Testicular torsion: a 15-year single-centre clinical and histological analysis.

AIM: This study reviewed the demographic, epidemiological and clinical factors of boys seen at a single centre who underwent surgical exploration for testicular torsion. METHODS: Retrospective single-centre review of boys with testicular torsion between 1996 and 2011 was made. RESULTS: Testicular torsion (right n = 43, left n = 60, bilateral n = 1) was identified in 104 boys between 0 and 18 years. Ten newborns presented with 11 intrauterine torsions. Nine torsions presented in undescended inguinal testes (one intrauterine). In 94 boys with descended testes, presentation included pain (76%), scrotal swelling (65%) and abdominal symptoms (22%). Ultrasonography was performed in 85 patients with false-negative results in 4 (4.7%). Orchiectomy was performed during initial exploration in 41, with significantly higher rates of orchiectomies in patients with late (>6 h) versus patients with early referrals (<6 h) (56% vs. 9.1%). Histological evaluation was carried out in 68 testes, with 43 resected testes demonstrating haemorrhagic necrosis. In 25 biopsied testes, histology revealed acute parenchymal bleeding (n = 14), onset of parenchymal infarction (n = 8), orchitis (n = 1) and normal tissue (n = 2). Eighty-two patients were followed up with pathological findings in four patients: testicular atrophies requiring orchiectomy (n = 2), testicular autolysis (n = 1) and small testicular vein thrombosis (n = 1). CONCLUSION: Chances of testicular salvage after torsion are higher if patients present early. The majority of patients presenting late (>6 h) require orchiectomy owing to testicular necrosis.

[Traumatic posterior dislocation of the sternoclavicular joint. A case report of joint stabilization with gracilis tendon graft]. / Die traumatische posteriore Luxation im Sternoklavikulargelenk. Fallpräsentation einer Stabilisierung mit Grazilissehnenplastik.

Dislocation of the sternoclavicular joint is an uncommon injury. Especially posterior dislocations with potentially life-threatening complications present a challenging situation for the treating surgeon regarding diagnosis and therapy. Reduction and fixation of the joint is the treatment of choice. We present the case of such an injury in an adolescent judoka who was treated by open reduction and reconstructive surgery using the gracilis tendon graft technique.

Analysis of nonsexual injuries of the male genitals in children and adolescents.

AIM: This study analysed nonsexual male genital injuries in boys with regards to aetiology, age, management and outcome. METHODS: Patients were identified from the hospital database (between 1999 and 2009) were analysed retrospectively. RESULTS: Seventy-four patients (2-17 years) were identified which included 24 toddlers and small children (2-5 years), 36 school age children (6-12 years) and 14 adolescents (13-17 years). Traumas were related to falls (n=14), kicks (n=11), sport (n=10), toilet seats (n=9), motor vehicles (n=8), bicycle (n=4), outdoor activities (n=4) and others causes (n=14). The leading cause of injuries in (i) toddler and small children was related to toilet seat (n=7) and falls (n=7), (ii) school age children to sport (n=8), kicks (n=7) and falls (n=6), and (iii) adolescents to motorcycle accidents (n=5). There were 45 scrotal and 29 penile injuries ranging from lacerations to contusions. Sixty-eight patients required hospital stay (0.5-36 days, Σ=2.4 days). Follow-up examinations were uneventful, except for one minor wound infection. CONCLUSION: Nonsexual traumas to the male external genitalia occur mostly in 6- to 12-year-old boys, with sport accidents, kicks and falls being the major causes. Scrotal and penile lacerations and testicular contusions are the most common injuries. Complications after injuries to the male genitals in children are rare.

Body-image, self-concept and mental exposure in patients with pectus excavatum.

