Specific small bowel injuries due to prolapse through vaginal introitus after transvaginal instrumental gravid uterus perforation: a review.

A small bowel prolapse through the vaginal introitus after a transvaginal instrumental gravid uterus perforation is a surgical emergency. To define the mechanisms of an irreversible, small bowel ischaemia due to small bowel prolapse through a vaginal introitus, ClinicalTrials.gov, PubMed, PubMed Central, and Google Scholar were searched. Out of the 81 articles screened, 28 cases of a small bowel evisceration through vaginal introitus were included. A small bowel obstruction severity grading was defined with risk factors; potential mechanisms of different severity grades after a transvaginal instrumental gravid uterine perforation with a vaginal evisceration. The duration of symptoms or a delay in the diagnosis did not change the incidence of the two most severe grades-mesenteric stripping and a small bowel degloving. Both obstruction types develop immediately during an instrumental abortion. The severity of obstruction does not influence the maternal outcome.

From Ataxia to Diagnosis of Askin Tumor - a Case Report.

Peripheral primitive neuroectodermal tumors (pPNET) are a group of extremely rare, aggressive, malignant tumors that are most often found in the thorax (Askin tumor), abdomen, pelvis, extremities and less frequently in the head and neck. The most important prognostic factor is the stage of the tumor. Significant progress both in surgery and in neoadjuvant and adjuvant chemotherapy and radiotherapy, as well as the improvement in diagnosis by cytogenetic and immunohistochemical analysis, should improve the survival rate. We report a case of a 14-year-old girl, with ataxic gait, cardiopulmonary compensated, without respiratory symptoms, who was referred to our hospital for further examination and treatment of newly discovered tumor of the left hemithorax. After a detailed radiological and laboratory investigation, next step was an extensive thoraco-neurosurgical surgery. After histopathological, cytological and molecular analysis, a diagnosis of Askin tumor was made.

Torsion of a mesenchymal hamartoma of the liver in a 1-year-old boy.

We report a case of a one-year-old boy who was referred to our clinic suspected of having acute abdomen. On physical examination, the abdomen was soft, diffusely tender with weak peristalsis. Ultrasonography and MRI of the right hemiabdomen demonstrated a well-defined, solid, expansive formation with slightly lobulated contours and an interspersed inhomogeneous structure with overall dimensions of 59 × 45 × 50 mm. After midline laparotomy was performed, a cystic tumor was found, twisted around a pedicle which was arising from the falciform ligament and it measured 5-6 cm in diameter. The tumor appeared to be necrotic. The mass was ligated and extirpated on the pedicle and sent for histopathological analysis. After the surgery, the boy was hemodynamically stable, without respiratory complications and all laboratory findings were within normal limits. Histopathological analysis showed that the tumor was composed of mesenchymal stroma with sparse glimpses of hepatocytes and bile ducts with partly cystic changes lined by orderly epithelium. Given the clinical data, histology and immunohistochemistry analysis (alpha-fetoprotein, CK8/18, hepatocyte, desmin and CD31) a diagnosis of a twisted mesenchymal hamartoma of the liver was made.

Rare Abdominal Wall Malformation: Case Report of Umbilical Cord Hernia.

The umbilical cord hernia is the rarest form of abdominal wall malformations, anatomically completely different from gastroschisis and omphalocele. It occurs due to the permanent physiological evisceration of abdominal organs into umbilical celom and persistence of a patent umbilical ring. The umbilical cord hernia is often mistaken for omphalocele and called "small omphalocele". Here we present a case of a female newborn with umbilical cord hernia treated in our Hospital. After preoperative examinations surgery was done on the second day of life. The abdominal wall was closed without tension. The aim of this article is to present the importance of the proper diagnose of these three entities and to stimulate academic community for the answer, is this umbilical cord hernia or small omphalocele.

[INITIAL EXPERIENCE WITH TOPICAL NEGATIVE PRESSURE THERAPY IN THE TREATMENT OF PEDIATRIC BURNS].

