Determining The Risk Factors For Anastomotic Stricture Development After Esophageal Atresia Repair: Results From The Turkish Esophageal Atresia Registry.

INTRODUCTION: Anastomotic stricture (AS) is the second most common complication after esophageal atresia (EA) repair. We aimed to evaluate the data in the Turkish Esophageal Atresia Registry to determine the risk factors for AS development after EA repair in a large national cohort of patients. METHODS: The data between 2015 and 2021 were evaluated. Patients were enrolled into two groups according to the occurrence of AS. Patients with AS (AS group) and without AS (No-AS group) were compared according to demographic and operative features, postoperative intubation status, and postoperative complications, such as anastomotic leaks, fistula recanalization, and the presence of gastroesophageal reflux (GER). A multivariable logistic regression analysis was performed to define the risk factors for the development of AS after EA repair. RESULTS: Among the 713 cases, 144 patients (20.19%) were enrolled into the AS group, and 569 (79.81%) in the non-AS group. The multivariable logistic regression showed that ,being a term baby (OR 1.706; p = 0.006), having a birth weight over 2500 g (OR 1.72; p = 0.006), presence of GER (OR 5.267; p<0.001), or having a recurrent tracheoesophageal fistula (TEF, OR 4.363; p = 0.006) were the risk factors for the development of AS. CONCLUSIONS: The results of our national registry demonstrate that 20% of EA patients developed AS within their first year of life. In patients with early primary anastomosis, birth weight greater than 2500 g, and presence of GER were risk factors for developing AS. When patients with delayed anastomosis were included, in addition to the previous risk factors, being a term baby, and having recurrent TEF also became risk factors.

Esophageal Atresia Associated with Congenital Duodenal Obstruction: Turkish Esophageal Atresia Registry (TEAR) Evaluation.

INTRODUCTION: Coexistent congenital duodenal obstruction and esophageal atresia (EA) is known to have significant morbidity and mortality. Management strategies are not well-defined for this association. The data from the Turkish EA registry is evaluated. MATERIALS AND METHODS: A database search was done for the years 2015 to 2022. RESULTS: Among 857 EA patients, 31 (3.6%) had congenital duodenal obstruction. The mean birth weight was 2,104 (± 457) g with 6 babies weighing less than 1,500 g. Twenty-six (84%) had type C EA. The duodenal obstruction was complete in 15 patients and partial in 16. Other anomalies were detected in 27 (87%) patients. VACTERL-H was present in 15 (48%), anorectal malformation in 10 (32%), a major cardiac malformation in 6 (19%), and trisomy-21 in 3 (10%). Duodenal obstruction diagnosis was delayed in 10 (32%) babies for a median of 7.5 (1-109) days. Diagnosis for esophageal pathologies was delayed in 2. Among 19 babies with a simultaneous diagnosis, 1 died without surgery, 6 underwent triple repair for tracheoesophageal fistula (TEF), EA, and duodenal obstruction, and 3 for TEF and duodenal obstruction in the same session. A staged repair was planned in the remaining 9 patients. In total, 15 (48%) patients received a gastrostomy, the indication was long-gap EA in 8. Twenty-five (77%) patients survived. The cause of mortality was sepsis (n = 3) and major cardiac malformations (n = 3). CONCLUSION: Congenital duodenal obstruction associated with EA is a complex problem. Delayed diagnosis is common. Management strategies regarding single-stage repairs or gastrostomy insertions vary notably depending on the patient characteristics and institutional preferences.

The effect of postoperative ventilation strategies on postoperative complications and outcomes in patients with esophageal atresia: Results from the Turkish Esophageal Atresia Registry.

OBJECTIVES: Postoperative ventilatory strategies in patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) may have an impact on early postoperative complications. Our national Esophageal Atresia Registry was evaluated to define a possible relationship between the type and duration of respiratory support on postoperative complications and outcome. STUDY DESIGN: Among the data registered by 31 centers between 2015 and 2021, patients with esophago-esophageal anastomosis (EEA)/tracheoesophageal fistula (TEF) were divided into two groups; invasive ventilatory support (IV) and noninvasive ventilatory support and/or oxygen support (NIV-OS). The demographic findings, gestational age, type of atresia, associated anomalies, and genetic malformations were evaluated. We compared the type of repair, gap length, chest tube insertion, follow-up times, tensioned anastomosis, postoperative complications, esophageal dilatations, respiratory problems requiring treatment after the operation, and mortality rates. RESULTS: Among 650 registered patients, 502 patients with EEA/TEF repair included the study. Four hundred and seventy of patients require IV and 32 of them had NIV-OS treatment. The IV group had lower mean birth weights and higher incidence of respiratory problems when compared to NIV-OS group. Also, NIV-OS group had significantly higher incidence of associated anomalies than IV groups. The rates of postoperative complications and mortality were not different between the IV and NIV-OS groups. CONCLUSION: We demonstrated that patients who required invasive ventilation had a higher incidence of low birth weight and respiratory morbidity. We found no relation between mode of postoperative ventilation and surgical complications. Randomized controlled trials and clinical guidelines are needed to define the best type of ventilation strategy in children with EA/TEF.