BACKGROUND: Pectus excavatum is the most common congenital anomaly of the sternum and anterior chest wall, which occurs about 3-4 times more often in boys than girls [1]. Although most patients do not report physical symptoms as cardiovascular and respiratory problems, they show a loss of self-esteem and a poor self-image. There exist very rare data about psychological state before the OP compared with data afterwards. OBJECTIVE: This study was conducted to examine psychological changes in body-image, self-concept and mental exposure in patients with pectus excavatum, who had undergone the Nuss procedure. METHODS: Seventeen patients (13 male, 4 female), who underwent 2003 a comprehensive psychological investigation, have been tested again in 2007 by means of the identical questionnaires to get postoperative data: OPE-FB (Wallisch; Operation-Expectation-Questionnaire), FKKS (Deusinger; Frankfurter Body Concept Scales) and SCL-90-R (Derogatis; Symptom Checklist Revised). The mean age at the second time of investigation was 19.6 years (SD = 2.5). The patients were classified into two groups based on a lower (n = 10) and a higher (n = 7) severity index of PE. Parents or a parent person were interviewed about the topics of OPE-FB by a structured interview. Data were analyzed using Mann-Whitney U test and Wilcoxon test. Interview data were evaluated with a content analysis. RESULTS: Nearly all patient's expectations in regard to the beneficial effect of the surgical procedure-investigated with the OPE-FB preoperatively-have been confirmed postoperatively. In patients with a lower severity index impairment in general interest in sports and improvements in self-assurance, health, self-acceptance of one's body and acceptance of one's body by others can be reported. Data from SCL-90-R, measuring mental exposure, had normal range. Interviews with relatives showed, that the external attribution could emphasize patient's data from the OPE-FB. CONCLUSIONS: The long-time follow-up can make us sure, that the Nuss procedure as a physical treatment has positive effects on physical as well as psychological aspects of young adults. The patient's confidence with the cosmetic result was very high, which reflects the excellent effects of the minimal invasive repair according to Nuss.

Mortality and economics in short bowel syndrome.

The incidence of patients with short-bowel syndrome (SBS) has increased over the years due to progress of intensive care medicine and parenteral nutrition techniques. These techniques have significantly improved the prognosis of neonates, children and adults who have lost major parts of their intestinal tract. Long-term survival is possible and does not depend primarily on the length of the remaining bowel but on complications such as parenteral nutrition-associated cholestasis, recurrent septicaemia, central venous catheter infections, and the motility of the remaining intestine. Thus, the overall related mortality in infants with SBS ranges from 15 to 25%, and in adults from 15 to 47%, depending on the age of the patients, the underlying disease, and the duration on total parenteral nutrition. Home parenteral nutrition (HPN) significantly decreases the complication rate and improves the psychological situation of the patient. Additionally, HPN reduces in-hospital cost significantly. Nevertheless, the annual costs/patient are between $100000 and $150000. The mortality rate of SBS patients on HPN is about 30% after 5 years, which is still lower than the 5-year survival rate of intestinal grafts, and it is about equal to patients' survival after intestinal transplantation. However, the overall costs of a successful intestinal transplantation are already lower after 2 years when compared with the cost of a prolonged HPN programme.

Special aspects of neonatal inguinal hernia and herniotomy.

In a retrospective study, we examined 23 pre-term infants (18 boys, 5 girls) with a median weight of 1540 g (range 720-2770 g) and a median age of 32 weeks (range 25-36 weeks) gestation, who were subsequently operated on after a median of 65 days (range 20-121 days) for 33 inguinal hernias. The infants were evaluated with respect to concomitant diseases as well as peri- and postoperative complications. The following surgical procedure was used in all patients: a high suture ligation after excision of the hernia sac, followed by closure of the groin according to Grob in boys, and according to Bassini in girls. Co-morbidity was high in the pre-term infants, both pre- and perinatally. Despite this high co-morbidity and a high rate of emergency operations due to incarcerations, the postoperative complication rate was very low. However, the rate of testicular atrophy (10%) and recurrent inguinal hernia (9%) registered by us in the median follow-up of 575 days (range 105-1118 days) was much higher than that seen in older infants. Nevertheless, based on the low perioperative complication rate registered in the present study, we postulate that early surgery is tenable in pre-term infants despite the high co-morbidity and is even meaningful for the purpose of reducing the high rate of incarceration and testicular atrophy. The high recurrence rate in pre-term infants appears to be related to the numerous concomitant diseases in these patients, the resultant increase in intra-abdominal pressure and the small size of anatomical structures.

Tracheobronchial injuries in childhood: review of two cases.

