Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract? A single-centre experience with 1000 cases.

BACKGROUND: Foreign body (FB) ingestion is frequently encountered in all departments that treat children. FB may bring about significant anxiety for parents and physicians. The present study aims to determine the appropriate approach for FB ingestion in children. METHODS: The records of 1000 children with a history of FB ingestion between the years 2005 and 2017 were reviewed retrospectively in this study. RESULTS: Of 1000 children, 53.8% were male. The most common types of FBs were coins (35%). X-ray was negative in 49% of the patients, and 86% of these patients received no intervention. Of the 504 (51%) X-ray-positive patients, the oesophagus (68%) was the most common location. Life-threatening complications were tracheo-oesophageal fistula (1), Meckel's diverticulum perforation (1), and perforation due to rigid endoscopy (1). CONCLUSION: We demonstrated that coins, which are the most commonly ingested FBs, have various types and sizes according to their countries of origin, and this affects spontaneous passage. We found that only 48% (quite low compared to the literature) of the coins passed spontaneously. In asymptomatic patients with a gastric button battery, we suggest a "watchful waiting" approach. The patients should be observed and managed at home. In our study, we found that 85% of the button batteries that reached the stomach passed spontaneously.

The long term effects of intrascrotal low dose and high dose N-acetylcysteine on testis damage in rat model of testicular torsion.

BACKGROUND/PURPOSE: During testicular torsion, the testes face oxidative damage owing to ischemia/reperfusion. We studied the long term effects of the intrascrotal administration of N-acetylcysteine (NAC) during detorsion procedure in a rat model of testicular torsion. METHODS: Twenty-eight rats were divided into 4 groups: (1) Control group: No procedure was done (2): Torsion-detorsion group: Testis torsion applied for 3 h (3): Low Dose Group: After testis torsion-detorsion (for 3 h) 10 mg/kg NAC was given into tunica vaginalis (4): High Dose Group: After testis torsion-detorsion (for 3 h) 100 mg/kg NAC was given into tunica vaginalis. We measured dimensions of the testes and examined pathological findings and Johnsen and Cosantino Scores. RESULTS: For testes height and volume, high dose NAC group had better results than the torsion-detorsion group (p = 0.019, p = 0.049). Testes weight showed no difference (p = 0.204). Sertoli cell number per tubule in the high dose NAC group was statistically different than the torsion-detorsion group (p = 0.017). CONCLUSIONS: When NAC was given intrascrotally at a dose of 100 mg/kg, it decreased the loss of testis volume and height, and Sertoli cell number per tubule was similar to the control group. These results suggest that the higher dose intrascrotal NAC administered during detorsion may have a protective effect.

Boix-Ochoa (Partial Fundoplication) Treats Reflux, Even in Neurologically Impaired Patients. Can it Take the Title of "Gold Standard" from Total Fundoplication?

BACKGROUND: In 4-5% of cases of gastroesophageal reflux disease (GERD), surgical treatment is required. The aim of the study was to evaluate the success of Boix-Ochoa antireflux surgery, which is considered more physiologic with a higher failure rate (need for reoperation) than Nissen fundoplication, which is believed to be the gold standard operation. METHOD: In the 13 years from 2005 to 2018, the medical records of all children who underwent Boix-Ochoa in a single institution by pediatric surgeons were reviewed retrospectively. RESULTS: A total of 133 fundoplications were performed, of which patients were divided into four groups: neurologically impaired, structurally impaired, neurologically and structurally impaired, and neurologically and structurally normal; there were 64, 8, 34, and 27 patients in each group, respectively. Structural impairments included hiatal hernia and esophagus atresia, having previously had a gastrostomy and esophageal stenosis. The most common short-term complication was distal esophageal stenosis (13%), which caused vomiting and dysphagia, and was treated by dilatations. There were six (4.5%) recurrences of GER, one in the neurologically and structurally impaired group with a hiatal hernia and five in the structurally impaired group (three esophagus atresias, two caustic esophageal strictures). The mean follow-up period was 5.27 ± 3.43 years. Neurological impairment did not affect the success rate. CONCLUSION: Although there has not any literature demonstrating significant benefits of one procedure, we detected with this largest study in the pediatric literature about Boix-Ochoa fundoplication (more physiologic and easily performed) that it was successful (95%) in protecting reflux even in neurologically impaired patients (98%). We consider Boix-Ochoa (partial fundoplication) to be an alternative method to Nissen (complete fundoplication), and it can be done safely with a high success rate.

