The outcomes of becoming a pediatric burn center in Turkey.

BACKGROUND: Burns are one of the most important causes of traumatic death in children worldwide. A pediatric burn center was established in our hospital in August 2009. The aim of this study was to compare patient profiles and data before and after the burn treatment center was established. METHODS: Burn patients were admitted to the pediatric surgery department between January 2005 and August 2009, and there was no intensive care service in this department. Intensive care service has been provided since August 2009 with the burn center established at our hospital. The 316 cases that were followed-up at the pediatric surgery department in the first period were identified as Group I and the 442 cases that were admitted to the burn center in the second period were identified as Group II. The data of the groups were then compared. RESULTS: Mean age of the cases was 5.1 years in Group I and 7.7 years in Group II. The total mean body burn percentage was 16.12% in Group I and 17.54% in Group II. Although scalding burns were the most subtype in both groups, flame burns were 2.13 times, electrical burns 3.44 times, flame+inhalation burns 8.33 times, and burns with an over 40% total burn surface area were 2.41 times more common in Group II than in Group I. The mortality rates were 0% in Group I and 2.26% in Group II. CONCLUSION: Converting to a normal department admitting burn patients in a burn unit format to an actual burn center means more severe cases will be admitted. This requires a patient and attentive process while the burn team struggles with the new patient profile on one hand and has to learn how to overcome with less personal trauma the loss of patients, a feeling it is unfamiliar with, on the other, which is also an actual training process for the entire burn team.

Decision for surgery in the management of a rare condition, childhood gallbladder polyps, and the role of ultrasonography.

Gallbladder polyps are tumors or tumor-like protrusions of the gallbladder. They are rarely seen in the pediatric age. Most important issue about these mostly incidental lesions is the risk of malignant transformation. Size more than 10 mm is the classicalcutoff for determining this risk, but it is rarely valid in children. Ultrasonography is the method of choice for follow-up, but it rarely demonstrates change of size or malignant transformation. Hereby, we report 6 cases of childhood gallbladder polyps, none of which had a genetic risk factor. Follow-up was uneventful in 4 of them. Two patients had undergone surgery, but none of the lesions were neoplastic. In the follow-up, a single experienced radiologist should handle the patient, in order to prevent inter-observer variation. The cut-off size for deciding surgery should be 10 mm for those cases with genetic background creating malignancy risk (metachromatic leukodystrophy, pancreaticobiliary duct abnormalities, achondroplasia, Peutz-Jeghers syndrome) or with accompanying cholelithiasis, and 15 mm for those without any risk factors to prevent any unnecessary operations.

Clinical experience in hypospadias: results of tubularized incised plate in 496 patients.

OBJECTIVES: To review the tubularized incised plate, a recently popularized technique, and provide outcomes. METHODS: From January 2000 to December 2006, 496 patients underwent the tubularized incised plate technique for hypospadias at our clinic. The patient age range was 6 months to 14 years. The postoperative follow-up time was 2 years (range 6 months to 3 years). The patients underwent the technique as described by Snodgrass, with some small technical modifications. The patients were hospitalized for 10 days postoperatively, with a urethral stent in place. RESULTS: Of the 496 patients, 48 experienced 53 complications. The most frequent complication was meatal stenosis (n = 27, 5%), followed by urethrocutaneous fistula (n = 25, 5%). Dehiscence was noted in 1 patient (0% of 496 patients and 2% of the 48 patients with complications). Initially, the fistula occurrence rate was 11% and 4% for all 496 and the 48 patients with complications, respectively, which had decreased to 3% and 8% in the most recent 3 years. During the study period, some technical modifications have applied, with a resulting decrease in the complication rates. Complications occurred in 48 patients (9%), of whom 25 required surgical repair (5% of 496 patients). CONCLUSIONS: The tubularized incised plate technique is a surgical method that can be applied to most hypospadias anomalies. Increasing clinical experience and minor additions to the technique have enhanced our success with this method.

Is hernial sac removal necessary? Retrospective evaluation of eight patients with Morgagni hernia in 5 years.

