Cystic lymphangiomatosis with severe intra-abdominal bleeding in a newborn: case report.

We report the case of a newborn girl with intestinal cystic lymphangiomatosis who presented with abdominal distension and intra-abdominal bleeding following a prenatal ultrasound diagnosis of intestinal anomaly. Postnatal abdominal ultrasound revealed disseminated submucosal and intramural cystic dilatations of various sizes in the bowel and intestinal lymphangiomatosis was diagnosed. The presence of severe bleeding diathesis and widespread disease led to conservative treatment. The patient died on postnatal day 7 and postmortem examination confirmed cystic lymphangiomatosis. Detection of intestinal hyperechogenicity and/or dilatation in prenatal ultrasonography and the persistence of these findings during pregnancy are suggestive for pathologies such as meconium ileus, meconium peritonitis, and intestinal atresia. Although rare, intestinal lymphangiomatosis should be kept in mind in patients whose prenatal sonographic findings persist until birth.

Surfactant replacement therapy in a pediatric near-drowning case in manure.

Drowning is defined as suffocation by submersion especially in water and is a leading cause of injury-related death in children. Age groups at greatest risk are toddlers and male adolescents. It is the second most common cause of accidental death in children after road accidents. Treatment consists of resuscitation and stabilization. The use of surfactant after near-drowning in water is reported in the literature in few case reports.We report here a boy whose condition did not get better with conventional treatment, but dramatically improved after surfactant treatment after near-drowning in a fluid with manure.

Laryngeal fracture due to blunt trauma presenting with pneumothorax and pneumomediastinum.

AIM: Injuries due to traffic accidents are frequent in childhood, and they have high mortality and morbidity. Laryngeal injury due to a traffic accident is a rare pathology and might be missed if not suspected. Here we present a laryngeal fracture in a child after a blunt chest trauma during a traffic accident that presented with pneumomediastinum and pneumothorax. CASE: A 14-year-old girl was referred for pneumomediastinum. Her physical examination was normal except subcutaneous emphysema, edema and tenderness in the cervical area, hoarseness, facial and extremity abrasions and ecchymoses. Chest tomography revealed pneumothorax and pneumomediastinum, and cranial tomography revealed maxillofacial fractures. Upper airway damage was suspected, flexible endoscopy revealed right vocal cord paralysis and cervical tomography revealed thyroid cartilage fracture. The fracture was repaired and tracheotomy was performed. She was discharged on postoperative day 6. Facial fractures were repaired in another center. Tracheotomy was removed on postoperative day 20. Her hoarseness, although decreased, still persists. CONCLUSION: Pneumomediastinum is a rare result of a laryngeal fracture and if not suspected, the fracture can easily be missed. It should be kept in mind after blunt cervical trauma with pneumomediastinum and/or pneumothorax. Direct endoscopy and cervical tomography may be necessary for the differential diagnosis.

Anal canal duplication.

INTRODUCTION: Anal canal duplication (ACD) is an extremely rare congenital intestinal anomaly. ACD is defined as a second anal orifice located posterior to the true anus ending blindly without connection to the rectum. Usually, there are no other accompanying hindgut pathologies. Patients are often asymptomatic and apply to clinics with their parent's attention. CASE 1: A 9-month-old girl was referred to our clinic because of a second orifice posterior to the true anus. On the physical examination, there was a 3 mm in diameter orifice, about 0.5 cm behind the anus, at 6 o'clock direction on the lithotomy position. Duplicated lumen was checked with a metal catheter; it was about 2 cm in length ending blindly without connection to the rectum. A prediagnosis of ACD was made and the patient was operated. Duplicated segment was excised totally. Postoperative course was uneventful. CASE 2: One-year-old girl was referred to our clinic because of the same complaint. On the physical examination, there was a 2 mm in diameter orifice, about 0.3 cm behind the anus, at 6 o'clock direction on lithotomy position. Duplicated lumen was checked with a metal catheter; it was about 1.5 cm in length ending blindly without connection to the rectum. CONCLUSION: ACD is a rare congenital intestinal anomaly located posterior to the anus. It can be confused with other types of anorectal pathologies, such as hemorrhoids, fistula-in-ano, and perianal abscess at the time of diagnosis. Although ACD is often asymptomatic, it should be removed surgically because of the risk of inflammatory complications and colloidal cancer.

An unusual cause of gastric perforation in childhood: trichobezoar (Rapunzel syndrome). A case report.

