Successful management without protective colostomy in an adult patient with anorectal mal-formation.

Anorectal malformations are rare occurrences characterized by the absence or abnormal localization of the anus. Clinical manifestations can vary from mild forms that require only minor surgery to more complicated cases that must be managed with multi-staged surgery. In this report, our aim is to present the clinical characteristics, management, and treatment outcome of an adult patient with an anorectal malformation with a vestibular fistula that was successfully repaired by posterior sagittal anorectoplasty (PSARP) and to discuss the case in the light of the relevant literature. We also would like to underline the fact that primary anorectal malformations can, although rarely, be observed in adult patients. A 26-year-old female patient presented with an imperforate anus and constipation with feces passing through a fistula located at the distal part of her vagina. She was continent for solid feces, but had leakage of flatus and fecal soiling. She also had concurrent left renal agenesis. A posterior sagittal anorectoplasty was successfully performed without a colostomy. The patient was discharged uneventfully on the postoperative 8th day. The patient was fully continent during a control visit after seven years of follow-up. Posterior sagittal anorectoplasty is a technique that can be successfully used in adult patients with anorectal malformations.

Venobiliary fistula related to umbilical venous catheter in a newborn.

We present a case of venobiliary fistula due to umbilical venous catheter (UVC). UVC was inserted the day before surgery in a newborn who was scheduled for type IIIB jejunal atresia surgery. The UVC was superimposed on the liver. It was noted that the gastric drainage became chylous and increased to 790 and then 1977 mL daily. I.v. contrast tomography with 650 mL contrast showed that the opaque substance was dispersed around the catheter and a venobiliary fistula formed, with the administered fluid accumulating in the duodenum. Rapid improvement was seen in the clinical picture after the UVC was removed. Venobiliary fistula may develop in patients with UVC that is not placed appropriately, and can direct the fluid administered from the UVC to the gastrointestinal system through the choledochal duct. The importance of contrast computed tomography in the diagnosis of venobiliary fistula in the newborn is also emphasized.

The effect of hypothermia on adnexal torsion/detorsion injury in a rat ovary model.

PURPOSE: Much attention has been given to hypothermia as it is effective in inhibiting inflammatory responses and also ischemia/reperfusion injury. Therefore, the aim of this study was to evaluate the effect of hypothermia on torsion/detorsion injury in rats. METHODS: Twenty-eight rats were randomly divided into four groups of sham-operated (SG), adnexal torsion/detorsion group (TG), adnexal torsion/detorsion+hypothermia group (THG) and hypothermia group (HG). In the SG group, right ovaries were excised after 3-h fixation to abdominal wall. In the TG, right adnexal underwent 720° torsion in a counterclockwise direction for 3h and then excised after 3-h detorsion period. In the THG, after 3-h torsion period, ovaries were immediately subjected to hypothermia (4°C) for 30-min and they were excised after 3-h detorsioned period. In the HG, the right ovaries were subjected to hypothermia for 30-min and excised after 3-h fixation period. One half of each ovary was immediately stored for antioxidant enzyme activity and tissue lipid peroxidation. The remainder was fixed for histopathological examination. RESULTS: Adnexal torsion and detorsion significantly increased the tissue level of Malondialdehyde, Superoxide dismutase and Reduced glutathione. On the other hand, hypothermia significantly reduced these oxidative stress parameters. The histopathological changes were less in the THG group; these changes were not statistically different from the other groups. CONCLUSION: The results of this study suggested that hypothermia inhibited the production of oxidative stress in the ovaries subjected to torsion/detorsion injury.

Surgical management of complete penile duplication accompanied by multiple anomalies.

Diphallus (penile duplication) is very rare and seen once every 5.5 million births. It can be isolated, but is usually accompanied by other congenital anomalies. Previous studies have reported many concurrent anomalies, such as bladder extrophy, cloacal extrophy, duplicated bladder, scrotal abnormalities, hypospadias, separated symphysis pubis, intestinal anomalies and imperforate anus; no penile duplication case accompanied by omphalocele has been reported. We present the surgical management of a patient with multiple anomalies, including complete penile duplication, hypo-gastric omphalocele and extrophic rectal duplication.