Eight children with Morgagni hernia were operated between January 2000 and May 2005. Medical records of the patients were evaluated retrospectively. Ages of the patients were between 3.5 months and 9 years. The diaphragmatic defect was on the right in all patients except one. One patient had bilateral diapragmatic hernia. All of the patients were operated by abdominal approach. All patients had hernial sacs. During operation sac of hernia was everted to peritoneal space without removal and the defect was closed by using nonabsorbable material. There was no intraoperative complication. The patients were discharged on the sixth day in uneventful condition. There was no complication or recurrence during follow up. Excision of sac of hernia is recommended in majority. Most of the published studies favour the removal of hernial sac. In our practise, in the treatment of Morgagni hernia we did not remove the hernia sac during the last 5 years.

Eventration of the diaphragm.

OBJECTIVE: Eventration of the diaphragm (ED) is defined as the abnormal elevation of the diaphragm. Although asymptomatic ED may be amenable to conservative treatment, symptomatic ED in children, either congenital or acquired, may require surgical treatment. This study evaluated the results of diaphragmatic plication in children with unilateral ED. METHODS: Fifteen patients who had undergone diaphragmatic plication for ED between 1997 and 2003 were evaluated retrospectively. The diagnosis of ED was established by routine chest radiographs and fluoroscopy. Patients who failed to respond to nonoperative treatment were referred for surgery. Nine patients underwent diaphragmatic fluoroscopy 1-5 years following plication to assess function. RESULTS: Indications for diaphragmatic plication were respiratory symptoms such as tachypnoea, dyspnoea, recurrent pneumonia and failure to thrive. In 14 patients, the position of the diaphragm was normal after plication, but the diaphragm was elevated without symptoms in one patient during postoperative follow-up. The motion of the diaphragm was investigated in nine patients. Fluoroscopic studies showed that the operated hemidiaphragm was immobile and there was no paradoxical motion. No return of symptoms was found during follow-up. CONCLUSION: ED is the abnormal elevation of the diaphragm as a result of paralysis or aplasia of the muscular fibres. The abnormally elevated diaphragm may compress the ipsilateral lung, and with respiratory effort the mediastinum may shift towards the normal side. Therefore, diaphragmatic plication is performed to restore normal pulmonary parenchymal volume by replacing the diaphragm in its normal location. After plication, there was immediate remission of symptoms in most patients and decreasing symptoms were observed for a year in others. During follow-up, the location of the diaphragm was normal and no paradoxical movement was observed. Relapse of symptoms was not noted in patients with immobile diaphragms.

Early bougienage for relief of stricture formation following caustic esophageal burns.

Accidental ingestion of corrosive substances remains a major health hazard in children. Most infants and children who ingest caustic substances present with very few symptoms or signs. Approximately 40% of caustic substance ingestions result in esophageal injury, but the optimal management of caustic esophageal burns remains controversial, with different treatment modalities in use. The aim of this study was to compare the results of prophylactic early bougienage with dilatation that was begun after stricture development. We retrospectively analyzed the management of 125 pediatric cases of corrosive substance ingestion. For children seen primarily at our institution, initial management consisted of prompt endoscopy. Of 125 children admitted with a history of caustic substance ingestion, 54 were found to have esophageal burns, and 32 underwent treatment for stricture formation. Patients with severe injury were divided into two groups: In group A, consisting of 20 patients, prophylactic early dilatation had been done. In the eight patients in group B, dilatation had begun after stricture development. The strictures had resolved after 6 months of dilatation in patients initially treated with prophylactic early bougienage, whereas in patients in whom dilatation began after stricture development, stricture resolution did not occur for more than a year. The goal of initial treatment is to avoid stricture formation. Although early dilatations do not eliminate stricture formation completely, the stricture can resolve more easily with early bougienage.

Cystic partially differentiated nephroblastoma. A case report.

Cystic partially differentiated nephroblastoma is a rare cystic renal neoplasm of infancy. It should be distinguished from solid Wilms' tumor with cystic change. Nephrectomy with a careful follow-up is the only adequate therapy for grade 1 tumor.