Management of pancreatic and duodenal trauma in childhood: a university hospital experience over a 10-year period.

PURPOSE: Duodenal/pancreatic injuries occur in less than 10% of intra-abdominal injuries in pediatric blunt trauma. Isolated duodenal/pancreatic injuries occur in two-thirds of cases, while combined injuries occur in the remaining. This study aimed to investigate pediatric patients with pancreatic and duodenal trauma. METHODS: Data from 31 patients admitted to Atatürk University, Medical Faculty, Department of Pediatric Surgery for pancreatic/duodenal trauma between 2010 and 2019 were retrospectively analyzed. Age/gender, province of origin, duration before hospital admission, trauma type, injured organs, injury severity, diagnostic and therapeutic modalities, complications, hospitalization duration, blood transfusion requirement, and mortality rate were recorded. RESULTS: Twenty-four patients were male, and 7 were female. The mean age was 9 years. The leading cause was bicycle accidents, with 12 cases, followed by traffic accidents/bumps, with 7 cases each. Comorbid organ injuries accompanied 18 cases. Duodenal trauma was most commonly accompanied by liver injuries (4/8), whereas pancreatic injury by pulmonary injuries (7/23). Serum amylase at initial hospital presentation was elevated in 83.9% of the patients. Thirty patients underwent abdominal CT, and FAST was performed in 20. While 54.8% of the patients were conservatively managed, 45.2% underwent surgery. CONCLUSION: Because of the anatomical proximity of the pancreas and the duodenum, both organs should be considered being co-affected by a localized trauma. Radiologic confirmation of perforation in duodenal trauma and an intra-abdominal pancreatic pseudocyst in pancreatic trauma are the most critical surgical indications of pancreaticoduodenal trauma. Conservative management's success is increased in the absence of duodenal perforation and cases of non-symptomatic pancreatic pseudocyst.

Effects of Laparoscopic Hernia Repair by PIRS (Percutan Internal Ring Suturing) Technique on Testicular Artery Blood Supply.

Purpose: Percutaneous internal ring suturing technique (PIRS) is a minimally invasive technique in pediatric inguinal hernia repair. In the present study, a negative effect on testicular blood flow using PIRS technique has been investigated. Methods: Forty male patients were included in the study prospectively. Two groups were formed as conventional open surgery (Group I) and PIRS technique (Group II). The resistive index (RI) value of the testicular artery was measured prospectively by using SMI (superb micro-vascular imaging) software with the color doppler ultrasound technique preoperatively and postoperatively at the first month. Results: Inguinal hernia was present on the left in 35% (n = 14) of the patients and on the right in 65% (n = 26) of the patients. There was no statistically significant difference (p = 0.727) between Group I and II with regard to preoperative RI value (0.66 ± 0.07 vs. 0.66 ± 0.45, respectively). Similarly, there was no statistically significant difference (p = 0.220) between Group I and II with regard to the RI values measured at the postoperative first month (0.58 ± 0.04 vs. 0.60 ± 0.04, respectively). Although the postoperative RI values decreased compared to the preoperative values in both groups, this difference was not statistically significant. (p = 0.447 in Group I, and p = 0.175 in Group II for intragroup comparison). Conclusions: Besides PIRS technique has the advantages provided by all other laparoscopic techniques defined for inguinal hernia repair, there is no significant difference between this technique and conventional open surgery with regard to testicular blood flow. It is an innovative candidate technique instead of the open surgery method besides its additional advantages.

Is Neuromuscular Blocker Necessary in Pediatric Patients Undergoing Laparoscopic Inguinal Hernia Repair with Percutaneous Internal Ring Suturing?

