Early postoperative complications in pediatric abdominal solid tumor surgery according to Clavian-Dindo classification.

PURPOSE: Postoperative period after abdominal solid tumor surgery is critical regarding complications. This study aimed to detect incidence and treatment of complications. METHODS: Single center retrospective study including years 2010-2019 for early postoperative complications were documented and graded according to Clavian-Dindo classification. RESULTS: The overall complication rate was 10% and they were chylous leak (n = 8, 2%), collection in surgical field (n = 8, 2%), acute renal failure (n = 7, 1.7%), hemorrhage (n = 5, 1.3%), intestinal obstruction (n = 4, 1%), surgical site infection (n = 3, 0.7%), thromboembolism (n = 3, 0.7%) and peripheric neuronal event (n = 2, 0.5%). Distribution of complications according to Clavian-Dindo classification was as follows: 2 grade I, 23 grade II, 9 grade IIIb, 5 grade IVa and 1 grade V. While age and percentage of benign or malignant disease were not different in groups with or without complications (p = 0.11, p = 0.24), males had more complications than female patients (p = 0.008). Having more than one surgery aiming tumor resection was associated with increased postoperative complications (p = 0.002). Incidence of complications were highest after extragonadal germ cell tumor (35%) and hepatic tumors (29%). CONCLUSIONS: Postoperative complications of abdominal tumor surgery are diverse in children. They are related with prolonged hospital stay and need for medical or surgical interventions. Number of surgeries, organ of origin and tumor type have an influence on risk of complications.

Not just about machines: Analysis of MRI quality determinants in the Turkish health system context.

This study aims to investigate the determinants of the quality MRI in the Turkish healthcare system. The analysis is done by analysing the referred cases to a major university radiology department in Turkey, and matching the hospital and MRI use characteristics of the source institutions, where the original MRI was taken. Quality of MRI was measured by specialist radiologists. The resulting quality was analysed by gender and imaging area characteristics, source institutional quality, MRI use statistics in source institution and MRI machine use inclination of the source institution. Chi-square and logistic regression were conducted, with regional fixed effects. In the largest dataset, the highest quality institutions have significantly higher average expected MRI quality compared to one level beneath them (0.74 vs. 0.63) (P = 0.02), there is also a significant MRI quality difference between the second highest level of institution, and the third and the fourth (0.63-0.54). Smaller (<0.1) but significant quality difference (P = 0.05) exists for institutions with the lowest two quality levels. In the smaller dataset, with data only from the lowest two institutional quality groups, with a finer institutional quality grading, differences in institutional quality is again found to be a significant driver of MRI quality (P = 0.035).

An unusual complication of tumor surgery: chylous leakage.

PURPOSE: This study was designed to evaluate the effectiveness of conservative treatment for chylous leak after tumor surgery and to propose a management algorithm. METHODS: The data of patients with postoperative chylous leak after tumor surgery in our institution between 2010 and 2019 were retrospectively reviewed. In this study, 469 laparotomies, 89 thoracotomies, and 57 cervical excisions were performed for tumor surgery in our institution. RESULTS: Twelve patients with a median age of 4 (IQR, 3-8) years had postoperative chylous leak. All patients received total parenteral nutrition for a median of 13 days. Five patients had intravenous somatostatin for a median of 14 days (IQR, 9-16) to decrease chyle production. Eventually, chylous leak ceased in all patients with conservative treatment and surgical drains were removed after no leak was observed with enteral feeding. CONCLUSIONS: The incidence of chylous leak in childhood tumor surgery is approximately 2%. Extended tumor resection and lymph node dissection lead to the injury of the delicate structures that drain chyle. Conservative treatment with total parenteral nutrition and somatostatin seems to be effective. In particular, somatostatin may be used in resistant cases. Conservative treatment can take up to 1 month. The algorithm consists of how to manage postoperative chylous leak in childhood.

Approach to pheochromocytoma and paraganglioma in children and adolescents: A retrospective clinical study from a tertiary care center.

