Management of traumatic bile duct injuries in children.

PURPOSE: Pediatric experience with biliary tract injuries (BTI) is limited and mostly consists of case presentations. The purpose of this study is to evaluate clinical and radiological findings of possible BTI, treatment strategies, and results. METHODS: The records of nine patients with the diagnosis of BTI between July 2009 and November 2017 were reviewed retrospectively. RESULTS: There were seven boys and two girls (mean 8.05 ± 4.39 years). The mechanisms were motor vehicle occupant, fall, crush and gunshot wound. Hepatic laceration routes that extended into the porta hepatis and contracted the gall bladder were demonstrated on computerized tomography (CT). Bile duct injury was diagnosed with bile leakage from the thoracic tube (n = 2), from the abdominal drain (n = 2) and by paracentesis (n = 5). Extrahepatic (n = 8) and intrahepatic (n = 1) bile duct injuries were diagnosed by cholangiography. Endoscopic retrograde cholangiography, sphincterotomy, and stent placement were successfully completed in five patients. Peritoneal drainage stopped after 3-17 days of procedure in four patients. The fifth patient was operated with the diagnosis of cystic duct avulsion. Cholecystectomies, primary repair of laceration, cystic duct ligation, and Roux-en-Y hepatoportoenterostomy were performed in the remaining four patients. All patients presented with clinically normal findings, normal liver functions, and normal ultrasonographic findings in the follow-up period. CONCLUSIONS: The presentation of the parenchymal injury extending to the porta hepatis with contracted gall bladder on CT and diffuse homogenous abdominal fluid should be considered as signs of BTI. We suggest a multi-disciplinary approach for the diagnosis and treatment of BTIs. Surgery may be indicated according to the patient's clinical condition, radiological findings and failure of non-operative treatment.

Intestinal malrotation needs immediate consideration and investigation.

BACKGROUND: The aim of this study was to evaluate clinical presentation, diagnostic studies, and volvulus rate and to describe the unusual clinical clues of intestinal malrotation. METHODS: A retrospective descriptive review was carried out of all patients diagnosed with intestinal malrotation between 2002 and 2014. Patients were divided into two groups: infants (≤1 year, n = 16; group 1); and children (>1 year, n = 12; group 2). Patient demographics, clinical history, symptoms, physical examination, diagnostic work-up, operative findings and early outcome were evaluated. RESULTS: Bilious vomiting was the cardinal complaint in both groups. Unusual symptoms such as respiratory insufficiency, dehydration, afebrile convulsion, and lethargy were prominent symptoms in six patients in group 1, whereas history of frequent hospitalization due to recurrent abdominal pain and feeding intolerance were prominent in six patients in group 2. Midgut volvulus was identified in 15 patients, four of whom were in group 2. Standard Ladd's procedure was done in addition to correction of volvulus. CONCLUSION: Malrotation with or without midgut volvulus is not a rare condition and should be kept in mind for any age group. Specific signs of diagnosis are not easily identified. In the case of unusual clinical presentation, diagnosis may be delayed and can result in catastrophic consequences if intestinal perfusion occurs. Although midgut volvulus is seen most frequently in infants, risk and complication rate are high beyond 1 year of age as well, and can manifest as failure to thrive, food intolerance, and abdominal pain needing recurrent hospitalization. Diagnostic suspicion and interdisciplinary coordination are essential for timely diagnosis and surgical treatment.

The separation of the epididymis and the abnormal attachment of the gubernaculum cause undescendence in the rat testes.

