[Duodenum perforations in children: case series]. / Çocuklarda duodenum perforasyonlari: Olgu serisi.

To analyse patients those admitted to our clinic due to perforation in duodenum. Fourteen patients those have been admitted to our center with perforation in duodenum between 1990 - 2014 analysed retrospectively. Ten patients (8M, 6F) those have been admitted to our clinic between 1990 - 2014 have a mean age of 6.2 years (25 days - 16 years). Two of cases admitted directly to our clinic and the rest referred from another hospitals. Mean time for appliance to our clinic was 3.2 days (1day - 1 week). Ulcer in duodenum was the cause of perforation in 10 cases while in 3 the cause was trauma and in 1 case was surgical complication of infantly persistant hyperinsulinism (IPHH). The case with hyperbilluribinemia after near total pancreatectomy due to IPHH had been explored and perforation in deuedenum diagnosed. Resection in first two parts of duodenum and pylor, choledochojejunostomy, gastrojejunostomy and jejunojejunostomy was performed. Primary repair was performed in the remaining patients. In one case with primary repair gastrostomy was performed, while in 9 cases omentoplasty were performed. In the follow-up 12 cases has no problems and doing well. Two patients died. Perforation in duedenum is a rare entity that pediatric surgeons should encounter and keep in mind. Primary repair (duodenoraphy ± omentoplasty) is safe and reliable surgical treatment modality.

Comparison of the efficiencies of esophageal manometry, vector volume analysis and esophagus pH monitoring in the diagnosis of gastroesophageal reflux.

AIM: In this study, we aimed to compare the superiorities of esophageal manometry, vector volume analysis and 24-hour pH meter studies in showing gastroesophageal reflux disease. MATERIAL AND METHODS: The files of the patients who presented to pediatric surgery and pediatric gastroenterology outpatient clinics of our hospital with suspicious gastroesophageal reflux disease between 2011 and 2012 and who were investigated were examined and 21 patients whose investigations had been completed were included in the study. The patients were evaluated by treatment method and were divided into three groups as Group 1 who were followed up with medical treatment, Group 2 in whom surgical intervention was performed and Group 3 who were not treated. Chi-square test was used in evaluation of the categorical variables, Kruskal Wallis test was used in comparison of the mean values between the groups and Dunn test was used in subgroup analyses when Kruskal Wallis test was found to be significant. A p value of <0.05 was considered statistically significant. RESULTS: Thirteen of 21 patients included in the study were female and eight were male. The mean age of the patients was 5.71 years (one-16 years). In the 24-hour pH monitoring study, the mean reflux index was found to be 48.7% in Group 1, 42.4% in Group 2 and 28.3% in Group 3. In esophageal manometry studies, the pressure difference at lower esophageal sphincter (LES) was found to be 13,4 cm H2O in Group 1, 31.8 cm H2O in Group 2 and 4.3 cmH2O in Group 3. In vector volume analyses, the mean vector volume was calculated to be 96.01 cm(3) in Group 1, 2 398.9 cm(3) in Group 2 and 196.3 cm(3) in Group 3. In the 24-hour pH monitoring study, a statistically significant difference (p<0.05) was found in terms of showing reflux, whereas statistical significance could not be shown in terms of need for surgical treatment or need for medical treatment in any other method (p>0.05). CONCLUSIONS: Twenty-four-hour pH monitoring was found to be efficient in making a diagnosis of gastroesophageal reflux disease, whereas esophageal manometry and vector volume analyses were not found to be efficient.

Types of HLA in the bladder transitional cell carcinoma (TCC).

HLA plays a complementary role in the interaction between tumor and body immunology. The aim of this study was to determine the existence of the association between the HLA system and transitional cell carcinoma (TCC). Using standard micro-lymphocytotoxic method of Terasaki, HLA-A, B, DR and DQ antigen types of 30 patients with TCC of the bladder were compared with the control group (30 healthy people). In the TCC patient group, HLA -DQ6(1) and HLA -DQ7(3) antigens were detected with a significantly higher frequency than in the control group (p=0.018 and p=0.038, respectively), whereas HLA-A10, B4, DR53 and DQ1 antigens were detected with significantly higher frequency in the control group (p less 0.05 in all). It suggests that patients who had the antigens detected were at higher risk of TCC, and the ones who had the antigens displaying protective features as were detected in the control group, were at lesser risk.

The relationship between human leukocyte antigens (HLA) and renal cell carcinoma.

