Testicular torsion: a 15-year single-centre clinical and histological analysis.

AIM: This study reviewed the demographic, epidemiological and clinical factors of boys seen at a single centre who underwent surgical exploration for testicular torsion. METHODS: Retrospective single-centre review of boys with testicular torsion between 1996 and 2011 was made. RESULTS: Testicular torsion (right n = 43, left n = 60, bilateral n = 1) was identified in 104 boys between 0 and 18 years. Ten newborns presented with 11 intrauterine torsions. Nine torsions presented in undescended inguinal testes (one intrauterine). In 94 boys with descended testes, presentation included pain (76%), scrotal swelling (65%) and abdominal symptoms (22%). Ultrasonography was performed in 85 patients with false-negative results in 4 (4.7%). Orchiectomy was performed during initial exploration in 41, with significantly higher rates of orchiectomies in patients with late (>6 h) versus patients with early referrals (<6 h) (56% vs. 9.1%). Histological evaluation was carried out in 68 testes, with 43 resected testes demonstrating haemorrhagic necrosis. In 25 biopsied testes, histology revealed acute parenchymal bleeding (n = 14), onset of parenchymal infarction (n = 8), orchitis (n = 1) and normal tissue (n = 2). Eighty-two patients were followed up with pathological findings in four patients: testicular atrophies requiring orchiectomy (n = 2), testicular autolysis (n = 1) and small testicular vein thrombosis (n = 1). CONCLUSION: Chances of testicular salvage after torsion are higher if patients present early. The majority of patients presenting late (>6 h) require orchiectomy owing to testicular necrosis.

[Traumatic posterior dislocation of the sternoclavicular joint. A case report of joint stabilization with gracilis tendon graft]. / Die traumatische posteriore Luxation im Sternoklavikulargelenk. Fallpräsentation einer Stabilisierung mit Grazilissehnenplastik.

Dislocation of the sternoclavicular joint is an uncommon injury. Especially posterior dislocations with potentially life-threatening complications present a challenging situation for the treating surgeon regarding diagnosis and therapy. Reduction and fixation of the joint is the treatment of choice. We present the case of such an injury in an adolescent judoka who was treated by open reduction and reconstructive surgery using the gracilis tendon graft technique.

Body-image, self-concept and mental exposure in patients with pectus excavatum.

BACKGROUND: Pectus excavatum is the most common congenital anomaly of the sternum and anterior chest wall, which occurs about 3-4 times more often in boys than girls [1]. Although most patients do not report physical symptoms as cardiovascular and respiratory problems, they show a loss of self-esteem and a poor self-image. There exist very rare data about psychological state before the OP compared with data afterwards. OBJECTIVE: This study was conducted to examine psychological changes in body-image, self-concept and mental exposure in patients with pectus excavatum, who had undergone the Nuss procedure. METHODS: Seventeen patients (13 male, 4 female), who underwent 2003 a comprehensive psychological investigation, have been tested again in 2007 by means of the identical questionnaires to get postoperative data: OPE-FB (Wallisch; Operation-Expectation-Questionnaire), FKKS (Deusinger; Frankfurter Body Concept Scales) and SCL-90-R (Derogatis; Symptom Checklist Revised). The mean age at the second time of investigation was 19.6 years (SD = 2.5). The patients were classified into two groups based on a lower (n = 10) and a higher (n = 7) severity index of PE. Parents or a parent person were interviewed about the topics of OPE-FB by a structured interview. Data were analyzed using Mann-Whitney U test and Wilcoxon test. Interview data were evaluated with a content analysis. RESULTS: Nearly all patient's expectations in regard to the beneficial effect of the surgical procedure-investigated with the OPE-FB preoperatively-have been confirmed postoperatively. In patients with a lower severity index impairment in general interest in sports and improvements in self-assurance, health, self-acceptance of one's body and acceptance of one's body by others can be reported. Data from SCL-90-R, measuring mental exposure, had normal range. Interviews with relatives showed, that the external attribution could emphasize patient's data from the OPE-FB. CONCLUSIONS: The long-time follow-up can make us sure, that the Nuss procedure as a physical treatment has positive effects on physical as well as psychological aspects of young adults. The patient's confidence with the cosmetic result was very high, which reflects the excellent effects of the minimal invasive repair according to Nuss.