PURPOSE: Epididymal anomalies are common in cryptorchid patients. This led us to consider that anomalies of the epididymis, to which the gubernaculum is attached, or abnormal attachment of the cranial end of the gubernaculum, could lead to cryptorchidism. METHODS: Twenty-eight male Sprague-Dawley rats were divided into two groups: In Group 1 rats (n = 14), the epididymis was isolated from the testis, and in Group 2 rats (n = 14), the gubernaculum was isolated from the epididymis and re-attached to the tail of the epididymis. In both groups, the non-operated testes were used as the control. RESULTS: In Group 1, cryptorchidism rates were 1/14 in the control testes and 8/14 in the operated testes (p < 0.01). In Group 2, cryptorchidism rates were 0/13 in the control testes and 6/13 in the operated testes (p < 0.01). CONCLUSION: Cryptorchidism was seen when the epididymis was loosely or non-connected to the testis and the gubernaculum was attached solely to the epididymis (mimicking anomalies of ductal fusion) and when the gubernaculum was attached to the tail of the epididymis (mimicking anomalies of ductal suspension). Therefore epididymal anomalies and abnormal attachment of the gubernaculum may play a role in the undescendence of the testes in the rats.

Management of pyloric stricture in children: endoscopic balloon dilatation and surgery.

BACKGROUND: Surgical correction is the most preferred treatment modality in pyloric stricture (PS). Recently a few studies reported the experience of balloon dilation in children with PS. This study was designed to present our experiences of the management of the patients with PS with balloon dilation and corrective surgery. METHODS: The records of 14 patients who were treated with the diagnosis of PS between August 2003 and August 2011 were reviewed retrospectively. RESULTS: There were nine boys and five girls (mean age, 3.4 ± 1.7 years). The history of caustic ingestion was detected in eight patients; six of them were admitted on the day of ingestion. Two patients were admitted with nonbilious vomiting more than 2 weeks after ingestion. Four patients did not have a remarkable medical history, including caustic ingestion. They admitted with the complaint of nonbilious vomiting. PS was detected during endoscopy in two patients who had a diagnosis of peptic ulcer disease. PS was shown by barium meal study in all patients. Endoscopy was performed in all patients. Endoscopic balloon dilation was tried in 12 patients. Overall eight patients required surgical procedures for PS. The complaints were resolved by endoscopic balloon dilation of pylorus in the remaining six patients. CONCLUSIONS: Although endoscopic balloon dilatation for benign PS in adults is a generally accepted method of treatment, there is less experience with endoscopic balloon dilatation for PS in children. PS due to benign disorders can be effectively and successfully treated through endoscopic balloon dilatation in suitable patients. In patients with successful pyloric balloon dilatation, surgery can be avoided.

Foreign body aspiration in children: analysis of diagnostic criteria and accurate time for bronchoscopy.

OBJECTIVES: The aims of this study were to evaluate the predictive diagnostic value of history, clinical signs and symptoms, and radiological finding and to evaluate whether bronchoscopy is a safe procedure and whether it should be performed in urgent conditions. METHODS: The medical records of 191 children who underwent bronchoscopy for suspected foreign body aspiration (FBA) between 2001 and 2009 were reviewed for demographic data, radiological studies, and bronchoscopic findings retrospectively. RESULTS: There were 117 male and 74 female patients. Their ages ranged from 2 months to 14 years. The major complaints were paroxysmal cough and respiratory insufficiency. Foreign body aspiration was confirmed in 123 patients (65%). Of 106 patients who were admitted in the first 24 hours, FBA was confirmed in 75 patients. Of 116 patients with a definite history of witnessed FBA, 87 patients (75%) were found to have positive bronchoscopic findings. Of 46 patients who had prolonged history of recurrent pulmonary infections, allergic asthma, or bronchiolitis, 31 (67.4%) were found to have FBs. Foreign bodies were frequently organic. Nineteen patients required urgent bronchoscopic evaluation. Sensitivity and specificity for each diagnostic criterion were as follows: clinical history (63% and 32%); symptoms (68% and 53%); physical examination findings (70.5% and 63%); radiological findings (73% and 68%); and the triad of cough, wheezing, and diminished breath sound (88% and 51%), respectively. There was a positive correlation between the presence of wheezing and FB-positive patients. CONCLUSIONS: Although there are no specific symptoms and signs to make a clear-cut diagnosis, history of witnessed FBA, admittance within 24 hours from the beginning of respiratory symptoms, and wheezing are proper indications for bronchoscopy. Bronchoscopy is a safe procedure with few and confined complications.