We are presenting the experience of the Referral Centre for Pediatric Traumatism of the Croatian Ministry of Health in the usage of topical negative pressure therapy (TNP) method for the treatment of pediatric burns. In the period of 20 months we have used negative pressure wound therapy method in eight children aged between 1.5 and 10 years. Burn injuries total body surface area ranged between 3% and 30%. TNP was used either for the wound bed conditioning or for the fixation of skin grafts. Average skin graft "take" was 86% eight days after surgery according to the evaluation by the senior author. Based on our initial experience, we can confirm that TNP is a very useful tool which enables good wound bed conditioning as well as a good fixation tool for skin grafts if the burned area does not exceed 30% of total body surface area.

[STERNAL CLEFT ­ REPORT OF THREE CASES]. / RASCJEP PRSNE KOSTI ­ PRIKAZ TROJE BOLESNIKA.

During the last 25 years we surgically treated three patients with sternal cleft anomaly, aged from 6 weeks to 2 years. The aim of this case series is to present this extremely rare congenital anomaly and differences in the operative treatment of sternal cleft (SC) depending on patients age due to flexibility of the chest wall. Patients presented to us with signs of sternal cleft; displaced sternoclavicular articulations and paradoxical motion of the skin over the defect. Preoperatively we performed X-ray and computed tomography of the chest which revealed displaced sternoclavicular articulations with superior incomplete sternal cleft and echocardiography which showed orthotopic heart without malformations of the great vessels. Surgical treatment included primary closure in two infants and Sabiston's technique in a two-year-old girl. All three patients were successfully operated without complications.

[THE SCALP AS A SPLIT-THICKNESS GRAFT DONOR IN THE TREATMENT OF A MASSIVE THERMAL INJURY]. / VLASISTE KAO DONOR TRANSPLANTATA DJELOMICNE DEBLJINE KOZE U LIJECENJU MASIVNE TERMALNE OZLJEDE.

We are presenting our initial experience with the utilization of the scalp as a donor for split thickness skin grafting in the treatment of massive thermal injuries. Rapid donor reepithelization, absence of hypertrophic scarring in the donor area, inconspicuous donor area and a large area for the procurement of grafts in the pediatric population are the advantages that are emphasized in the literature. The outcome in a 3-year-old boy who suffered a burn injury from an open fire in the family house on the 57% of his total body surface area (48% full thickness burn) showed that the "take rate", in the absence of a massive local infection, was around 80% and that the scalp can be utilized again as a donor area after a period of 14 days. Folliculitis and alopecia are complications that should be kept in mind when using this technique.

[A rare tumor of the lung in childhood--inflammatory myofibroblastic tumor]. / Rijetki tumor pluca u djecjoj dobi --inflamatorni miofibroblasticni tumor.

Inflammatory myofibroblastic tumor (IMT) is a rare benign neoplasm, mainly involving the lungs of the children. It represents 0.7% of all lung tumors. It was first described by Brunn in 1939.2 Diagnosis is very difficult and often only possible after resection of the tumor. We would like to present a case of pulmonary IMT in a 13-year-old girl who presented with symptoms like cough, shortness of breath, and chest discomfort. Chest X ray and computed tomography revealed the presence of a right lower lobe lung mass. Its clinical and radiological findings were diverse and non specific. The mass was removed in toto, histopathology confirmed the inflammatory myofibroblastic tumor of the lung. Intraoperative and postoperative courses were uneventful. The patient has been without any signs of relapse 2 years after the surgery.

The Impact of the COVID-19 Pandemic on the Most Common Diagnoses in Pediatric Surgery: Abdominal Pain, Acute Scrotum, Upper and Lower Extremity Injuries-Tertiary Center Experience.