Purpose The aim of this study is to evaluate operating conditions during general anesthesia with or without neuromuscular blocker (NMB) in patients undergoing percutaneous internal ring suturing (PIRS). Materials and Methods In this study, 40 patients, with American Society of Anesthesiologists I and II between the ages of 1 and 12 years, were randomly assigned to two groups to receive muscle relaxant with endotracheal tube (ETT) (ETT group) or without muscle relaxant with supreme laryngeal mask airway (sLMA) (LMA group). Anesthesia was maintained with sevoflurane in oxygen (Fio 2 0.3-0.5), thiopental sodium, fentanyl, and rocuronium in ETT group. In LMA group, same protocol was used without rocuronium. Heart rate, blood pressure, peak airway pressure, end-tidal carbon dioxide (EtCO2), and Spo 2 were recorded before and during pneumoperitoneum maintained at a pressure of 8 to 10 mm Hg. Duration of surgery, recovery time, anesthetic time, and grade of quality view were also recorded. Airway problems (cough, hoarseness, laryngospasm, and aspiration) were recorded. Results In LMA group, there was a statistically significant reduction in recovery time versus ETT group (11.6 ± 4.08 vs. 17.15 ± 5.32 minutes; p = 0,001). There were no statistically significant differences grade of quality view between the two groups (p = 0.548). There were no statistically significant differences in oxygen saturation (Spo 2), peak airway pressure, and EtCO2 between the two groups before or during insufflation (p > 0.05). Postoperative airway complications were significantly more prevalent in the ETT group. There was no case of inadequate ventilation, regurgitation, or aspiration recorded. Conclusion sLMA is safe and suitable alternative to ETT and NMB is not necessary in general anesthesia with sLMA, pediatric patients undergoing laparoscopic hernia repair with PIRS.

Intravesical catheter knotting: an unusual complication of suprapubic catheterization.

Suprapubic catheterization is commonly used to drain urine temporarily from the bladder. Although it is a commonly performed procedure, it is not without complications. Many of these complications related to surgical technique. However, some unpredictable complications are related to the catheter itself. Intravesical catheter knotting is a very rare event and usually has been reported in feeding catheters used as an urethral catheter. We report a case of a suprapubic Cystofix catheter knot, removed by sustained traction. This complication was probably due to an excessive length of catheter having been inserted into the bladder, thus forming redundant loops that increased the risk of bending onto itself.

Diagnostic performance of diffusion-weighted MR imaging in detecting acute appendicitis in children: comparison with conventional MRI and surgical findings.

PURPOSE: To determine the value of diffusion-weighted MRI for the diagnosis of acute appendicitis in children. MATERIALS AND METHODS: Forty-five consecutive patients with a clinical diagnosis of acute appendicitis underwent abdominal MRI; 39 were operated on for acute appendicitis. First, the diffusion-weighted imaging (DWI) alone was reviewed, followed by conventional MRI alone, and then conventional MRI and DWI were reviewed by two observers within a consensus. The surgical findings were compared with the MRI. Sensitivity, specificity, and accuracy were calculated for DWI, conventional MRI, and combined DWI and conventional MRI for the depiction of acute appendicitis. RESULTS: A combination of DWI and conventional MRI was the most sensitive and the most accurate, with corresponding sensitivity and accuracy of 0.92 and 0.92, respectively. Using DWI alone the sensitivity and accuracy was found to be 0.78 and 0.77, respectively. Using conventional MRI alone, sensitivity of 0.81 and accuracy of 0.82 was found for the consensus of the two observers. CONCLUSION: The use of combination of DWI and conventional MRI is a valuable technique in the diagnosis of acute appendicitis in children.

An unusual presentation of alveolar echinococcosis in a 12-yr-old immunocompetent child.

AE is a parasitic disease caused by Echinococcus multilocularis (E.m.). AE is a rare form of echinococcosis and mostly seen in 50- to 70-yr-old patients. Its asymptomatic invasive tumor-like lesion development period, which lasts as much as 20 yr, is too long. Hence, this disease is very rare in children. Herein, we report an AE in a 12-yr-old girl who was not eligible for surgical treatment because of a radiological evaluation of non-resectable lesion and was scheduled for a LT.

Diagnosis and management of hydatid liver disease in children: a report of 156 patients with hydatid disease.