The effect of azygos vein preservation on postoperative complications after esophageal atresia repair: Results from the Turkish Esophageal Atresia Registry.

AIM: Preservation of the azygos vein (AV) maintains normal venous drainage of the mediastinum and decreases postoperative congestion. The modification of esophageal atresia (EA) repair by preserving AV may prevent postoperative complications and may lead to better outcomes. The data from the Turkish Esophageal Atresia Registry (TEAR) were evaluated to define the effect of AV preservation on postoperative complications of patients with EA. METHODS: Data from TEAR for a period of five years were evaluated. Patients were enrolled into two groups according to the preservation of AV. Patients with divided (DAV) and preserved AV (PAV) were evaluated for demographic and operative features and postoperative complications for the first year of life. The DAV and PAV groups were compared according to the postoperative complications, such as fistula recanalization, symptomatic strictures, anastomotic leaks, total number of esophageal dilatations, and anti-reflux surgery. In addition, respiratory problems, which required treatment, were compared between groups. RESULTS: Among 502 registered patients; the data from 315 patients with the information of AV ligation were included. The male female ratio of DAV (n = 271) and PAV (n = 44) groups were 150:121 and 21:23, respectively (p > 0.05). The mean body weight, height, gestational age, and associated anomalies were similar in both groups (p > 0.05). The esophageal repair with thoracotomy was significantly higher in DAV group, when compared to the PAV group (p < 0.05). The rates of primary anastomosis and tensioned anastomosis were similar in both groups (p > 0.05). There was no difference between DAV and PAV groups for anastomotic leaks, symptomatic anastomotic strictures, fistula recanalization, and the requirement for anti-reflux surgery (p > 0.05). The rate of respiratory problems, which required treatment, was significantly higher in the DAV group (p < 0.05) CONCLUSION: The data in the TEAR demonstrated that preserving the AV during EA repair led to no significant advantage on postoperative complications, with exception of respiratory problems. AV should be preserved as much as possible to maintain a normal mediastinal anatomy and to avoid respiratory complications.

Outcome of Very Low and Low Birth Weight Infants with Esophageal Atresia: Results of the Turkish Esophageal Atresia Registry.

INTRODUCTION: The data of the Turkish Esophageal Atresia Registry (TEAR) was evaluated to define the outcome of very low birth weight (VLBW) and low BW (LWB) infants with esophageal atresia (EA). MATERIALS AND METHODS: The data registered by 24 centers between 2014 and 2018 were evaluated for demographic features, prenatal findings, associated anomalies, surgical treatment, and outcome. Patients were enrolled in three groups according to their BWs (VLBW <1,500 g), LWB = 1,500-2,500 g), and normal BW (NBW; >2,500 g). RESULTS: Among the 389 cases, there were 37 patients (9.5%) in the VLBW group, 165 patients (42.4%) in the LBW group, and 187 patients (48.1%) in the NBW group. Prenatal diagnosis rates were similar among the three groups (29.7, 34.5, and 24.6%, respectively). The standard primary anastomosis was achieved at a significantly higher rate in NWB cases than in the other groups (p < 0.05). In patients with tracheoesophageal fistula (TEF), patients of the NBW group had significantly higher rates of full oral feedings, when compared with VLBW and LBW cases (p < 0.05). At the end of the first year, when we evaluate all patients, the number of cases with fistula recanalization and esophageal anastomotic strictures (AS) requiring esophageal dilatation was similar among the groups. The weight and height measurements at 6 months and 1 year of age of the survivors were similar in all the groups. The overall mortality rate was significantly higher in the VLBW and LBW groups, when compared with the NBW patients, even in patients with tension-free anastomosis (p < 0.05). The incidence of the associated anomalies was 90.6% in cases with mortality, which was significantly higher than in survivors (59.6%; p < 0.05). According to Spitz's classification, the survival rate was 87.1% in class I, 55.3% in class II, and 16.7% in class III. The most common causes of mortality were associated with cardiovascular diseases, pneumonia, and sepsis. CONCLUSION: The national data of TEAR demonstrates that the developmental and feeding parameters are better in NBW patients. Although VLBW patients have higher risk of developing fistula canalization than the LBW and NBW groups, long-term complications, such as anastomotic strictures, weight, and height values, after 1 year are similar in both groups. According to our results, associated anomalies and LBWs are still significant risk factors for mortality in cases with EA.