Management of traumatic bile duct injuries in children.

PURPOSE: Pediatric experience with biliary tract injuries (BTI) is limited and mostly consists of case presentations. The purpose of this study is to evaluate clinical and radiological findings of possible BTI, treatment strategies, and results. METHODS: The records of nine patients with the diagnosis of BTI between July 2009 and November 2017 were reviewed retrospectively. RESULTS: There were seven boys and two girls (mean 8.05 ± 4.39 years). The mechanisms were motor vehicle occupant, fall, crush and gunshot wound. Hepatic laceration routes that extended into the porta hepatis and contracted the gall bladder were demonstrated on computerized tomography (CT). Bile duct injury was diagnosed with bile leakage from the thoracic tube (n = 2), from the abdominal drain (n = 2) and by paracentesis (n = 5). Extrahepatic (n = 8) and intrahepatic (n = 1) bile duct injuries were diagnosed by cholangiography. Endoscopic retrograde cholangiography, sphincterotomy, and stent placement were successfully completed in five patients. Peritoneal drainage stopped after 3-17 days of procedure in four patients. The fifth patient was operated with the diagnosis of cystic duct avulsion. Cholecystectomies, primary repair of laceration, cystic duct ligation, and Roux-en-Y hepatoportoenterostomy were performed in the remaining four patients. All patients presented with clinically normal findings, normal liver functions, and normal ultrasonographic findings in the follow-up period. CONCLUSIONS: The presentation of the parenchymal injury extending to the porta hepatis with contracted gall bladder on CT and diffuse homogenous abdominal fluid should be considered as signs of BTI. We suggest a multi-disciplinary approach for the diagnosis and treatment of BTIs. Surgery may be indicated according to the patient's clinical condition, radiological findings and failure of non-operative treatment.

Natural History and Conservative Treatment Outcomes for Hydroceles: A Retrospective Review of One Center's Experience.

OBJECTIVE: To elucidate epidemiological data and hydrocele progression, we reviewed pediatric patients diagnosed with hydroceles in our institution retrospectively. MATERIALS AND METHODS: We reviewed data from 355 pediatric patients with hydroceles. Questionnaires regarding age at diagnosis, time of delivery, presence of hydroceles in the father and brothers, age at recovery, age at surgery, cause of hydrocele (if present), type of hydrocele, associated pathologies, treatments, and posthydrocelectomy complications were completed by reviewing patients' medical records and interviewing their families. RESULTS: Patients with congenital hydroceles were more frequently born prematurely (32.5%) than were patients with noncongenital hydroceles (15.9%; P = .001). Fathers of 10 patients (3.7%) and brothers of 21 patients (7.7%) also had hydroceles. Hydroceles were associated with inguinal hernias on the same side (12.2%), cryptorchidism (7.5%), varicoceles (6.0%), and testis torsion (0.5%). Among patients aged >1 year (n = 185), 27 did not undergo operations and healed spontaneously at an average of 5.30 ± 3.36 months. For children aged >1 year who did not undergo surgery, the rate of spontaneous recovery within 6 months was 77.8% and that within 1 year was 96.3%. CONCLUSION: Until strong evidence of hydrocele-induced testicular damage in children arises, we recommend following up congenital hydroceles until at least 1 year and preferably 2 years of age. We recommend following up noncongenital hydroceles for at least 6 months and preferably 1 year if there is no associated pathology indicating the need for earlier surgery such as an inguinal hernia, cryptorchidism, tense hydrocele, testis torsion, or testis mass.