BACKGROUND/PURPOSE: There are many published reviews on adult hydatid disease and a guideline published by World Health Organization Informal Working Group (WHO-IWGE) in 2010. However, there are very few reports on hydatid liver disease in children with limited numbers of patients, and no comments were offered on childhood hydatid liver disease in the WHO-IWGE 2010 guideline. The aim of this study is to present our 17-year experience with 156 pediatric patients with hydatid liver disease and provide a treatment algorithm for children. METHODS: The clinical records of 156 children with hydatid liver disease treated from January 1994 to January 2011 were retrospectively reviewed. Patient sex, age at diagnosis, symptoms, disease location, cyst numbers and sizes, treatment choices, medical treatment duration, surgical methods, and complications were recorded. Treatment of liver hydatidosis included 3 different schedules: (1) small (<5 cm) liver cysts treated with albendazole (ABZ) only, (2) cysts (>5 cm) located at the liver surface treated with surgery combined with ABZ, and (3) all (>5 cm) liver cysts embedded deep in the liver parenchyme treated with percutaneous drainage and ABZ. Albendazole was given (10 mg/kg twice a day) and continued for 6 months after initial therapy. RESULTS: There were 92 boys and 64 girls with an average age of 9.2 years (range, 1.1-15 years). A total of 376 cysts were detected in 156 patients. The follow-up period ranged from 1 to 10 years (median, 6.5 years). Complications were classified according to the Dindo classification. After the first 6 months of therapy, grade I complications occurred in 12.1% of patients, grade II complications in 7.4%, and grade IIIb complications in 7.3%. There were no grade IIIa, IVa, or IVb complications. At 1 year, grade II complications were recorded in 9.6% of 15 patients, and grade IIIb complications, in 1.2% of patients. During the 17 years reviewed, there were no mortalities (0% grade V complications). CONCLUSIONS: Based on this experience, we believe that suitable treatment should be chosen based on factors such as cyst number, cyst location (on the surface or deep in the organ), proximity to vascular structures, whether the cyst is complicated, and additional organ involvement or not. In addition, although the results of our study mostly agree with the results in the WHO-IWGE 2010 report, there are some noticeable differences between these 2 studies. Hence, we believe that the WHO-IWGE 2010 recommendations should be updated by incorporating the childhood observations.

Clinical characteristics of neonates with VACTERL association.

BACKGROUND: The VACTERL association (VA) is the non-random co-occurrence of vertebral anomalies, anal atresia, cardiovascular malformations, tracheoesophageal fistula and/or esophageal atresia, renal anomalies, and/or limb anomalies, and is referred to by the first letters of its components. Studies investigating the clinical characteristics of VA patients and probing of the observed current six component types are limited, and none of them is focused on neonates. We investigated the clinical characteristics of our patients diagnosed as having VA in the newborn period. METHODS: We retrospectively reviewed the neonates whose final diagnosis was VACTERL association. Presence of at least three components of previously reported six anomalies was accepted as VACTERL association. Sex, birthweight, gestational age, postnatal age, anomalies of the systems that are included in VA, and the other features were recorded. RESULTS: There was a male predominance (14/11) of 28 patients; and there were three patients with ambiguous genitalia. The most common observed VACTERL component was vertebral anomalies (n= 26), followed by anal atresia (n= 19), tracheoesophageal fistula/esophageal atresia (n= 17), renal anomalies (n= 15), limb anomalies (n= 15) and cardiac anomalies (n= 14). The most frequent combination was VCTL (n= 4). Fifteen (57%) patients had non-VACTERL anomalies and the most frequent of these was ambiguous genitalia (n= 3). CONCLUSION: VA patients may have different clinical characteristics in different populations, and clinicians may miss some component features if the patients are evaluated after the neonatal period.

The protective effects of metyrosine, lacidipine, clonidine, and moxonidine on kidney damage induced by unilateral ureteral obstruction in rats.

