Presenting clinical features and outcome in intussusception.

OBJECTIVE: To evaluate if a correlation exists between the clinical and radiologic characteristics at presentation; and the success of conservative management, morbidity and outcome of patients with intussusception. METHODS: All patients (total 179) treated for intussusception in our unit between 1993 and 2003, were retrospectively reviewed to find out the effects of physical examination (general appearance, consciousness, body temperature, abdominal distention and tenderness, blood on rectal examination), laborat (leukocyte count) and radiologic (air-fluid level on X-ray, free abdominal fluid on ultrasonography) findings on selection of first step therapeutic modality, conservative management (reduction with barium or air) success rate and surgical complication (serosal defect, intestinal perforation) rate. Additionally, the patients were subdivided into three subgroups as group A (patients for whom surgical management was performed primarily), group B (the ones who were operated after failure of reduction attempt with barium or air), group C (patients who had successful conservative reduction). These groups were compared within each other with regard to duration of nasogastric suction, antibiotic therapy; onset of oral feeding and duration of hospitalization. The chi-square, Kruskal-Wallis and ANOVA tests were used for the statistical analysis and p value less than 0.05 was considered to be significant. RESULTS: Incidence of selecting conservative treatment primarily was lower in patients with toxic appearance (p=0.02) and with free fluid on ultrasonography (p=0.007). Success rate of conservative treatment was lower in patients with moderate general appearance (p=0.000), lethargy (p=0.011), blood on rectal examination (p=0.004), air-fluid level on X-ray (p=0.039), free fluid on ultrasonography (p=0.001). Surgical complication rate was higher in patients with moderate general appearance (p=0.000), lethargy (p=0.007), air-fluid level on radiograph (p=0.009). In group A; the duration of N/G suction, antibiotic therapy and hospitalization was longer; the onset of oral feeding was later than the other two groups (p=0.000). In group B; the duration of N/G suction, antibiotic therapy and hospitalization was longer; the onset of oral feeding was later than group C (p=0.000). CONCLUSION: Toxic appearance, lethargy and air-fluid level on radiograph not only decrease the success rate of conservative management, but increase the surgical complication rate as well. Thus, these parameters deserve more importance in the management scheme. Reduction with conservative management is the most important factor which decreases the morbidity. Morbidity is lower in cases who are operated after failure of conservative management than the ones for whom surgery is performed primarily. Thus, conservative management should be tried for all patients unless there is a clear cut contraindication such as peritonitis and/or pneumoperitoneum.

Do radiologic studies correlate with each other and with surgical findings in intussusception?

In this research, we aimed to evaluate the accordance of radiologic study results with each other and with surgical findings with regard to presence and/or absence of intussusception. One hundred and seventy-nine patients treated for intussusception between 1993 and 2003 inclusive were retrospectively reviewed to compare results of initial ultrasonography, colonography, followup ultrasonography after conservative management (reduction with barium enema and/or air insufflation) and surgical findings to determine their accordance within each other with regard to diagnosis of intussusception. Results of initial ultrasonography were not in accordance with results of colonography. There was accordance between conservative management and follow-up ultrasonography results. Conservative management results were not in accordance with surgical findings. There was no accordance between followup ultrasonography results and surgical findings. Discordance of radiologic examination results with each other and with surgical findings indicates that intussusception is still a clinical diagnosis and clinical parameters deserve more importance in surgical decision-making. Radiologic examinations should be considered as complementary studies, not as definitive discriminators of childhood intussusception to achieve appropriate diagnosis and treatment.

Endoscopic treatment of vesicoureteral reflux in children: our experience and analysis of factors affecting success rate.

