia repair, and for determining contralateral hernia. There is no need to use additional working forceps for the technique and the surgeon can perform the procedure without any assistance for laparoscope.

Evaluation of 968 children with corrosive substance ingestion.

BACKGROUND AND AIMS: The aim of the study was to evaluate the etiology, treatment, and prognosis in children who had presented at our clinic with corrosive substance ingestion and comparison of our results with the literature. MATERIALS AND METHODS: The patients were put on nil by mouth and broad-spectrum antibiotics were administered. Oral fluids were started for patients whose intraoral lesions resolved and who could swallow their saliva. Steroids were not given, a nasogastric catheter was not placed, and early endoscopy was not used. RESULTS: A total of 968 children presented at our clinic for corrosive substance ingestion during the 22-year period. The stricture development rate was 13.5%. Alkali substance ingestion caused a stricture development rate of 23%. A total of 54 patients required 1-52 sessions (mean 15 ±12) of dilatation. CONCLUSION: We do not perform early endoscopy, administer steroids, or place a nasogastric catheter at our clinic for patients who had ingested a corrosive substance. This approach has provided results similar to other series. We feel that determining the burn with early esophagoscopy when factors that prevent or decrease the development of corrosive strictures will be very important.

A rare case of multiple skip segment Hirschsprung's disease in the ileum and colon.

As a rare form of Hirschsprung's disease, skip segment Hirschsprung's disease (SSHD) involves a "skip area" in normally ganglionated intestine, surrounded by aganglionosis. We report a case of multiple SSHD in the ileum and colon with total colonic aganglionosis. To our knowledge, this is the 27th case of SSHD, the third paper on multiple-segment SSHD, and the second patient with SSHD in the ileum to be reported in the English literature.

Thyroid nodules in children and adolescents: a single institution's experience.

OBJECTIVE: The aims of this study were to analyze the role of fine-needle aspiration biopsy (FNAB) in the management of pediatric thyroid nodules and to analyze the malignancy risk of thyroid nodules by studying the association between autoimmune thyroiditis and thyroid cancer. METHODS: We conducted a retrospective study on 111 patients with thyroid nodules diagnosed in childhood or adolescence. FNAB was performed in 46 participants with thyroid nodules after ultrasonography (US). Cytology diagnoses were categorized as insufficient, benign, suspicious, and malignant. Clinical and surgical follow-up data were obtained from medical records. The clinical correlation and accuracy of FNABs were evaluated. RESULTS: The family history was positive in four patients. Forty-six patients had positive antithyroid antibodies and an inhomogeneous hypoechogenic US pattern. One patient had previous neck irradiation history. Eighty-six patients (%77.5) were euthyroid. All patients underwent US examination. The FNAB results of the 46 patients were 29 (63%) benign cases, 7 (15%) insufficient, and 10 (22%) suspicious patients. Malignancy was not reported at all. A repetition of FNAB in two benign cases, which were diagnosed with papillary carcinoma during followup, reported these cases as suspicious. Ten patients with suspicious FNAB results underwent surgery because of increases in the size of the nodules; two patients were diagnosed with papillary carcinoma. In this study, the prevalence of malignancy was 4.5% in patients with thyroid nodules. CONCLUSION: In this study, the importance of FNAB in the diagnosis and follow-up of thyroid nodules in childhood has been observed, and risk factors, such as history of familial thyroid carcinoma, radiotherapy to the neck at younger ages, suspicious cytological findings, and increased nodular sizes during follow-up in cases with Hashimoto thyroiditis have been correlated with increased thyroid carcinoma malignancy risk.

Seizure due to somatostatin analog discontinuation in a case diagnosed as congenital hyperinsulinism novel mutation.