Trichobezoars are hair balls found in the stomach and formed following trichitillomania and trichopaghia. Rapunzel syndrome is a rare condition in which the presence of giant trichobezoars causes mechanical obstruction. To date, only two cases of stomach perforation caused by trichobezoars have been reported among pediatric patients. We report a 14-year-old female patient who experienced nausea, vomiting and severe abdominal pain for 1 month. Physical examination revealed diffuse abdominal distension. Palpation detected a mobile and sensitive mass, 15 x 15 cm , which filled the upper quadrant. Urgent surgery revealed that the stomach was perforated by the trichobezoar ball. This trichobezoar mass was totally excised by expanding the perforation area. Conclusion This is the reported third case of gastric perforation caused by trichobezoar in a pediatric patient. Among acute abdominal cases, gastric perforation should remain a possibility in differential diagnosis.

Preoperative sonography of nonreducible inguinal masses in girls.

PURPOSE: Inguinal hernia is one of the most common surgical pathologies in childhood. Any of the abdominal organs can slide into the hernial sac and become incarcerated there. In girls, the fallopian tubes, ovaries, uterus, and-rarely-ovarian cysts can form the sliding component of an inguinal hernia. The aim of this study was to investigate the diagnostic value of preoperative sonographic examination in girls with nonreducible inguinal masses. METHODS: Nine girls ranging in age from 2 months to 8 years who were admitted to our clinic with nonreducible inguinal masses were included in the study. All patients underwent sonographic examination followed by surgery on the day of admission. RESULTS: A definitive diagnosis was obtained in 6 patients on preoperative sonographic evaluation, whereas 3 patients were misdiagnosed. One patient was diagnosed sonographically as having lymphadenopathy, but surgery revealed an ovarian cyst sliding into the hernial sac. A second patient was found to have an infected lymph node at surgery instead of a strangulated bowel loop as diagnosed on sonographic examination. In the third patient, the preoperative sonographic diagnosis was an ovarian cyst in the hernia sac, but surgery revealed a cyst of the canal of Nuck. CONCLUSION: Inguinal masses in young girls must be carefully evaluated, because the sonographic preoperative diagnosis may be misleading.

Benign Cystic Mesothelioma in a Child: Case Report and Review of the Literature.

BACKGROUND: Benign cystic mesothelioma (BCM) is a rare tumor with benign characteristic. There are only 8 child cases reported in the English literature. In this report, we present this rare entity a brief review of the literature. CASE REPORT: A two year-old boy presenting with abdominal swelling was hospitalized. Physical examination revealed a mass filling the abdomen. Laboratory findings were not specific. Abdominal computerized tomography showed a 15×13×11 cm cystic mass extending from the bladder to the liver with no solid components and no infiltration to adjacent organs. Operation revealed a cystic mass filled with yellow-green serous fluid which was attached to the right lobe of the liver with a 1 cm thick peduncle. Total excision of the mass was performed by clamping and cutting the narrow attachment. Recovery was uneventful. Pathology revealed multiple cysts lined with mesothelial cells. No recurrence was seen after 5 years of follow-up. CONCLUSION: BCM should be kept in mind as a rare cause of the abdominal mass in children, as it may lead to confusion in preoperative diagnosis. Although rare, patients should be followed throughout life because of the risk of recurrence and malignant degeneration.

Homocysteine and ghrelin link with polcystic ovary syndrome in relation to obesity.

AIM: Elevated levels of plasma homocysteine and depressed ghrelin levels have been found to be associated with insulin resistance in a number of clinical situations, such as polycystic ovary syndrome. This study was designed to determine the relationship of plasma homocysteine and ghrelin levels with obesity in polycystic ovary syndrome. MATERIAL AND METHODS: Forty-four adolescents and young women (24 lean, 20 obese) 16-21 years old with polycystic ovary syndrome and age matched 20 healthy adolescents and young women were participated the study. Fasting samples were collected for serum vitamin B12, folate, plasma total homocysteine and ghrelin levels. Serum levels of follicle-stimulating hormone, luteinizing hormone, dehydroepiandrosterone sulfate, insulin, 17-hydroxyprogesterone, free testosterone, sex-hormone binding globulin were measured. Also, serum concentrations of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides were determined. Oral glucose tolerance test was done, and HOMA-IR index was used to define insulin resistance. RESULTS: Plasma total homocysteine levels were significantly higher in women with polycystic ovary syndrome and their plasma ghrelin levels were depressed compared to control group (P < 0.05). Obese adolescents with polycystic ovary syndrome had more depressed plasma ghrelin levels compared to lean ones (P < 0.05). Homocysteine levels didn't correlate with body mass index, but positively correlated with insulin resistance (P < 0.05). CONCLUSION: Elevated plasma homocysteine levels in polycystic ovary syndrome was independent from obesity. Adversely ghrelin levels were depressed with polycystic ovary syndrome in relation to obesity.