Foreign body punctured the spleen: An incidental diagnosis.

Inal-Aslan G, Ötgün I, Güney LH, Hiçsönmez A. Foreign body punctured the spleen: An incidental diagnosis. Turk J Pediatr 2017; 59: 97-99. A foreign body can enter the body via penetration through the skin. In the presented case, a broken syringe needle was found and removed from the splenic parenchyma. In order to prevent such iatrogenic injuries, which could have fatal consequences, the hospital staff must give particular care in the handling of sharp FBs.

The effect of intraperitoneal n-acetylcysteine on postoperative adhesions in rat models.

AIM: In this study, we researched the effect of local administration of N-acetylcysteine (NAC) on postoperative intraabdominal adhesion formation in the rat models. METHODS: 20 female Wistar Albino rats which were 5-7 months old are used for the study. The rats were divided into two equal groups. Group one was administered saline solution (n=10) while group two was administered NAC (n=10) after caecal abrasion. They were dissected on postoperative tenth day and were examined macroscopically and microscopically for the adhesion formation. Intraperitoneal adhesion formation was scored blinded with Evans model. The most adherent bowel section was excised for histopathologic examination. Mann Whitney U test were used for statistical analysis. RESULTS: In Group one, all rats have had adhesions. None of the rats in Group two had either severe inflammatory cell reaction or dense interstitial fibrosis. Macroscopic adhesion formation and microscopic inflammatory cell reaction and interstitial fibrosis formation after surgery were less at the group two (NAC applied) (p<0.05, p<0.05, p<0.05). CONCLUSION: We believe that the intraperitoneal single dose usage of NAC may be promising for decreasing the postoperative intraabdominal adhesions. KEY WORDS: N-acetylcysteine, Postoperative adhesion, Rat, Fibrosis.

Spleen Salvaging Treatment Approaches in Non-parasitic Splenic Cysts in Childhood.

The aim of this study was to evaluate our experience with primary non-parasitic splenic cysts (NPSC) which are relatively rare in children and consist almost exclusively of single case reports or small case series in the literature. The medical records of all patients who presented to our clinic with NPSC between 2005 and 2015 were evaluated retrospectively. There were 22 children whose ages ranged from 2 months to 14 years (mean 9.2 ± 4.7 years). The size of the cysts was in the range of 5 to 200 mm (mean 55.4 ± 48.2 mm). Ten patients underwent surgery for splenic cysts. Partial splenectomy (n = 2), total cyst excision (either open n = 4 or laparoscopically n = 1), and total splenectomy (n = 3) were performed. The non-operated patients were asymptomatic and followed with ultrasound (US). The follow-up period in non-operated patients ranged from 6 months to 5 years (mean 2.27 ± 1.29 years). Complete regression was observed in four (33 %) non-operated patients. The regressed cyst measurements were 10, 16, 30, and 40 mm, respectively. Approximately half of the NPSC is diagnosed incidentally. Small (<5 cm) asymptomatic cysts should be under regular follow-up with US/physical examination for regression. If surgery is required, we prefer open cyst excision as it gives excellent results and preserves splenic immune function.

Intestinal malrotation needs immediate consideration and investigation.