The most common reason for refractory hypoglycemia in newborns is congenital hyperinsulinism. We report a girl with congenital hyperinsulinism due to novel homozygous mutation (c.2041-25 G>A; aberrant splicing mutation) in the ABCC8 gene encoding SUR1 and during somatostatin analog (octreotide) discontinuation developed by nonhypoglycemic seizures. The newborn (birth weight of 3,750 g) was referred to our clinic because of hypoglycemic seizures at 4 h postnatal. On admission, blood glucose was 24 mg/dL and intravenous glucose infusion was started. The patient's insulin level was 27 mIU/mL during the hypoglycemic period. Phenobarbital (5 mg/ kg/day) was added because of short-acting generalized clonic seizures. Although the patient received high doses of diazoxide, esidrex, and octreotide approximately for 2 months, hypoglycemic episodes continued. Then the patient had near-total pancreatectomy, and pathology confirmed a diffuse form of congenital hyperinsulinism. There was homozygous mutation in the ABCC8 gene encoding SUR1, which confirmed the diagnosis of autosomal recessive congenital hyperinsulinism. During octreotide discontinuation, the patient developed non-hypoglycemic seizures, which were controlled by restarting the previous doses. In the light of in vitro and in vivo studies on antiepileptic effects of somatostatin, we believe that seizures in our case have developed secondary octreotide discontinuity.

A case of Langerhans cell histiocytosis with thyroid involvement.

Thyroid involvement with Langerhans cell histiocytosis (LCH) is very rare. We report here the case of a 15-year-old female patient with LCH affecting the thyroid gland. She was referred to the department of pediatric endocrinology for secondary amenorrhea. Prior to the diagnosis of LCH, the patient had symptoms of diabetes insipidus (DI) and amenorrhea. The mean time from symptom onset to diagnosis was 2 years. On physical examination the patient had grade 2 goiter, and ultrasound showed bilateral multiple hypoechoic nodules and thyroid heterogeneity. Biochemical analysis indicated central diabetes insipidus and panhypopituitarism. Magnetic resonance imaging (MRI) demonstrated a mass lesion involving the hypothalamus, which appeared iso- to hypo-intense on T2-weighted images and had an intense postcontrast enhancement on T1-weighted images. Nodular goiter coinciding with a hypothalamic mass suggested LCH, and an excisional biopsy was performed. Histological evaluation of the thyroid gland revealed extensive involvement by LCH, and this was confirmed by immunohistochemical analysis showing S-100 protein and CD1a positive Langerhans cells that were weakly positive for CD68. LCH should be considered in the differential diagnosis of a diffusely enlarged firm and irregular thyroid gland and posterior or anterior pituitary dysfunction.

Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome.

PURPOSE: The aims of this study are to evaluate the clinical characteristics of perianal abscess and fistula-in-ano in children, and to assess our experience in treatment, and to identify factors that affected the clinical outcomes. METHODS: A retrospective review of children with perianal abscess and fistula-in-ano was carried out in a tertiary care children's hospital from January 2005 to December 2010. Demographic information of the patients, localization of the lesions, treatment procedures, microbial organisms in pus, usage of antibiotics, abscess recurrence, development of fistula-in-ano, and duration of symptoms were recorded. Patients with systemic diseases and inflammatory bowel diseases were excluded from the study. RESULTS: A total of 158 children (146 males, 12 females) treated for perianal abscess and fistula-in-ano with a median age of 7.2 months (ranging 16 days to 18 years) were eligible for the study. Initial examination of the 136 patients revealed perianal abscess and 22 patients with fistula-in-ano. Primary treatment was incision and drainage (I/D) for the fluctuating perianal abscess (73.5%), and local care for the spontaneously (S/D) drained abscess (26.5%) with or without antibiotic therapy. Patients were divided into two groups according to age distribution, 98 of the patients were younger than 12 months, and 60 were older than 12 months of age. There was no significant difference in sex distribution, localization of the lesions, treatment procedures, recurrence of abscess and fistula-in-ano formation between the two age groups (p > 0.05). Recurrence rates (27% in I/D and 30.6% in S/D, p > 0.05) and development of fistula-in-ano (20% in I/D and 27.8 in S/D, p > 0.05) were not significant I/D and S/D groups. Kind of the microorganisms in pus swaps did not effect the fistula-in-ano formation. Usage of antibiotics significantly reduced the development of fistula-in-ano (p = 0.001), but did not effect the recurrence of perianal abscess (p > 0.05). The mean follow-up period was 10.6 ± 8.6 months. While the 9 of the overall 52 fistula-in-ano (22 initial, 30 after abscess treatment) were resolved spontaneously, 43 of the remaining needed surgical intervention (fistulotomy/fistulectomy). CONCLUSIONS: Although management of perianal abscess is still controversial, simple drainage of the perianal abscess with additional antibiotic therapy reduces the development of fistula-in-ano. Fistula-in-ano within children has a chance of spontaneous resolution thus the immediate surgical intervention should be avoided.