A practical offer for hypospadias dressing: Allevyn®.

INTRODUCTION: An ideal hypospadias dressing material must be cheap and non-allergenic. It also must be easily and quickly applied, non-adherent to the incision, effectively absorb the leakages of the wound, pressurise the flaps and grafts effectively, without damaging the blood circulation, protect against infections, and must be easily and painlessly removable. We use a product that is produced for healing chronic wounds and burns, Allevyn Adhesive® , as a wound dressing after hypospadias surgery and circumcision. MATERIALS AND METHODS: We included 61 hypospadias and 85 circumcision cases operated in our clinic between November 2007 and August 2010, for the study. Allevyn Adhesive® dressing was used in all the cases. For approximately every 10 patients a sheet sized 22.5 x 22.5 cm was used. RESULTS: We did not meet any difficulty in application and removal of the dressings and the dressing could be performed easily even by inexperienced health personnel. The cost of the application is about $5 for each case. We did not encounter any complications with regard to the dressing during the follow-up. CONCLUSION: We did not encounter any of the complications with Allevyn Adhesive® that were seen with the use of traditional dressing products, such as, problems with removal of the dressing, development of maceration secondary to inadequate absorption of leakages from the wound, cohesions of the wound lips, and infections and necrosis of the flaps and grafts, secondary to erroneous locations of the dressings. There was no additional therapeutical cost due to the use of this product. For these reasons we thought that Allevyn Adhesive® is a good alternative for the dressing of hypospadias and circumcision.

Asymptomatic diaphragmatic rupture with retroperitoneal opening as a result of blunt trauma.

Blunt traumas of the abdomen and thorax are important clinical problems in pediatric ages. Severity of trauma may not always be compatible with the patients' clinical situation. A 2-year-old male child was admitted to our emergency clinic as a result of tractor crash accident. Physical examination of the child was normal. The abdominal and thoracic ultrasonography (USG) examination performed in the emergency clinic was normal. In thoracic computed tomography (CT) scan of the patient, there was irregularity of the right diaphragmatic contour that was described as micro perforation-rupture (the free air was just in the perihepatic and retroperitoneal area, which was not passing through the abdomen). The patient was followed-up for 1 week in the hospital with a diagnosis of retroperitoneal diaphragmatic rupture. It is not appropriate to decide the severity of trauma in childhood on the basis of clinical findings. Although severe trauma and sustaining radiological examinations, the patients' clinical pictures may be surprisingly normal, as in our patient. In such cases, there may not be any clinical symptom. CT scan examination must be preferred to USG for both primary diagnosis and follow-up of these patients. According to the current literature, there is no reported case with retroperitoneal rupture of the diaphragm.

Cross ectopic multicystic dysplastic kidney with ureterocele in nonectopic site.

Crossed renal ectopy (CRE) is the second most common fusion anomaly of the kidney, with an incidence of 1 in 7000 autopsies; it comes in second after horseshoe kidney. Crossed renal ectopy is associated with an ectopic ureter and generally an ectopic kidney fused with a normal kidney. A 7-month-old boy who had left-to-right crossed non-fused renal ectopy and multicystic renal dysplasia with ureterocele in nonectopic kidney was reported in English language literature. In this article, we present the first case of CRE where surgical intervention has been performed.

The prognostic importance of trauma scoring systems in pediatric patients.