Analysis of nonsexual injuries of the male genitals in children and adolescents.

AIM: This study analysed nonsexual male genital injuries in boys with regards to aetiology, age, management and outcome. METHODS: Patients were identified from the hospital database (between 1999 and 2009) were analysed retrospectively. RESULTS: Seventy-four patients (2-17 years) were identified which included 24 toddlers and small children (2-5 years), 36 school age children (6-12 years) and 14 adolescents (13-17 years). Traumas were related to falls (n=14), kicks (n=11), sport (n=10), toilet seats (n=9), motor vehicles (n=8), bicycle (n=4), outdoor activities (n=4) and others causes (n=14). The leading cause of injuries in (i) toddler and small children was related to toilet seat (n=7) and falls (n=7), (ii) school age children to sport (n=8), kicks (n=7) and falls (n=6), and (iii) adolescents to motorcycle accidents (n=5). There were 45 scrotal and 29 penile injuries ranging from lacerations to contusions. Sixty-eight patients required hospital stay (0.5-36 days, Σ=2.4 days). Follow-up examinations were uneventful, except for one minor wound infection. CONCLUSION: Nonsexual traumas to the male external genitalia occur mostly in 6- to 12-year-old boys, with sport accidents, kicks and falls being the major causes. Scrotal and penile lacerations and testicular contusions are the most common injuries. Complications after injuries to the male genitals in children are rare.

[Treatment of pediatric radial neck fractures: consideration of patient age and fracture dislocation]. / Behandlung kindlicher Radiushalsfrakturen: Berücksichtigung von Patientenalter und Frakturdislokation.

Fractures of the radial neck represent approximately 5-10% of all injuries of the elbow in children. Depending on the degree of radial head displacement, either an operative intervention or conservative treatment is recommended. The medical records of 168 children treated between 1999 and 2008 were analyzed and fractures were classified according to the Judet classification system. The fractures were treated according to an algorithm depending on age and fracture dislocation and 103 type I, 21 type II, 30 type III and 14 type VI fractures were found. Conservative treatment was possible in 124 patients and 44 were treated operatively. The overall outcome was good.

[Non-accidental injuries in childhood and the nature of their appearance]. / Die nicht akzidentelle Verletzung des Kindes und deren Erscheinungsformen.

Child abuse has been the leading cause of death in pediatric patients for a long time. The subject is complex in its etiology, appearance, consequences and prognosis. To be confronted with the patient is emotional. Inpatient treatment at a pediatric centre should be performed in any suspicious cases of non-accidental injury. The child protection group consists of one pediatric specialist as well as four ward physicians, one psychotherapist, two staff nurses and one graduated social worker. The team's aims are the early detection of violence towards children, the safeguarding of child protection policies and the provision of family centred, interdisciplinary treatment. During a 6-year period (2001-2006) 476 children were treated at our department. Cruelty was found in 47%, sexual abuse in 28% and willful neglect in 25%. Only 12% of the patients presented obvious injuries. In 88% secondary symptoms resulted in the correct diagnosis. Child protection groups are important institutions for dealing with the complex matter of child abuse. The burden and responsibility for the single person can be reduced within the team. Medical practitioners outside the hospital may give a referral without a loss of confidence.

[Surgical treatment of vascular malformations in children and adolescents]. / Chirurgische Therapie vaskulärer Malformationen bei Kindern und Jugendlichen.

Vascular malformations are inborn errors of vasculogenesis in localised regions of the body. They are present at birth and grow proportionally with the child without ever showing any tendency to regress. This fact distinguishes them clearly from haemangiomas, which represent vascular tumours with high proliferation during the first year of life followed by a slow involution thereafter. The strategy for the treatment of vascular malformations differs substantially from the one for haemangiomas. According to the type of vascular malformation, the treatment may consist in laser therapy, sclerotherapy, selective embolisation, and/or surgical resection. Whereas systemic medication may save the life of children with life-threatening haemangiomas, such treatment would have no significant effect in children with vascular malformations. The aim of the surgical treatment is to perform a complete resection of the malformation in order to prevent its recurrence. However, since vascular malformations often have an infiltrative growth, frequently only subtotal resections can be performed to avoid unacceptable functional or cosmetic disfigurement of the body. Generally, an optimal management of children with vascular malformations includes a multidisciplinary approach with critical consideration of all potential treatment procedures.