The ongoing problem with peripheral lymphadenopathies: which ones are malignant?

PURPOSE: Peripheral lymphadenopathy is frequently encountered in children, but it is difficult to determine the etiology. Our aim in this study was to evaluate the risk of malignancy in childhood peripheral lymphadenopathy, determine the factors accompanying a malignant etiology and find out which additional findings strongly indicate malignancy. METHODS: Patients from whom a peripheral lymphadenopathy biopsy had been obtained between January 2005 and December 2007 were retrospectively reviewed. The patients were divided into two groups as malignant and benign. RESULTS: There were 32 patients in the malignant group and 52 in the benign group. The mean age was higher (P < 0.001), lymphadenopathy duration shorter (P = 0.007) and lymphadenopathy size larger (P = 0.019) in the malignant group. The incidence of malignancy was higher in supraclavicular and axillary lymphadenopathies. Hodgkin's disease was the most common disease in the malignant group, while it was reactive lymphoid hyperplasia in the benign group. The biopsy result was malignant in 58.3% of abdominal and 60% of mediastinal lymphadenopathy cases. The best indicator for malignancy was a hypoactive spleen nodule. CONCLUSIONS: Increased patient age, supraclavicular lymphadenopathy localization, presence of abdominal or mediastinal lymphadenopathy and especially a hypoactive spleen nodule increase the risk of malignancy.

Obstructive jaundice and severe pancreatitis due to the foramen of Winslow hernia with multiple anomalies.

Internal hernia through the foramen of Winslow is a very rare condition, especially in children. Here we report a 16-month-old girl who presented with obstructive jaundice and elevation of pancreatic enzymes and was ultimately diagnosed with internal hernia and malrotation by radiologic investigation and open approach surgery. To the best of our knowledge, obstructive jaundice with pancreatitis and other congenital abnormalities in children with the foramen of Winslow hernia have not been reported previously in the literature.

A hidden danger of childhood trauma: bicycle handlebar injuries.

PURPOSE: To evaluate childhood bicycle handlebar injuries. METHODS: We evaluated retrospectively 14 patients who presented with bicycle handlebar injuries within a 3-year period. Bicycle injuries not caused by the handlebar were excluded. RESULTS: The mean age of the patients was 8.8 +/- 2 years (range, 5-12 years) and 79% were boys. The injuries comprised gastrointestinal perforation in 21%, traumatic abdominal hernia in 21%, and spleen laceration in 14%. The three children with intestinal perforation and the one with a penetrating abdominal injury underwent surgery, whereas the others were treated medically. An isolated traumatic abdominal hernia resolved spontaneously. There was no mortality. CONCLUSIONS: Although bicycle handlebar injuries occur at relatively low speeds, the transfer of energy from the end of the handlebar, with a small cross-sectional area, to a small field leads to intra-abdominal injuries that are more severe than predicted. Thus, bicycle handlebar injuries should be considered as a serious intraabdominal injury until proven otherwise.

Do not rush into operating and just observe actively if you are not sure about the diagnosis of appendicitis.