BACKGROUND: The aim of this study was to evaluate clinical presentation, diagnostic studies, and volvulus rate and to describe the unusual clinical clues of intestinal malrotation. METHODS: A retrospective descriptive review was carried out of all patients diagnosed with intestinal malrotation between 2002 and 2014. Patients were divided into two groups: infants (≤1 year, n = 16; group 1); and children (>1 year, n = 12; group 2). Patient demographics, clinical history, symptoms, physical examination, diagnostic work-up, operative findings and early outcome were evaluated. RESULTS: Bilious vomiting was the cardinal complaint in both groups. Unusual symptoms such as respiratory insufficiency, dehydration, afebrile convulsion, and lethargy were prominent symptoms in six patients in group 1, whereas history of frequent hospitalization due to recurrent abdominal pain and feeding intolerance were prominent in six patients in group 2. Midgut volvulus was identified in 15 patients, four of whom were in group 2. Standard Ladd's procedure was done in addition to correction of volvulus. CONCLUSION: Malrotation with or without midgut volvulus is not a rare condition and should be kept in mind for any age group. Specific signs of diagnosis are not easily identified. In the case of unusual clinical presentation, diagnosis may be delayed and can result in catastrophic consequences if intestinal perfusion occurs. Although midgut volvulus is seen most frequently in infants, risk and complication rate are high beyond 1 year of age as well, and can manifest as failure to thrive, food intolerance, and abdominal pain needing recurrent hospitalization. Diagnostic suspicion and interdisciplinary coordination are essential for timely diagnosis and surgical treatment.

Is every intussusception treatment an emergency intervention or surgery?

BACKGROUND: Intussusception is the second most common cause of acute abdomen in children, following appendicitis. The aim of the present study was to evaluate the experience of the authors, in an effort to promote intussusception management, especially that of small bowel intussusception. METHODS: Records of intussusception diagnosed between July 2002 and September 2014 were evaluated in terms of patient age, sex, clinical findings, admission time, ultrasonographic findings, treatment methods, and outcomes. RESULTS: Eighty-one patients, 52 males and 29 females, were included (mean age: 10.6 months). Intussusceptions were ileocolic (IC) in 52 cases, ileoileal (IL) in 26, and jejunojejunal (JJ) in 3. Nineteen (23.5%) patients underwent surgery. Hydrostatic reduction was performed in 45 (55.5%) IC cases. Seventeen (21%) patients with small bowel intussusceptions (SBIs), measuring 1.8-2.3 cm in length, spontaneously reduced. All patients who underwent surgery had intussusceptums ≥4 cm. Three of the 4 intestinal resection cases had history of abdominal surgery. CONCLUSION: If peritoneal irritation is present, patients with intussusception must undergo surgery. Otherwise, in patients with IC intussusception and no sign of peritoneal irritation, hydrostatic or pneumatic reduction is indicated. When this fails, surgery is the next step. SBIs free of peritoneal irritation and shorter than 2.3 cm tend to spontaneously reduce. For those longer than 4 cm, particularly in patients with history of abdominal surgery, spontaneous reduction is unlikely.

Meckel diverticulum in children: Evaluation of macroscopic appearance for guidance in subsequent surgery.

BACKGROUND: The treatment of incidentally encountered asymptomatic Meckel diverticulum (MD) is controversial. We evaluated whether the macroscopic appearance correlates with clinical features, histopathological findings, future complications, and management decisions. METHODS: Patients who underwent MD resection at a single institution from 2000 to 2012 were retrospectively analyzed in terms of age, sex, clinical features, laboratory data, perioperative findings (diverticulum length, diameter, depth, thickening, and height-to diameter ratio [HDR]), pathology, and postoperative follow-up. RESULTS: Fifty children were enrolled. Sixteen percent of the resected MDs were found incidentally. Of 42 complicated MDs, 17 (40%) were long (HDR ≥2), 14 (33%) were thickened, and 29 (70%) exhibited base widening. Histopathologically, ectopic mucosa was found in 32 (64%) of all MDs and in 5 (62%) of incidentally removed MDs. There was no statistical difference between the macroscopic appearance and clinical signs, sex, or presence of ectopic tissue based on palpation. CONCLUSION: The macroscopic appearance of MD does not indicate the presence or absence of HGM and cannot be used to guide subsequent surgery. Additionally, 40% of symptomatic patients in our study had life-threatening complications requiring prompt fluid resuscitation. We consider that incidentally detected MD should be removed regardless of its macroscopic appearance.

Huge Neck Masses Causing Respiratory Distress in Neonates: Two Cases of Congenital Cervical Teratoma.