AIM: To clarify the factors affecting the success rate of endoscopic subureteral injection (ESI) treatment of vesicoureteral reflux (VUR). METHOD: All patients who had ESI treatment for VUR at our unit between 1999 and 2002 were retrospectively reviewed with regard to age, gender, causes of VUR, reflux grade, type of injected materials, number of injections, results of cystourethrograms (VCUG), and outcome. The injected implants were gluteraldehyde cross-linked bovine collagen (GclBC), dextranomers in sodium hyaluronan (DiSH) and calcium hydroxylapatite (CH). A successful result was defined as absence of VUR confirmed by VCUG performed 3 months after the ESI procedure. Basic descriptive statistics were performed along with the chi(2) test (p < 0.05 was significant). RESULTS: 50 children (81 ureters) consisting of 27 girls (43 ureters) and 23 boys (38 ureters) with a mean age of 7.4 +/- 4.6 years constituted the study group. Grade III VUR was the most prominent grade (42%, 34 ureters) noted in all age groups. There was no significant difference between boys and girls with regard to the number of each grade of VUR. The success rate of first ESI procedure was 55.6% and was similar in each grade of VUR varying from 50 to 66%. Repeated injections have resulted in an overall success rate of 84%. No significant difference was noted between the age groups with regard to the success rate of ESI. Repeated ESI procedures were found to be unsuccessful in grade V VUR when compared to other grades (p < 0.05).There was a significant difference between primary reflux (76.5%, 62 ureters) and exstrophic (21%, 17 ureters) patients with regard to the grade of VUR and success rate of ESI. Exstrophic patients presented with a higher incidence of grade V VUR (41%) and with a lower success rate of ESI (64.7%). DiSH was the most commonly used agent (47 ureters) followed by CH (22 ureters) and GclBC (12 ureters). The success rates of the ESI procedure by each material were 91.5, 81.8, and 58.3%, respectively. No significant difference was noted between DiSH and CH. Low success rates by GclBCwere attributed to less usage of the material. 82% of the ESI procedures were done by surgeon A (49 ureters) and B (18 ureters) with a success rate of 96 and 72%, respectively. No significant difference was noted between A and B with regard to the success rate and type of injected material and the success rate in each grade of VUR (p > 0.05). No untoward effects were noted in short- and long-term follow-up (mean 4 +/- 1.2 years) of any patient. CONCLUSION: The ESI procedure provides a high success rate for the treatment of VUR which decreases in grade V VUR and presence of exstrophia vesica. Single injection of various materials has been found to be successful in most of the patients with grade II VUR, whereas grade IV and III patients have required repeated injections which have resulted in 100 and 94% success rates, respectively. Grade I VUR can be managed by close follow-up and appropriate antibiotic therapy without any surgical and/or endoscopic intervention. Patients presenting with grade V VUR should undergo open surgery if the first trial of ESI procedure results in failure as repeated injections have proved to be unsuccessful in this grade. The success rate of the ESI procedure does not seem to be affected by the type of injected material and different surgeons performing the procedure after achieving the learning curve.

Histological response to injected dextranomer-based implant in a rat model.

To investigate the short and long term histopathological alterations caused by submucosal injection of dextranomers in sodium hyaluronan (DiHA) based on an experimental rat model. Sixty Sprague-Dawley rats were assigned into two groups as group I and II, each containing 30 rats. Totally 0.1 ml of saline solution and 0.1 ml of DiHA were injected into the submucosa of bladder of first (control) and second groups, respectively. Both group I and II were further subdivided into three other groups as Group IA, IB, IC and Group IIA, IIB, IIC according to the sacrificial period. Group IA and IIA, IB and IIB, IC and IIC rats (ten rats for each group) were sacrificed 3, 6, and 12 months after surgical procedure, respectively. Two slides prepared from injection site of the bladder were evaluated completely for each rat by being unaware of the groups and at random by two independent senior pathologists to determine the fibroblast invasion, collagen formation, capillary growth and inflammatory reaction. Additionally, randomized brain sections from each rat were also examined to detect migration of the injection material. The measurements were made using an ocular micrometer at 10x magnification. The results were assessed using t-tests for paired and independent samples, with P<0.05 considered to indicate significant differences; all values were presented as the mean (SD). Migration to the brain was not detected in any group. Significant histopathological changes in the DiHA injected groups were granuloma formation in 43.3%, foreign body type giant cells in 76.6%, inflammatory infiltration in 100%, and fibroblasts surrounding microspheres in 100% of the rat bladder. The interaction between granuloma formation and long-term tissue effects in children is still obscure. We emphasize that further prospective human (and/or animal) studies are required to clarify the long-term effects of granuloma formation with regard to clinical applications.