A case report with sacral appendage: Is it accessory penis or human tail?

Kocaoglu C, Kocaoglu Ç, Akkoyun I, Karanis IE. A case report with sacral appendage: Is it accessory penis or human tail? Turk J Pediatr 2017; 59: 335-337. Lumbo-sacro-coccygeal appendages are very rare congenital anomalies. It is difficult to say that they are a evolutionary inheritance (tail) from our ancestors or an anomaly (pseudotail) occuring during embrional development. If it is a true tail, this lesion contains adipose and connective tissue, striated muscle, blood vessel and nerves, and is covered by skin. However, if this lesion is a pseudotail, it may be an anomalous prolongation of the coccygeal vertebra, lipoma, teratoma, condrodystrophy or parasitic fetus. We present an infant with a sacral appendage resembling a penis, and its clinical and pathologic differential diagnosis and management are discussed based on literature. Sacral appendages, such as asaccessory penis or human tail, are treated through simple surgical excision. However, patients must be carefully evaluated regarding teratoma and spinal cord pathology.

Anaesthetic Management of Laparoscopic Morgagni Hernia Repair in a Patient with Coexisting Down Syndrome, Patent Foramen Ovale and Pectus Carinatum.

Laparoscopic repair has several advantages with a minimally invasive surgical option for children with Morgagni hernias; however, a number of physiological sequelae results from pneumoperitoneum and insufflation. These physiological changes may be more significant in patients with a congenital heart disease. Perioperative detailed evaluation, meticulous monitorization and cooperation with a surgical team are important in cases with patent foramen ovale for the possible risk of the paradoxical gas embolism. We present the anaesthetic management of a patient with patent foramen ovale, Down syndrome and pectus carinatus who successfully underwent laparoscopic Morgagni hernia repair. Under a well-managed anaesthesia that prevented complications because of pneumoperitoneum, laparoscopic surgery would be safe enough for patients with Morgagni hernia having an associated congenital heart disease.

Effects of carbon dioxide insufflation on regional cerebral oxygenation during laparoscopic surgery in children: a prospective study / Efeitos da insuflação de dióxido de carbono sobre a oxigenação cerebral regional durante cirurgia laparoscópica em crianças: um estudo prospectivo

ABSTRACT BACKGROUND AND OBJECTIVES: Laparoscopic surgery has become a popular surgical tool when compared to traditional open surgery. There are limited data on pediatric patients regarding whether pneumoperitoneum affects cerebral oxygenation although end-tidal CO2 concentration remains normal. Therefore, this study was designed to evaluate the changes of cerebral oxygen saturation using near-infrared spectroscope during laparoscopic surgery in children. METHODS: The study comprised forty children who were scheduled for laparoscopic (Group L, n = 20) or open (Group O, n = 20) appendectomy. Hemodynamic variables, right and left regional cerebral oxygen saturation (RrSO2 and LrSO2), fraction of inspired oxygen, end-tidal carbon dioxide pressure (PETCO2), peak inspiratory pressure (Ppeak), respiratory minute volume, inspiratory and end-tidal concentrations of sevoflurane and body temperature were recorded. All parameters were recorded after anesthesia induction and before start of surgery (T0, baseline), 15 min after start of surgery (T1), 30 min after start of surgery (T2), 45 min after start of surgery (T3), 60 min after start of surgery (T4) and end of the surgery (T5). RESULTS: There were progressive decreases in both RrSO2 and LrSO2 levels in both groups, which were not statistically significant at T1, T2, T3, T4. The RrSO2 levels of Group L at T5 were significantly lower than that of Group O. One patient in Group L had an rSO2 value <80% of the baseline value. CONCLUSIONS: Carbon dioxide insufflation during pneumoperitoneum in pediatric patients may not affect cerebral oxygenation under laparoscopic surgery.