PURPOSE: To investigate the effects of metyrosine, lacidipine, clonidine, and moxonidine on the renal damage in rats with unilateral ureteral ligation by examining the histological evidence of parenchymal damage and tubular dilatation, as well as biochemical changes indicating cell membrane damage and DNA oxidation. METHODS: Thirty-six albino Wistar rats were randomly divided into six equal groups: a healthy (intact) group, a unilateral ureteral ligation (control) group, and four drug treatment groups given metyrosine (50 mg/kg), lacidipine (2 mg/kg), clonidine (0.075 mg/kg), or moxonidine (0.2 mg/kg), respectively, for 10 days. The latter five groups underwent ligation of the left ureter. Ten days after the operation, we removed both kidneys from each rat in the control and drug treatment groups for renal pathological and biochemical [malondialdehyde (MDA), total glutathione, 8-hydroxy-2-deoxyguanine (8-OH-Gua)] examinations. Spectrophotometric assays were used to detect the malondialdehyde and total glutathione levels of the renal tissue. High-performance liquid chromatography was used to measure the 8-hydroxy-2-deoxyguanine levels. RESULTS: When the drug treatment groups were compared with the control group, the drug treatment groups' total glutathione level was higher and their malondialdehyde level was lower than that of the control group (P < 0.05), especially in the clonidine group (P < 0.0001). The 8-hydroxy-2-deoxyguanine levels of the drug treatment groups, except the lacidipine group, were significantly lower than that of the control group (P < 0.0001). There was no significant difference between the contralateral kidneys of the treatment groups and control group, according to the biochemical results. As revealed via light microscopy, clonidine and moxonidine treatment significantly reduced the tubular and glomerular damage, as well as the tubular dilation. The interstitial inflammation of the kidneys in the lacidipine group was higher than that of the other treatment groups. However, the apoptotic cell count was at a high level in both the lacidipine and metyrosine groups. The increase in the collagen content was most pronounced in the lacidipine and metyrosine groups. An examination of the contralateral kidneys showed no marked pathological findings. CONCLUSIONS: The use of a direct or indirect α2-adrenergic receptor agonist for the temporary treatment of unilateral ureteral obstruction-induced renal damage may be important for preventing renal structural injury. A more advanced study is necessary to determine the mechanisms underlying the protective effects of these drugs with regard to renal damage in ureteral obstruction.

A case of undifferentiated embryonic liver sarcoma mimicking cystic hydatid disease in an endemic region of the world.

Undifferentiated embryonic liver sarcoma (UELS) is a rare highly malignant neoplasm that predominantly occurs in children between 5 and 10 years of age. The typical radiologic appearance on ultrasound and computed tomography of UELS shows a large septated mass having combined cystic and solid components. These radiographic features, however, are not specific to UELS and are shared by other more common and benign diseases of the liver. For example, cystic hydatid disease (CHD), caused by larvae of the Echinococcus tapeworm, is the most common indication for hepatic operations in children residing in endemic regions of the world. Undifferentiated embryonic liver sarcoma and CHD are 2 diseases that share overlapping presenting features of patient age, symptoms, and radiologic appearance. Surgeons who operate in Echinococcal endemic regions must be aware that not all hepatic cystic masses are necessarily CHD and may be other more rare malignant diseases such as UELS.

Does obesity limit the sonographic diagnosis of appendicitis in children?

PURPOSE: The purpose of this study is to evaluate whether obesity has a negative impact on the ultrasound (US) visualization of the appendix in children clinically diagnosed with appendicitis. METHODS: The medical records and US examinations of 122 children who underwent surgery due to acute or perforated appendicitis between February 2007 and January 2010 were reviewed. The body mass index (BMI) of each child was calculated and children were placed in one of three categories: group 1, underweight (BMI <10th percentile); group 2, normal weight (BMI between 10th and 85th percentiles); and group 3, overweight (BMI >85th percentile). US findings were classified as nonvisualized, normal, or inflamed appendix. The visualization rates of the appendix were compared between the three groups and the diagnostic accuracy of the US examination was calculated based on the histopathological results for each group. RESULTS: There was no statistical difference between the three groups with regard to the visualization of the appendix by US. Diagnostic accuracy of US was 90.4%, 80.5%, and 80% in group 1, group 2, and group 3, respectively. CONCLUSION: The findings of our study, in contrast to the findings of other reported studies, demonstrate that obesity does not affect the success rate of US in the visualization of the inflamed appendix in children.

Growth hormone reduces tissue damage in rat ovaries subjected to torsion and detorsion: biochemical and histopathologic evaluation.