Etiologies of Renal Cell Carcinoma (RCC) are not clear despite of the fact that many risk factors have been suggested. Especially in high stages RCC can affect the immune system in various ways. Human Leukocyte Antigens (HLA) may play a complementary role in the activation between the tumor and immunity. Our aim was to determine the existence of the relationship between HLA system and RCC. By using the standard microlymphocytotoxic method of Terasaki in our study, the HLA A, B, DR and DQ antigen types of 20 patients with RCC Stage T1 and T2 were compared with the control group consisting of healthy 30 people. In our RCC patient group, HLA-A23(9) and DQ7(3) antigens were significantly higher than the control group statistically (p=0.005, p=0.0028; respectively). HLA-A10, DQ1, DR10 and B44 antigens were significantly higher in the control group than the patient group (p=0.011; for all).The findings made us suggest that the people, carrying the antigens which were detected in the patient group, were at high risk for RCC and the people, carrying the protective antigens that were detected in the control group were at less risk for RCC. There may be a dramatic regression for the patients who underwent immunotherapy and HLA expression, which is known to play role in tumor biology, may direct the effects of immunotherapeutic agents. Immunologic description and destruction is avoided in case of change or disappearance of HLA expression by cancer cells. Further investigations which will be performed in our population in the future will be more illuminating to confirm those results. We have concluded that, HLA profiles may be evaluated for detection the people at risk of RCC, the prognosis of the patients and their treatments.

Heterotopic gastric mucosa leading to recurrent intussusceptions: report of a case.

Although most cases of intussusception during childhood are caused by viral enlargement of the Peyer's patches, the remainder of the cases may be due to congenital anomalies, such as heterotopic gastric mucosa (HGM). This report presents a case of HGM in a 4-year-old boy. The patient presented with acute abdominal signs with a right lower quadrant mass. His medical history indicated three episodes of recurrent intussusceptions. The abdominal ultrasound examination detected an intussusception. A laparotomy revealed an ileocolic intussusception and reduction was accomplished. During exploration, an intraluminal mass in the ileum, which was the lead point, was discovered by palpation. An enterotomy showed a 2-cm-diameter crater-shaped mucosal thickening. An ileal resection and anastomosis was performed. The histopathological examination revealed HGM. Heterotopic gastric mucosa is supposed to be of vitellointestinal tract origin and may cause intussusception as being a lead point in the ileum. Despite its rarity, HGM should be considered in cases of recurrent intussusceptions and diagnostic studies should be performed. A laparotomy is required for the diagnosis and treatment in complicated cases. Surgical management should include reduction of the intussusception and careful manual examination of the ileum which may expose such pathology. An intestinal resection and anastomosis is sufficient to prevent complications.

Segmental dilatation of the ileum accompanying hypoproteinemia.

PURPOSE: Segmental intestinal dilatation (SID) is a rare pathologic finding, which causes intestinal obstruction in newborn period and gastrointestinal bleeding, anemia, abdominal pain, malabsorption, and growth failure in older children. We present a case of SID causing hypoproteinemia. PATIENT: A 10-year-old girl presented with recurrent abdominal distension since she was 8.5 months old. She was diagnosed to have protein-losing intestinal lymphangiectasia. Result of physical examination was normal except moderate growth retardation. Her blood workup showed depletion in total protein, albumin, and globulin levels. Gastrointestinal series revealed a dilated segment of small intestine, and Tc(99m)-pertechnetate scintigraphy detected ectopic activity in abdomen. The patient was taken to operation with the presumptive diagnosis of intestinal duplication. A dilated segment of ileum was encountered, and segmental resection and anastomosis were performed. RESULTS: Patient was discharged on the postoperative fourth day and remains well. Histopathologic examination of the specimen revealed SID. DISCUSSION: Segmental intestinal dilatation is an uncommon congenital anomaly. Most of the cases were operated on in newborn period because of intestinal obstruction, and their diagnoses were made perioperatively; the others were diagnosed in older ages during the investigation of nonspecific symptoms. The index patient is the second case of SID having hypoproteinemia in the literature. Gastrointestinal series suggested the diagnosis, and segmental resection and anastomosis were the adequate treatments.

Management of esophageal perforation secondary to caustic esophageal injury in children.

PURPOSE: To review our management of esophageal perforation in children with caustic esophageal injury. METHOD: We reviewed the medical records of 22 children treated for esophageal perforations that occurred secondary to caustic esophageal injury. RESULTS: There were 18 boys and 4 girls (mean age, 5 years; range, 2-12 years). Three children were treated for perforation during diagnostic endoscopy and 19 were treated for a collective 21 episodes of perforation during balloon dilatation. One child died after undergoing emergency surgery for tracheoesophageal fistula and pneumoperitoneum. Another patient underwent esophagostomy and gastrostomy. Twenty patients were treated conservatively with a nasogastric tube, broad spectrum antibiotics, and tube thoracostomy, 16 of whom responded but 4 required esophagostomy and gastrostomy. Although the perforation healed in 21 patients, 20 were left with a stricture. Two children were lost to follow-up, 8 underwent colonic interposition, and 10 continued to receive periodic balloon dilatations. Two of these 10 patients underwent colonic interposition after a second perforation. The other 8 became resistant to dilatations: 4 were treated by colon interposition; 2, by resection and anastomosis; and 2, by an esophageal stent. CONCLUSIONS: Esophageal perforation can be managed conservatively. Because strictures tend to become resistant to balloon dilatation, resection and anastomosis is preferred if they are up to 1 cm in length, otherwise colonic interposition is indicated.