PURPOSE: Traumas are among important causes of morbidity and mortality in the pediatric group. Our aim was to evaluate the predicting effects of general trauma scores on mortality and morbidity rates. METHODS: The files of 74 patients, who were admitted to our hospital with trauma between the years 2006 and 2008, were retrospectively investigated. Patients' ages, sex, types of trauma, the time between the trauma and entrance to the hospital, vital and laboratory findings, length of hospital stay, length of intensive care unit (ICU) stay, surgical interventions, the organs affected by the trauma, morbidity, and mortality rates were recorded., glasgow coma scale (GCS), abbreviated injury scale (AIS), trauma score-injury severity score (TRISS), revised trauma score (RTS), injury severity score (ISS), pediatric trauma score (PTS), specific trauma scores for lung, liver, and spleen were calculated using the data in the files. RESULTS: The mean age of patients was 7.0+/-4.34 (1-16) years and 50% of them were men. The types of the trauma were blunt in 66 (89.2%) patients, penetrating in 5 (6.8%) patients and injury due to gun shot in 3 (4.1%) patients. The mean time between the trauma and entrance to the emergency service was 80.40+/-36.67 (10-120) min. Emergency operation and elective surgery was performed in 13 (17%) and 20 (27%) patients, respectively. The mean length of hospitalization was 4.50+/-7.93 (1-35) days.Seven (9.5%) patients needed ICU. The morbidity and mortality rates were 60.8% (n=45) and 2.7% (n=2), respectively. AIS, ISS, TRISS and PTS were independent predictors of morbidity (p<0.05). AIS and ISS were independent predictors of the length of hospital stay (p<0.05). RTS, TRISS, ISS and PTS were independent predictors of the need for ICU (p<0.05). Among laboratory findings, blood glucose, AST and ALT were found to be independent predictors of liver trauma. CONCLUSION: ISS was found to be more valuable than other trauma scoring systems for prognostic evaluation of pediatric trauma patients. On the other hand, blood glucose, AST, and ALT are easily available, cheap, and valuable alternative laboratory findings in prognostic evaluation.

Esophageal muscle cell interaction with biopolymers.

BACKGROUND: The in vitro interactions of esophageal smooth muscle cells (SMCs) with synthetic absorbable polymers were tested and artificial muscle tissues harvested from subcutaneous implantation were examined. MATERIAL/METHODS: Esophageal tissue samples from adult and fetal (25-day gestational age) rabbits were cut into small pieces and cultured in Dulbecco's Modified Eagle Medium supplemented with 10% fetal bovine serum. Growing cells were identified as SMCs by immunostaining for anti-actin and anti-myosin antibodies. Equal volumes of agar gel and medium were mixed and used for 3-D culture. 5x10(5) cells and 1 mg polyglycolic acid (PGA) and poly-lactide-co-glycolide acid (PLGA) fibers were seeded in six-well tissue culture plates. On days 2 and 7 growing cells were counted by a hemocytometer and cell-polymer interactions were evaluated with light microscopy. Adult and fetal SMCs were seeded onto the PGA and PLGA scaffolds, cultivated for two weeks, and implanted subcutaneously on the backs of the rabbits. Cell-polymer implants were retrieved after four weeks and muscle formation was evaluated histologically and immunohistochemically. RESULTS: Growing cells stained positive for actin and myosin proteins. Cell-polymer interactions were poor after 24 hours, whereas intensive attachment to the fibers was detected 48 hours following cultivation. Both fiber materials supported cell proliferation. PLGA scaffolds improved muscle formation more efficiently than PGA, and fetal and adult SMCs showed similar mass quality. CONCLUSIONS: Scaffolds are important as cell-carrying vehicles, and material-cell interactions should be tested before application. A 3-D culture prepared with agar gel and medium is practical for testing material toxicity.

Is peritoneal drainage necessary in childhood perforated appendicitis?--a comparative study.

PURPOSE/BACKGROUND: In this study, we aimed to evaluate the effect of peritoneal drainage (PD) on postoperative infective complications in cases with perforated appendicitis. METHOD: One hundred nine patients (with PD) were evaluated retrospectively and 117 cases (with no drainage [ND]) were evaluated prospectively regarding complications like wound infection (WI), intraabdominal abscess (IAA), and small bowel obstruction caused by adhesions (SBO) in perforated appendicitis cases. The abdomen was irrigated with isotonic NaCl solution and the wounds were closed primarily in all patients. RESULTS: The total number of patients was 226 (male, 66.4%; female, 33.6%), with a mean age of 8.6 +/- 3.4 years (range, 1-15 years). The WI rates in PD and ND groups were 28.4% to 16.2%, respectively. The ratio of IAA in the PD group was 12.8% which decreased to 3.4% in the ND group. The difference was statistically significant (P < .05). The postoperative hospitalization period in the PD and ND groups were 10.2 +/- 6.5 and 8.3 +/- 3.3 days, durations of antibiotic use were 9.5 +/- 5.5 and 7.7 +/- 2.7 days, durations of NG tube usage were 3.2 +/- 1.5 and 2.2 +/- 1.2 days, time to oral feeding was 3.7 +/- 1.7 and 2.5 +/- 1.4 days, and time to normalization of the body temperatures was 3.7 +/- 2.3 vs 2.3 +/- 1.7 days. All differences were statistically significant (P < .05). The ratio of SBO increased from 2.8% to 3.4% in the ND group, but this result was not statistically significant. CONCLUSIONS: As a result of this study, we recommend that peritoneal drainage should be abandoned in childhood appendicitis.