Penetrating injuries of the tracheobronchial tree in children are very rare. With prompt diagnosis nonoperative treatment seems to be appropriate and safe without complications. Delayed diagnosis may result in surgical exploration with severe complications afterwards caused by poor condition at the time of intervention. Two children with penetrating tracheobronchial injuries were referred to our pediatric surgical center in the last 12 years. A 10-year-old boy suffered an iatrogenic penetrating injury of the tracheobronchial tree, and a 6-year-old boy a direct penetrating injury of the distal trachea in an agricultural accident. Cervical emphysema and bronchoscopy identified the lesion in these patients. Both of them could be treated conservatively without any sequelae.

Ovary in hernia sac: prolapsed or a descended gonad?

BACKGROUND/PURPOSE: The ligament that lies in the inguinal hernia sac of girls is known to be the round ligament and is described as homologous to the male gubernaculum. An ovary in a hernia sac might be assumed to mimic descent of the testis. The aim of this study is to determine whether this ligament has a role in final ovarian position. METHODS: Samples of peritoneal tissues containing the ligament were obtained from 15 female infants and children who underwent inguinal hernia repair. Tissue specimens were evaluated through histopathologic and immunohistological analyses. RESULTS: The ligament consists of striated and smooth muscle fibers, abundant nerves, and vessels. Estrogen receptors (ER) and progesterone receptors (PR) were identified in submesothelial stromal and smooth muscle cells. No androgen receptors (AR) were found. CONCLUSIONS: Although its termination in the processus vaginalis is not found to be consistent with the classical description of the round ligament, localization of ERs and PRs prove that the ligament is a target organ influenced by hormones. Because the round ligament is supposed to be the female gubernaculum that has an altered anatomy and localization because of absence of androgen responsiveness, its modified presentation in a processus vaginalis raises the suspicion that the ovary in a hernia sac may not simply be prolapsed, but is a descended gonad.

Morbidity and mortality of the short-bowel syndrome.

From 1976 to 1998 we have treated 17 neonates with short-bowel syndrome. Those 8 patients who had an intact ileocecal valve as well as the total colon preserved did significantly better than the 9 children without ileocecal valve and > 50% missing colon. In addition to the length of the intestinal remnants, motility had a major impact on the incidence of complications and final outcome. Four patients died (23.5%). All of them had an intestinal length of less than 30 cm, severe dysmotility, no ileocecal valve and an incomplete colon. The average duration of hospitalization of the children weaned from parenteral nutrition (n = 11) was 8.5 months. The majority of them still need supplementation of vitamins and/or trace elements. Two children suffer from recurrent d-lactic acidemia. Six children have a significant psychomotor developmental delay with three suffering from congenital cerebral abnormalities.

Bacterial translocation in short-bowel syndrome in rats.

Massive intestinal resection results in short-bowel syndrome (SBS) and is associated with an increased risk of infectious complications mainly caused by the egress of intestinal bacteria to distant organs, a process termed bacterial translocation (BT). The purpose of this experimental study in rats was to investigate in different models of SBS the impact of the type of intestinal resection on bacterial growth in the residual small bowel and on the occurrence of BT. SBS was created in 30 rats either by jejunal resection (JR), by ileal resection (IR) or by ileal resection including the ileocecal valve (IR+ICV). 10 animals underwent only a sham laparotomy (SL) and served as controls. Two weeks after the operative procedure, intestinal bacterial colonization and BT to the portal vein, vena cava, mesenteric lymph nodes, liver and spleen were determined. All resected animals showed a decreased weight gain and a significant bacterial overgrowth in the residual small bowel compared to the SL group. BT occurred after SL in 12%, after JR in 70%, after IR in 58%, and was significantly less frequent (35%) after IR+ICV, respectively. These experimental findings suggest that BT in SBS might be promoted by the intestinal bacterial overgrowth in the residual bowel, and the incidence of BT seems to be related to the presence or absence of the ileocecal valve.

Congenital short-bowel; a case study and review of the literature.

A congenital short bowel (CSB) is a rare entity in pediatric surgery. We present the case of a newborn boy with a total small intestinal length of 47 cm, malrotation and gastroesophageal reflux, who is 19 months old at the time of this report. Main treatment steps were Ladd's procedure, a fundoplication and long-term parenteral nutrition. We suggest that missing physiological herniation of the gut into the coelomic cavity may impair normal intestinal growth and rotation and lead to congenital short bowel. Review of all cases reported in the literature shows a considerable mortality of 88%. The limiting factor seems to be reduced motility of the short small bowel causing functional obstruction and liver failure.

