Endoscopic balloon dilatation of benign esophageal strictures in childhood: a 15-year experience.

The study aims to evaluate the effectiveness and safety of endoscopic balloon dilatation (EBD) in childhood benign esophageal strictures. The medical records of 38 patients who underwent EBD from 1999 to 2013 were retrospectively reviewed. Demographic features, diagnoses, features of strictures, frequency and number of EBD, complications, outcome, and recurrence data were recorded. Median age was 1.5 years (0-14), and female/male ratio was 17/21 (n = 38). Primary diagnoses were corrosive esophageal stricture (n = 19) and esophageal atresia (n = 19). The length of strictures were less than 5 cm in 78.9% (n = 30). No complication was seen in 86.8% (n = 33). Perforation was seen in 10.5% (n = 4), and recurrent fistula was seen in 2.7% (n = 1). Total treatment lasted for 1 year (1-11). Dysphagia was relieved in 60.5% (n = 23). Recurrence was seen in 31.6% (n = 12). Treatment effectiveness was higher, and complication rates were lower in strictures shorter than 5 cm compared with longer ones (70% vs. 25%, P < 0.05, and 3.4% vs. 37.5%, P < 0.05). Although there was no statistical difference, treatment effectiveness rates were lower and complication and recurrence rates were higher in corrosive strictures compared with anastomotic ones (P > 0.05). EBD is a safe and efficient treatment choice in esophageal strictures, especially in strictures shorter than 5 cm and anastomotic strictures.

Transinguinal laparoscopic evaluation of contralateral side during unilateral inguinal hernia repair for children.

BACKGROUND: Inguinal hernia repair is a common procedure in daily pediatric surgical practice. OBJECTIVES: The present study was planned to find out whether transinguinal laparoscopic exploration (TILE) of the contralateral groin is effective in reducing the need of operation for contralateral metachronous inguinal hernia (CMIH) in children. STUDY DESIGN: Charts of 1103 children who underwent inguinal hernia repair between 2006 and 2016 were retrospectively analyzed. Eighty-eight children with bilateral hernia at the presentation were excluded, and 705 patients whose parents could be contacted by phone to get the latest information about children's condition were included in the study. RESULTS: Of the 705 children with unilateral inguinal hernia repair, 362 (51.4%) and 343 (48.6%) of them had right-sided and left-sided inguinal hernia, respectively. Transinguinal laparoscopic exploration was performed in 479 of the 705 children with unilateral hernia and a hernia or contralateral patent processus vaginalis (PPV) was found and ligated in %28.3 (n = 136) of them. Mean follow-up time was 60 ± 36 months. Fifteen (4.3%) of 479 patients who had TILE and 31 (13.6%) of 226 the patients who did not have TILE developed CMIH. When the videos of 15 patients who developed CMIH were reviewed, overlooked PPV was found in 10 (3.3%) patients who had TILE during early phases of institutional learning curve. DISCUSSION AND CONCLUSIONS: TILE of the contralateral side during pediatric inguinal hernia repair is a simple and effective method to evaluate contralateral PPV. This approach clearly and significantly reduces the need of operation for a metachronous hernia at a later date.

Health-related Quality of Life of Liver Donors: A Prospective Longitudinal Study.

Living donor liver transplantation is a widely accepted option to treat liver diseases in several indications. Risk of liver donation is being discussed and quality of life of donors is also studied. Changes and the change pattern of quality of life were analyzed in this prospective longitudinal study. PATIENTS AND METHODS: Fifty-five donors were included. The Medical Outcomes Study Short Form 36 (SF-36) was fulfilled either in-person or during a telephone interview each donor preoperatively and at the end of the third, sixth, and 12th months. RESULTS: Physical subdomain scores of SF-36 decreased significantly in the third postoperative month compared to preoperative score. The scores recovered in the sixth postoperative month, except for the bodily pain domain. The pain score recovered at the end of the 12th month. While social functioning score among mental subdomains of SF-36 temporarily decreased and recovered at postoperative 12th month, other mental subdomain scores and mental composition summary scores did not show a significant change. CONCLUSION: The quality of life of living liver donors is not permanently affected by donation. There are well-defined changes in the physical aspects of the quality of life that all seem to recover within 1 year. Donors should be preoperatively informed about this temporary change as well as complications.

Effect of local and remote ischemia-reperfusion injury on healing of colonic anastomoses.