AIM: Pheochromocytoma (PCC) and paraganglioma (PGL) are rare tumors in childhood. They are catecholamine secreting tumors and present with signs or symptoms related to their excess. Most common signs and symptoms are hypertension, headache and diaphoresis. The management of children usually depend on experience of adulthood. This study is conducted to present the clinical characteristics, surgical management and outcome of childhood PCC and PGL in a tertiary care center. MATERIAL AND METHODS: We reviewed clinical records of all patients operated for PCC and PGL between 2000 and 2020 retrospectively. RESULTS: There were 18 children operated for PCC and PGL in the study period. The female to male ratio was 1:1. The median age at diagnosis was 13 (IQR, 9-15) years. The most common presenting symptoms were headache and diaphoresis. Hypertension was the most common sign. Three patients had von Hippel-Lindau (VHL). Tumors of two patients with VHL were detected during routine follow-up. Three patients had multifocal disease. Medical preparation for surgery was carried out in all patients. Antihypertensive treatments were administered preoperatively. Since the patients are at risk for postoperative hypotension due to chronic vasoconstriction and blood volume contraction, high salt diet was recommended. Intravenous normal saline at a rate of 3000 ml/m2 body surface area per day was started for intravascular volume expansion preoperatively. The mean duration for preoperative medication to achieve normal blood pressure was 22 days (range, 16-30). Twenty-five tumors were excised in eighteen patients. One patient who had bone metastases on diagnosis and is on I131MIBG therapy. The median follow-up time was 5.6 years (range, 1 months - 21 years). Five patients reached adulthood during the study period. Four of these had recurrent metastases (n = 2) and new tumors (pancreatic neuroendocrine tumor, n = 1 and pancreatic neuroendocrine tumor and renal cell carcinoma, n = 1) after the age of 18. CONCLUSION: Multidisciplinary approach is necessary to achieve safe surgical treatment and surveillance of PCC and PGL. Detection of associated familial cancer susceptibility syndromes and long-term follow-up is essential to detect late recurrences and new tumors.

The results and outcome of primary spontaneous pneumothorax in adolescents.

AIM: Primary spontaneous pneumothorax (PSP) is a rare pulmonary pathology that occurs in the absence of known lung disease. A retrospective study was performed to evaluate the results and outcome of PSP treatment in adolescents. METHODS: The cases with PSP from January 2004 to December 2017 were evaluated for age, sex, family and smoking history, clinical and radiological findings and results of treatment. RESULTS: Ten cases with PSP were included. The mean age of the patients was 15 years (10-17 years) and the male to female ratio was 9:1. Two of the patients (20%) had family history of PSP and four cases (40%) had smoking history. The initial complaints were chest pain (n=8), acute onset of cough (n=1) and breathing difficulty (n=1). Tube thoracostomy was performed in nine cases in which three of them were bilateral. Chest computed tomography (CT) demonstrated bullae (n=4; 40%) and subpleural blebs (n=2; 20%). Pleurodesis with talc was performed in four patients with pneumothorax for longer than a week in follow-up (n=4; 40%). Five cases had recurrent PSP within one year (n=5; 50%) and underwent pleurodesis with talc (n=4), autologous-blood (n=1) and bleomycin (n=1). Bleb excision was performed in two cases with persistent pneumothorax despite pleurodesis. CONCLUSION: Tube thoracostomy and oxygen supplementation, are considered as initial and adequate treatment of PSP in most of the adolescents. Prolonged air leaks require pleurosdesis as the first line treatment and surgical excision of blebs should be reversed for the patients who are unresponsive to other treatment options.

Socio-economic and behavioral determinants of prescription and non-prescription medicine use: the case of Turkey.

