Child Migrant Health: The Role of Pediatric Surgery in the Migrants' Route across Balkan Countries to North-West Europe.

INTRODUCTION: Child migrants are the most vulnerable population, prone to various health conditions due to trauma and the bad living conditions that they experience during their migration. The objective of this study was to determine the pediatric surgical conditions of migrant children treated in our hospital on their way toward North-West Europe. MATERIALS AND METHODS: A retrospective analysis was performed on all admitted migrants in one tertiary and one secondary level hospital from 2016 to 2018. Only migrant children with surgical issues who had been hospitalized or treated in outpatient clinics were included in the study. RESULTS: There were 47 migrants admitted to hospitals and outpatient clinics; 32 from Afghanistan, 11 from Iraq, 1 from Syria, 2 from Iran, and 1 from Algeria. There were 27 boys and 20 girls, average age 7.96 years (range: 3 months-17 years). The average length of hospitalization was 14.1 days (range: 1-48), and average stay in the intensive care unit (ICU) was 7.4 days (range: 1-15). There were 29 migrants treated in outpatient clinics, and 18 were hospitalized. The cause of seeking surgical treatment was trauma in 33 and non-traumatic surgical problems in 14. The most common types of trauma were isolated fractures which occurred in one, followed by isolated head injury in eight. Polytrauma occurred in five. A lethal outcome occurred in one 9-year-old boy from Afghanistan due to severe polytrauma. CONCLUSION: Trauma, predominantly fractures and head injuries, was the leading cause of morbidity in migrant children treated in these two hospitals.

Are Interferential Electrical Stimulation and Diaphragmatic Breathing Exercises Beneficial in Children With Bladder and Bowel Dysfunction?

OBJECTIVE: To evaluate the effects of interferential current (IC) stimulation and diaphragmatic breathing exercises (DBEs) in children with bladder and bowel dysfunction. PATIENTS AND METHODS: Seventy-nine children with dysfunctional voiding and chronic constipation who were failures of primary care interventions were included in the prospective clinical study. All the children were checked for their medical history regarding lower urinary tract symptoms and bowel habits. Physical examination, including abdominal and anorectal digital examination, was performed. Children kept a bladder and bowel diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys, and uroflowmetry with pelvic floor electromyography. Eligible children were divided into 3 groups (A, B, and C). All groups were assigned education and behavioral modifications. Additionally, group A underwent DBEs and IC stimulation, whereas group B received only DBEs. The treatment was conducted for 2 weeks in the clinic in all 3 groups,. The behavioral modifications and DBEs were continued at home for 1 month. Clinical manifestations, uroflowmetry parameters, and postvoided residual urine were analyzed before and after 6 weeks of therapy. RESULTS: After the treatment, significant improvement in defecation frequency and fecal incontinence was noticed only in group A (P < .001 and P < .05, respectively). These children demonstrated significant improvement in lower urinary tract symptoms and postvoided residual urine (P < .001 and P < .05, respectively). Bell-shaped uroflowmetry curve was observed in 73.3% of group A patients (P < .001). CONCLUSION: IC stimulation and DBEs are beneficial in chronically constipated dysfunctional voiders. Further trials are needed to define the long-term effects of this program.

Scaphoid fractures in children.

INTRODUCTION: Scaphoid fractures are rare in childhood. Diagnosis is very difficult to establish because carpal bones are not fully ossified. In suspected cases comparative or delayed radiography is used, as well as computerized tomography, magnetic resonance imaging, ultrasound and bone scintigraphy. Majority of scaphoid fractures are treated conservatively with good results. In case of delayed fracture healing various types of treatment are available. OBJECTIVE: To determine the mechanism of injury, clinical healing process, types and outcome of treatment of scaphoid fractures in children. METHODS: We retrospectively analyzed patients with traumatic closed fracture of the scaphoid bone over a ten-year period (2002-2011).The outcome of the treatment of"acute"scaphoid fracture was evaluated using the Mayo Wrist Score. RESULTS: There were in total 34 patients, of mean age 13.8 years, with traumatic closed fracture of the scaphoid bone, whose bone growth was not finished yet. Most common injury mechanism was fall on outstretched arm--76% of patients. During the examined period 31 children with "acute" fracture underwent conservative treatment, with average immobilization period of 51 days. Six patients were lost to follow-up. In the remaining 25 patients, after completed rehabilitation, functional results determined by the Mayo Wrist Score were excellent. CONCLUSION: Conservative therapy of "acute" scaphoid fractures is an acceptable treatment option for pediatric patients with excellent functional results.