Analysis of HLA antigens in Turkish sarcoidosis patients.

BACKGROUND: Sarcoidosis is a systemic granulomatous disorder associated with high CD4+cell activity, without any detectable pathogen. Clustering in families occurs, and the existence of a genetic predisposition to sarcoidosis is widely accepted. There are differences among different ethnic groups. METHODS: We studied HLA polymorphisms in 64 Turkish patients with biopsy proven sarcoidosis. The control group was taken of 160 donor candidates of kidney transplantation within the same period. RESULTS: Fifty-one patients were female, and 13 were male. The mean age was 39 +/- 6.1 years. Frequency of HLA A2, A9, A24 (9), A25, A69 (28), B12, B22, B38, B49 (21), DR4, and DR14 antigens were significantly higher, and frequencies of HLA B7 and DR7 were significantly less in sarcoidosis patients. Clustering in some families were also noted in our study. CONCLUSIONS: This study implies a genetic predisposition to sarcoidosis in the Turkish population. Clustering in some families should be kept in mind.

Extrathoracic liver hamartoma.

Mesenchymal hamartoma is a benign tumor of the liver that often presents because of a palpable abdominal mass or respiratory distress. An unusual protrusion of this tumor through the chest wall of a neonate with Poland's syndrome is reported.

Neonatal gastric perforation: review of 23 years' experience.

PURPOSE: To review our experience of treating 13 neonates with gastric perforation (GP) over the past 23 years. METHODS: The records of all 13 patients were reviewed, noting gender, weight, gestational age, age at admission, associated anomalies, site of perforation, type of operation, and clinical outcome. RESULTS: There were 11 boys and 2 girls, with a mean body weight of 2 375 g, including 4 (45%) preterm infants. The mean age at admission was 3.2 days. Three (23%) infants had associated anomalies. Perforation occurred in the lesser curvature and anterior wall in 3 (23%) infants, at the greater curvature and anterior wall in 2 (15.4%), in necrosis of anterior wall in 1 (7.7%), at the esophageal junction and posterior wall in 2 (15.4%), at the lesser curvature and posterior wall in 1 (7.7%), at the lesser curvature and esophageal junction in 1 (7.7%), and the site was not specified in 3 (23%). Twelve patients were treated with gastrorrhaphy and drainage, and 1 was treated with gastrorrhaphy alone. Three patients required additional gastrostomy. Mortality was 53.8% (n = 7). Early diagnosis and management before clinical deterioration of the metabolic status improved the prognosis. CONCLUSION: The pattern of presentation and surgical findings should be investigated comparatively in premature and full-term neonates, as the etiology of this condition is likely to differ in these two gestational groups.

Intestinal rotation anomalies in childhood: review of 22 years' experience.

PURPOSE: We review our experience of treating intestinal rotation anomalies in infants and children in the 22-year period between 1978 and 2000. METHODS: The type of operation performed, postoperative complications, and mortality were compared in three age groups. Group 1 consisted of neonates <1 month old, Group 2 consisted of infants aged <1 year old, and Group 3 consisted of children aged >1 year old. RESULTS: There were 101 infants and children, with a female : male ratio of 2 : 1. Of the 101 patients, 72 (71%) were neonates, with a mean age of 11.8 days (range 1-28 days); 20 (19.8%) were under the age of 1 year, with a mean age of 6.7 months (range 1-12 months); and 9 (8.9%) were >1 year of age, with a mean age of 6 years (range 1-9 years). Eighty-five (84%) patients underwent emergency procedures. Ladd's operation was performed in all patients, with various additional procedures. The most frequent postoperative complications were adhesive intestinal obstruction, stoma necrosis, evisceration, and short bowel syndrome. The mortality rate was 36% in Group 1, 20% in Group 2, and 0% in Group 3. CONCLUSIONS: In this series surgery was usually performed as an emergency procedure, with higher morbidity and mortality in newborns than in older infants and children.

Pyloric atresia: 15-year review from a single institution.