BACKGROUND: Demographic and socio-economic factors determine pharmaceutical health care utilization for individuals. Prescription and non-prescription medicine use are expected to have different determinants. Even though prescription and non-prescription medicine use is being well researched for developed countries, there are only a few studies for developing countries. OBJECTIVES: This paper aims to analyze the socio-economic and individual characteristics that determine the use of prescription and non-prescription medicine. We examine the issue for the specific case of Turkey since Turkey's health system has undertaken significant changes in the last two decades and especially after 2003 with the "Health Transformation Programme". METHODS: Data from the nationally representative "Health Survey" are used in the analysis. The data set covers the 2008-2016 period with two-year intervals. Pooled multivariate logistic regression is employed to identify the underlying determinants of prescription and non-prescription medicine use. RESULTS: When compared to 2008, non-prescription medicine use decreases until 2012, however, an increasing trend appears after 2012. For prescription medicine use, a decreasing trend emerges after 2012. Findings from the marginal effects indicate that for non-prescription medicine use, the highest effect stems from the health status. For prescription medicine use, the highest marginal effects arise from age, health and employment status indicating the importance of the need and predisposing factors. CONCLUSION: Decreasing non-prescription medicine use largely depends on easier access to health care service utilization. Although having a health insurance has a positive relationship with prescription medicine use, there is still a problem for individuals living a rural area and heaving a lower income level since they are more likely to use non-prescription medicine.

Foreign Body Aspiration in Infants: Role of Self-Feeding.

Background: Foreign body aspiration (FBA) is a serious life-threatening condition in childhood. "Baby-led weaning (BLW)" is a popular method in which the babies are encouraged to self-feed to gain oral motor abilities. The role of BLW in FBA is controversial. A retrospective study was performed to evaluate the results of FBA in infants (<1 year of age) and its relation to the feeding method. Materials and Methods: Children who underwent bronchoscopy for FBA for the past 10 years were included. Infants (<1 year of age) were evaluated for age, gender, clinical findings, and the results of bronchoscopy. The type of feeding, including self-feeding or caregiver-assisted feeding, was noted. Results: The medical records of 826 patients who underwent bronchoscopy were evaluated. FBA was noted in 50.2% (n = 417) of cases. Only 9.07% (n = 75) of patients were <1 year of age and 67% (n = 50) of them had a foreign body according to the bronchoscopy. The mean age was 9 months (5-12 months) and 36% of them were male. When the feeding characteristics of patients were surveyed, 80% of cases aspirated when self-feeding and 14% aspirated during caregiver-assisted feeding. Conclusions: Self-feeding to promote oral motor function may cause FBA in infants. Emergent bronchoscopy is more common in infants and reveals the aspiration of foods that cannot be consumed safely in this age group.

Surgical Treatment of Childhood Inflammatory Myofibroblastic Tumors.

Aim A retrospective study was performed to evaluate the clinical features, diagnostic methods, and treatment alternatives of childhood inflammatory myofibroblastic tumors (IMTs). Patients and Methods Patients who underwent surgical treatment for IMT between 2000 and 2015 were evaluated for age, sex, presenting symptoms, physical examination findings, diagnostic methods, treatment modalities, histopathologic findings, and results of surgical treatment during long-term follow-up. Results Eleven patients who underwent surgical treatment were included in the study. Male:female ratio was 7:4 and the mean age of the patients was 6.09 years (1-10 years). Presenting symptoms were respiratory difficulty, cough (n = 7, 63.3%), abdominal pain, vomiting (n = 2, 18.8%), loss of body weight (n = 1, 9.09%), palpable mass (n = 1, 9.09%), and rectal bleeding (n = 1, 9.09%). Ultrasonography (n = 4, 36.3%) and computed tomography (n = 9, 81.1%) were used for diagnosis. Localizations of tumors were lungs (n = 5, 45.4%), mediastinum (n = 2, 18.1%), spleen (n = 1, 9.09%), neck (n = 1, 9.09%), colon (n = 1, 9.09%), and rectum (n = 1, 9.09%). The mean size of mass was 6.6 cm (2-12 cm) and six patients were diagnosed with preoperative biopsy. Lung lobectomy (right lower lobe; n = 3, right middle and lower lobe; n = 2), total resection of mass with adjacent bowel (n = 2), partial splenectomy (n = 1), total resection of neck mass (n = 1), and incomplete resection (n = 2) were the choice of surgical treatment. Incomplete resection was performed in masses closely adjacent to atrium and mediastinal structures. In histopathologic evaluation, surgical margins were free of tumor in four cases, positive in six cases, and were not reported in one case. Anaplastic lymphoma kinase (ALK) positivity was detected in six cases, negative in two cases, and was not evaluated in three cases. Two cases who had residual mass with positive ALK received chemotherapy. Mean follow-up time was 68.2 months (5 months to 12 years). During follow-up, there was no recurrence or distant metastasis. Ten patients survived and one patient was lost to follow-up. Conclusion IMT is a rare tumor of childhood with a spectrum of clinical findings because of variable localization. Surgical treatment is the first choice of treatment. Patients with residual mass and ALK positivity may require medical treatment. In our series, long-term survival of patients was favorable in patients with total resection.