Congenital cervical teratomas are rare and usually large enough to cause respiratory distress in the neonatal period. We present two cases of congenital huge cystic neck masses in which distinguishing cervical cystic hygroma and congenital cystic teratoma was not possible through radiologic imaging techniques. Experience with the first case, which was initially diagnosed and treated as cystic hygroma by injection sclerotherapy, led to early suspicion and surgery in the second case. The masses were excised completely and histopathologic diagnoses were congenital teratoma in both patients. Our aim is to review congenital huge neck masses causing respiratory distress in early neonatal life to highlight this dilemma briefly with these interesting cases.

Choledochal cysts in children: Intrahepatic ductal dilatation does not indicate true intrahepatic biliary duct disease.

BACKGROUND/AIMS: Choledochal cysts (CCs) are rare abnormalities of the biliary tract. Presenting our clinical experience with CCs herein, we aimed to identify if intrahepatic ductal dilatation indicates true intrahepatic biliary duct disease. MATERIALS AND METHODS: We retrospectively reviewed all cases of CCs in children diagnosed at a single center (Baskent University Fac-ulty of Medicine, Department of Pediatric Surgery) institution from 2005 to 2015. RESULTS: Of 18 patients with CCs, 7 were males (39%). The age range was 3 months to 17 years (mean age, 6.2±3.8 years). Intrahepatic bile duct dilatation was detected in 13 (72%) patients by preoperative scanning. Type I, II, III, and IVA cysts were diagnosed in 13, 1, 1, and 3 patients, respectively. In all patients, total cyst excision and Roux-en-Y hepaticoenterostomy were performed. CONCLUSION: In this study, most intrahepatic ductal dilatations seen on preoperative imaging were thought to be caused by a distal obstruction, not true intrahepatic biliary duct disease. This study supports the hypothesis that preoperatively distinguishing between type I and type IVA CCs is not necessary; it does not affect the initial treatment. We consider that complete cyst excision with Roux-en-Y hepaticojejunostomy is safe and should be performed soon after diagnosis, irrespective of symptom severity to avoid future complications.

Bloody nipple discharge as a benign, self-limiting disorder in young children: A systematic review including two related case reports.

BACKGROUND/PURPOSE: Bloody nipple discharge (BND) is rare, distressing for parents, and presents a challenge for physicians. METHODS: We used PubMed to search for cases of BND that were diagnosed before adolescence and added data from two of our cases. RESULTS: The analyzed cohort comprised 46 patients (28 boys and 18 girls; mean [SD] age, 12.5±13.3months; range, 20days to 4years). The mean time for spontaneous resolution was 2.8±2.4months (range, 1week to 8months) after onset of BND without any intervention. The diagnosis was mammary ductal ectasia (MDE) in 15 patients, gynecomastia with MDE in two patients, hemorrhagic cysts in two patients, and gynecomastia alone in one patient. The majority (89.3%) of patients <1year old were managed conservatively, but half of them aged >1year (50.0%) underwent surgery. Surgery was performed more often in patients in whom a mass had been identified. CONCLUSIONS: Age and findings at physical examination affect selection of treatment, but not sex. We found no reported cases of malignancy. Symptoms in children who are managed conservatively resolve within 10months. Children with BND should be conservatively managed to avoid the risk of developing breast deformities before adolescence.

Abdominal Problems in Children with Congenital Cardiovascular Abnormalities.