BACKGROUND: Pyloric atresia (PA) is a rare pathology. Calder presented the first pyloric atresia case in 1749 and Touroff, Sussman, Meltz, and their colleagues presented the first successful operation in 1940. PA has 3 types of anatomic variations: (1) type A, pyloric membrane or web; (2) type B, the pyloric channel is a solid cord; and (3) type C, in which there is a gap between the stomach and duodenum. Associated anomalies also have been described. Epidermolysis bullosa (EB) and intestinal anomalies occur most often with this condition. METHODS: Charts of 16 cases of congenital PA, aged 1 to 30 days and admitted to our department between 1986 and 2001, were studied retrospectively in regard to sex, prenatal diagnosis, presence of polyhydramnios, time of admission, pathology, type of operation, associated anomalies, and mortality rate. RESULTS: In the study group, the male to female ratio was 5:3, the mean birth weight was 2,312 g and the mean age of admission was 6.5 days. The distribution of the anatomic variations was type A in 9 (56.3%) and type B in 7 (43.7%) of cases. Associated anomalies were present in 7 cases (43.8%). Familial occurrence was a prominent feature of our series. Seven of 16 cases occurred in 3 families. We performed 9 web excisions together with Heineke Mikulicz (H-M) pyloroplasty, 5 atresia excisions and gastro-duodenostomy, and 2 H-M pyloroplasties alone. Stamm gastrostomy was supplemented in 3 cases. The overall mortality rate (n = 9) was 56.3%. CONCLUSIONS: Pyloric atresia can be managed successfully if it is diagnosed early. In this group of patients, congenital anomalies or septicemia are the main causes of mortality.

An infrequent cause of misdiagnosis in esophageal atresia.

Inability to pass an oral tube in infants with esophageal atresia often leads to the diagnosis of this anomaly. This report describes an infant with a delay in diagnosis resulting from initial passage of an oral tube through a distal tracheoesophageal fistula into the stomach.

Tracheostomy in childhood: 20 years experience from a pediatric surgery clinic.

BACKGROUND: There is a limited indication for tracheostomy procedures in pediatric surgery. It is rarely applied to the pediatric patient because they can be kept intubated for a longer duration compared with adults. Problems and complications can occur after tracheostomy, even during the childhood period. PURPOSE: The purpose of this study is to evaluate our experience with tracheostomy procedure. METHODS: Records of 17 children treated over a 20-year period (1978-99) were reviewed retrospectively in the aspects of indication, complication and mortality. RESULTS: There were 13 boys and four girls with a mean age 30.3 months (range: 1 week-13 years). Indications for tracheostomy were prolonged intubation (n = 5), subglottic stenosis (n = 3), general body trauma (n = 2), tracheomalasia (n = 2), tracheoesophageal cleft (n = 1), cervical tumor pressing trachea and larynx (n = 1), congenital myotonic dystrophy plus respiratory failure (n = 1), burn injury of trachea and esophagus (n = 1), and foreign body aspiration (n = 1). In the last decade the number of cases with tracheotomy increased due to the development of new intensive care units, the use of mechanical ventilation and the increasing number of patients needing prolonged ventilation support. In this group, tracheostomies were mainly performed electively. The overall complication rate was 29%. Mortality was 59% and there was one death related to the tracheostomy procedure. CONCLUSION: Tracheostomy is a life saving procedure when performed with an appropriate indication and surgical technique. Therefore, the pediatric surgeons dealing with this procedure should be aware of the tracheostomy care problems, fatal complications and the need for reconstructive surgery. With strict indications and experience of the procedure, this should be enough effort to minimize its complications and related care problems.

An association between mesial temporal lobe epilepsy with hippocampal sclerosis and human leukocyte antigens.

PURPOSE: Mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) is one of the medically intractable epilepsies that may be remediable with surgery. Although the pathogenesis of HS still remains obscure, genetics may play a role as a predisposing factor, with the genetically controlled immune system as one of its aspects. Our aim in this study was to investigate whether there is any association between human leukocyte antigens (HLAs) that are related to chromosome 6 and this specific type of epilepsy. METHODS: HLA class I and II typing were performed with the microlymphocytotoxicity method on 65 Turkish patients with MTLE-HS and on 184 healthy controls. RESULTS: Our study revealed a significantly high frequency of class II antigens HLA-DQ2, -DR4, and -DR7 alleles and the combination of HLA-DR4-DQ2, and DR7-DQ2 alleles. CONCLUSIONS: The HLA alleles that occur with increased frequency in many HLA- associated conditions appear to serve as risk factors that increase susceptibility but are not essential for disease expression. Our data support the role of genetic factors in the development of HS, possibly related to early childhood events that may act as a trigger factor to initiate the cascade in genetically prone patients with specific HLA types to give rise to MTLE eventually.