Multicenter survey of endoscopic treatment of vesicoureteral reflux using polyacrylate-polyalcohol bulking copolymer (Vantris).

OBJECTIVE: To evaluate an outcome of endoscopic correction of vesicoureteral reflux (VUR) using Vantris (Promedon, Cordoba, Argentina) in terms of its effectiveness and morbidity in a multicenter study. MATERIALS AND METHODS: From 2009 to 2013, 611 patients (210 boys and 401 girls) with a mean age of 3.56 years (range, 1 month-18 years) were treated at 7 centers worldwide endoscopically with Vantris injection. VUR was unilateral in 413 and bilateral in 198 patients comprising 809 renal refluxing units (RRUs). Of these, primary VUR was present in 674 RRUs (83.3%) and 135 (16.7%) were complex cases. Reflux was grades I-V in 24 (2.96%), 123 (15.2%), 451 (55.8%), 158 (19.5%), and 53 (6.6%) RRUs respectively. The follow-up continued from 6 to 54 months. RESULTS: Reflux resolved in 759 RRUs (93.8%) after first Vantris injection, in 26 (3.1%) after second, and in 6 (0.7%) after third injection, respectively. VUR improved to grade I after 1 or 2 injections in 5 ureters (0.6%), which needed no further treatment. Thirteen ureters (1.6%) failed endoscopic correction and required ureteral reimplantation. Vesicoureteral junction obstruction requiring ureteral reimplantation developed in 6 ureters (0.7%) and in 4 (0.5%) required stent insertion. Twenty-three patients (3.8%) suffered afebrile urinary tract infection. Seven (1.2%) developed febrile urinary tract infection. None of the studied patients demonstrated VUR recurrence on voiding cystourethrography. CONCLUSION: The results of this multicenter survey confirm that endoscopic subureteral Vantris injection is a simple, safe, and effective outpatient procedure for treating all grades of VUR.

Scintigraphy evaluation of the types of functional constipation in children with bowel bladder dysfunction.

PURPOSE: To evaluate the types of constipation according to colonic transit time in chronically constipated children with dysfunctional voiding (bowel bladder dysfunction, BBD group) and to compare the results with transit type in children with chronic functional constipation without urinary symptoms (constipation group) and children with normal bowel habits, but with lower urinary tract symptoms (control group). PATIENTS AND METHODS: One-hundred and one children were included and their medical histories were obtained. The BBD group kept a voiding diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys and uroflowmetry with pelvic floor electromyography. Radionuclear transit scintigraphy was performed in all children according to a standardized protocol. Patients were categorized as having either slow-transit (ST), functional fecal retention (FFR) or normal transit. RESULTS: FFR was diagnosed in 31 out of 38 children with BBD, and 34 out of 43 children in the constipation group. ST was found in seven children with BBD, compared with nine children in the constipation group. The control group children demonstrated normal colonic transit. Urgency, daily urinary incontinence and nocturnal enuresis were noted only in children with FFR. Both children with ST constipation and FFR complained of difficulties during voiding, voiding postponement and urinary tract infections. CONCLUSIONS: FFR is the most common form of constipation in children with dysfunctional voiding. However, some children might suffer from ST constipation. Differentiation between these two types of constipation is clinically significant because they require different treatment. Future studies with larger numbers of patients are needed to confirm the noted differences in urological symptoms in these two groups of constipated children..

Intestinal obstruction in children: could it be congenital abdominal bands?

Chronic abdominal pain is the most commonly seen condition in the pediatric population. Many causes can be successfully managed by conservative treatment; nevertheless, surgical intervention is sometimes inevitable. Among many surgical conditions, such as appendicitis as the most frequent cause, one is also to think about congenital abdominal bands. We report a case of a 10-year-old boy with chronic abdominal pain, who suddenly developed clinical and radiologic signs of intestinal obstruction. The cause of chronic abdominal pain as well as the intestinal obstruction was revealed during the operation: 2 congenital abdominal bands, trapping the gut convolutes. To our knowledge, this is the first report of 2 bands in a single patient.

Ectopic adrenocortical tissue: an incidental finding during inguinal surgery in children.