[Medical treatment of children with hemangiomas and its limitations]. / Hämangiomtherapie im Kindesalter: medikamentöse Therapiemöglichkeiten und ihre Grenzen.

Children with disfiguring and/or life-threatening hemangiomas need medical treatment. Initial therapy comprises the oral administration of prednisolone in a dosage between 2-3 mg/kg/day. In cases of insufficient response to prednisolone the therapy may be extended by additional subcutaneous administration of interferon-alpha in a dosage between 1-3 million U/m(2)/day. However, due to the possible serious side effects of interferon-alpha, such as irreversible spastic diplegia, this therapy must be accompanied by close and meticulous neurological examinations of the treated children. The chemotherapeutic substance vincristine has nowadays become an alternative to interferon-alpha for life-threatening hemangiomas. The substance proved effective in a dosage of 0.05 mg/kg for children less than 10 kg and 1.5 mg/kg for children more than 10 kg given weekly strictly intravenously. In worst-case scenarios, a successful disease control has been achieved by intravenous administration of cyclophosphamide in a dosage of 10 mg/kg/day given on 3 consecutive days. Medical treatment of children with life-threatening hemangiomas still remains challenging for all involved persons and should always be performed in specialised centres.

Small bowel intussusceptions: issues and controversies related to pneumatic reduction and surgical approach.

AIM: This study aims to determine the incidence, clinical presentation, management and outcome of small bowel intussusceptions (SBI) in the paediatric population managed at our centre. METHODS: Hospital charts of SBI patients from 1999 to 2006 were reviewed retrospectively. The data collected involved the clinical presentation, diagnostic examinations, management strategy as well as outcome. RESULTS: Ileocecal intussusceptions were documented in 83 patients (74.8%) and SBI in 28 (25.2%). The median age of patients with SBI was 2.5 years (range 9 weeks to 16 years). In 18/28 patients SBI reduced spontaneously. Ileoileal SBI had an incidence of 80% in the 10/28 cases requiring intervention. In seven patients, pneumatic reductions were successful in 6/7 ileoileal intussusceptions, but unsuccessful in 1/7 where the level of intussusception (jejunojejunal intraoperative findings) could not be determined by ultrasound. Surgical intervention was required in four patients with bowel resection in three cases. CONCLUSION: Pneumatic reduction is successful in ileoileal intussusceptions with signs of bowel viability. It should be attempted with caution in patients with jejunojejunal or ileoileal SBI with pathologic lead points or bowel ischaemia. Accurate interpretation of ultrasound along with judicious implementation of pneumatic reduction or surgical options can reduce morbidity. Early diagnosis is associated with better outcomes using non-surgical reduction techniques.

Factors influencing management and comparison of outcomes in paediatric intussusceptions.

AIM: This study aims to compare management strategy and outcomes of paediatric ileocolic intussusceptions (ICI) versus small-bowel intussusceptions (SBI). METHODS: Hospital charts of patients with intussusceptions between January 1999 and June 2006 were reviewed retrospectively. RESULTS: A total of 135 patients with the diagnosis of intussusceptions were found in the database. In 111 patients the diagnosis was confirmed using ultrasound. The median age of the patients was 2.25 years (range 9 weeks-10 years). ICI were documented in 83 patients (74.8%) and SBI in 28 (25.2%). Spontaneous reductions were observed in 11 of 83 (13.3%) ICI and 18 of 28 (64.3%) SBI. Pneumatic reductions were attempted and were successful in 61 of 67 (91%) ICI and 6 of 7 (85.7%) SBI. Surgery was performed in 11 of 83 (13.3%) ICI and 4 of 28 (14.3%) SBI; with 2 of 83 (2.4%) ICI and 3 of 28 (10.7%) SBI patients requiring bowel resections. The median age of patients requiring surgery was 9 months in ICI and 6 years in SBI. CONCLUSION: There are differences in ICI and SBI with regard to spontaneous reductions, and bowel resection, and age with regard to surgery and bowel resection. The treatment efficacy depends on time of presentation, intussusception type, pathologic lead points, ultrasound/colour Doppler interpretation and expertise in reduction techniques.