OBJECTIVE: The coronavirus disease-19 pandemic has brought new patterns of behavior among patients and their parents. The reorganization of the health care system has reduced the number of elective surgical procedures in Croatia. In our study, we were interested in whether the pandemic has caused a statistically significant decrease in the number of examinations of children in the emergency department according to the most common diagnoses in pediatric surgery and whether there was a decrease in the number of emergency surgeries. MATERIALS AND METHODS: We retrospectively analyzed data from the Hospital Information System. The analysis included 15 months of the pre-coronavirus disease-19 period and 15 months of the coronavirus disease-19 period. The primary outcome of the study was to determine the cumulative number of all examinations and then to determine the number of examinations according to the most common diagnoses and, consequently, to determine whether there was a statistically significant decrease. The secondary outcome was to determine the cumulative number of all operations and then to determine the number of the most common emergency operations and, consequently, to see if there was a statistically significant decrease. RESULTS: In the 15 months of the pre- coronavirus disease-19 period, a total of 33 646 children were examined in the emergency department, while in the coronavirus disease-19 period, 26 831 were examined (P = .010). Although a decrease was recorded in all categories, a statistically significant decrease was recorded for diagnoses of abdominal pain (P = .007) and lower extremity injuries (P = .014). The total number of operations, due to strict measures and reduction of the elective program, decreased statistically significantly in the coronavirus disease-19 period (P < .0001). The number of most common emergency operations did not decrease statistically significantly. CONCLUSION: This study represents the first longer, 15-month experience of a pandemic in the only and largest children's hospital in Croatia. There is no doubt that coronavirus disease-19 had the effect of reducing the number of examinations in the emergency department for all the most common diagnoses, but the number of operations did not change significantly.

Suicide attempt by swallowing sponge or pica disorder: a case report.

INTRODUCTION: There are many ways how children with mental illness have actually tried to hurt themselves. Suicidal thinking or attempts always indicate that professional help is needed (2). Every object which can be potential dangerous should be removed but this is very difficult to do. Some of children with these symptoms had Pica diseases. Pica is a medical disorder characterized by an appetite for substances largely non-nutritive (e.g. metal, coal, soil, feces, paper, soap, gum, etc.) or an abnormal appetite for some things that may be considered foods. MATERIAL AND METHODS: The patient swallow sponge from a pillow over a long period of time and she came into our hospital with abdominal pain. She was 16 years old and had abdominal distension, vomiting, abdominal cramping and failure to pass gas or stool. Immediately we suspected mechanical blockade of the intestine. Diagnosis was clinically confirmed by X-rays of the abdomen and with ultrasound. RESULTS: The operative treatment was indicated and we found the proximal bowel distended and the distal segment collapsed. The part of bowel necrosis was removed and anastomosis was done. CONCLUSION: When patients are determined to attempt suicide or have Pica disorder it is very difficult to prevent.

Expression and prognostic value of the Ki-67 in Wilms' tumor: experience with 48 cases.

PURPOSE: Ki-67, tumor proliferation marker, is an important prognostic factor in a variety of cancers. In the present study, we investigated the expression and the prognostic value of Ki-67 in nephroblastoma. METHODS: Ki-67 expressions were investigated by immunohistochemistry on paraffin-embedded material in 48 children operated on because of nephroblastoma. Patients were treated according to SIOP protocol. The mean follow-up period was 5.4 years. A proliferation index was obtained by immunohistochemistry using anti-Ki-67 anti-body. RESULTS: The mean Ki-67 proliferation index in the blastemal type was 12.3%, and in the epithelial type, 21.4%. In the anaplastic type, Ki-67 proliferation index was: in the blastemal component 20%, in the stromal 21%, and in the epithelial 31%. In the mixed tumor type, Ki-67 proliferation index was assessed as: in the blastemal component 10%, in the epithelial 33% and in the stromal 31.5%. Proliferation index for the epithelium was significantly higher than those found for the blastema (P = 0.001). A correlation between Ki-67 and tumor stage found proliferation index significantly higher in stages I and II (P = 0.002). CONCLUSION: The results support the conclusion that Ki-67 is a relevant marker for assessing the proliferative activity and tumor cell dynamics of nephroblastoma, but it may not be a good clinical prognostic marker.

The relationships between self-esteem, emotional reactions and quality of life in pediatric locomotory trauma patients.