RESUMO JUSTIFICATIVA E OBJETIVOS: A cirurgia laparoscópica se tornou uma ferramenta cirúrgica popular em comparação com a cirurgia aberta tradicional. Há poucos dados sobre pacientes pediátricos no que se refere ao pneumoperitônio afetar a oxigenação cerebral enquanto a concentração de CO2 no fim da expiração continua normal. Portanto, este estudo teve como objetivo avaliar as alterações da saturação de oxigênio cerebral com espectroscopia de infravermelho próximo durante cirurgia laparoscópica em crianças. MÉTODOS: O estudo recrutou 40 crianças programadas para apendicectomia laparoscópica (Grupo L, n = 20) ou aberta (Grupo A, n = 20). Variáveis hemodinâmicas, saturação de oxigênio cerebral regional direita e esquerda (RrSO2 e LrSO2), fração inspirada de oxigênio, pressão expiratória final de dióxido de carbono (PETCO2), pico de pressão inspiratória (Ppico), volume minuto respiratório, concentrações de sevoflurano inspirado e expirado e temperatura corporal foram registrados. Todos os parâmetros foram registrados após a indução da anestesia e antes do início da cirurgia (T0, basal), 15 minutos após o início da cirurgia (T1), 30 minutos após o início da cirurgia (T2), 45 minutos após o início da cirurgia (T3), 60 minutos após o início da cirurgia (T4) e no fim da cirurgia (T5). RESULTADOS: Houve diminuição progressiva em ambos os níveis de RrSO2 e LrSO2 nos dois grupos, mas não foi estatisticamente significativa em T1, T2, T3, T4. Os níveis de RrSO2 do Grupo L em T5 foram significativamente menores do que os do Grupo A. Um paciente do Grupo L apresentou um valor rSO2 < 80% do valor basal. CONCLUSÕES: A insuflação de dióxido de carbono durante o pneumoperitônio em pacientes pediátricos pode não afetar a oxigenação cerebral em cirurgia laparoscópica.

Effects of carbon dioxide insufflation on regional cerebral oxygenation during laparoscopic surgery in children: a prospective study.

BACKGROUND AND OBJECTIVES: Laparoscopic surgery has become a popular surgical tool when compared to traditional open surgery. There are limited data on pediatric patients regarding whether pneumoperitoneum affects cerebral oxygenation although end-tidal CO2 concentration remains normal. Therefore, this study was designed to evaluate the changes of cerebral oxygen saturation using near-infrared spectroscope during laparoscopic surgery in children. METHODS: The study comprised forty children who were scheduled for laparoscopic (Group L, n=20) or open (Group O, n=20) appendectomy. Hemodynamic variables, right and left regional cerebral oxygen saturation (RrSO2 and LrSO2), fraction of inspired oxygen, end-tidal carbon dioxide pressure (PETCO2), peak inspiratory pressure (Ppeak), respiratory minute volume, inspiratory and end-tidal concentrations of sevoflurane and body temperature were recorded. All parameters were recorded after anesthesia induction and before start of surgery (T0, baseline), 15min after start of surgery (T1), 30min after start of surgery (T2), 45min after start of surgery (T3), 60min after start of surgery (T4) and end of the surgery (T5). RESULTS: There were progressive decreases in both RrSO2 and LrSO2 levels in both groups, which were not statistically significant at T1, T2, T3, T4. The RrSO2 levels of Group L at T5 were significantly lower than that of Group O. One patient in Group L had an rSO2 value <80% of the baseline value. CONCLUSIONS: Carbon dioxide insufflation during pneumoperitoneum in pediatric patients may not affect cerebral oxygenation under laparoscopic surgery.

[Effects of carbon dioxide insufflation on regional cerebral oxygenation during laparoscopic surgery in children: a prospective study]. / Efeitos da insuflação de dióxido de carbono sobre a oxigenação cerebral regional durante cirurgia laparoscópica em crianças: um estudo prospectivo.