Adrenal rests are usually unrecognized during operation, and the incidence of ectopic adrenal cortical tissue in pediatric patients during inguinal surgery procedures is unknown. We performed 3028 groin surgical explorations in 2680 patients aged 1 month to 17 years. Ectopic adrenal tissue was found in 69 inguinal operations (2.2%): 37 during 1.524 orchiopexy (2.4%), 23 during 1.115 herniectomy (2.0%), and 9 during 389 hydrocoela operation (2.3%). Statistically there were no significant differences among those three groups. No adrenal rests were detected in females. Although a few reported cases with hormonal activity of ectopic adrenocortical tissue (EACT), the recommendation is to remove them if found.

Gigantic ureteral diverticulum or pelvic cyst?

Ureteral diverticulum is a rare anomaly, and very few reported cases concerning it can be found in literature. We report a 3.5-year-old boy who presented with urinary tract infection, rare voiding, and straining during voiding. Ultrasonography and magnetic resonance imaging showed a cystic pelvic mass. At surgical intervention, however, a massive ureteral cystic structure communicating both with the ureteropelvic and ureterovesical portion of the ureter was observed. Finding the presence of a smooth muscle layer, the pathologist confirmed this to be a true diverticulum. The fact that fenoterol (which was used for the prevention of preterm labor in the boy's mother) significantly decreases frequency and amplitude of upper urinary tract contractions suggests that fenoterol treatment might have influenced the occurrence of this abnormality.

[Evaluation of using Alvarado score and C-reactive protein in diagnosing acute appendicitis in children].

BACKGROUND/AIMS: Acute appendicitis (AA) remains a diagnostic challenge in children, despite ongoing researches. With an aim to facilitate making diagnosis of AA many scoring systems have been created; among them Alvarado score is the most popular. C-reactive protein (CRP) has proven significance for diagnosing AA in adults, but not in children. The aim of this study was to evaluate significance of Alvarado score, as well as CRP values, in making diagnosis of AA in children. METHODS: This prospective six-month study was performed on 257 patients under the age of 15, admitted for acute abdominal pain in the Clinic of Pediatric Surgery and Orthopedics in the Clinical Centre of Nis. Alvarado score and CRP values were determined on admission and compared with final diagnosis on discharge. The patients were divided into two groups: group I--non operated patients with abdominal pain (n=184) and group II--operated on patients for appendectomy (n=73). RESULTS: Values of Alvardo score were statistically significantly different between groups (group I: 4.9 +/- 1.21, group II: 8.55 +/- 1.32). Also, our results showed significantly high values of CRP measured in operated children (group I: 8.17 +/- 4.7 mg/L, group II: 38 +/- 26 mg/L). Values of validity parameters for Alvarado score were: sensitivity 90%, specifity 80%, positive predictive values 87%; for CRP 95%, 70% and 80%, respectively. CONCLUSION: Alvarado score and CRP are very useful adjuvant diagnostic tool for AA to a less experienced surgeon. High values of Alvarado score and CRP cannot be ignored neither at the same time, used as the sole diagnostic method for discriminating children with AA.

[Peripheral nerve blocks in paediatric anaesthesia].

INTRODUCTION: Most children undergoing surgery can benefit from regional anaesthetic techniques, either as the sole anaesthetic regimen or, as usual in paediatric practice, in combination with general anaesthesia. The use of peripheral nerve blocks (PNBs) in paediatric anaesthesia is an effective way to decrease the side-effects and complications associated with central blocks. In spite of their many advantages, including easy performance end efficacy, peripheral nerve blocks are still underused. OBJECTIVE: This article discusses a general approach to PNBs in children and provides data concerning the practice of this regional technique in different age groups. METHODS: Data from 1,650 procedures were prospectively collected during the period from March 1, 2007 to February 29, 2008. The type of PNB, if any, as well as the patient age were noted. Our patients were divided into four groups: 0-3 years, 4-7 years, 8-12 years and 13-18 years. RESULTS: During the investigated period, PNBs as a sole technique or in anaesthetized children were performed in 7.45% of cases. Ilioinguinal/iliohypogastric nerve block and penile block were the most common (70% of all PNBs) distributed mainly among the children between 4-7 years of age (p < 0.05). In older children, extremity PNBs predominate in regard to other types of blocks. PNBs are most frequently performed under general anaesthesia (85%), so the perineural approach requires a safe technique to avoid nerve damage. CONCLUSION: The observed differences in PNB usage seem to be related to patient age and correlate with common pathology and also with technical availability of PNB performance.

Botulinum toxin type A in combination with standard urotherapy for children with dysfunctional voiding.