OBJECTIVE: To evaluate the effects of growth hormone (GH) as an antioxidant and tissue-protective agent and analyse the biochemical and histopathological changes in rat ovaries due to experimental ischemia and ischemia/reperfusion injury. STUDY DESIGN: Forty-eight adult female rats were randomly divided into eight groups. In Group 1, a period of bilateral ovarian ischemia was applied. In Groups 2 and 3, 1 and 2 mg/kg of GH was administered, and 30 min later, bilateral ovarian ischemia was applied (after a 3-h period of ischemia, both ovaries were surgically removed). Group 4 received a 3-h period of ischemia followed by 3h of reperfusion. Groups 5 and 6 received 1 and 2 mg/kg of GH, respectively, 2.5 h after the induction of ischemia. At the end of a 3-h period of ischemia, bilateral vascular clips were removed, and 3h of reperfusion continued. Group 7 received a sham operation plus 2mg/kg of GH. Group 8 received a sham operation only. After the experiments, superoxide dismutase and myeloperoxidase activity and levels of glutathione and lipid peroxidation were determined, and histopathological changes were examined in all rat ovarian tissue. RESULTS: Ischemia and ischemia/reperfusion decreased superoxide dismutase activity and glutathione levels in ovarian tissue, but increased lipid peroxidation levels and myeloperoxidase activity significantly in comparison to the sham group. The 1 and 2 mg/kg doses of GH before ischemia and ischemia/reperfusion decreased lipid peroxidation levels and myeloperoxidase activity in the experimental groups. The administration of GH before ischemia and ischemia/reperfusion treatments also increased superoxide dismutase and glutathione levels. The histopathological findings also suggested a protective role of GH in ischemia/reperfusion injury. That is, ovarian tissues in the ischemia groups showed histopathological changes, such as haemorrhage, cell degeneration, and necrotic and apoptotic cells, but these changes in the GH groups were lesser. Moreover, in the ischemia/reperfusion groups, acute inflammatory processes--such as neutrophil adhesion and migration, apoptotic and degenerative cells, stromal oedema and haemorrhage--were present. However, the ovarian tissues of the IR+GH (1 mg) group had minimal apoptotic cells, and the IR+GH (2 mg) group had no apoptotic cells. In addition, the general ovarian histological structures of these groups were similar to those of the healthy control group. CONCLUSIONS: The administration of GH is protective against ischemia and/or ischemia/reperfusion-induced ovarian damage. This protective effect can be attributed to the antioxidant properties of GH.

Influence of adrenal hormones in the occurrence and prevention of stress ulcers.

PURPOSE: The aim of the study was to examine whether endogenous cortisol and adrenalin have a role in the formation of stress ulcers in intact and adrenalectomized rats. METHODS: The study was composed of 4 experiments: ulcerated areas in stomachs of adrenalectomized and intact rats were measured, adrenaline (100 µg/kg) and prednisolone (5 mg/kg) were injected intraperitoneally in adrenalectomized rats, metyrapone (200 mg/kg) and metyrosine (200 mg/kg) were administered to intact rats, and metyrapone (200 mg/kg) and metyrosine (200 mg/kg) were administered orally with yohimbine (10 mg/kg) and yohimbine (10 mg/kg) alone were administered to intact rats. After 24-hour restraint stress, ulcerated areas were measured. RESULTS: In the stomach of intact rats, the degree of stress ulcer was 7.25 times more severe than that noted in adrenalectomized rats. Furthermore, stress ulcers in adrenalectomized rats that received adrenaline or prednisolone only were fewer and less severe than rats receiving both adrenaline and prednisolone. CONCLUSIONS: Simultaneous administration of adrenaline and prednisolone did not prevent the formation of stress ulcers. However, either of these hormones alone (adrenaline or prednisolone), in the absence of the other, repressed the formation of stress ulcers. This antiulcer activity may be related to α2-adrenergic receptor activity.

A comparative study to evaluate the effect of double dartos flaps in primary hypospadias repair: no fistula anymore.