PURPOSE: The aim of this study was to determine whether the admission and active observation of children where the diagnosis of acute appendicitis is uncertain is a safe and effective way to improve the diagnostic accuracy of appendicitis and safely reduce the incidence of negative laparotomies without increasing complications. METHODS: We performed a retrospective cohort study of children who presented with a complaint of right lower quadrant pain and were hospitalized with a diagnosis of appendicitis or suspected appendicitis from 1 January to 31 December 2007. RESULTS: A total of 569 patients were included in the study. The mean age was 9.5 +/- 3.2 (range 1.1-17) years. The number of patients directly operated on with a diagnosis of appendicitis was 186 (32%) from the total of 575 while 389 patients (68%) were observed in the surgical ward as the examination and/or investigation findings were equivocal. Of the 383 patients admitted for observation, 173 (45%) were operated on with a suspicion of appendicitis after 14.4 +/- 6.7 h while 210 (55%) were discharged after 1.1 +/- 1.2 days as there seemed to have no surgical problem. Our total negative appendectomy rate was 4% (14/350) and total perforation rate was 37.4% (131/350). The patients operated on directly and those operated on after observation were similar, and there was no difference for the preoperative duration of symptom, histopathological diagnosis, postoperative complication rate, postoperative inpatient days and hospital charges. Total hospitalization duration was significantly longer and the hospital charges significantly higher in the negative appendectomy group. CONCLUSION: Both the features and results and the complication rates and costs of the group operated on after observation were the same as the directly operated on group. However, patients undergoing a negative appendectomy stayed as inpatients longer than only observation patients with higher treatment charges. We could therefore decrease the negative appendectomy rate, the associated cost and duration of hospitalization without causing extra complications if we observe and investigate patients with right lower quadrant pain with a doubtful diagnosis and did not operate on them directly.

A huge ovarian mucinous cystadenoma in a 14-year-old premenarchal girl: review on ovarian mucinous tumor in premenarchal girls.

Superficial epithelial ovarian tumors are unusual in adolescent girls (when compared with adult women) and extremely rare before menarche. Mucinous cystadenoma (MCA) in children that is a rare form of epithelial tumor is a benign cystic ovarian neoplasm. To our knowledge, there are only eight cases of mucinous cystadenoma, three of borderline mucinous cystadenoma, and three of mucinous cystadenocarcinoma reported in the English-language literature. We present a 14-year-old premenarchal girl with a giant ovarian mucinous cystadenoma. This review is supported by the finding that epithelial ovarian neoplasms are extremely rare prior to puberty and that only 14 mucinous tumors have been reported prior to menarche.

Ostomy Closures in Children: Variations in Perioperative Care Do Not Change the Outcome.

This study aimed to evaluate ostomy closure applications and outcomes and determine the effect of personal differences among surgeons on patient postoperative course. Ninety-eight patients who underwent elective ostomy (ileostomy and colostomy) closure for 8 years at a pediatric surgery training department were investigated. Postoperative complications included superficial surgical site infection (SSI; 9.4 %), organ/cavity infection (1 %), small bowel adhesions (8.2 %), and incisional hernia (1 %). SSI and postoperative complications were not affected by the preoperative antibiotic regimen used. Operation duration, pre- and postoperative antibiotic use durations, postoperative inpatient period, ostomy type, primary diagnosis, performance of abdominal exploration, SSI, and postoperative complications were not significantly different. However, the time of nasogastric (NG) tube withdrawal, time to oral feeding initiation, abdominal closure method used, and preoperative antibiotic regimen were significantly different among different surgeons. We conclude that while surgeons used different preoperative antibiotic regimens and abdominal closure methods and stipulated different times for NG tube withdrawal and oral feeding initiation, the postoperative course and prognosis were unaffected Thus, the pre- and postoperative inpatient period and antibiotic use duration can be decreased in children by procedure standardization using practice guidelines; the procedures can also be performed with a more aesthetic, acceptable incision.

Single Incision Pediatric Endoscopic Surgery: Advantages of a Relatively Large Incision.