The protective role of erdosteine on testicular tissue after testicular torsion and detorsion.

Testicular torsion and detorsion are important clinical problems for infertile man and oxidative stress may have a role in this clinical situation. The aim of this study was to investigate the protective role of erdosteine, an antioxidant, on unilateral testicular reperfusion injury in rats. The rats were divided into four groups including seven rats in each group: control, torsion, torsion/detorsion and torsion/detorsion+erdosteine. Rats, except the sham operation group, were subjected to left unilateral torsion (720( composite function) rotation in the clockwise direction) without including the epididymis. The experiments were finished after sham operation time for control, 120 min torsion for torsion group and 120 min torsion and 240 min detorsion for torsion/detorsion groups. Bilateral orchiectomy was performed for all groups of rats. The ipsilateral and controlateral testis were divided into two pieces to analyse biochemical parameters and to investigate the light microscopic view. Malondialdehyde level of ipsilateral testis was increased in torsion and torsion/detorsion groups in comparison with the other groups (p < 0.05). Erdosteine treatment ameliorated lipid peroxidation after torsion/detorsion in ipsilateral testis (p < 0.05). Also, xanthine oxidase activity of ipsilateral testis was increased in torsion/detorsion group in comparison with the others (p < 0.05). Nitric oxide (NO) level of ipsilateral testis was higher in all experimental groups than sham operated control group (p < 0.05). Also, NO level of torsion group was increased in comparison with detorsion groups (p < 0.05). Erdosteine treatment caused increased glutathione peroxidase activity in comparison with torsion and torsion/detorsion groups and catalase activity in comparison with the other groups in ipsilateral testis (p < 0.05). Superoxide dismutase activity of ipsilateral testis was higher in torsion/detorsion and torsion/detorsion+erdosteine groups than control and torsion groups (p < 0.05). The biochemical parameters were not affected in controlateral testis in all groups. Torsion, torsion/detorsion and torsion/detorsion+erdosteine groups showed ipsilateral testicular damage in the histological examination, but the specimens from torsion/detorsion had a significantly greater histological injury than those from the other groups (p < 0.05). Control rats showed normal seminiferous tubule morphology. Rats in torsion group had slight-to-moderate disruption of the seminiferous epithelium. Rats in torsion/detorsion group displayed moderate-to-severe disruption of the seminiferous epithelium. In all animals from torsion/detorsion+erdosteine group, the testicular tissues were affected with slight-to-moderate degenerative changes of the seminiferous epithelium. Administration of erdosteine resulted in a significantly reduced histological damage associated with torsion of the spermatic cord compared with torsion/detorsion. In all groups, the contralateral testes were histologically normal. In conclusion, the results clearly displayed that erdosteine treatment may have a protective role on testicular torsion/detorsion injury.

Comparison of two methods for the management of appendicular mass in children.

Appendicitis is the most common surgical emergency in pediatric surgery. In the presence of an appendicular mass, surgical management can be difficult. We evaluate the results of appendix mass management both with immediate operation and conservative treatment over a period of 5 years. Forty children who presented with appendicular mass over a period of 5 years were reviewed. Their mean age was 7.6+/-2.7 years, and the mean duration of symptoms was 7.8+/-2.7 days. We evaluated the children in two groups: The first group included 19 children who were operated on immediately, and the second group included 21 children who were managed conservatively, followed by elective appendectomy. In the first group, mean hospitalization time was 8.7+/-3.2 days. The complication rate was found to be high (26.3%). Ileal injury occurred in two patients, intraabdominal abscess developed in one patient, and wound infection developed in another. Appendectomy could not be done in one patient who required another laparotomy 8 weeks later. In the second group, mean hospitalization time was 8.9+/-2.6 days. Two patients (8.6%) failed to respond to conservative management. Elective appendectomy was performed after 2-3 months. Two patients returned with perforated appendicitis 5 months and 12 months later, respectively, because they were not brought back for subsequent appendectomy. It can be concluded that conservative treatment of appendicular mass is safe; we also advocate elective appendectomy because of the probable risk of recurrence.