Long-term management of corrosive esophageal stricture with balloon dilation in children.

BACKGROUND AND PURPOSE: There are only a few studies focused on efficacy and safety of balloon dilation in corrosive esophageal stricture in children. The aim of this study is to assess the long-term clinical results of balloon dilation in the treatment of corrosive esophageal stricture in children. MATERIALS AND METHODS: We retrospectively analyzed the management of 18 children (median age 3 years) who were treated with balloon dilation because of caustic esophageal stricture between January 2001 and December 2008. RESULTS: A total of 295 sessions of balloon dilation were performed in all patients over an 8-year period. Technical success was achieved in all patients, whereas clinical success was achieved only in eight (44.4%) patients after first dilation. Eight (44.4%) of all patients showed recovery within the first year and another six (33.3%) patients recovered within 2 years. Esophageal perforation occurred in one (5%) patient, during one dilation session (0.33%). The average number of dilation sessions was 12.7, 2.8, and 1, respectively, in the first, second, and third year. There was significant difference between the mean number of dilation sessions in the first and second year, and second and third year (p < 0.01 and p = 0.043). CONCLUSION: Short-segment esophageal strictures, improvement of food intake capacity, and increase in intervals of dilation sessions are good patient indicators. We suggest that esophageal balloon dilatation is a safe and effective method of treatment in caustic esophageal strictures and recommend that balloon dilation program be performed for at least 2 years before deciding that dilation has failed and preferring other treatment modalities which have higher risk of complications.

Perianal abscess and fistula-in-ano in children: aetiology, management and outcome.

AIM: We aimed to assess our experience in treatment and outcome of perianal abscess and/or fistula-in-ano in children. METHOD: The patients who were treated for perianal abscess and/or fistula-in-ano from January 2000 to December 2005 were included. Age, sex, duration of symptoms, number and site of the perianal abscess and/or fistula-in-ano, treatment modality and recurrences were recorded. RESULTS: The study consisted of 39 patients (36 boys) with a mean age of 29 +/- 49.1 months. At first examination the diagnosis was perianal abscess in 20 patients, perianal abscess with fistula in five patients and fistula-in-ano in 14 patients. No patients had an underlying illness. The primary local treatment of perianal abscess with or without fistula was incision and drainage (with or without antibiotic therapy) in 21 patients, and local care with antibiotic therapy was given to four patients. Of 20 patients with perianal abscess, 17 developed fistula-in-ano and three healed. One patient in the perianal abscess group who developed fistula-in-ano and two patients in the fistula group were lost to follow-up. Thirty-three patients with fistula-in-ano underwent surgical treatment either through a fistulotomy or through a fistulectomy. Five (15.1%) patients who experienced recurrent fistula-in-ano underwent fistulotomy were completely cured after the second operation. CONCLUSION: Treatment of a perianal abscess either through incision and drainage with antibiotics or through antibiotics alone resulted in a high rate (85%) of fistula formation. Fistula-in-ano can be treated either by fistulotomy or by fistulectomy, both of which are associated with a reasonable chance of recurrence of fistula-in-ano formation. We obtained good results in our patients through surgical approach (fistulotomy or fistulectomy), for fistula-in-ano formed following treatment of perianal abscess.

An unusual cause of acute abdominal pain in a child: an inverted Meckel diverticulum: report of a case.

Inverted Meckel diverticulum has been reported as a lead point for intussusception in children. However all cases of isolated inversion of a Meckel diverticulum have involved adults in whom the diagnosis was clinically unexpected. We describe the sonographic appearance of isolated inversion of Meckel diverticulum in a 3-year-old boy with acute abdominal symptoms.

Chest wall lipoblastomatosis in a 2-year-old girl: a case report and literature review.