The main aim of this study was to establish the relationships between several psychosocial characteristics in children and adolescents differently treated for isolated long tubular bones' fractures. Examined variables were: self-esteem, basic emotional reactions toward illness or injury including depression and anxiety, as well as perception of quality of life and social support during the treatment. Whole sample comprehends 135 patients, both gender, 10-18 years of age, treated for mentioned fractures in period 2003-2005 at the Departments of Pediatric Surgery of 3 hospitals: University Hospital Centre in Rijeka and Clinical Children's Hospital in Zagreb, both in Croatia and University Hospital in Mostar, BiH. 73 patients were treated conservatively (CT), 40 of them underwent Elastic Stable Intramedullary Nailing (ESIN) and 22 of them underwent other surgical techniques (OST). Basic methods of work were: interview to collect data for half-structured socio-demographical questionnaire, evaluation of medical records and self-reported questionnaires including: Rosenberg Self-esteem Scale (RSS), Children Depression Inventory (CDI), Spielberg State Trait Anxiety Inventory (STAI), Short Form 36 Health Survey (SF-36) and Test of Perception of Social Support (TPSS). RSS, CDI and STAI were administered to the patients at baseline and after 6 months of the trauma, while SF-36 and TPSS after 1 month of the trauma. Results of this study point to close and strong relationships between examined variables, mostly statistically significant at level p < 0.01 in all patients with fractures, regardless of the type of the treatment. There were also statistically significant differences in all variables between first and second measure; self-esteem increased and depression and anxiety decreased during the time in all patients (with different dynamics regarding the type of treatment); higher perception of social support enhanced that effect. Perception of quality of life in whole sample in summary measures was statistically significant at level p < 0.01 correlated positively with self-esteem and negatively with depression and anxiety, thus connection with perception of social support was statistically significant only in sibdomain of physical pain. There was also statistically significant difference in self-perception of quality of life related to psychosocial variables according to the type of treatment (F = 3.27; p = 0.01). Results of this study suggest that there are strong connections between physical trauma and different psychosocial variables in patients which point at need of understanding locomotory trauma in children in wider context including physical state and social functioning of the patient as well as the choice of type of treatment of fractures which influences complete process of healing.

Treatment of rectal prolapse in children with cow milk injection sclerotherapy: 30-year experience.

AIM: To evaluate the role and our experience of injection sclerotherapy with cow milk in the treatment of rectal prolapse in children. METHODS: In the last 30 years (1976-2006) we made 100 injections of sclerotherapy with cow milk in 86 children. In this study we included children who failed to respond to conservative treatment and we perform operative treatment. RESULTS: In our study we included 86 children and in all of the patients we perform cow milk injection sclerotherapy. In 95.3% (82 children) of patients sclerotherapy was successful. In 4 (4.7%) patients we had recurrent rectal prolapse where we performed operative treatment. Below 4 years we had 62 children (72%) and 24 older children (28%). In children who needed operative treatment we performed Thiersch operation and without any complications. CONCLUSION: Injection sclerotherapy with cow milk for treatment rectal prolapse in children is a simple and effective treatment for rectal prolapse with minimal complications.

The quality of life during the treatment of long bone fractures in children and adolescents.

This paper evaluates and compares basic emotional reactions towards the illness, as well as the quality of life in relation to the various types of treatment of isolated long tubular bone fractures of extremities in children and adolescents. This prospective clinical research comprehends 135 patients (94 males and 41 females), aged 10 to 18, treated for the mentioned bone fractures in the period from October 2003 till March 2005 at The Departments for Pediatric Surgery of three hospitals: the Clinical Hospital Centre in Rijeka (88.8% of the patients), the Clinical Children's Hospital in Zagreb (9.7% of the patients) both in Croatia, and 1.5% of the patients in the Clinical Hospital in Mostar (Bosnia and Herzegovina). 53.3% of the patients were treated conservatively, 29.6% of them underwent the elastic stable intramedullary nailing (ESIN), while the remaining 17.1% of the patients were treated with other surgical techniques (AO-plates or Kirschner-wire ostheosyntheses). The basic methods were self-reported questionnaires: the Spielberg State Trait Anxiety Inventory (STAIl) to establish momentary anxiety and the Short Form-36 Health Survey (SF-36) to evaluate quality of life, i.e. the perception of the illness during treatment. The STAI1 was administered twice to the patients: within 1 week of the experienced trauma (at baseline) and 6 months after the trauma, whereas the SF-36 was administered only once, i.e. a month after the experienced trauma. Our results point at an increased anxiety indicators in all the patients immediately after the experienced trauma, mostly in patients treated surgically, especially those who underwent the ESIN method; whereas after 6 months from the experienced trauma the anxiety indicators were greatly reduced. The quality of life was better in patients who underwent a conservative treatment, both physically and mentally, than in those surgically treated. This points to the fact that the surgical method itself despite its type, is an additional stressor which causes additional anxiety and depressive reaction. Our results suggest (from psychological point of view) that the conservative method of treating long bone fractures in children and adolescents should be used since it causes less emotional reactions on the illness ascertaining a better health experience during the treatment than the active surgical treatment (regardless of the type), which should be practised with criticism and according to strict surgical indications. If the surgical treatment should be necessarily adopted, we should take into consideration the possibility of psychologically preparing the patients in order to diminish the psychological reaction on the surgical treatment.