BACKGROUND: Congenital cardiovascular abnormality is an important cause of morbidity and mortality in childhood. Both the type of congenital cardiovascular abnormality and cardiopulmonary bypass are responsible for gastrointestinal system problems. AIMS: Intra-abdominal problems, such as paralytic ileus, necrotizing enterocolitis, and intestinal perforation, are common in patients who have been operated or who are being followed for congenital cardiovascular abnormalities. Besides the primary congenital cardiovascular abnormalities, ischemia secondary to cardiac catheterization or surgery contributes to the incidence of these problems. STUDY DESIGN: Cross-sectional study. METHODS: In this study, we aimed to screen the intra-abdominal problems seen in patients with congenital cardiovascular abnormalities who had undergone surgical or angiographical intervention(s). Patients with congenital cardiovascular abnormalities who had been treated medically or surgically between 2000 and 2014 were analyzed retrospectively in terms of intra-abdominal problems. The patients' demographic data, type of congenital cardiovascular abnormalities, the intervention applied (surgical, angiographic), the incidence of intra-abdominal problem(s), the interventions applied for the intra-abdominal problems, and the results were evaluated. RESULTS: Fourteen (Group I) of the 76 patients with congenital cardiovascular abnormalities diagnosis were operated due to intra-abdominal problems, and 62 (Group II) were followed-up clinically for intra-abdominal problems. In Group I (10 boys and 4 girls), 11 patients were aged between 0 and 12 months, and three patients were older than 12 months. Group II included 52 patients aged between 0 and 12 months and 10 patients older than 12 months. Cardiovascular surgical interventions had been applied to six patients in Group I and 40 patients in Group II. The most frequent intra-abdominal problems were necrotizing enterocolitis and intestinal perforation in Group I, and paralytic ileus in Group II. Seven of the Group I patients and 22 of the Group II patients died. The patients who died in both groups had more than three congenital cardiovascular abnormalities in the same patient, and 80% of these patients had been operated for congenital cardiovascular abnormalities. CONCLUSION: The gastrointestinal system is involved in important complications experienced by patients with congenital cardiovascular abnormalities. The mortality rate was higher in operated patients due to gastrointestinal complications. Gastrointestinal complications are more frequent in patients with cyanotic anomalies. The presence of more than one congenital cardiovascular abnormality in a patient increased the mortality rate.

Aspiration of an interesting foreign body: Myiasis.

Myiasis is a rare condition caused by the invasion of tissues by the larvae of flies. Many cases of myiasis involving various human organs have been reported. Tracheopulmonary or intratracheal myiasis is a very unusual and aberrant form of the disease in humans. We present a case of respiratory myiasis after aspiration of larvae by a healthy 8-month-old girl, which cannot be found in the English literature.

Solid variant of aneurysmal bone cyst of the rib presenting as a left intrathoracic mass without radiological bone destruction.

An aneurysmal bone cyst (ABC) is a benign but often rapidly expanding osteolytic multi-cystic osseous lesion that occurs as a primary, secondary, intra-osseous, extra-osseous, solid, or conventional lesion. A 15-year-old boy presented with a left-sided intrathoracic mass displacing the lung without bone destruction. The mass was totally resected without rib resection, and the pathological diagnosis was ABC. The clinical manifestations, etiology, management, and pathology are discussed, with a brief discussion regarding the difficulty in the preoperative differential diagnosis.

The separation of the epididymis and the abnormal attachment of the gubernaculum cause undescendence in the rat testes.

PURPOSE: Epididymal anomalies are common in cryptorchid patients. This led us to consider that anomalies of the epididymis, to which the gubernaculum is attached, or abnormal attachment of the cranial end of the gubernaculum, could lead to cryptorchidism. METHODS: Twenty-eight male Sprague-Dawley rats were divided into two groups: In Group 1 rats (n = 14), the epididymis was isolated from the testis, and in Group 2 rats (n = 14), the gubernaculum was isolated from the epididymis and re-attached to the tail of the epididymis. In both groups, the non-operated testes were used as the control. RESULTS: In Group 1, cryptorchidism rates were 1/14 in the control testes and 8/14 in the operated testes (p < 0.01). In Group 2, cryptorchidism rates were 0/13 in the control testes and 6/13 in the operated testes (p < 0.01). CONCLUSION: Cryptorchidism was seen when the epididymis was loosely or non-connected to the testis and the gubernaculum was attached solely to the epididymis (mimicking anomalies of ductal fusion) and when the gubernaculum was attached to the tail of the epididymis (mimicking anomalies of ductal suspension). Therefore epididymal anomalies and abnormal attachment of the gubernaculum may play a role in the undescendence of the testes in the rats.