Lipoblastoma is an uncommon tumor of adipose tissue that usually occurs in infancy and early childhood. They predominantly locate in the extremities, but are less frequently found in the head and neck region, trunk and various other locations. The most common sign is a rapidly growing mass. In spite of their potential for local invasion and rapid growth, they are benign tumors and have no distant metastasis. Although more than 180 cases of lipoblastoma distributed over various parts of the body have been reported, only nine cases were located in the thoracic wall. We present the case of a two-year-old girl with lipoblastomatosis of the chest wall that was identified by histologic examination. In this article, the English literature on this disorder is briefly reviewed.

Diagnostic difficulties in esophageal atresia with proximal and distal tracheoesophageal fistula: a case report.

The authors report two patients with esophageal atresia and double fistula, one of whom was diagnosed intraoperatively and the other preoperatively through upper pouch contrast study. Patients with proximal and distal fistula do not present with excessive oral secretion and drooling because they can swallow the saliva/meals that reach the trachea from the proximal esophagus via the proximal fistula and then from the trachea to the distal esophagus via the distal fistula. Thus, since this clinical entity can be easily overlooked, some radiological and clinical signs that are helpful for preoperative and intraoperative diagnosis of a proximal fistula are discussed.

Ingested foreign bodies in children: Do they really pass spontaneously from the gastrointestinal tract? A single-centre experience with 1000 cases.

BACKGROUND: Foreign body (FB) ingestion is frequently encountered in all departments that treat children. FB may bring about significant anxiety for parents and physicians. The present study aims to determine the appropriate approach for FB ingestion in children. METHODS: The records of 1000 children with a history of FB ingestion between the years 2005 and 2017 were reviewed retrospectively in this study. RESULTS: Of 1000 children, 53.8% were male. The most common types of FBs were coins (35%). X-ray was negative in 49% of the patients, and 86% of these patients received no intervention. Of the 504 (51%) X-ray-positive patients, the oesophagus (68%) was the most common location. Life-threatening complications were tracheo-oesophageal fistula (1), Meckel's diverticulum perforation (1), and perforation due to rigid endoscopy (1). CONCLUSION: We demonstrated that coins, which are the most commonly ingested FBs, have various types and sizes according to their countries of origin, and this affects spontaneous passage. We found that only 48% (quite low compared to the literature) of the coins passed spontaneously. In asymptomatic patients with a gastric button battery, we suggest a "watchful waiting" approach. The patients should be observed and managed at home. In our study, we found that 85% of the button batteries that reached the stomach passed spontaneously.

The long term effects of intrascrotal low dose and high dose N-acetylcysteine on testis damage in rat model of testicular torsion.

BACKGROUND/PURPOSE: During testicular torsion, the testes face oxidative damage owing to ischemia/reperfusion. We studied the long term effects of the intrascrotal administration of N-acetylcysteine (NAC) during detorsion procedure in a rat model of testicular torsion. METHODS: Twenty-eight rats were divided into 4 groups: (1) Control group: No procedure was done (2): Torsion-detorsion group: Testis torsion applied for 3 h (3): Low Dose Group: After testis torsion-detorsion (for 3 h) 10 mg/kg NAC was given into tunica vaginalis (4): High Dose Group: After testis torsion-detorsion (for 3 h) 100 mg/kg NAC was given into tunica vaginalis. We measured dimensions of the testes and examined pathological findings and Johnsen and Cosantino Scores. RESULTS: For testes height and volume, high dose NAC group had better results than the torsion-detorsion group (p = 0.019, p = 0.049). Testes weight showed no difference (p = 0.204). Sertoli cell number per tubule in the high dose NAC group was statistically different than the torsion-detorsion group (p = 0.017). CONCLUSIONS: When NAC was given intrascrotally at a dose of 100 mg/kg, it decreased the loss of testis volume and height, and Sertoli cell number per tubule was similar to the control group. These results suggest that the higher dose intrascrotal NAC administered during detorsion may have a protective effect.

Prenatal diagnosis of a mass in the adrenal region that proved to be a teratoma.