Prepubertal vaginal discharge: Vaginoscopy to rule out foreign body.

Medical records of all prepubertal patients who underwent vaginoscopy to rule out vaginal foreign body between 2004 and 2013 were reviewed retrospectively. All patients were evaluated by pediatricians prior to surgical consultation. Vaginoscopy is performed in the operating room under general anesthesia. During the study period, 20 girls with persistent vaginal discharge with a mean age of 6.8 years (1-13 years) underwent vaginoscopy to rule out vaginal foreign body. Six patients had bloody vaginal discharge and 4 had recurrent vaginal bleeding lasting for more than one month. Ten patients had purulent vaginal discharge lasting for 1-7 months. None of vaginal cultures revealed pathological bacteria or candida species. Preoperative imaging techniques revealed vaginal foreign body in one patient only. Vaginoscopy demonstrated vaginal foreign bodies in four patients. Foreign bodies were grass inflorescence, safety pin and undefined brownish particles (n=2), which may be pieces of toilet paper or feces. There was no complication related to vaginoscopy and removal of foreign body. Hymen integrity was preserved in all patients. Persistent or recurrent vaginal discharge in prepubertal girls should raise the suspect of vaginal foreign body. Continuous flow vaginoscopy is mandatory to detect and remove any vaginal foreign body. Early diagnosis would prevent complications secondary to long-standing foreign bodies.

Evaluation of the removal reasons of totally implantable venous devices in children: a retrospective study.

Totally implantable venous access devices (TIVADs) increase the quality of life in children with hematologic and oncologic diseases or organ failures. The aim of this study is to determine the reasons for port removal. The port catheters, implanted and removed in patients between January 2000 and June 2013 were evaluated retrospectively. The patients were divided into two groups, whose port catheters were removed due to completed therapy (completed therapy group, CTG) and whose port catheters were removed because of a port catheter-related complications (complication group, CG). In the CG, the patients whose port catheters are removed for infectious reasons are investigated for whether there is a relationship with age, gender, body mass index (BMI), height and weight at the time of port implantation and removal. In total, 242 patients who underwent port implantation and removal were included in the study. The male to female ratio was 1.32/1 and the mean age of the patients was 9.4±4.9 years (0-24 year). Patients were enrolled in CTG (n=170, 70.2%), and CG (n=72, 29%). There is a positive correlation between BMI and infections (p < 0.05). In the CG, patients under steroid treatment had higher incidence of non-infectious causes than infectious causes (p < 0.05). Oppositely, non infectious complications were higher in steroid free patients (p < 0.05). There was no catheter related mortality in the entire study group. The hematological malignancies and solid tumors are the most common underlying primary disease in patients with port removal because of complications. Infectious complications are most common cause of port removal in children and despite other microorganism, fungi should be considered as a cause of catheter related infections.

Eccentric circummeatal based flap with limited urethral mobilization: An easy technique for distal hypospadias repair.