PURPOSE: We investigated the role of botulinum toxin type A and urotherapy in the treatment of children with dysfunctional voiding. MATERIALS AND METHODS: Nine female children with dysfunctional voiding refractory to standard urotherapy and alpha1-adrenergic blocking agents were included in the prospective clinical study. Botulinum toxin type A in a dose of 500 units was injected transperineally into the external urinary sphincter. Bladder rehabilitation was introduced 2 weeks after botulinum toxin type A treatment. Uroflow studies with ultrasound residual urine volumes were obtained before and 6 months after treatment. All children were tested before and 6 months after treatment using the empirically designed International Reflux Study in Children modified questionnaire. RESULTS: After treatment the mean +/- SD voided volume increased from 180 +/- 73 to 228 +/- 94 ml (p <0.05) while post-void residual urine volume decreased from 52 +/- 40 to 19 +/- 18 ml (p <0.05). Significant differences in other uroflowmetry parameters were not found. However, significant symptom score improvement was detected 6 months after treatment, being decreased by 7 vs 20 (p <0.01). No systemic side effects occurred following botulinum toxin type A injection. CONCLUSIONS: Our study demonstrates that the voiding mechanism in children with dysfunctional voiding refractory to standard therapy can be significantly improved and maintained at least 6 months after combined botulinum toxin type A injection and bladder rehabilitation.

[Functional voiding disorders: rehabilitation of children with urge syndrome].

Urge syndrome is a condition associated with functional voiding disorders. Urological symptoms (urgency, frequency and incontinence) are manifestations of uninhibited detrusor contractions. The goal of rehabilitation programs is to develop voluntary bladder control, to improve urologic symptoms and to increase bladder capacity. Bladder training, strategies to suppress urgency, electrical stimulations such are anogenital, transcutaneous and percutaneous electrical nerve stimulations have been used in the treatment.

[Transverse testicular ectopia]. / Transverzalna ektopija testisa.

Transverse testicular ectopia is an extremely rare anomaly, characterized by migration of one testis towards the opposite inguinal canal, usually associated with inguinal hernia. Spermatic cord of the ectopic testis originates from the appropriate side. In most reported cases, the accurate diagnosis has not been made before surgery. This is a case report of transverse testicular ectopia in eleven-year-old boy who had undergone an operation for the left inguinal hernia in age of ten months. At the time of herniorrhaphy, the right testis was absent. Ten years later, during re-operation of the left inguinal hernia, both testis were found in left inguinal canal and easily brought down sequentially through the left groin into the scrotum. The right testis was fixed in the left hemiscrotum, due to shorter funicular elements, and the left was trans-septally moved to the right hemiscrotum (a modified Ombrédanne operation). Ultrasonography and voiding cystoureterography showed no associated genitourinary anomalies and no Mülerian duct remnants. The rupture of gubernaculum and dysfunction of the genitofemoral nerve could explain the etiology of crossed testis ectopia. Although ectopic testis could be localized preoperatively by ultrasonography, CT, MRI, arteriography and venography, correct diagnosis was made intraoperatively in the majority of cases. Treatment modalities include laparoscopic and surgical procedures. Atrophic testis should be removed. If testes are fused, they have to be brought into one hemiscrotum. In cases where testes are completely separated with individual funicular elements and vas deferens, an ipsilateral or contralateral orchiopexy should be performed depending on the length of funicular elements.

Extracorporeal shock wave lithotripsy for cystine urolithiasis in children: outcome and complications.

The Siemens Lithostar Litotriptor was used to treat 6 children with cystine nephrolithiasis, previously treated by open surgery. Five children had renal calculi (3 multiple caliceal, 2 pelvis) and one had ureteral calculus. Stone size ranged from 0.2-2.5 cm in diameter, and stone burden was from 0.24 to 10.81 cm3 per kidney. From one to 4 ESWL sessions per unit were applied, with a total of 1,800 to 12,000 shock waves. The stone free rate at 3 months was 50%. A complete elimination was obtained with cystine stones in renal pelvis and ureter, however, up to 4 ESWL treatments failed in caliceal stones. Rather location of cystine calculi than previous surgery was associated with ESWL success rate. Two patients with positive urine cultures were successfully treated with appropriate antibiotics before ESWL was attempted. Perirenal hematoma was major complication demonstrated by radionuclide scintigraphy in one patient, and resolved spontaneously by 3 months. In the combined treatment of cystine urolithiasis in children ESWL, as auxillary procedure, was safe and effective in pelvis stone but failed in caliceal stones. Medical dissolution for retained fragments was found effective.