Lung contusion-lacerations after blunt thoracic trauma in children.

Chest trauma in children is an indicator of injury severity and is associated with a high mortality rate. The aim of this study was to investigate the impact of pulmonary contusion-laceration on short and long-term outcome of pediatric patients after blunt thoracic trauma. A retrospective analysis of records of 41 children aged 10 months to 17 years who were treated for pulmonary and associated injuries between 1986 and 2000 was done concerning mode of injury, types of injuries, management and outcome. In addition, a follow-up investigation was performed 4.5+/-1 years after injury. Of the patients 27 were involved in motor vehicle accidents (MVA group) and 14 patients suffered other types of accidents (others group). The mean injury severity score (ISS) was 30+/-2 (range 9-75) with no significant difference between the groups. Patients from the MVA group suffered more frequently bilateral pulmonary lesions and needed more often chest tube placement ( p<0.05), 5 patients died (12%) all from the MVA group. The follow-up investigation of 34 patients showed unremarkable chest x-rays and normal lung function in all but 1 patient with bronchial asthma. In conclusion, children who recover after a pulmonary contusion-laceration trauma do not suffer from significant late respiratory problems.

Mortality and economics in short bowel syndrome.

The incidence of patients with short-bowel syndrome (SBS) has increased over the years due to progress of intensive care medicine and parenteral nutrition techniques. These techniques have significantly improved the prognosis of neonates, children and adults who have lost major parts of their intestinal tract. Long-term survival is possible and does not depend primarily on the length of the remaining bowel but on complications such as parenteral nutrition-associated cholestasis, recurrent septicaemia, central venous catheter infections, and the motility of the remaining intestine. Thus, the overall related mortality in infants with SBS ranges from 15 to 25%, and in adults from 15 to 47%, depending on the age of the patients, the underlying disease, and the duration on total parenteral nutrition. Home parenteral nutrition (HPN) significantly decreases the complication rate and improves the psychological situation of the patient. Additionally, HPN reduces in-hospital cost significantly. Nevertheless, the annual costs/patient are between $100000 and $150000. The mortality rate of SBS patients on HPN is about 30% after 5 years, which is still lower than the 5-year survival rate of intestinal grafts, and it is about equal to patients' survival after intestinal transplantation. However, the overall costs of a successful intestinal transplantation are already lower after 2 years when compared with the cost of a prolonged HPN programme.

Nephron-sparing procedures in 11 patients with Wilms' tumor.