BACKGROUND: Hypospadias is a common congenital anomaly. Over 300 techniques have been described for repairing hypospadias. OBJECTIVE: Eccentric circummeatal based flap with combined limited urethral mobilization technique (ECMB-LUM) is a simple procedure to repair distal hypospadias with minimal complication rate. This study presents results of this technique, highlighting surgical pitfalls to achieve the best result. STUDY DESIGN: Medical records of patients with distal hypospadias operated on using the same technique between 1998 and 2011 were reviewed retrospectively. Age at surgery, position of meatus preoperatively and postoperatively, duration of urethral catheterization and hospitalization, early and late complications, previous hypospadias repairs, and secondary surgical interventions were evaluated. In the surgical technique an eccentric circummeatal based flap is outlined. The proximal part of the flap is dissected from the underlying urethra and Buck's fascia. If the flap is not long enough, the distal urethra is mobilized a few millimeters (Figure). The eccentric flap is sutured to the tip of the glans. The glans wings are approximated in the midline. A urethral catheter of 6 Fr or 8 Fr is passed and left in the bulbous urethra or the urinary bladder. Diverged limbs of corpus spongiosum are approximated on the urethra, then, the glans and skin of the penile shaft are sutured. RESULTS: Of the 171 consecutive patients operated on using the ECMB-LUM technique; 115 had coronal, 47 had subcoronal, and nine had glanular meatus. The mean age at surgery was 4.5 (1-17) years. Patients were hospitalized for 2.2 ± 0.7 days. Mean duration of urethral catheterization was 2.3 ± 0.5 days. All but eight patients had ECBF-LUM as primary repair. There were no early complications such as bleeding, hematoma, and wound infection. All patients voided spontaneously after catheter removal. Late complications were meatal stenosis, urethrocutaneous fistula, meatal regression, and glandular dehiscence (Table). These patients were treated using dilatation, fistula repair, meatoplasty, and secondary repair with the same technique, respectively. Eventually all patients had a vertical slit-like meatus on the tip of a natural looking glans. DISCUSSION: The most commonly used distal hypospadias repair techniques are glanular approximation, meatal advancement and glanuloplasty, Koff, Mathieu, Thiersch-Duplay procedure, tubularized incised plate repairs, and modifications of these techniques. Cosmetic and functional results and complication rates of ECMB-LUM technique are comparable with those of the commonly used techniques.

Factors affecting survival in neonatal surgery unit in a tertiary care university hospital during 26 years.

This clinical study was designed to evaluate mortality rate and the factors that may affect survival in neonatal surgery unit. Randomly chosen 300 (ß: 0.20) patients among 1,439 patients treated in neonatal surgery unit during years 1983 to 2009, were evaluated retrospectively. The patients were separated into three groups according to date of treatment; Group A: 1983 - 1995, Group B: 1996 - 2005 and Group C: 2005 - 2009. M/F ratios did not differ between non-survived and survived patient populations. Mortality rates were 37%, 22% and 13% in Group A, B, and C respectively (p < 0.001). Parenteral nutrition, maternal age, time until admission and gestational age did not affect mortality rate, however median age of newborn was lower in non-survived cases (1 day vs. 3 days, p < 0.001). Associating abnormality, low birth weight ( < 1,500 g), associating sepsis, need of globulin and requirement of respiratory support were determinants of lower survival (p < 0.001). The mortality rate for patients that underwent thoracotomy (42%) and laparotomy (41%) were higher than patients that underwent other operations (8%) and observation (10%) (p < 0.001). Diaphragmatic hernia had higher mortality rates than the other pathologies (p < 0.001). Survival rate is increasing to date in newborn pediatric surgery unit; it is independent from parenteral nutrition, maternal age, time to admission and gestational age however it is affected adversely by the age of patient, associating abnormality, low birth weight, presence of sepsis and requirement of respiratory support. Increase in survival could be related to various additional factors such as development of delicate respiratory support machines, broad spectrum antibiotics, hospital infection control teams, central venous catheters, use of TPN by central route, volume adjustable infusion pumps, monitoring devices, neonatal surgical techniques, prenatal diagnosis of pediatric surgical conditions and developments of environmental control methods in neonatal surgical units.

Imaging Findings of Fetal-Neonatal Ovarian Cysts Complicated With Ovarian Torsion and Autoamputation.

