Minimally invasive inguinal technique for the management of duplex ureteric anomaly.

OBJECTIVE: To present outcomes of a minimally invasive inguinal technique for the separation of the distal part of ureters in duplex systems and for the extravesical ureteroneocystostomy of only the pathologically involved ureter. MATERIALS AND METHODS: From November 2001 to February 2007, we performed extravesical reimplantation of only the involved ureter in 21 duplex systems, of which 14 were refluxing (megaureters) and seven had obstruction of the ureterovesical junction. The mean (range) age of the patients was 39 (17-59) months. In seven patients, ureterocutaneostomy (of the involved ureter only) was performed first, with reimplantation 3-6 months later, after the diameter of the ureter had decreased, to ensure safe reimplantation. The mean (range) postoperative follow-up was 28 (12-47) months. RESULTS: Postoperative voiding cysto-urethrograms (VCUGs) and magnetic resonance imaging (MRI), showed an absence of vesico-ureteric reflux (VUR) or obstruction in the ureters of the first 10 patients. In the remaining 11 patients, there was no ultrasound detectable dilatation, but symptomatic urinary tract infection developed in two of these patients. Subsequent VCUG and MRI results showed no obstructions or VURs. CONCLUSION: Our results showed that the minimally invasive inguinal approach to separation of ureters in duplex systems and single ureteroneocystostomy of only the pathologically involved ureter represents a viable treatment option.

Association of hereditary elliptocytosis and Gilbert's syndrome as the cause of biliary calculosis: case report.

INTRODUCTION: Biliary calculosis is rare in children. It occurs associated with different haemolytic and non-haemolytic disorders, which are sometimes also combined. CASE OUTLINE: A 15-year-old male was hospitalized due to biliary calculosis and non-conjugated hyperbilirubinemia. A mild non-conjugated hyperbilirubinemia, without anaemia and other symptoms of liver dysfunction, was registered at age 8 years, and 7 years later cholelithiasis with transitory choledocholithiasis. The finding of ellyptocytes in blood smear, which was also verified in mother, normal haemoglobin count and the absence of diseases followed by secondary dysmorphic erythrocytes of this type, indicated a clinically milder (compensated) hereditary ellyptocytosis, while more than a double increase of non-conjugated serum bilirubin fracture after a three-day hypocaloric diet (400 kcal per day) showed the concurrent presence of Gilbert's syndrome. In the laparascopically removed gallbladder a larger number of small pigmented calculi were disclosed. CONCLUSION: Gilbert's syndrome is an essential precipitating factor of biliary calculosis in patients with chronic haemolytic condition. Thus, in all cases of biliary calculosis and non-conjugated hyperbilirubinemia with absent clinical and laboratory parameters of liver disorders and anaemia, except in compensated haemolytic disease and Gilbert's syndrome as isolated disorders, a possibility of their association should be taken into consideration.

Clinical characteristics of idiopathic ulcerative colitis in children.

INTRODUCTION: Idiopathic ulcerative colitis (IUC) represents a rare disease of childhood. It usually occurs at age over 10 years, and below that exceptionally rarely. OBJECTIVE: The aim of the paper was to analyze the clinical signs, symptoms and therapeutic procedures in children with IUC. METHODS: The aims of the paper were based on a sample of 17 children (11 male and 6 female, mean age 11.90 +/- 3.50 years; range 3.8-17.5 years) with IUC. The disease diagnosis was based on characteristic endoscopic and pathohistological findings. RESULTS: The basic signs of the disease involved chronic mucosal haemorrhagic diarrhoea which was confirmed in 16 of 17 patients, with body weight deficiency (10), recurrent abdominal pain (6), fever (5), slowed-down maturation (5), marked anorexia (4), and tenesmus (3).Two patients had recurrent aphthous stomatitis, 2 anal fissures, 2 arthralgia, one autoimmune hepatitis and one pyoderma gangrenosum. None of the children had longitudinal growth retardation. Elevated sedimentation rate and C-reactive protein in blood were registered in 11, sideropenia in 10, anaemia in 6 and hypoalbuminemia in 3 patients. The remission of proctosigmoiditis and left-sided colitis was achieved with aminosalicylates, and of pancolitis with the combination of aminosalicylates and glucocorticoids, except in cases of steroid-dependent colitis, which additionally required azathioprine. CONCLUSION: The main signs of IUC in children are chronic mucous haemorrhagic diarrhoea, body weight loss and sideropenic anaemia, while the basic therapy consists of aminosalicylates, and in more severe cases of the disease the initial use of glucocorticoids and later azathioprine.