OBJECTIVE: To describe Single Incision Pediatric Endoscopic Surgery (SIPES) performed on children with various diagnoses, emphasizing its advantages. STUDY DESIGN: An observational case series. PLACE AND DURATION OF STUDY: Department of Pediatric Surgery, Dr. Sami Ulus Maternity and Child Health Hospital, Ankara, Turkey, from January 2011 to November 2014. METHODOLOGY: A review of patient charts was conducted in which SIPES was preferred as the surgical procedure. Patient demographics, operative details, operative time, clinical outcomes, postoperative pain and cosmesis were analyzed. RESULTS: SIPES was performed on 45 patients (21 girls, 24 boys). Thirty-three appendectomies, 5 varicocelectomies, 3 oophorectomies, 2 ovarian and one paratubal cyst excision, and one fallopian tube excision were performed. All except one procedures were performed through our standard 2 cm umbilical vertical or smile incision. In 18 cases, abdominal irrigation/aspiration was easily performed through the existing larger incision, as is done with open surgical technique. None of the patients had early postoperative shoulder/back pain since complete disinflation of CO2could be ensured. All of the patients/parents were satisfied with the cosmesis. CONCLUSION: SIPES has the advantages of limiting the surgical scar to within the umbilicus and providing easy disinflation of CO2, allowing intraabdominal cleaning and extraction of large volume tissue samples through a single large umbilical incision.

Are neutrophil CD64 expression and interleukin-6 early useful markers for diagnosis of acute appendicitis?

BACKGROUND/PURPOSE: The aim of the study is to evaluate the diagnostic value of interleukin-6 (IL-6) level and neutrophil cluster of differentiation 64 (CD64) expression in diagnosis of acute appendicitis (AA). METHODS: A prospective controlled trail was performed. Children who were hospitalized with a diagnosis of right lower quadrant pain were our cohort. Serum samples for white blood cell, C-reactive protein (CRP), leukocyte CD64 expression, and IL-6 were obtained from the patients just after their admission. Operation was performed if appendicitis seemed probable, others were observed actively. Patients who had noncomplicated appendicitis were Group 1, patients who had complicated appendicitis were Group 2, and patients who had discharged after observation without operation with a diagnosis of nonspecific abdominal pain and had negative appendectomy without another surgical disease were Group 3. RESULTS: In this study, 49 patients were enrolled. CRP and CD64 levels were found higher in Group 2. IL-6 levels were found to be lower in Group 3 than Groups 1 and 2. CONCLUSIONS: There was a difference between Group 2 and the other groups about CD64 levels. The CRP level and expression of leukocyte CD64 level did not effectively predict the diagnosis of noncomplicated appendicitis, but it predicted well the patients with complicated appendicitis. However, IL-6 levels are statistically significantly different between Group 3 and Groups 1 and 2. According to this result, IL-6 levels predicted well the patient with appendicitis. Applying additional diagnostic methods such as IL-6 levels seems to be helpful in reducing the numbers of false-positive diagnosis of AA.

Factors affecting mortality in stage 3b necrotizing enterocolitis.

This study aimed to determine the factors that may affect the development of mortality in patients with stage 3b necrotizing enterocolitis (NEC). Between January 2005 and December 2012, patients with the diagnosis of stage 3b NEC who were surgically treated were enrolled in the study. Gestational age, birth weight, presence of hypoxemia history, major congenital heart diseases, enteral feeding, age at perforation, drainage type, operation, and laboratory findings were considered regarding their possible relationship with mortality. Thirty-one patients were enrolled in this study. Following treatment, 15 patients died, while 16 patients recovered and were discharged. Feeding type, high levels of prothrombin time (PT), activated partial thromboplastin time (aPTT), creatinine, and low platelet count, as well as need of inotropic support were associated with mortality. When the cut-off point of platelet level for mortality development in stage 3b NEC was calculated by receiver operating characteristic (ROC) curve, the cut-off point for thrombocyte level was found to be 110,000/µL, with 93.3% sensitivity and 87.5% specificity. Despite the innovations in newborn intensive care, the mortality rate of stage 3b NEC remains very high. Breastfeeding has a significantly positive impact on the survival of patients with NEC. Thrombocytopenia is the most important risk factor of mortality in stage 3b NEC.

Analysis of 3,776 pediatric inguinal hernia and hydrocele cases in a tertiary center.