PURPOSE: In unilateral Wilms' tumor (WT), tumor nephrectomy is the standard surgical approach, whereas partial nephrectomy (PN) is controversially discussed. The aim of our retrospective study was to show that in selected cases of unilateral WT kidney-sparing operations could be a reasonable alternative to nephrectomy and to discuss the results of patients with bilateral WT treated by tumor enucleation. MATERIALS AND METHODS: From 1981 to 1998, seven patients with unilateral nephroblastoma (four stage I, one stage III and two stage IV) had tumor resection by PN (five right side, two left side), which was planned when the tumor volume was reduced after 4 to 6 weeks of chemotherapy by at least 50%, when the tumor occupied one pole or was easily resectable, when 50% or more of the kidney tissue remained and when paraaortic lymph nodes were free by intraoperative histological examination. In four patients with bilateral WT (stage V) bilateral tumor enucleation was carried out-except in one patient in whom the contralateral kidney had to been removed because of extension of the tumor via the inferior vena cava to the right atrium. All patients ( n = 11) received pre- and postoperative chemotherapy followed by radiotherapy in four patients. RESULTS: All patients with unilateral WT ( n = 7) are still alive and disease free (follow-up time: mean 6.6 years, range: 28 months to 11 years) with normal renal function, although two patients with secondary nephrectomy revealed creatinine clearance levels at the lower range. In six patients primary PN was performed successfully. In a stage III tumor patient (intraperitoneal metastasis, free lymph nodes), secondary nephrectomy was necessary due to renal arterial thrombosis 2 days after PN. In one stage IV tumor patient (lung metastasis, free lymph nodes), the primary resection was not far enough away from the tumor margin so that an additional slice of tissue with then tumor-free margins had to be resected. This patient evolved a local relapse 19 months after PN and had to be nephrectomised thereafter. In the group of bilateral WT patients ( n = 4), one child died 2 months after surgery during chemotherapy because of central venous line sepsis. One patient who additionally suffered from inferior vena cava tumor thrombosis extending to the right atrium making nephrectomy of the right kidney necessary developed chronic renal failure 4.7 years postoperatively. The other two stage V tumor patients have creatinine clearance levels within the normal range. CONCLUSIONS: Kidney-sparing procedures remain the operative approach of choice in patients with bilateral WT, but bear the risk of chronic renal failure when one kidney has to be removed. PN in children with unilateral WT, carried out by an experienced surgeon, is a reasonable alternative to nephrectomy if strict guidelines such as excellent tumor response to preoperative chemotherapy and easy resectability far away from the tumor margins through healthy kidney tissue are followed. Paraaortic lymph nodes must be free of tumor invasion in order to avoid local radiotherapy. PN prevents the patient from having to have dialysis in cases of contralateral nephrectomy resulting from metachronous WT or subsequent renal trauma.

Mutation analysis of the RET gene in total intestinal aganglionosis by wave DNA fragment analysis system.

BACKGROUND/PURPOSE: Total intestinal aganglionosis (TIA) extending from the duodenum to the rectum is the most rare form of Hirschprung's disease (HSCR) and usually is fatal. RET is the major gene associated with HSCR, and germline mutations of this gene account for up 50% of familial and up to 15 to 20% of sporadic cases in HSCR. The aim of this study was to investigate DNA variants in the RET gene in TIA patients using the WAVE DNA Fragment Analysis System. METHODS: Genomic DNA was extracted from whole blood samples from 6 patients with TIA. Polymerase chain reaction (PCR) amplification of the 21 exons of RET was performed using published oligonucleotide primers. Heteroduplexes were followed by the WAVE DNA Fragment Analysis System with the DNASep cartridge. RESULTS: WAVE system technology detected 16 variants in the RET gene in the 6 patients with TIA. Three patients had a significant mutation in exon 8, 11, and 15, respectively. Thirteen RET polymorphic variants also were detected in the 6 patients, with L746L variant in exon 13 occurring in 4 patients. CONCLUSIONS: WAVE system technology is an efficient method for the detection of DNA sequence variants. Our findings suggest that not only RET mutations but also RET polymorphic variants may contribute to the occurrence of TIA.

The role of transanal endorectal pull-through in the treatment of Hirschsprung's disease - a multicenter experience.

The transanal approach (TAA) is a new technique for surgery of Hirschsprung's disease (HD) that was introduced by de la Torre in 1998. The purpose of this multicenter study, including experience from three Austrian and one Italian departments of peadiatric surgery, was to evaluate the role of this approach in HD in 18 children aged 1-72 months. In 14 children the TAA only was performed; in 3 an additional laparoscopy was performed and in 1 conversion to a laparotomy was necessary. One complication (abscess) occurred after laparoscopic-assisted pull-through. The postoperative recovery was rapid, no severe long-term problems were observed. The transanal pull-through technique is generally possible in most classic cases of HD with extension of the disease to the sigmoid colon. If necessary, it can be combined with laparoscopy. Our preliminary results show that the technique is safe, less invasive, and gives excellent cosmetic results, and allows rapid recovery. Long-term results are still pending.

[Thyroglossal duct cysts in paediatric patients: early operative intervention reduces rate of complications]. / Mediane Halszysten im Kindesalter: frühzeitige Operation senkt die Komplikationsrate.