BACKGROUND: Although the effect of locally applied ischemia-reperfusion (I-R) injury on gastrointestinal anastomoses has been studied, to our knowledge there is no previous study that investigates the effect of remote I-R injury on gastrointestinal anastomotic healing. The aim of this study was to investigate and compare the effects of local I-R injury and remote I-R injury on the healing of colonic anastomoses. METHODS: Anastomosis of the right colon was performed in 30 rats that were divided into 5 groups. Group 1 was the control group. In Group 2, I-R was applied to the colonic segment containing the anastomosis. Unilateral lower extremity I-R, unilateral renal I-R, and segmental small intestinal I-R was applied to the rats in Groups 3, 4, and 5, respectively, at the same time as colonic anastomosis. On the fourth postoperative day, animals were killed and bursting pressure and tissue hydroxyproline concentration of the anastomoses were analyzed and compared. RESULTS: The mean bursting pressure values were: 143 mm Hg in Group 1, 40.8 mm Hg in Group 2, 82.8 mm Hg in Group 3, 46.1 mm Hg in Group 4, and 52.3 mm Hg in Group 5 (P <.0001; 1-way analysis of variance). Mean tissue hydroxyproline concentration values were: 5.3 microg/mg in Group 1, 1.6 microg/mg in Group 2, 2.2 microg/mg in Group 3, 1.3 microg/mg in Group 4, and 1.5 microg/mg in Group 5 (P <. 0001, 1-way analysis of variance). Bursting pressure and tissue hydroxyproline concentration values had a good correlation r = 0.86, P <.001, Pearson correlation analysis). CONCLUSIONS: This study showed that I-R injury is a systemic phenomenon, and remote organ I-R can significantly delay anastomotic healing. This has to be kept in mind when constructing an intestinal anastomosis in the presence of local or remote I-R injury.

Intrabiliary rupture of a hepatic hydatid cyst: associated clinical factors and proper management.

HYPOTHESIS: The prediction of an intrabiliary rupture of a hepatic hydatid cyst using associated clinical factors is important for early diagnosis and proper management. DESIGN: Case series of patients with hepatic hydatid cysts treated between January 1, 1992, and January 1, 2000, in a single institution. SETTING: A tertiary care teaching hospital. PATIENTS: The clinical findings in 116 patients with a hepatic hydatid cyst were reviewed. Of the 116 patients, 24 (21%) had a cyst-biliary communication: 15 (13%) had an occult rupture, and 9 (8%) had a frank rupture. MAIN OUTCOME MEASURES: The following variables were analyzed as potential predictors of an intrabiliary rupture: age, sex, type and duration of symptoms, findings on physical examination, leukocyte count, liver function test results, serologic test results, suggestive ultrasonographic findings, ultrasonographic cyst features (type, diameter, number, and localization), and whether the cyst is primary or recurrent. RESULTS: The independent clinical factors for the presence of an occult rupture were a history of nausea and vomiting (P = .004), alkaline phosphatase level greater than 144 U/L (P = .004), total bilirubin level greater than 0.8 mg/dL (>13.5 micromol/L) (P< .001), and cyst diameter greater than 14.5 cm (P< .001) in multivariate analysis. Multivariate analysis also showed that history of jaundice (P< .001), jaundice found on physical examination (P = .05), cyst diameter greater than 10.5 cm (P = .009), a type IV cyst (P< .001), and suggestive ultrasonographic findings (P< .001) were the independent clinical predictors for the presence of a frank intrabiliary rupture. Patients with cyst-biliary communications had increased morbidity rates (13 [54%] of 24 patients vs 13 [14%] of 92 patients; P< .001) and longer mean postoperative hospital stays (13.7 vs 9.4 days; P = .03) compared with others. CONCLUSION: Clinical predictors should be considered for early diagnosis and proper management of intrabiliary ruptures in patients with hepatic hydatid cysts.

Transient post-partum thyroid dysfunction and postnatal depression.

In the course of a population study of thyroid dysfunction in pregnancy and the post-partum period, 65 women, considered to be antibody-positive (microsomal and thyroglobulin), and 82 antibody-negative women were assessed for postnatal depression at 6-8 weeks post partum. The women were also assessed for the development of post-partum thyroid dysfunction. Of the 147 women, 22 met DSM-III criteria for major depression. The presence of autoantibodies showed little association with depressed mood but there was a minor association of postnatal depression with actual thyroid dysfunction in that incidence of the latter condition was higher in depressed women (Raskin scale P less than 0.01; Edinburgh scale P less than 0.05; Montgomery-Asberg scale P less than 0.1). Three of eight mothers with thyroid dysfunction had major depression and were depressed on all three scales.

Effect of persistently elevated intraabdominal pressure on healing of colonic anastomoses.