BACKGROUND AND OBJECTIVES: Laparoscopic surgery has become a popular surgical tool when compared to traditional open surgery. There are limited data on pediatric patients regarding whether pneumoperitoneum affects cerebral oxygenation although end-tidal CO2 concentration remains normal. Therefore, this study was designed to evaluate the changes of cerebral oxygen saturation using near-infrared spectroscope during laparoscopic surgery in children. METHODS: The study comprised forty children who were scheduled for laparoscopic (Group L, n=20) or open (Group O, n=20) appendectomy. Hemodynamic variables, right and left regional cerebral oxygen saturation (RrSO2 and LrSO2), fraction of inspired oxygen, end-tidal carbon dioxide pressure (PETCO2), peak inspiratory pressure (Ppeak), respiratory minute volume, inspiratory and end-tidal concentrations of sevoflurane and body temperature were recorded. All parameters were recorded after anesthesia induction and before start of surgery (T0, baseline), 15min after start of surgery (T1), 30min after start of surgery (T2), 45min after start of surgery (T3), 60min after start of surgery (T4) and end of the surgery (T5). RESULTS: There were progressive decreases in both RrSO2 and LrSO2 levels in both groups, which were not statistically significant at T1, T2, T3, T4. The RrSO2 levels of Group L at T5 were significantly lower than that of Group O. One patient in Group L had an rSO2 value <80% of the baseline value. CONCLUSIONS: Carbon dioxide insufflation during pneumoperitoneum in pediatric patients may not affect cerebral oxygenation under laparoscopic surgery.

Inguinal hernias containing the uterus: a case series of 7 female children.

BACKGROUND: Hernia uteri inguinale (HUI), or uterus-containing inguinal hernia, is an extremely rare condition in which the uterus and uterine adnexa are found in the inguinal hernial sac in female infants. The uterus may be free within the sac adherent to the wall by adhesions or a true sliding component. However, in true sliding-type HUI, one of the walls of the hernia sac is formed by the uterus itself. PATIENTS AND METHODS: The medical records for all female children with inguinal hernia who were operated from 1999 through 2010 were reviewed retrospectively (n = 3100). RESULTS: Among these patients, we identified seven cases of HUI in infants with a normal female karyotype. The incidence of HUI was 0.23%. Patients were discharged on the postoperative 1st day with no complications. CONCLUSIONS: Surgeons should be aware of the possibility of presence of the uterus or another organ in the hernial sac in phenotypic female children, and sliding components should be replaced carefully into the abdomen to prevent any damage.

Cyst of the canal of nuck in pediatric patients.

BACKGROUND: Cyst of the canal of Nuck is a rare cause of inguinal swelling in female infants and children. AIM: The purpose of this study is to discuss the clinical, radiological, and histopathological findings, differential diagnosis, and surgical treatment of this disease in the light of our experience. MATERIALS AND METHODS: This study was conducted in six children who were operated on with cyst of the canal of Nuck at the pediatric surgery clinic in July 1998-March 2013. All information was collected from patient's files and computer records retrospectively. RESULTS: Patients were between the ages of 1 and 12 years. Size of the cysts has varied between 23 mm and 55.2 mm. In all cases, cyst was on the right side. In physical examination while five cases had palpable, well-circumscribed, mobile and painless mass, in one case the mass was immobile. In one patient, the mass was reducible; in the other 5 patients the mass was non-reducible. First patient was operated immediately with the early diagnosis of incarcerated inguinal hernia, the second one was operated under elective conditions with early diagnosis of inguinal hernia and it was diagnosed during operation, and in the last 4 patients pre-operative true diagnosis was possible. CONCLUSIONS: As clinical findings of the cyst of the canal of Nuck are variable, pre-operative true diagnosis can only be related to increasing experience.

Outpatient laparoscopic appendectomy in children: a single center experience with 92 cases.

PURPOSE: The purpose of this study was to present the possibility of laparoscopic appendectomy (LA) in children as an outpatient procedure. METHODS: A total of 129 pediatric patients underwent LA at our clinic from July 2009 to September 2011. As, in our treatment protocol, patients with gangrenous and perforated appendicitis would not be placed in an early-discharge list, patients who had gangrenous and perforated appendicitis (37 cases) were excluded from this study because these patients usually receive inpatient intravenous antibiotic therapy for 48 to 72 hours. Finally, 92 pediatric patients who had undergone LA for the treatment of uncomplicated appendicitis were evaluated retrospectively. RESULTS: Eighty-five of 92 patients (92.4%) were discharged in <24 hours and the mean postoperative length of hospital stay was 14.1 hours. Readmissions to the emergency room were not seen during the postoperative period. Complications such as wound infection, trocar site hernia, adhesive small-bowel obstruction, and abscess formation did not occur. CONCLUSIONS: We recommend that an LA can be performed safely as an outpatient procedure in children with uncomplicated appendicitis.