BACKGROUND/PURPOSE: This study describes the pediatric inguinal hernia and hydrocele experience of a tertiary care training hospital. METHODS: A total of 3776 patients who had been operated between January 2005 and June 2009 for inguinal hernia, cord hydrocele, and hydrocele were included. The surgeries and patient follow-up were performed by 6 pediatric surgery specialists and 8 pediatric surgery residents. RESULTS: The patient age varied from 6 days to 17 years. There were 2959 (78.4%) males and 817 (21.6%) females (ratio: 3.6:1). The hernia was on the right in 2306 (61.1%) patients, on the left in 1111 (29.4%) patients, and bilateral in 359 (9.5%) patients. Age at presentation was younger in males (p<.001). Contralateral hernia repair was required later on during follow-up in 2% of the patients. Postoperative complications developed in 1.2% of the patients. Reoperation was needed because of wound infection in 0.6%, recurrence in 0.4%, hematoma in 0.1%, testicular atrophy in 1 patient, and acquired undescended testis in 1 patient. CONCLUSIONS: The age of first hernia symptoms was younger in males compared to females and in premature babies compared to term babies (p<.05). The recurrent hernia rate was higher in infancy. The complication rate was higher in hernia surgery in the newborn period and in cases of incarcerated hernia compared to the overall rate (p<.05). There was no indication for contralateral routine exploration.

The first case of Bruck syndrome associated with gastroschisis.

Bruck syndrome is an extremely rare disorder featuring the unusual combination of skeletal changes resembling osteogenesis imperfecta with congenital contractures of large joints. Although the genotypic and phenotypic features of Bruck syndrome are heterogeneous, we report a baby girl having gastroschisis complicated with jejunal perforation in addition to bone fractures and joint contractures, which supported the diagnosis of Bruck syndrome. After surgical procedures for gastroschisis, the fractures were treated with splints, and cyclic pamidronate treatment was started. On postoperative day 30, the patient was discharged without any complications. She is now seven months of age, gaining weight and has had no additional fractures with the ongoing pamidronate treatment. Although prematurity and low birth weight are common in gastroschisis, musculoskeletal anomalies have not been reported until now, and thus the case is unique. Additionally, cyclic pamidronate administration is a good treatment choice for bone fragility in Bruck syndrome to reduce the number of fractures, and it may be beneficial for the subsequent clinical deterioration of the patients.

Treatment of adolescent pilonidal disease with a new modification to the Limberg flap: symmetrically rotated rhomboid excision and lateralization of the Limberg flap technique.

BACKGROUND/PURPOSE: Pilonidal disease is a common and frustrating problem among adolescents due to its high recurrence rate. The rhomboid excision and Limberg flap techniques promise successful results, but the lower part of the incision left on the intergluteal sulcus is prone to recurrences. Consequently, we have developed a new modification to this technique and have designed a descriptive prospective study to evaluate its efficiency. METHODS: We conducted this prospective study between March 2011 and March 2012. All of the patients who were operated on for sacrococcygeal pilonidal disease were included in this study. The surgical procedure primarily consisted of symmetrically rotated (clockwise) rhomboid excision and lateralization of the Limberg flap in order to keep the inferior corner of the suture line apart from the intergluteal sulcus. RESULTS: A total of 15 adolescents (8 boys and 7 girls) were included in the study group. Of the patients, 47% were normal, 13% were overweight, and 40% were obese. Five patients were operated on under general anesthesia, and 10 were operated on under spinal anesthesia. The length of the flap margins ranged from 2.5 to 7 cm (median=4 cm). The median duration of hospitalization was 5 days, and the median duration of suction drainage was 4 days. The median postoperative follow-up period was 4 months (ranging from 1 to 12 months), and we did not encounter any wound infection or recurrent disease during this period. Only one patient had wound hematoma as a result of drain breakdown and was treated with wound care without any additional complications. CONCLUSION: Although the number of patients in this study was small and the follow-up period was short, we obtained satisfactory results without any recurrence by performing a symmetrically rotated rhomboid excision and lateralized Limberg flap procedure.