BACKGROUND: The adverse effects of elevated intraabdominal pressure (IAP) on abdominal organs are realized, but its influence on anastomotic healing has not been studied. The aim of this study was to evaluate the effect of elevated IAP on healing of colonic anastomoses. METHODS: Thirty rats, which all had right colonic anastomoses, were divided into five groups. Group 1 was the control group, and group 2 had fecal peritonitis. IAP was maintained between 4 to 6 mm Hg in group 3, 8 to 12 mm Hg in group 4, and 14 to 18 mm Hg in group 5 until all rats were sacrificed on day 4. Bursting pressures and tissue hydroxyproline concentrations of anastomoses were then analyzed and compared. RESULTS: Mean +/- SEM of bursting pressures were 143+/-2.9 mm Hg in group 1, 72+/-14.4 mm Hg in group 2, 77.3+/-7.9 mm Hg in group 3, 57.5+/-11.2 mm Hg in group 4, and 40.1+/-9.6 mm Hg in group 5 (P<0.0001, one-way analysis of variance [ANOVA]). Mean +/- SEM of tissue hydroxyproline concentrations were 5.3+/-0.3 microg/mg in group 1, 4.7+/-0.5 microg/mg in group 2, 4.6+/-0.6 microg/mg in group 3, 3.6+/-0.5 microg/mg in group 4, and 2.4+/-0.2 microg/mg in group 5 (P = 0.0026, one-way ANOVA). The bursting pressure and hydroxyproline concentrations had good correlation (P<0.001, r = 0.76). CONCLUSIONS: Elevated IAP delays healing of colonic anastomoses and 4 to 6 mm Hg IAP delays healing as much as fecal peritonitis. More elevated IAP delays healing more than fecal peritonitis. These events may be clinically important and may result from local-systemic effects of IAP.

A risk score for conversion from laparoscopic to open cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has become the standard operative procedure for cholelithiasis, but there are still some patients requiring conversion to open cholecystectomy mainly because of technical difficulty. Our aim was to develop a risk score for prediction of conversion from laparoscopic to open cholecystectomy. METHODS: Preoperative clinical, laboratory, and radiologic parameters of 1,000 patients who underwent laparoscopic cholecystectomy were analyzed for their effect on conversion rates. Six parameters (male sex, abdominal tenderness, previous upper abdominal operation, sonographically thickened gallbladder wall, age over 60 years, preoperative diagnosis of acute cholecystitis) were found to have significant effect in multivariate analysis. A constant and coefficients for these variables were calculated and formed the risk score. RESULTS: Overall 48 patients required conversion to open cholecystectomy (4.8%). These patients had significantly higher scores (mean 6.9 versus -7.2, P <0.001). Increasing scores resulted with significant increases in conversion rates and probabilities (P <0.001). Ideal cut-off point for this score was -3; conversion rate was 1.6% under -3, but 11.4% over this value (P <0.001). CONCLUSIONS: Conversion risk can be predicted easily by this score. Patients having high risk may be informed and scheduled appropriately. An experienced surgeon has to operate on these patients, and he or she has to make an early decision to convert in case of difficulty.

A prognostic score for gastric cancer.

BACKGROUND: Scoring systems are generally used for predicting prognosis in the intensive care unit, but there is no score being used frequently for predicting prognosis in gastric cancer. The aim of this study was to develop a prognostic score for gastric cancer patients. METHODS: Demographic, clinical, laboratory, radiologic, histopathologic data, and operative findings for 128 patients who had curative or palliative resection for gastric cancer were analyzed for their effect on overall and disease-free survival. Ten variables-invasion depth of tumor, node status (American Joint Committed on Cancer, 1992), metastasis, node status (Union Internationale Contre le Cancer, 1997), metastatic lymph node ratio, resectability, tumor location, extent of lymphadenectomy, Borrmann type, Lauren type-that have independent significant effect or borderline significance on both overall and disease-free survival according to multivariate analysis were chosen. Coefficients were calculated for these variables by using Cox regression analysis, and thus the Prognostic Score for Gastric Cancer (PSGC) was designed. All patients were scored using the PSGC and also staged clinically (AJCC 1992) and histopathologically (AJCC 1992 and UICC 1997). RESULTS: Patients were grouped according to their scores: group 1, patients with scores 20 to 50 (probability of 5-year overall survival 50% to 95%); group 2, patients with scores 51 to 80 (probability of 5-year overall survival 10% to 50%); and group 3, patients with scores 81 and higher (probability of 5-year overall survival <10%). Overall survival and disease-free survival decreased significantly with increasing scores. The association of PSGC and staging systems with survival was analyzed by stepwise logistic regression and Cox regression analyses. PSGC was proved to have the most significant association with overall and disease-free survival. CONCLUSIONS: Inclusion of more variables in PSGC seems to make it superior than staging. It is easy to adapt PSGC to different patient populations, which may make it accepted as a practical and useful scoring system in clinical practice.