OBJECTIVE: Large nonresolving neonatal ovarian cysts may be a risk factor for complications such as torsion, mass effect, rupture, intracystic hemorrhage, and autoamputation. Torsed cysts and autoamputated cysts can cause a diagnostic dilemma. The objective of our study was to correlate the imaging findings of intrauterine ovarian torsion and autoamputated ovaries with their pathologic findings. MATERIALS AND METHODS: We retrospectively analyzed the pre- and postnatal medical records, sonographic findings, operation notes, and pathologic reports of 15 patients with ovarian torsion. All patients had complex cysts noted on postnatal sonographic examination. A complex heterogeneous ovarian cyst was defined by the presence of a fluid-debris level indicating hemorrhage within the cyst, a retracting clot, septations with or without internal echoes, calcification, and a solid component. RESULTS: On ultrasound examination, four cysts had solid components, and 11 were heterogeneous and had a fluid-debris level. Calcifications were seen in two patients. The mean patient age at the time of surgery was 3.9 months. Exploratory laparotomy was performed on all patients. Torsed ovaries were identified in five patients. Ten patients had ovaries that were floating free in the peritoneal cavity at the time of surgery. Histopathologic evaluation revealed that 11 of the cysts consisted of extensive hemorrhagic, necrotic autolytic tissue with dystrophic calcification. None of the cysts contained any ovarian tissue. CONCLUSION: A complex heterogeneous ovarian cyst with a fluid-debris level indicating hemorrhage is a significant sonographic hallmark for the diagnosis of ovarian torsion. A calcified abdominal mass, with or without wandering, can be an autoamputated ovary.

Composition of parenteral nutrition solution affects the time of occurrence but not the incidence of cholestasis in surgical infants.

Parenteral nutrition-associated cholestasis (PNAC) is one of the most important complications of parenteral nutrition (PN). This study was conducted to define the incidence, characteristics and precipitating factors of PNAC in infants treated with two different PN regimens in the pediatric surgery department. The records of infants who received two different PN regimens during January 2000-May 2008 (Group 1) and June 2008-May 2012 (Group 2) were reviewed retrospectively. Patients with and without PNAC comprised the study (Groups 1a-2a) and control groups (Groups 1b-2b), respectively. With Group 1 (n=109) and Group 2 (n=46) constituted as indicated, Group 1a (n=13), Group 1b (n=32), Group 2a (n=6) and Group 2b (n=8) were evaluated. The incidence of PNAC was 14.1% (n=22), and the type of PN regimen did not affect the incidence (14.6% vs. 13.0%, p=0.39). The duration of PN was longer in Group 1a than in Group 1b (34 ± 3 7 vs. 13 ± 10 days, p=0.01), and longer in Group 2a than in Group 1a or Group 2b (146 ± 148 vs. 34 ± 37 days, p=0.02, and 14.0 ± 5.9 days, p=0.002). PNAC developed later in Group 2a than in Group 1a (42.0 ± 24.6 vs. 9.0 ± 8.3 day, p=0.02). The lipid dosage was higher in Group 1a than in Group 1b (3.5 ± 0.7 vs. 3.45 ± 0.54 g/ kg/day, p=0.001) or Group 2a (2.2 ± 0.4 g/kg/day, p=0.01). The lipid dosage was also higher in Group 2a than in Group 2b (p=0.001). Two different regimens resulted in similar PNAC rates. The composition of nutrients in PN solution affects the time of occurrence but not the duration of PNAC. PNAC should be detected as early as possible and treated promptly.

An unexpected diagnosis in children with male phenotype and bilateral nonpalpable gonad: congenital adrenal hyperplasia with female genotype.

PURPOSE: Female pseudohermaphroditism is the most frequent form of ambiguous genitalia in children with congenital adrenal hyperplasia (CAH). However, a small group of children with complete urethral development in contrast to 46XX karyotype can be encountered. We aimed to define the characteristics of patients with 46XX CAH but having fully developed male external genitalia. METHODS: The records of 11 children with CAH and 46XX karyotype but having male phenotype, encountered from 1990 to 2012 were reviewed retrospectively. The age, presenting signs and symptoms, diagnostic studies, surgical procedures, early results and outcome were noted. All patients were evaluated by gender assignment team and the decision of the family was also taken into consideration during gender assignment. RESULTS: Eleven children (mean age 3.64 ± 3 years) (range 5 days-10 years) were enrolled. The main presenting signs were nonpalpable gonads (n = 7), hyperpigmentation (n = 2), jaundice (n = 1) and electrolyte imbalance (n = 1). All patients had bilateral nonpalpable gonads and male phenotype with mean phallus length of 4.5 ± 1.7 cm. Urethral meatus is located at normal position (n = 6) or hypospadiac (n = 5). Labioscrotal fusion was complete in all cases and they were classified as 4th (n = 3) or 5th (n = 8) degree of virilization according to Prader's classification. All children had CAH and 46XX genotype. Pelvic ultrasound (n = 8) and genitocystogram (n = 9) were used, and genitocystoscopy was performed (n = 6). Male gender was assigned in most (n = 10) and female gender in one. Corrective surgery could be performed in 10 patients. The surgical procedures were hysterectomy + bilateral salphingo-oophorectomy + vaginectomy (n = 9), chordee release (n = 3) and then second-stage (n = 2) or one-stage urethra repair (n = 1), and pure one-stage urethra repair (n = 1). One case underwent surrenalectomy before the diagnosis of CAH. Mastectomy (n = 1) and fistula repair (n = 3) were additional operations. Only one child could be undergone feminizing genitoplasty and another was lost to follow-up. CONCLUSION: Unfortunately, most of the children underwent surgery in adverse to genotype because of constituted sexual identity. Children with male phenotype and bilateral nonpalpable gonads should undergo promptly biochemical analyses for CAH and early chromosomal analysis.