A prenatally detected suprarenal cystic mass measuring 2 cm was found to have enlarged upon postnatal ultrasonography at 6 weeks of age. Magnetic resonance imaging showed a 57 x 50 mm mass in the left adrenal region displacing the kidney inferiorly. The infant underwent an adrenalectomy with total resection of the tumor, which proved on histologic examination to be a mature teratoma. Prenatally detected suprarenal masses are likely to be neuroblastoma or adrenal hemorrhage, but may be rare benign lesions such as extralobar pulmonary sequestration, bronchogenic cyst, or renal dysplasia. Although teratoma in the adrenal region is extremely rare, it should be included in the clinical and radiologic differential diagnosis of prenatally detected suprarenal masses. Total excision of the mass for histologic diagnosis is indicated.

Bilateral chylothorax after blunt thoracic trauma: a case report.

Traumatic chylothorax other than iatrogenic thoracic duct injury is extremely rare in children. Chylothorax can cause cardiopulmonary abnormalities and significant nutritional, metabolic and immunologic consequences. The management of chylothorax ranges from conservative treatment to surgical intervention. We present a four-year-old boy who presented with respiratory difficulty due to multiple rib fractures and bilateral chylothorax, which developed after a blunt chest trauma. The patient was successfully treated through a conservative approach with total parenteral nutrition, nothing by mouth, and bilateral chest tube drainage. The nature of pleural effusion developed following a blunt thoracic trauma is important in the management of trauma patients.

Boix-Ochoa (Partial Fundoplication) Treats Reflux, Even in Neurologically Impaired Patients. Can it Take the Title of "Gold Standard" from Total Fundoplication?

BACKGROUND: In 4-5% of cases of gastroesophageal reflux disease (GERD), surgical treatment is required. The aim of the study was to evaluate the success of Boix-Ochoa antireflux surgery, which is considered more physiologic with a higher failure rate (need for reoperation) than Nissen fundoplication, which is believed to be the gold standard operation. METHOD: In the 13 years from 2005 to 2018, the medical records of all children who underwent Boix-Ochoa in a single institution by pediatric surgeons were reviewed retrospectively. RESULTS: A total of 133 fundoplications were performed, of which patients were divided into four groups: neurologically impaired, structurally impaired, neurologically and structurally impaired, and neurologically and structurally normal; there were 64, 8, 34, and 27 patients in each group, respectively. Structural impairments included hiatal hernia and esophagus atresia, having previously had a gastrostomy and esophageal stenosis. The most common short-term complication was distal esophageal stenosis (13%), which caused vomiting and dysphagia, and was treated by dilatations. There were six (4.5%) recurrences of GER, one in the neurologically and structurally impaired group with a hiatal hernia and five in the structurally impaired group (three esophagus atresias, two caustic esophageal strictures). The mean follow-up period was 5.27 ± 3.43 years. Neurological impairment did not affect the success rate. CONCLUSION: Although there has not any literature demonstrating significant benefits of one procedure, we detected with this largest study in the pediatric literature about Boix-Ochoa fundoplication (more physiologic and easily performed) that it was successful (95%) in protecting reflux even in neurologically impaired patients (98%). We consider Boix-Ochoa (partial fundoplication) to be an alternative method to Nissen (complete fundoplication), and it can be done safely with a high success rate.

An uncommon presenting sign of Langerhans cell histiocytosis: focal perianal lesions without systemic involvement.

A 3-year-old boy presented with constipation and perianal lesions resembling condyloma latum. The results of a biopsy of the perianal lesions confirmed the diagnosis of Langerhans cell histiocytosis (LCH). Although uncommon, LCH may involve the perianal region. In patients with functional constipation associated with perianal lesions that do not respond to conventional treatment, LCH should be part of the differential diagnosis. A simple biopsy of the external lesion and histologic examination of the mass are essential for diagnosis.

Natural History and Conservative Treatment Outcomes for Hydroceles: A Retrospective Review of One Center's Experience.