[Ingestion of caustic substances in childhood]. / Ingestion von ätzenden Substanzen im Kindesalter.

Patients who ingest caustic substances continue to pose difficult problems in diagnosis and management. Flexible fiberoptic endoscopy and radiological studies have helped to assess the extent of damage caused by corrosives. A number of non surgical techniques are available for therapy, mainly corticosteroids and antibiotics. In a retrospective study from January 1976 till October 1988 we analysed 86 children aged from 1 month to 11 years. The purpose of our analysis was to check the outcome in patients with corrosive burning treated by standardized therapeutic management. Alkaline household substances caused the injury in 75% of our patients. No lesions were found in 19 patients. There were 21 patients with first degree, 28 with second degree ans 18 with third degree lesions. The diagnosis was confirmed by endoscopy within the first 48 hours. Therapeutic management in 2nd and 3rd degree lesions was based on corticosteroids, antibiotics and early bougienage of the oesophagus over an endless thread. Three patients with 2nd degree and all 18 patients with 3rd degree lesions underwent bougienage. Corticosteroids were given for two to four weeks, depending on the severity of the lesion. Our results demonstrate that early diagnosis and therapy can help to reduce stenosis and prolonged illness of these patients. In addition, public health efforts should be made to educate people about the dangers of caustic substances.

Psychosocial and psychomotoric development of very low birthweight infants with necrotizing enterocolitis.

UNLABELLED: Twenty-six very low birthweight infants (VLBI) were treated for necrotizing enterocolitis (NEC). We investigated their consecutive health problems and psychosocial development. METHOD: One to 13 years after onset of NEC, follow-up studies were performed in 12 of the surviving children. Identical follow-up studies were performed in 6 VLBI who had been operated on for diseases other than NEC (control group). We used a detailed interview, a Denver test and a drawing test. RESULTS: Five children of the NEC group had major persistent health problems that impaired their psychomotoric and psychosocial development (including hearing impairment, concomitant strabismus, early onset bronchial asthma). Nine of 12 VLBI of the NEC group showed signs of reduced social contact, logopaedic problems and minimal partial skill reductions. CONCLUSION: We found similar results in both children who suffered from NEC and in a small control group of VLBI who had not suffered from NEC, therefore impaired psychomotoric and psychosocial development is probably due to prematurity.

Surgical strategies in very-low-birthweight neonates with necrotizing enterocolitis.

Very-low-birthweight (VLBW) neonates are more prone to complications and death than term infants are. In a 15-year period, 19 neonates with VLBW were operated on for necrotizing enterocolitis (NEC). Indications for operation were pneumoperitoneum in 12 and deterioration of general condition in 7. Bowel resection and intestinal diversion was performed in 12, a lateral enterostomy at the site of perforation was created in 5, and 2 neonates with necrosis of the whole bowel underwent an exploratory laparotomy without any further surgical treatment. Surgical complications were found in one-third of the patients. The mortality rate was significantly higher when the ileum was affected. The survival rate was 68%. Prior to 1984 the survival rate was 37% (3/8); subsequently, it has improved to 91% (10/11) as a result of improved intensive therapy.

Problems of ileostomy in necrotizing enterocolitis.

Exteriorization of the intestine and resection of the gangrenous bowel are major therapeutic regimens for necrotizing enterocolitis (NEC). Ileostomy associated complications are well known, therefore the time of ileostomy closure is a matter for discussion. Between 1975 and 1992, 84 patients with NEC were treated surgically. Ileostomies were performed in 37 children (44%). Of these 37 neonates, 9 (7M, 2F) died. In the remaining 28 patients (16M, 12F) with a mean gestational age of 35.8 weeks and a mean birth weight of 2412 g, ileostomies were performed between the 2nd and 11th days after birth. On average, the stomies were in function for 91 days, and within this period the average weekly weight gain was 153 g. Nineteen patients of this group did not show any problems attributable to the ileostomy. In 9 patients (32%) complications occurred, requiring a preplanned closure of the stoma. Postinflammatory strictures of bowel were diagnosed in 9 patients and resection of the stenotic intestine was performed at the same time as stoma closure. In conclusion, an appropriate weight gain can be achieved in patients with an ileostomy with an adequate feeding regimen. In otherwise uncomplicated cases, ileostomy closure can be delayed by up to 10 weeks when simultaneous surgical correction of additional intestinal strictures is possible. In one-third of patients with an ileostomy, however, complications may occur and urge a preplanned closure of the stoma.