Thymomas in childhood: 11 cases from a single institution.

AIM: Thymomas are rare in children. Our aim was to review clinical and pathologic characteristics and outcome in children with thymomas. PATIENTS AND METHODS: Between 1979 and 2011, 11 children with thymomas were diagnosed. Hospital files were reviewed for presenting complaints, clinical, radiologic, and other laboratory data, surgical practices, chemotherapy and radiotherapy outcomes. RESULTS: Median age was 8 years (range, 1 to 13 y). Male to female ratio was 9/2. Most common initial complaints were dyspnea, cough, chest pain, and fever. Median time from onset of symptoms was 1 month (range, 0.23 to 3 mo). Associated conditions including hyper-IgE syndrome, hypogammaglobulinemia, and systemic lupus erythematosus plus idiopathic thrombocytopenic purpura were present in 3 patients. Chest x-rays and/or thoracic computed tomographies displayed thymic hyperplasia and/or masses in anterior mediastinum accompanied by pleural (n = 2) and pericardial effusions (n = 1), pulmonary metastases (n = 1), and cervical lymph node metastasis (n = 1). Compression or invasion of trachea or vessels was documented in 5 cases. Seven cases underwent initial tumor resection; others experienced open or trucut biopsies. Histopathologically, 5 cases had invasive and 6 had benign thymomas. Benign thymomas did not receive any postoperative treatment; all cases are disease free at a median follow-up of 211 months. Three of 5 cases with invasive thymomas underwent surgery, 4/5 received chemotherapy and external radiotherapy (3600 to 4500 cGy). Two invasive thymomas died of disease. Three cases with invasive thymomas are disease free at a median follow-up of 209 months. CONCLUSIONS: Benign thymomas have excellent prognosis. For invasive thymomas with or without metastasis, radiotherapy, and chemotherapy offers survival advantage. Complete surgical resection may increase chances for cure.

The prognostic factors in children undergoing pulmonary metastatectomy.

A retrospective analysis was performed to determine the prognostic factors affecting survival in children who underwent pulmonary metastatectomy. Seventeen patients who underwent pulmonary metastatectomy between 2000-2006 were evaluated retrospectively by means of age, sex, primary diagnosis, time of metastasis appearance, number of nodules found on imaging examinations, type of management, surgical data, and outcome. Video-assisted thoracoscopic surgery (VATS) was used in 11 patients, and all patients underwent thoracotomy consequently. The nodule was composed of tumor cells in 13 (76%) patients and had positive surgical margins in 5 (38%). The time of metastasis appearance, number of metastases and completeness of the nodule excision did not affect survival (p=0.31, p=0.87 and p=0.56, respectively). Nodule size >1 cm was associated with dismal survival (p=0.008). Time elapsed until the diagnosis of pulmonary metastasis, number of metastases and the completeness of metastatectomy do not have an impact on survival. The only significant prognostic factor is the size of the largest metastatic nodule. The presence of a metastatic nodule >1 cm is associated with a worse outcome in pediatric patients. VATS is an adjunct method to thoracotomy in the surgical management of pulmonary metastasis in children.

Papillary thyroid carcinoma does not have standard course in children.