Distribution of affected muscles and degree of neurogenic lesion in patients with spina bifida.

INTRODUCTION: Patients with spina bifida in the lumbosacral region usually have various degrees of motor and sensory dysfunctions of the lower extremities and anal sphincter. The aim of our study was to evaluate the distribution and differences in frequencies of affected muscles, number of affected muscles and degree of neurogenic lesion between patients with spina bifida occulta (SBO) and spina bifida aperta (SBA). MATERIAL AND METHODS: In 100 patients with SB, 6 muscles in the lower limbs were separately analysed. Due to the number of affected muscles, we evaluated 5 groups of patients: with 1 affected muscle, 2 affected muscles, 3 affected muscles, 4 affected muscles and 5 affected muscles. Three degrees of neurogenic lesions were assessed: mild, moderate and severe. RESULTS: The tibialis anterior muscle was most frequently affected in SB patients. The outer anal sphincter was frequently affected in the group of SBA patients. Single muscle affection is frequent in the group of patients with SBO, while in the group of patients with SBA, 4 muscles were significantly frequently affected. The great majority of patients (45.46%) with affected outer anal sphincter (OAS) in the group of SBO were without affection of other muscles, while for the SBA group it was for every third patient. Mild neurogenic lesion was significantly frequent in SBO patients, while severe form was significantly frequent in SBA patients. CONCLUSIONS: Patients with SBO usually present with mild to moderate clinical presentation, while multiple root involvement and severe degree of neurogenic lesion is associated more frequently with SBA.

[Laparoscopic operations in pediatric surgery]. / Laparoskopske operacije u decjoj hirurgiji.

From January 2003 to January 2004, laparoscopy was performed in 100 cases, aged from 10 months to 19 years. Diagnostic laparoscopy was applied in 39 patients, most often in nonpalpable testes (29), ovarian cysts (4), abdominal trauma (1), abdominal cysts (2) and intersex states (3). Ninety patients underwent operative laparoscopy: appendectomy (44), orchiopexy (2), orchiectomy (1), herniorrhaphy (1), varicocelectomy (8), adnexectomy (2), cholecystectomy (8), Fowler-Stephens procedure (1), abdominal cysts (2), ovarian cystectomy (6), subdiaphragmatic abscess (1), adhesiotomy (11), liver cysts (2) and splenectomy (1). Diagnostic laparoscopy has proved to be more reliable and less invasive method in comparison to previously used methods. Our conclusion is that operative laparoscopy has many advantages compared with some of the classical surgical procedures.

[Laparoscopic appendectomy in children--a new fashion or a privilege]. / Laparoskopska apendektomija kod dece--moda ili privilegija.

Whether laparoscopic appendectomy is superior to open appendectomy for simple and perforated appendicitis in children is still debatable. To answer this question, surgical experience of three experienced pediatric surgeons in a single institution was studied during one year in all cases of laparoscopic appendectomy. From January 2003 to January 2004, all laparoscopic appendectomies were reviewed for operative technique, advantages, disadvantages, operative time and length of stay. There were 44 laparoscopic appendectomies in children aged 4 to 19 years. Operating time dropped from 52 minutes at the beginning to less than 25 minutes at the end of year. Operating time in perforated appendicitis was slightly longer, from 58-65 minutes. Length of stay was 1-2 days for simple cases, and maximum 5 days for perforated ones. There were no postoperative complications such as abscess, bowel obstruction, bleeding, wound infection or mortality. Laparoscopic appendectomy is at least as safe and effective, if not superior to, as open appendectomy for both, simple and perforated appendicitis. Postoperative pain is less, and recovery is faster. Laparoscopic appendectomy is our procedure of choice in pediatric surgery.