BACKGROUND: Thyroglossal duct cysts arise from mucus production in an incomplete regressed thyroglossal duct. Often they are only noticed in case of infection or secondary fistulation. The operative management is a Sistrunk procedure. METHOD AND PATIENTS: In a retrospective study we analyse 26 patients aged 0,3 - 10 years with histological confirmed thyroglossal duct cysts, 13 of these (50 %) had signs of infection. In 15 patients the cyst was primarily cored out, in 11 patients the core out followed a primarily incision and drainage. RESULTS: 5 patients (19 %) developed recurrent cysts. Patients with signs of infection or incomplete resection of hyoid bone had a high risk of developing recurrence. CONCLUSIONS: We propose an early operative treatment for thyroglossal duct cysts with a complete Sistrunk procedure.

Special aspects of neonatal inguinal hernia and herniotomy.

In a retrospective study, we examined 23 pre-term infants (18 boys, 5 girls) with a median weight of 1540 g (range 720-2770 g) and a median age of 32 weeks (range 25-36 weeks) gestation, who were subsequently operated on after a median of 65 days (range 20-121 days) for 33 inguinal hernias. The infants were evaluated with respect to concomitant diseases as well as peri- and postoperative complications. The following surgical procedure was used in all patients: a high suture ligation after excision of the hernia sac, followed by closure of the groin according to Grob in boys, and according to Bassini in girls. Co-morbidity was high in the pre-term infants, both pre- and perinatally. Despite this high co-morbidity and a high rate of emergency operations due to incarcerations, the postoperative complication rate was very low. However, the rate of testicular atrophy (10%) and recurrent inguinal hernia (9%) registered by us in the median follow-up of 575 days (range 105-1118 days) was much higher than that seen in older infants. Nevertheless, based on the low perioperative complication rate registered in the present study, we postulate that early surgery is tenable in pre-term infants despite the high co-morbidity and is even meaningful for the purpose of reducing the high rate of incarceration and testicular atrophy. The high recurrence rate in pre-term infants appears to be related to the numerous concomitant diseases in these patients, the resultant increase in intra-abdominal pressure and the small size of anatomical structures.

Tracheobronchial injuries in childhood: review of two cases.

Penetrating injuries of the tracheobronchial tree in children are very rare. With prompt diagnosis nonoperative treatment seems to be appropriate and safe without complications. Delayed diagnosis may result in surgical exploration with severe complications afterwards caused by poor condition at the time of intervention. Two children with penetrating tracheobronchial injuries were referred to our pediatric surgical center in the last 12 years. A 10-year-old boy suffered an iatrogenic penetrating injury of the tracheobronchial tree, and a 6-year-old boy a direct penetrating injury of the distal trachea in an agricultural accident. Cervical emphysema and bronchoscopy identified the lesion in these patients. Both of them could be treated conservatively without any sequelae.

Experience with gastro-intestinal duplications in childhood.

BACKGROUND: Intestinal duplications are rare congenital malformations. The different locations and sizes of these duplications require a specific diagnostic and surgical approach. This study reviews our paediatric patients with intestinal duplications in order to analyse the influence of prenatal sonography and laparoscopy on the clinical course. PATIENTS AND METHODS: Thirteen duplications of the alimentary tract in 12 patients have been treated over a 10-year period from 1989 to 1999. Six of our patients were diagnosed prenatally by ultrasound and were free of symptoms until surgery, except for one patient who had meconium-ileus owing to cystic fibrosis. In another five patients, the diagnosis was made on the basis of symptoms with signs of obstruction. In one child, the duplication was found incidentally during an operation for an anorectal malformation. The location of the 13 duplications was the stomach in three cases, the duodenum in one case, the jejunum in two cases, the ileum in six cases and the rectum in one case. Laparotomy was performed in ten patients. Two cases were treated by laparoscopic-assisted resection. CONCLUSION: Early diagnosis and treatment of uncomplicated intestinal duplications by means of prenatal sonographic screening and laparoscopic-assisted resection, respectively, are desirable in this congenital malformation. Resection of the duplication with or without minimal resection of the adjacent normal intestine should be mandatory.