Isodicentric Y (p11.32) chromosome in an infant with mixed gonadal dysgenesis.

Among the structural abnormalities affecting the human Y chromosome, dicentric chromosomes are the most common. A wide spectrum of phenotypes of patients with a dicentric Y chromosome exists, ranging from almost males through mixed gonadal dysgenesis to females with Turner syndrome. Here, we describe an infant with mixed gonadal dysgenesis and mosaic karyotype 45,X/46,X,idic(Y)(qter-->p11.32:p11.32-->qter)/47,X,+2idic(Y) (qter-->p11.32:p11.32-->qter)/47,XYY. This was demonstrated by fluorescence in situ hybridization (FISH) analysis with whole Y chromosome painting (WCP-Y) probe. Molecular studies were performed on genomic DNA extracted from peripheral blood lymphocytes. To examine the sex determined region (SRY), azoospermia factor (AZF) region and deletion in azoospermia gene (DAZ), polymerase chain reaction (PCR) analyses were done with sequence-tagged site (STS) primers of 20 loci along the Y chromosome (SRY, DYS271, DYS148, DYS273, KALY, DYS212, SMCY, DYS215, DYS218, DYS219, DYS221, DYS223, DYS224, DYF51S1, DYS236, DAZ, DYS240), and all tested loci were found positive. Because of the possibility of a mutation in the SRY gene, we analyzed the PCR fragment by DNA sequencing and did not observe any mutation or nucleotide alteration. We present detailed molecular-cytogenetic characterization of a patient with idic(Y)(p11.32), and results are discussed with the previously described patients. As far as we know, this is the fifth report of a 46,X, idic(Y)(p11.32) karyotype and the first presentation with mixed gonadal dysgenesis and isodicentric Y. Since the correlation between phenotype and karyotype is not yet well defined, the clinical reports will be helpful in defining the phenotypic range of this chromosomal abnormality.

Histological response to injected gluteraldehyde cross-linked bovine collagen based implant in a rat model.

BACKGROUND: The aim of present study is to investigate the short and long term histopathological alterations caused by submucosal injection of gluteraldehyde cross-linked bovine collagen based on an experimental rat model. METHODS: Sixty Sprague-Dawley rats were assigned into two groups as group I and II each containing 30 rats. 0.1 ml of saline solution and 0.1 ml of gluteraldehyde cross-linked bovine collagen were injected into the submucosa of bladder of first (control) and second groups, respectively. Both group I and II were further subdivided into 3 other groups as Group IA, IB, IC and Group IIA, IIB, IIC according to the sacrification period. Group IA and IIA, IB and IIB, IC and IIC rats (10 rats for each group) were sacrificed 3, 6, and 12 months after surgical procedure, respectively. Two slides prepared from injection site of the bladder were evaluated completely for each rat by being unaware of the groups and at random by two independent senior pathologists to determine the fibroblast invasion, collagen formation, capillary ingrowth and inflammatory reaction. Additionally, randomized brain sections from each rat were also examined to detect migration of the injection material. The measurements were made using an ocular micrometer at x10 magnification. The results were assessed using t-tests for paired and independent samples, with p < 0.05 considered to indicate significant differences; all values were presented as the mean (SD). RESULTS: Migration to the brain was not detected in any group. Significant histopathological changes in the gluteraldehyde cross-linked bovine collagen injected groups were fibroblast invasion in 93.3%, collagen formation in 73.3%, capillary ingrowth in 46.6%, inflamatory reaction in 20%. CONCLUSION: We emphasize that the usage of gluteraldehyde cross-linked bovine collagen in children appears to be safe for endoscopic treatment of vesicoureteral reflux.

Paratesticular metastasis from Wilms tumor associated with a hydrocele.