OBJECTIVE: To elucidate epidemiological data and hydrocele progression, we reviewed pediatric patients diagnosed with hydroceles in our institution retrospectively. MATERIALS AND METHODS: We reviewed data from 355 pediatric patients with hydroceles. Questionnaires regarding age at diagnosis, time of delivery, presence of hydroceles in the father and brothers, age at recovery, age at surgery, cause of hydrocele (if present), type of hydrocele, associated pathologies, treatments, and posthydrocelectomy complications were completed by reviewing patients' medical records and interviewing their families. RESULTS: Patients with congenital hydroceles were more frequently born prematurely (32.5%) than were patients with noncongenital hydroceles (15.9%; P = .001). Fathers of 10 patients (3.7%) and brothers of 21 patients (7.7%) also had hydroceles. Hydroceles were associated with inguinal hernias on the same side (12.2%), cryptorchidism (7.5%), varicoceles (6.0%), and testis torsion (0.5%). Among patients aged >1 year (n = 185), 27 did not undergo operations and healed spontaneously at an average of 5.30 ± 3.36 months. For children aged >1 year who did not undergo surgery, the rate of spontaneous recovery within 6 months was 77.8% and that within 1 year was 96.3%. CONCLUSION: Until strong evidence of hydrocele-induced testicular damage in children arises, we recommend following up congenital hydroceles until at least 1 year and preferably 2 years of age. We recommend following up noncongenital hydroceles for at least 6 months and preferably 1 year if there is no associated pathology indicating the need for earlier surgery such as an inguinal hernia, cryptorchidism, tense hydrocele, testis torsion, or testis mass.

The effect of intraperitoneal n-acetylcysteine on postoperative adhesions in rat models.

AIM: In this study, we researched the effect of local administration of N-acetylcysteine (NAC) on postoperative intraabdominal adhesion formation in the rat models. METHODS: 20 female Wistar Albino rats which were 5-7 months old are used for the study. The rats were divided into two equal groups. Group one was administered saline solution (n=10) while group two was administered NAC (n=10) after caecal abrasion. They were dissected on postoperative tenth day and were examined macroscopically and microscopically for the adhesion formation. Intraperitoneal adhesion formation was scored blinded with Evans model. The most adherent bowel section was excised for histopathologic examination. Mann Whitney U test were used for statistical analysis. RESULTS: In Group one, all rats have had adhesions. None of the rats in Group two had either severe inflammatory cell reaction or dense interstitial fibrosis. Macroscopic adhesion formation and microscopic inflammatory cell reaction and interstitial fibrosis formation after surgery were less at the group two (NAC applied) (p<0.05, p<0.05, p<0.05). CONCLUSION: We believe that the intraperitoneal single dose usage of NAC may be promising for decreasing the postoperative intraabdominal adhesions. KEY WORDS: N-acetylcysteine, Postoperative adhesion, Rat, Fibrosis.

Foreign body punctured the spleen: An incidental diagnosis.

Inal-Aslan G, Ötgün I, Güney LH, Hiçsönmez A. Foreign body punctured the spleen: An incidental diagnosis. Turk J Pediatr 2017; 59: 97-99. A foreign body can enter the body via penetration through the skin. In the presented case, a broken syringe needle was found and removed from the splenic parenchyma. In order to prevent such iatrogenic injuries, which could have fatal consequences, the hospital staff must give particular care in the handling of sharp FBs.

Huge Neck Masses Causing Respiratory Distress in Neonates: Two Cases of Congenital Cervical Teratoma.

Congenital cervical teratomas are rare and usually large enough to cause respiratory distress in the neonatal period. We present two cases of congenital huge cystic neck masses in which distinguishing cervical cystic hygroma and congenital cystic teratoma was not possible through radiologic imaging techniques. Experience with the first case, which was initially diagnosed and treated as cystic hygroma by injection sclerotherapy, led to early suspicion and surgery in the second case. The masses were excised completely and histopathologic diagnoses were congenital teratoma in both patients. Our aim is to review congenital huge neck masses causing respiratory distress in early neonatal life to highlight this dilemma briefly with these interesting cases.