Inguinal herniotomy with the Mitchell-Banks' technique is safe in older children.

PURPOSE: There is a tendency for the majority of surgeons to open the inguinal canal in children over two years old when performing inguinal hernia repair. On the other hand, in small children, most surgeons perform the herniotomy superficially to the external ring, as in Mitchell-Banks' technique (MBT). Our aim was to compare the Ferguson hernioplasty (FH) and Mitchell-Banks' technique in terms of recurrence and complication rates in older children. METHODS: We retrospectively reviewed the office medical records of children who were at least two years old and who underwent a herniotomy procedure for inguinal hernia between 1997 and 2012. RESULTS: The 4520 inguinal herniotomy procedures in boys who were over two years old were included in this study. Of these cases, 1607 cases (40.2%) were operated on by a FH with opening the inguinal canal, and 2388 cases (59.8%) by MBT superficially to the external ring. The median ages were 5.1 years (range, 2.0-16.2) in the FH group and 4.6 years (2.0-14.6) in the MBT group. The total complication rates were 2.3% in the FH group and 2.9% in the MBT group (P>.05). Early complications such as wound infection, scrotal edema, and hematoma were seen in 13 (0.8%), 15 (1%), and 10 (0.6%) in the FH group, and 12 (0.5%), 18 (0.7%), and 15 (0.6%) in the MBT group, respectively (P>.05). Late complications such as recurrence, trapped undescended testis, and testicular atrophy were seen in 2 (0.12%), 1 (0.06%), and 2 (0.12%) in the FH group, and 3 (0.12%), 1 (0.04%), and 2 (0.08%) in the MBT group (P>.05). CONCLUSION: The Mitchell-Banks technique is a simple and safe procedure in older boys.

Determining external genital abnormalities with a pre-circumcision examination in previously undiagnosed male school children.

PURPOSE: We investigated whether children getting ready for circumcision under local anesthesia had any additional genital region abnormalities not detected before the circumcision. MATERIALS AND METHODS: We performed circumcision under local anesthesia for children with normal physical examination findings, and together with corrective surgery for those with other genital anomalies among the children aged 6 years old and over presenting at the pediatric surgery department of our hospital during the school break. RESULTS: Circumcision was planned under local anesthesia in a total of 1,695 cases aged between 6 and 17 years during the June to September 2010 and 2011 periods. We found an external genital anomaly in the pre-circumcision physical examination in 58 patients (3.4%), with a mean age of 7.87 ± 1.49 years. These patients were operated on with corrective surgery while 1,637 children underwent circumcision under local anesthesia. The most common anomaly was inguinal hernia seen in 14 (24.1%), followed by hypospadias in 11 (18.9%), hydrocele in 9 (15.9%) and undescended testis in 8 (13.8%). CONCLUSION: In countries where circumcision is traditional, an intervention room within the hospital to perform circumcision under local anesthesia can enable many children to be circumcised under hospital conditions and previously undetected genital abnormalities to be found with a pre-circumcision genital region examination.

Using the parents' video camera for the follow-up of children who have undergone hypospadias surgery decreases hospital anxiety of children.