Metastatic sites other than the lungs, lymph nodes, and liver are unusual for Wilms tumor (WT). Intra-scrotal metastasis is very rare. We report a 3-year-old boy with stage IIA WT, who experienced paratesticular metastasis 2 months after surgery for an abdominal recurrence. He had right scrotal hydrocele at initial diagnosis. The patient underwent right radical orchiectomy, and pathological examination revealed paratesticular WT metastasis. Intra-abdominal and peritoneal disseminated metastases followed. We considered that tumor cells spread through the patent processus vaginalis and grew at paratesticular space in hydrocele. One month after the end of 12 months of salvage chemotherapy and abdominal radiotherapy, the patient has no evidence of disease.

Waardenburg syndrome associated with bilateral renal anomaly.

A 1-year-old girl with Waardenburg syndrome type I presented with double collecting system of left kidney accompanied by nonobstructive hydronephrosis of lower pole and by ureteropelvic junction obstruction of right kidney. Renal involvement in Waardenburg syndrome was reported once in a 4-month-old boy with unilateral duplication of the renal collecting system and in a 16-day-old girl who had right multicystic dysplastic kidney and hydronephrosis in the left kidney. The third case of renal involvement in Waardenburg syndrome is presented here, with special emphasis on early diagnosis and management of renal anomaly. The authors conclude that urinary system anomalies should also be considered in the wide spectrum of Waardenburg syndrome clinical features to avoid life-threatening complications.

Calcifying fibrous pseudotumor of lung: a previously unreported entity.

Calcifying fibrous pseudotumor (CFP) is one of the most unusual benign tumors of childhood and is located mostly in soft tissues, pleura, and peritoneum. The first case of pulmonary CFP in a 7-year-old boy is presented. The clinicopathologic features of this rare entity are discussed with special emphasis on histopathologic features and prognosis including a brief literature review. There are no presumptive clinical and laboratory findings, including tumor markers and imaging techniques, that distinguish CFP from other space-occupying lung lesions. The most important diagnostic aid is to bear this entity in mind when a child presents with an unexplained pulmonary mass. Total excision is mandatory for the appropriate diagnosis and treatment.

CT virtual bronchoscopy in the evaluation of children with suspected foreign body aspiration.

OBJECTIVE: Computed tomography (CT) virtual bronchoscopy is a noninvasive technique that provides an internal view of trachea and major bronchi by three-dimensional reconstruction. The aim of this study was to investigate the usefulness of virtual bronchoscopy in the evaluation of suspected foreign body aspiration in children. MATERIALS AND METHODS: Twenty-three children (12 girls, 11 boys) with a mean age of 2.4 years (8 months-14 years) who were admitted to emergency room with a suspicion of foreign body aspiration were included in this study. Chest radiograms, spiral computed tomography scans and virtual bronchoscopy images were obtained. Then, rigid bronchoscopy was performed within 24 h. RESULTS: CT virtual bronchoscopy and conventional bronchoscopy revealed the location of the foreign body in seven patients. It was in the right main bronchus in four patients, in the right lower lobe bronchus in one patient, and in the left main bronchus in two patients. There was no discordance between two modalities. CT examination revealed hyperaeration of the ipsilateral lung in four patients, hyperaeration of the ipsilateral lung and mediastinal shift in one patient and bronchiectatic changes in one patient. CT detected no additional finding in one patient with a foreign body in the right main bronchus. In 10 of 16 patients without foreign body, CT examination demonstrated atelectasis, infiltration, peribronchial thickening, and paratracheal lymphadenpoathy. CONCLUSION: Helical CT scanning with virtual bronchoscopy should be performed in only selected cases with suspected foreign body aspiration. When the chest radiograph is normal and the clinical diagnosis suggests aspirated foreign body, helical CT and virtual bronchoscopy can be considered in order to avoid needless rigid bronchoscopy.

Ureteropelvic junction obstruction causes histologic alterations in contralateral kidney.