Advantages of abandoning abdominal cavity irrigation and drainage in operations performed on children with perforated appendicitis.

PURPOSE: This study evaluates the effect of peritoneal irrigation and drainage on postoperative morbidity when used together for perforated appendicitis. MATERIAL AND METHODS: This study was conducted on children undergoing open appendectomy for perforated appendicitis. Sixty-one children with perforated appendicitis operated on with irrigation and drainage between July 1998 and September 2001 (group DI) and 173 children with perforated appendicitis who underwent surgery without irrigation and drainage (group NDI) between October 2001 and November 2011 were retrospectively evaluated (a total of 234 patients). All patients were treated and followed up by the same pediatric surgeon using the same protocol. Both groups were compared in respect to postoperative complications, including wound infection, wound dehiscence, intraabdominal abscess, prolonged ileus, the presence of small bowel obstruction requiring surgery, operative time, and length of postoperative hospital stay. RESULTS: Of the total 234 patients, 151 were male and 83 were female with a mean age of 8.9 ± 3.7 years (range, 1.5-15 years). The wound infection rates were 4.9% in group DI and 1.7% in group NDI (P = .184). Wound dehiscence was seen in 1.6% vs 0%, prolonged ileus in 8% vs 2.3%, intraabdominal abscess in 4.9% vs 1.7%, and small bowel obstruction requiring surgery in 1.6% vs 0.6% of the patients (P = .261, P = .054, P = .184, and P = .454, respectively). No statistically significant difference in postoperative infectious complications was found between both groups. The length of postoperative hospital stay was 9.9 ± 4.1 days in group DI vs 6.3 ± 2.4 days in group NDI (P < .001). The operation times were 39 ± 8 and 31 ± 11 minutes, respectively (P < .001). CONCLUSION: This study demonstrates that peritoneal irrigation and drainage in children with perforated appendicitis is not required, and in fact, these procedures cause an increase in operative time.

Laparoscopic cystectomy for the treatment of benign ovarian cysts in children: an analysis of 21 cases.

STUDY OBJECTIVE: To evaluate the outcomes of treatment with minimal invasive surgery in children with benign ovarian cysts. DESIGN: Retrospective chart review. SETTINGS: Maternity and children hospital. PATIENTS: Between May 2007 and May 2011, 21 children were treated by laparoscopic method for ovarian cysts at our clinic. The age, symptoms, ultrasonographic findings, operation records and follow-up times were retrospectively evaluated. RESULTS: The mean age was 13.2 years. One patient presented with findings of torsion and another presented with findings of rupture; both were urgently operated on. The other patients presented with intermittent abdominal pain and were operated on under elective basis. The mean cyst size was 8.4 cm (5-13 cm). One patient with necrotic ovary and salpinx due to torsion underwent salpingo-oophorectomy while the others were administered ovary-preserving cystectomy. Only 4 patients required iv paracetamol as an analgesic in the postoperative period. Two patients were discharged on the second postoperative day while the remaining 19 patients were discharged on the first postoperative day. During a mean follow-up of 14 months, no recurrence was seen in this period. Cosmetic appearance was good in all patients. CONCLUSION: The authors demonstrated that laparoscopic cystectomy was a technically feasible and safe method in the treatment of benign ovarian cysts, associated with short hospitalization, minimal analgesic requirement, and a good cosmetic appearance.

The advantages of using photographs and video images in telephone consultations with a specialist in paediatric surgery.

BACKGROUND: The purpose of this study was to evaluate the advantages of a telephone consultation with a specialist in paediatric surgery after taking photographs and video images by a general practitioner for the diagnosis of some diseases. MATERIALS AND METHODS: This was a prospective study of the reliability of paediatric surgery online consultation among specialists and general practitioners. RESULTS: Of 26 general practitioners included in the study, 12 were working in the city and 14 were working in districts outside the city. A total of 41 pictures and 3 videos of 38 patients were sent and evaluated together with the medical history and clinical findings. These patients were diagnosed with umbilical granuloma (n = 6), physiological/pathological phimosis (n = 6), balanitis (n = 6), hydrocele (n = 6), umbilical hernia (n = 4), smegma cyst (n = 2), reductable inguinal hernia (n = 1), incarcerated inguinal hernia (n = 1), paraphimosis (n = 1), burried penis (n = 1), hypospadias (n = 1), epigastric hernia (n = 1), vulva synechia (n = 1), and rectal prolapse (n = 1). Twelve patients were asked to be referred urgently, but it was suggested that only two of these patients, who had paraphimosis and incarcerated inguinal hernia be referred in emergency conditions. It was decided that there was no need for the other ten patients to be referred to a specialist at night or at the weekend. All diagnoses were confirmed to be true, when all patients underwent examination in the pediatric surgery clinic in elective conditions. CONCLUSION: Evaluation of photographs and video images of a lesion together with medical history and clinical findings via a telephone consultation between a paediatric surgery specialist and a general practitioner provides a definitive diagnosis and prevents patients from being referred unnecessarily.