PURPOSE: The aim of this study was to compare the complication rates of the single flap and double flaps versus flapless procedure in the tubularized incised plate urethroplasty. PATIENTS AND METHODS: One hundred and seventy-two patients with any type of hypospadias underwent surgical repair by tubularized incised plate (TIP) urethroplasty between April 2002 and July 2009 in the two pediatric surgical units. Group 1 (17 patients) underwent hypospadias repair that used the standard TIP urethroplasty. Group 2 (23 patients) had a single dartos flap covering. Group 3 (132 patients) had double dartos flaps covering. Surgeries were performed by one of three surgeons. RESULTS: In group 3, urethrocutaneous fistula was detected in 1 (0.7%) patient, whereas there were 5 (29.4%) and 6 (26%) fistulas in groups 1 and 2, respectively. Penile torsion was noted in 10 (43.5%) and 5 (3.8%) patients in group 2 and 3, respectively. Four of the patients of group 3 had wound dehiscence (3%). Meatal stenosis was seen in 1 (5.8%), 1 (4.3%) and 6 (4.5%) patients in groups 1, 2 and 3, respectively. CONCLUSION: The additional covering of the neourethra with a second layer dartos flap is an improvement in the TIP urethroplasty, in terms of fistula formation avoidance.

Annular pancreas in children: a decade of experience.

OBJECTIVE: Annular pancreas is an uncommon cause of duodenal obstruction in children. In this study, the clinical, radiological, and prognostic findings related to this disorder over a 12-year review period were analyzed. MATERIALS AND METHODS: A retrospective review of 22 patients with annular pancreas who were treated with surgical repair between April 1998 and February 2010 was performed at two different pediatric surgical units. Presenting symptoms, associated anomalies, radiological findings, the type of surgery performed, postoperative outcomes, and complications were analyzed. RESULTS: Twenty-two patients were identified. Thirteen of the 22 patients (59.1%) were born prematurely, 11 patients (50%) had low birth weight, 2 patients (9.1%) had very low birth weight and 1 patient (4.5%) had extremely low birth weight. The mean birth weight was 2285.23±675.12 g. (970-3300). All patients presented with vomiting, which was bilious in nine (40.9%). Nine patients (40.9%) had chromosomal anomalies. Corrective surgery consisted of duodenoduodenostomy in 9 patients (40.9 %), duodenojejunostomy in 9 patients (40.9%), and gastrojejunostomy in 4 patients (18.1%). Fourteen of the 22 patients have survived (63.6%). The causes of death were combinations of sepsis, pneumonia, brain hemorrhage, and cardiac anomaly. CONCLUSION: Infants with annular pancreas associated with duodenal obstruction were often born prematurely and/or had low birth weights; many had cardiovascular anomalies. Annular pancreas associated with duodenal obstruction correlated strongly with the trisomy 21 karyotype among the chromosomal anomalies, as did duodenal atresia. The oral feeding tolerance time was nearly the same for all patients regardless of the surgical procedure used.

A predisposing factor for spontaneous choledochal cyst perforation: esophageal dilatation procedures.

Cyst rupture is one of the rarest complications of choledochal cysts (CC). We report an 8-year-old boy with CC rupture leading to bile peritonitis following repeated esophageal dilatations for corrosive stricture, and discuss how the esophageal dilatation procedures might constitute a predisposing factor for CC perforation.

Genotoxic effect of albendazole in pediatric patients with hepatic hydatid disease.

OBJECTIVE: Hydatid disease occurs throughout the world and is treated with both surgery and medical administration of albendazole. Some adverse effects of albendazole are known. However, its genotoxic effect on humans has not been reported yet. In this study, we aimed to investigate the genotoxic effect of albendazole on human lymphocytes in vivo. METHODS: The study involved 14 children (eight males and six females) who had undergone operations for hepatic hydatid disease. The ages of the patients ranged from 6 to 13 years. Genotoxicity of albendazole was evaluated as the frequency of sister chromatid exchange (SCE) and micronucleated cells in the patient's lymphocytes. Prior to and after albendazole treatment, blood samples were obtained from these patients for SCE and micronucleus (MN) studies. SCE and MN frequencies of the patients were measured separately before and after albendazole treatment. RESULTS: All patient SCE values increased significantly after albendazole administration (p<0.001). Similarly, MN frequencies in all the patients increased significantly following albendazole treatment (p<0.001). CONCLUSION: This study revealed that both SCE and MN frequencies are higher after albendazole treatment. The results suggest that albendazole may be genotoxic to human lymphocytes in vivo.