PURPOSE: We investigated the benefits of using the parents' video camera records for the follow-up of children who had undergone hypospadias surgery in terms of reducing fear and hospital anxiety of the children and the time spent in the waiting room. METHODS: This prospective study was performed on children with proximal hypospadias. The patients were called for the follow-up appointment on the 7th postoperative day and were divided into 3 groups. The first group was the control group where parents were not given any follow-up visit direction. The parents of the second group were told to have their child drink enough fluids and come with a full bladder, while the third group of parents recorded their child's micturition using a video camera. The fear and anxiety of children at the postoperative visit were evaluated and recorded using a scoring system between 0 and 4 using the Children's Fear Scale (CFS) brochure. The time elapsed from the arrival of the parents in the outpatient clinic to their departure was also recorded for comparison of the total time spent during the follow-up visit among the groups. RESULTS: Thirty boys who underwent hypospadias repair were enrolled in this study. The median CFS scores at the postoperative follow-up visit were 2.99±0.99 (range: 1-4) in the first group, 2.90±0.87 (range: 1-4) in the second group, and 0.00 (range 0-0) in the third group. The median total time spent during the follow-up visit in the 3 groups was 61.50±17.08 (range 35-88), 18.1±13.01 (range 4-45), and 4.0±0.81 (3-5) minutes, respectively. Both CFS and total time spent were significantly lower in the third group (p<0.01). CONCLUSION: Imaging of micturition at home by using a video camera for outpatient visits following hypospadias surgery will decrease the fear and anxiety of children and the time that the family spends at the hospital.

A rare cause of childhood ileus: giant mesenteric lipoma and a review of the literature.

Mesenteric lipomas are benign tumors of mature fat cells. They are usually asymptomatic and create a clinical picture that depends on the localization and size of the lipoma. Although rare, unusually large mesenteric giant lipomas can cause partial or complete bowel obstruction. Lipomas resulting in partial bowel obstruction can present with symptoms such as intermittent abdominal pain and abdominal distention. With complete obstruction, a child can present with an acute abdomen. Treatment is the excision of the mass along with the affected portion of bowel. In this case study, a 2-year-old female presented with a bowel obstruction due to the presence of a giant mesenteric lipoma. Clinical features of 16 cases published in the English literature to date are presented.

Effect of intraperitoneal erythropoietin on the degree of mucosal damage of left colon flaps in rats.

BACKGROUND: Several modifications to an esophageal replacement approach have been described, using the left, the right, or the transverse colon as an interposition flap. Interposition of the left colon has become the most popular procedure. Intraoperative clamping of the arterial blood supply and venous drainage of the flap is a possible reason for ischemic flap failure. Thus, we designed a novel model to investigate whether erythropoietin (EPO), which has a tissue-protective effect in ischemia, would have any protective effect on prepared colon flaps in rats. METHODS: A total of 56 rats were randomly divided into four main groups, consisting of sham, sham + EPO, colon flap, and colon flap + EPO, and each main group was divided into two sub-groups. In the colon flap and colon flap + EPO groups, the colon flap was prepared and the pediculated free flap fixed tautly to the anterior abdominal wall. The sub-groups were subjected to post-reoperative histopathological investigation on the first and the seventh days, respectively. RESULTS: Our model was reliable for research related to colon interposition techniques. There was significant histopathological damage in the colon flap group both for the long and short limbs of the flap. On the other hand, EPO administration prevented the mucosal damage seen in the colon flap group. CONCLUSIONS: This study suggests that a colon flap attached tautly to the abdominal side wall simulates colon transposition techniques and also shows that intraperitoneal EPO markedly decreases flap damage in rats with prepared colon flaps.

3-aminobenzamide, a poly ADP ribose polymerase inhibitor, attenuates renal ischemia/reperfusion injury.