BACKGROUND/PURPOSE: Ureteropelvic junction (UPJ) obstruction causes histologic alterations both in ipsilateral and contralateral kidney. Because these alterations directly affect the fate of renal damage, definition of these alterations is of utmost importance from the clinical point of view. Thus, an experimental study is designed to determine the alterations of renal histology in response to partial and complete UPJ obstruction. METHODS: Fifteen adult female New Zealand rabbits were assigned randomly into 3 groups (each containing 5 rabbits) according to the degree of unilateral UPJ obstruction as group I, sham operation was performed and served as the control group; group II, partial UPJ obstruction was made; group III, complete UPJ obstruction was made. The animals in group I and II were killed after 3 weeks, and animals in group III were killed after 2 weeks. Tissue samples were prepared and processed according to routine light microscopic tissue processing. RESULTS: UPJ obstruction led to glomerulosclerosis, dilatation of proximal and distal tubules of loops of Henle, and dilatation of collecting tubes consistent with necrotic and apoptotic changes in ipsilateral kidneys. Severity of these degenerative changes depended on degree of obstruction. UPJ obstruction also led to histologic alterations on the contralateral kidneys such as glomerular edema, congested blood vessels, dilated tubuli, and necrotic and apoptotic changes in epithelia, which were more prominent in group III than group II. CONCLUSIONS: It is well known that compensating changes including increased blood flow and parenchymal hypertrophy occurs in contralateral kidney as a response to unilateral UPJ obstruction. However histologic findings of this study confirmed progression of parenchymal damage and presence of apoptosis in contralateral kidney for the first time.

Bronchoscopy for evaluation of foreign body aspiration in children.

PURPOSE: The aim of this study was to present the entire spectrum of pediatric bronchoscopy performed for foreign body aspiration (FBA), with emphasis on accuracy of diagnostic tools, technical aspects, and predictors of complications. METHODS: Records of patients who underwent bronchoscopy for evaluation of FBA in our unit from 1991 to 2000, inclusive, were reviewed retrospectively. Age, sex, history of FBA, symptoms, results of radiologic studies, bronchoscopy findings, complications, and outcome were recorded and statistically analyzed to find out the most accurate diagnostic tool. RESULTS: A total of 740 bronchoscopies were done in 663 children (402 boys, 261 girls) presenting with a mean age of 3.1 +/- 0.1 years. FBA was confirmed in 563 (85%) patients, whereas normal bronchoscopic findings, signs of pulmonary infection, and endobronchial mass were noted in 43 (6%), 54 (8%), and 3 (0.4%) patients, respectively. There was significant difference between patients with and without FBA with regard to presence of definite history (91% v 54%), normal physical examination findings (14% v 46%), and normal radiologic findings (13% v 31%). However, none of these parameters or their associations were found to be reliable to predict the presence of FBA or clinical complications. Presence of history was the most sensitive (91%), accurate (84%), and specific (46 %) diagnostic tool. Bronchoscopic removal of-foreign bodies was succeeded in 558 (99%) children. Worsening of respiratory tract infection (n = 13), cardiac arrest (n = 6), laryngeal edema (n = 5), pneumothorax (n = 5), pneumomediastinum (n = 2), tracheal laceration (n = 2), and bronchospasm (n = 2) were the life-threatening complications observed in 21 (4%) patients with FBA and 14 (14%) patients without FBA (P <.05). There were 5 (0.8%) deaths. Of these, 2 patients presented with cardiopulmonary arrest immediately after FBA. Although foreign bodies were removed as quickly as possible, cardiac arrest was irreversible. The remaining 3 patients died of complications of bronchoscopy as irreversible cardiac arrest during bronchoscopy (n = 1) and worsening of respiratory tract infection after bronchoscopy (n = 2). CONCLUSIONS: The third year of the life carries the highest risk for FBA. There are no specific symptoms and signs to make a clear-cut differential diagnosis between FBA and respiratory tract infection. Bronchoscopy is invariably indicated on the basis of reliable history alone even when symptoms are minimal, and imaging studies are negative. Secondary bronchoscopy should be done in patients with persistent signs and symptoms to rule out overlooked organic foreign body particles or to remove persistent granulation tissue to avoid long-term complications necessitating lobectomy. The long duration of the procedure, presence of dense granulation tissue, and type of foreign body are important predictors of complications. Bronchoscopy should be regarded as an expert procedure and done with great care to avoid lethal complications. Differential diagnosis of respiratory tract infection by various diagnostic tools is of utmost important to avoid morbidity and mortality related to needless bronchoscopy.