A new, easy, and safe suturing technique for laparoscopic repair of Morgagni hernias.

Laparoscopic repair is gaining attention as a minimally invasive surgical option for children with Morgagni hernias. There are very few reports in the literature in which different suturing techniques are described. In this report, the authors detail a new, easy, and safe suturing technique used in the laparoscopic repair of a Morgagni hernia in a five-and-a-half-month-old baby.

Closing the appendicular stump with a polymeric clip in laparoscopic appendectomy: analysis of 121 pediatric patients.

INTRODUCTION: The purpose of this study was to evaluate the technical feasibility and other advantages of closing the appendicular stump with a polymeric clip in laparoscopic appendectomy (LA). METHODS: In this study, 121 pediatric patients who underwent LA between July 2009 and July 2011 were included. Age and gender of the patients, the number of clips, operative time and length of hospitalization, complications, and follow-up periods were evaluated retrospectively. RESULTS: Of appendicular stump of a total of 121 patients who were underwent LA, 71 were closed with double polymeric clips and 50 were closed with a single polymeric clip. Patients were between the ages of 3 and 15 years (mean 8.3 years). Out of the 121 patients, 54 were female and 67 were male. The duration of the operation was ranged from 13 to 55 minutes (mean 28 minutes). Of these, 83 patients were discharged in less than 24 hours. The cost of a single clip was 10 USD. The follow-up period of patients were ranged between 1 and 23 months (mean 13 months). No operative or postoperative complications occurred depending on the application of the polymeric clip. CONCLUSION: LA using polymeric clip/s to close appendicular stump in children is a safe, feasible, and inexpensive method.

The use of digital photos and video images taken by a parent in the diagnosis of anal swelling and anal protrusions in children with normal physical examination.

PURPOSE: The purpose of this study is to demonstrate that digital photos and video images taken by a parent can provide a definite diagnosis and makes some diagnostic procedures (eg, air contrast enema, sigmoidoscopy) unnecessary for anal swelling and anal protrusions in children with normal physical examination. METHODS: In a 41-month period (September 2007-January 2011), 23 parents brought their children to the clinic, stating that they saw a swelling in the anal region and/or that something protruded from the anus while their children were defecating. If the visual inspection of the anal region and digital rectal examination of the patients were normal, parents were asked to take photos or record videos when the lesion occurred to make a diagnosis and avoid the need for air contrast enema and/or sigmoidoscopy. The parents were also asked either to send these images to the surgeon via e-mail or bring an image or the camera to the surgeon's office. The patients age, sex, symptoms, medical history, results of their first physical examination, photos and video records, and the diagnosis and treatment were recorded. All of these information were retrospectively reviewed. RESULTS: The photos provided by 20 parents and the video records from 3 parents were assessed, and the diagnoses of all patients were confirmed. Of these 23 patients, a definitive diagnosis of rectal prolapse in 8, hemorrhoids in 10, rectal polyps in 3, and sentinel skin tag in 2 was made. In addition, the photographic and video evidence gave the clinicians an idea of the degree of rectal prolapse in patients for whom this was a problem. Three patients diagnosed with a rectal polyp underwent polyp excision. One patient with rectal prolapse who was unresponsive to medical treatment underwent laparoscopic posterior rectopexy, and all other patients received medical treatment. CONCLUSION: When a swelling or protruding anal lesion in a child is discovered by parents and visual inspection of the anal region and digital rectal examination is normal, parents should be encouraged to take photos or videos of the anal region before performing air contrast enema and/or sigmoidoscopy. These photos and videos can provide a definitive diagnosis and prevent unnecessary diagnostic procedures.