INTRODUCTION: This study was designed to investigate whether 3-amino benzamide (3-AB), a poly (ADP-ribose) polymerase (PARP) inhibitor, has a protective effect on kidney injury induced by renal ischemia/reperfusion (I/R) by decreasing oxidative and nitrosative stress on renal dysfunction and injury. MATERIALS AND METHODS: Thirty-two male Sprague-Dawley rats were divided into four groups: sham-operated, sham-operated + 3-AB, I/R, I/R + 3-AB. Rats were given 3-AB (100 mg/kg/day ip) 14 days prior to I/R. I/R and I/R + 3-AB groups underwent 60 min of bilateral renal ischemia followed by 6 h of reperfusion. After reperfusion, kidneys and blood were obtained for evaluation. Superoxide dismutase, glutathione peroxidase, malondialdehide, protein carbonyl content, and nitrite/nitrate level (NO(x)) were determined in the renal tissue. Serum creatinine (S(Cr)), blood urea nitrogen (BUN), and aspartate aminotransferase (AST) were determined in the blood. Additionally, renal sections were used for histological grade of renal injury. RESULTS: 3-AB significantly reduced the I/R-induced increases in S(Cr), BUN, and AST. In addition, 3-AB markedly reduced elevated oxidative stress product, restored decreased antioxidant enzymes, and attenuated histological alterations. Moreover, 3-AB attenuated the tissue NO(x) levels, indicating reduced NO production. CONCLUSIONS: 3-AB has beneficial effect on renal glomerular and tubular dysfunction in rats' kidneys subjected to I/R injury. Moreover, 3-AB has ameliorating effect on both oxidative stress and nitrosative stress of the kidneys, which correlated with histopathological evaluation.

Comparison of the efficacy of melatonin and 1400W on renal ischemia/reperfusion injury: a role for inhibiting iNOS.

INTRODUCTION: We investigated the roles of melatonin (a powerful antioxidant, iNOS inhibitor, and a scavenger of peroxynitrite) and 1400W (a strong and selective inhibitor of inducible nitric oxide) on renal dysfunction and injury induced by ischemia/reperfusion (I/R) of rat kidney, since oxidative and nitrosative injury are believed to be the major causes. MATERIALS AND METHODS: Thirty-two male Sprague-Dawley rats were divided into four groups of sham-operated, I/R, I/R + Melatonin and I/R + 1400W. Rats were given either melatonin (10 mg/kg) or 1400W (10 mg/kg) in the I/R + Melatonin and I/R + 1400W groups respectively at 6 h prior to ischemia and at the beginning of reperfusion via intraperitoneal route. I/R injury was induced by 60 min of bilateral renal ischemia followed by 6 h of reperfusion. After reperfusion, kidneys and blood were obtained for histopathologic and biochemical evaluation. RESULTS: Melatonin and 1400W had an ameliorative effect on both oxidative and nitrosative stress in the kidneys against renal I/R injury in rats. In addition, melatonin significantly reduced elevated nitro-oxidative stress product, restored decreased antioxidant enzymes and attenuated histological alterations when compared with 1400W. CONCLUSIONS: Both Melatonin and 1400W were efficient in ameliorating experimental I/R injury of the kidneys. Moreover, melatonin was more effective than 1400W possibly through inhibiting iNOS as well as scavenging free oxygen radicals and peroxynitrite.

Waardenburg syndrome with extended aganglionosis: report of 3 new cases.

PURPOSE: The Waardenburg-Shah syndrome is an autosomal recessive disease with varied penetration where Hirschsprung's disease and the Waardenburg syndrome are seen together. Although the length of the involved intestinal segment varies in this syndrome, most patients had total colonic aganglionosis with or without small bowel involvement. We present in this study 2 siblings and one first-degree relative for a total of 3 male patients with Waardenburg syndrome and total colonic aganglionosis with or without small bowel involvement, together with their clinical characteristics and treatment methods. PATIENTS: The patients who presented with intestinal obstruction findings within the first 48 hours after birth were operated on with 2 patients under elective conditions and 1 as an emergency. The ganglionic segment lengths were 6, 8, and 20 cm, respectively. Aganglionic enterostomy was performed, and the Ziegler operation was used for these patients. The enterostomies started to function on the third postoperative week, and they started to gain weight. However, all died because of sepsis on the 5th to 12th month. CONCLUSION: Waardenburg-Shah syndrome patients have a higher incidence of total colonic aganglionosis with or without small bowel involvement. The Ziegler operation may be used in patients with inadequate ganglionic bowel length to gain some time for the child to grow and to decrease total parenteral nutrition complications.