Practical recommendations for the prediction and management of common bile duct stones in patients with gallstones.

BACKGROUND: Approximately 10% of patients with symptomatic gallstones may have associated common bile duct stones (CBDS). However, the predictive value of noninvasive tests as well as the preoperative diagnosis and management of CBDS have not been well defined. The aim of this study was to define an accurate and simple model for the prediction and management of CBDS. METHODS: A prospective database containing 986 cholecystectomies performed from 1994 through 1999 was evaluated. Univariate analysis using the Pearson chi-square test was performed to determine the factors significantly related to the presence of CBDS. Then logistic regression analysis was performed for multivariate analysis to discover independent predictors. RESULTS: Of the 986 patients in this study, 48 (5%) had CBDS. Of the 48 patients with choledocholithiasis, 22 (46%) were men and 26 (54%) were women. The mean age was 55.3 years (range, 16-87 years). As a result of multivariate analysis, abdominal ultrasonographic findings suggestive of CBDS (common bile duct diameter exceeding 8 mm or visible stones), total bilirubin, and gamma glutamyl transpeptidase levels above normal were the independent predictors of CBDS in patients age 70 or younger. On the other hand, an elevated bilirubin level was found to be the single independent factor related to CBDS in the elderly. CONCLUSIONS: For patients with gallstones, suggestive ultrasonographic findings in those younger than 71 years and elevated direct or total bilirubin level in those older than 70 years are the most valuable and practical predictors of CBDS, and thus are the proper indications for preoperative endoscopic retrograde cholangiography.

Risk factors resulting in conversion of laparoscopic cholecystectomy to open surgery.

BACKGROUND: Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder diseases. However, there still is a substantial proportion of patients in whom laparoscopic cholecystectomy cannot be successfully performed, and for whom conversion to open surgery is required. METHODS: In this study, 1,000 laparoscopic cholecystectomies performed at Ankara Numune Hospital, Fourth Department of Surgery, from March 1992 to July 1999 were prospectively analyzed. The patients studied included 804 women (80.4%) and 196 men (19.6%) with a mean age of 43.8 years (range, 30-80 years). From the data collected, only factors available to the surgeon preoperatively were considered for analysis. These factors included age, gender, history of acute cholecystitis, jaundice or pancreatitis, previous abdominal surgery, obesity and concomitant disease, white blood cell (WBC) count, preoperative liver function tests, ultrasound findings of the gallbladder, preoperative endoscopic retrograde cholangiopancreatography (ERCP), and suspicion of common bile duct stones. Also we analyzed the case numbers as a measure of institutional experience. RESULTS: Of the 1,000 patients in whom laparoscopic cholecystectomy was attempted, 48 (4.8%) required conversion to open surgery. The most common reason for conversion was inability to define anatomy in patients with inflamed contracted gallbladder (n = 34). Significantly independent predictive factors for conversion were male gender, previous abdominal surgery, acute cholecystitis, thickened gallbladder wall on preoperative ultrasonography, and suspicion of common bile duct stones. CONCLUSIONS: An appreciation for the aforementioned predictors of conversion will allow appropriate planning by the patient, the institution, and the surgeon.

Management of main bile duct injuries that occur during laparoscopic cholecystectomy.

The introduction of laparoscopic cholecystectomy in surgical practice resulted with an increased incidence of bile duct injuries and required new classification systems. This article presents six cases of major bile duct injuries that occurred in our first 1,000 laparoscopic cholecystectomies. Four female and two male patients (ages, 36-71 years) were detected to have major bile duct injuries. Laparoscopic dissection was difficult because of acute inflammation in four patients and fibrosis in two patients. These six cases were between laparoscopic cholecystectomies 26 and 377 performed by the operating surgeons. Three of the patients had type E2 injury according to the Strasberg classification: one detected intraoperatively and the other two postoperatively. All were treated with Roux-en-Y hepaticojejunostomy. The other three patients had type D injuries: two realized intraoperatively and one postoperatively. Two of these injuries were repaired primarily over a T-tube. The remaining patient, whose injury was realized intraoperatively, underwent nasobiliary drainage postoperatively. Only one patient had a complication associated with a trocar injury to the liver parenchima during the first operation. A hepatic abscess and external biliary fistula developed, which were treated conservatively. At this writing, all the patients are well and without problems after 2.5 to 6 years of follow-up evaluation. Difficulties in laparoscopic dissection because of severe inflammation or fibrosis resulted in injuries to our patients. We can underscore the fact that experience may not always protect from complications, and that conversion to laparotomy might have prevented some of these injuries. Patients with a minor injury and a controlled leak can be treated by a combination of surgical and endoscopic or radiologic techniques. The treatment plan must be individualized for every patient, depending on the injury type, presentation, and condition of the patient.