Fist fractures at child's age.

The aim of this work is to confirm or deny the hypothesis that the fist fracture medical treatment at child's age in the General Hospital in Zadar does not differ much from the medical treatment method in other centers which have already published their results. The work is based on the retrospective study. The examinees are children with fist fractures in the General Hospital in Zadar from 1999 to 2003. The control group is formed by the examinees of the published studies about children fist fractures, which have been collected and statistically elaborated. The examinees of our group and the control group are classified by the same criterion: age, sex, place, sort and type of fracture as well as the method of medical treatment. The used statistical methods are the testing of frequency differences and chi2 test. Statistically essential differences between our group and the control group have been noticed. There are also differences among the control group subgroups. The difference in the method of medical treatment is statistically essential and shows that the methods are not the same as in our group and the control group. The surgical way of treatment is less represented by our results than in those of the control group. The different attitude in medical treatment is conditioned by the attitude that surgical intervention of finger bones does not always give us the expected functional result.

[Laparoscopic decapsulation of congenital splenic cyst]. / Laparoskopska dekapsulacija prirodene ciste slezene.

Nonparasitic splenic cysts are uncommon and may be congenital or post-traumatic in origin. Complications may include enlargement with pain, rupture, and infection. The laparoscopy is widely accepted method in the treatment of this condition with numerous approaches. A technique of partial decapsulation-fenestration designed to minimize the risk of splenic loss and cyst recurrence is presented.

Bilateral Ovarian Torsion during Follow-up for Antenatally Detected Ovarian Cysts.

Ovarian torsion is a surgical emergency demanding timely diagnosis and treatment to prevent loss of the ovaries which if happens may result in functional and emotional consequences. Simple (less than 5cm in size) ovarian cysts require follow-up for potential self-resolution. We describe a case of antenatally detected bilateral ovarian cysts that developed bilateral ovarian torsions on follow-up, postnatally.

Treating Giant Congenital Nevus With Integra Dermal Regeneration Template in a 9-Year-Old Girl.

Integra dermal regeneration template has been well established in treating deep extensive burns, but there are very few cases reported of treating large full-thickness skin defects such as giant nevi. Apart from psychological and cosmetic burdens, the giant congenital nevus carries increased risk of malignant alteration. We present the case of a 9-year-old girl with a giant congenital nevus on her left lower leg. A total excision was done and she was successfully treated with Integra (LifeSciences Corp, Plainsboro, NJ). Three weeks later, a thin split-skin graft was applied over the neodermal skin layer. The takeoff was 91%. Protected with the silver wound dressing, the rest of the wound healed. A donor site morbidity was minimal, and the final result was excellent both in aesthetic and functional aspects.

A 5-year experience of a minimally invasive technique for correction of pectus excavatum in Croatia.

The aim of this study was to assess the results of 5-year experience with minimally invasive operation without medial incision and resection cartilages for correction of pectum excavatum. From 2000 we made in our Hospital minimally invasive technique for the correction of pectus excavatum. 75 patients were treated by minimally invasive technique. A convex steel bar is inserted under the sternumtrough small bilateral Incisions. The steel bar is inserted with the convexity facing posteriorly, and when it is in position, the bar is turned over. After 2 years the bar is removed when permanent remolding has occurred. Initial excelent results were maintained in 54 patients (normal chest), good results in 16 (mild residual pectus) and poor in 5 (severe recurrence requiring further treatment). The mean follow-up since surgery were 3 months to 3 years. Average blood loss was 25 ml. Average length of hospital stay was 8 days. Patients returned to full activity after 2 month. Complications were pneumothorax in 12 patients, pneumonia in 6 patients and displacement of the steel barr requiring revision in 2 patients. Poor results occurred because steel bar was too soft in 3 patients, and soft sternum in 2 patients with Marfan's syndrome. The minimally invesive technique is effective without cartilage incision and resection or sternal osteotomy.