Late intestinal strictures following successful treatment of necrotizing enterocolitis.

Between 1975 and 1992, in 16 infants (14%) out of 113 neonates with previous necrotizing enterocolitis (NEC) a total of 25 intestinal strictures had to be treated. Four (16%) were found in the ileum and 21 (84%) in the colon, and in 50% multiple strictures were present. In these 16 patients initial treatment for acute NEC included conservative treatment in 5, primary resection and enterostomies in 6 and proximal diverting enterostomies in 5. Therefore, the incidence of late strictures was 11% after conservative therapy, 11% after primary resection and 55% after primary proximal diverting enterostomies. An average of 49 days elapses between the recovery from NEC and the diagnosis of late strictures in conservatively treated patients. After initial surgical treatment, late strictures were detected on contrast studies on an average of 80 days. In pathologic specimens, marked fibrosis in the submucosa was consistently present in all strictures, whereas inflammatory changes in the mucosa, disruption or hypertrophy of the muscle layers or absence of ganglion cells were seen less frequently. All strictures were resected and primary end-to-end anastomosis was performed. But despite the development of late intestinal strictures, bowel preservation was improved after initial restrictive surgical therapy and aggressive medical treatment.

[Non-accidental injuries in childhood and the nature of their appearance]. / Die nicht akzidentelle Verletzung des Kindes und deren Erscheinungsformen.

Child abuse has been the leading cause of death in pediatric patients for a long time. The subject is complex in its etiology, appearance, consequences and prognosis. To be confronted with the patient is emotional. Inpatient treatment at a pediatric centre should be performed in any suspicious cases of non-accidental injury. The child protection group consists of one pediatric specialist as well as four ward physicians, one psychotherapist, two staff nurses and one graduated social worker. The team's aims are the early detection of violence towards children, the safeguarding of child protection policies and the provision of family centred, interdisciplinary treatment. During a 6-year period (2001-2006) 476 children were treated at our department. Cruelty was found in 47%, sexual abuse in 28% and willful neglect in 25%. Only 12% of the patients presented obvious injuries. In 88% secondary symptoms resulted in the correct diagnosis. Child protection groups are important institutions for dealing with the complex matter of child abuse. The burden and responsibility for the single person can be reduced within the team. Medical practitioners outside the hospital may give a referral without a loss of confidence.

[Treatment of pediatric radial neck fractures: consideration of patient age and fracture dislocation]. / Behandlung kindlicher Radiushalsfrakturen: Berücksichtigung von Patientenalter und Frakturdislokation.

Fractures of the radial neck represent approximately 5-10% of all injuries of the elbow in children. Depending on the degree of radial head displacement, either an operative intervention or conservative treatment is recommended. The medical records of 168 children treated between 1999 and 2008 were analyzed and fractures were classified according to the Judet classification system. The fractures were treated according to an algorithm depending on age and fracture dislocation and 103 type I, 21 type II, 30 type III and 14 type VI fractures were found. Conservative treatment was possible in 124 patients and 44 were treated operatively. The overall outcome was good.

[Surgical treatment of vascular malformations in children and adolescents]. / Chirurgische Therapie vaskulärer Malformationen bei Kindern und Jugendlichen.

Vascular malformations are inborn errors of vasculogenesis in localised regions of the body. They are present at birth and grow proportionally with the child without ever showing any tendency to regress. This fact distinguishes them clearly from haemangiomas, which represent vascular tumours with high proliferation during the first year of life followed by a slow involution thereafter. The strategy for the treatment of vascular malformations differs substantially from the one for haemangiomas. According to the type of vascular malformation, the treatment may consist in laser therapy, sclerotherapy, selective embolisation, and/or surgical resection. Whereas systemic medication may save the life of children with life-threatening haemangiomas, such treatment would have no significant effect in children with vascular malformations. The aim of the surgical treatment is to perform a complete resection of the malformation in order to prevent its recurrence. However, since vascular malformations often have an infiltrative growth, frequently only subtotal resections can be performed to avoid unacceptable functional or cosmetic disfigurement of the body. Generally, an optimal management of children with vascular malformations includes a multidisciplinary approach with critical consideration of all potential treatment procedures.