BACKGROUND AND PURPOSE: Papillary thyroid carcinoma has a favorable outcome in children. Recent experience with young children cases with early recurrences, after the total thyroidectomy and excision of palpable lymph nodes, in contrast to usual course of disease in adolescent cases, prompted us to review our experience on papillary carcinoma surgery. MATERIALS AND METHODS: Sixteen children who underwent surgery for papillary carcinoma between 1997 and 2010 were included. The charts and surgery notes were evaluated retrospectively and age, sex, complaints and physical findings at presentation, past medical history, results of laboratory tests, imaging findings, aspiration biopsy, extent of disease, details of surgery, complications and postoperative course were noted. RESULTS: Male to female ratio was 3:1. The mean age was 10.9 years (range, 5-16). The presenting symptom was palpable swelling in the neck (n = 12) or asymptomatic nodule was detected incidentally (n = 4). Physical examination findings were palpable nodule (n = 7), lymphadenopathy (n = 6) or both (n = 4). Thyroid ultrasound (US) revealed nodule (n = 9), heterogenisity of the parenchyma and enlargement of thyroid (n = 9), and microcalcifications (n = 5). Fine-needle aspiration biopsy was performed in 12 patients and was suggestive for malignancy in most cases (91%). Pulmonary metastasis was detected at presentation in two patients and appeared after thyroidectomy in one patient. Complementary thyroidectomy was performed in nine patients because the total thyroidectomy with or without cervical lymph node dissection was the treatment of choice (n = 15). Iodine scan was performed 4 weeks later following thyroidectomy. Radioactive iodine ablation (RIA) therapy was given to 11 patients who had residual or recurrent disease. Postoperative complications were permanent hypoparathyroidism (n = 4), recurrent laryngeal nerve injury (n = 3), lymphorea (n = 1) and Horner's syndrome (n = 1). CONCLUSION: Total thyroidectomy and excision of affected lymph nodes is the current mode of surgical management for thyroid papillary carcinoma in children. However, especially in young children (<10 years), modified lymph node dissection should be added to total thyroidectomy in order to avoid leaving the residual tumor foci which can impair the efficacy of the ablation therapy.

Late-onset hypertrophic pyloric stenosis: definition of diagnostic criteria and algorithm for the management.

BACKGROUND AND PURPOSE: Gastric outlet obstruction (GOO) may be caused by various congenital and acquired conditions in children. The authors report 11 cases of GOO caused by muscular hypertrophy of the pylorus, which was proven histologically in 7. They describe this entity as "late-onset hypertrophic pyloric stenosis (HPS)," define the diagnostic criteria of the disease, and produce an algorithm for its management. MATERIALS AND METHODS: The medical records of patients with GOO treated from 1999 and 2009 were retrospectively reviewed. Patients with infantile HPS and GOO secondary to corrosive ingestion or neoplasm were not included. Age, sex, family history, presenting symptoms and signs, radiologic methods and findings, type of management, histopathologic features, and outcome were noted for each patient. RESULTS: Eleven patients (4 male, 7 female) ranging in age from 2 to 8 years (mean, 3.6 years) were included in the study. The symptoms were nonbilious vomiting (n = 11), abdominal pain (n = 4), and weight loss (n = 2). Abdominal ultrasound (n = 6) and upper gastrointestinal contrast studies were obtained (n = 11). Gastroscopy revealed complete (n = 6) or partial (n = 5) obstruction of the pylorus. Balloon dilatation of the pylorus was performed in 5 cases and repeated in 3 cases. Conservative treatment was initially attempted in 11 patients. Two patients with chronic gastritis and Helicobacter pylori (n = 2) were treated with amoxicillin-clavulanic acid, clarithromycin, and lansoprazole. A Billroth I procedure was performed in 7 cases. Hypertrophied pyloric muscle was noted in 7 patients and chronic gastritis in 2. The postoperative course was uneventful. CONCLUSION: Hypertrophic pyloric stenosis is rarely seen after infancy. Analysis of our results and review of the literature prompted us to redescribe this entity as "late-onset HPS" and define the diagnostic criteria. Late-onset HPS is probably an acquired disease of unknown etiology. The management of late-onset HPS has been summarized in an algorithm, which will also be useful in the treatment of GOO in children caused by etiologies other than classical infantile HPS.