Traumatic diaphragmatic hernias: a report of 26 cases.

Traumatic diaphragmatic hernias, when diagnosed many years after the traumatic event, are observed in about 10% of diaphragmatic injuries. Due to coexisting injuries and the silent nature of diaphragmatic injuries, the diagnosis is easily missed or difficult. The medical records of 26 patients, who were treated for diaphragmatic hernias during the last 20 years, were analysed retrospectively. The patients were divided into acute phase and late-presenting groups, in whom emergency surgery and elective intervention were performed respectively. Chest radiography was diagnostic in 34.6% (n = 9) of patients. 92.3% of the hernias were on the left side, while the most common herniated organs were the stomach (31.8%) and the colon (27.2%). Coexisting injuries were recorded in 38.4% (n = 10) of the patients. Primary repair was predominantly used (92.3%). The hospitalisation period was longer in the late-presenting group (24.1 +/- 18.8 vs. 14.3 +/- 7.7 days). Two deaths occurred in the late-presenting group. Diaphragmatic hernia should be suspected in all blunt abdominal trauma patients. Prompt surgical repair is the treatment of choice in all traumatic diaphragmatic hernias.

Cremasteric reflex and retraction of a testis.

PURPOSE: A clinical study has been planned to define the clinical characteristics of cremasteric reflex (CR) for deciding on the possibility of a prolonged suprascrotal stay of a testis through this reflex. METHODS: Five hundred boys from 3 days to 16 years of age were divided into 6 groups according to their ages and were evaluated for the presence of the CR. After evoking CR, the presence or absence of changes in testicular location and the most elevated position of the testis were recorded. Testicular position difference (TPD), the duration of the stay of testis in the most elevated position (DEP), and the interval for reevoking the CR (IRCR) were determined. The number of consecutive responses after repetitive evokings were recorded as reproducibility (R). Mean TPD, DEP, IRCR, and R values for both sides were calculated and compared among groups. The boys with a positive reflex were classified further according to their TPD, DEP, IRCR, and R values. Three groups were established according to the aforementioned criteria by dividing the values into 3 equal parts. The association of each of the parameters to other parameters were compared. RESULTS: Bilateral positive CR was encountered in 42.7% of newborns, 36.3% of the boys between 1 month and 1 year old, 38.1% of the boys between 2 years and 4 years old, 75.2% of the boys between 5 years and 8 years old, 70.3% of the boys between 9 years and 12 years old, and 72.1% of the boys between 13 and 16 years old. The highest percentage of the contralateral activations during ipsilateral evokings were encountered in boys who were between 5 and 8 years of age. The highest mean TPD and mean R, the longest mean DEP, and mean IRCR were encountered in boys between 5 and 8 years of age. Boys with the highest TPD did not have shortest IRCR and highest R values. Similarly, boys with the longest DEP or shortest IRCR and highest R values did not have the association of other parameters that would suggest a hypersensitivity. CONCLUSIONS: The rate of presence and the characteristics of a positive CR vary largely. However, suprascrotal location of a testis for extended periods through the activation of this reflex does not seem to be likely. Instead of a hyperactive reflex, the clinical condition, so called the retractile testis, might have resulted through alterations within the cremaster muscle itself. J Pediatr Surg 36:863-867.

Cremasteric reflexes of boys with descended, retractile, or undescended testes: an electrophysiological evaluation.

BACKGROUND/PURPOSE: Retractile testis traditionally has been regarded as suprascrotal location of testis resulting from hyperactivity of the cremasteric reflex (CR). However, the activity of CR is evaluated poorly in the literature. Electrophysiological characteristics of CR in boys with various testicular localizations have been evaluated comparatively. METHODS: Cremasteric responses that were evoked by electrical stimulation of the upper-inner aspect of thigh were recorded using a concentric needle electromyography (EMG) electrode inserted into the cremaster muscle. Evoked EMGs of groups, each consisting of 10 boys with bilateral descended (DT), unilateral retractile (RT), or unilateral undescended testes (UT) were compared for response latencies and durations. RESULTS: Three components with different onset latencies (R1, R2, and R3) were identified in EMG responses. In patients with UT, the latency of the R1 was shorter than that of the patients with DT, and the duration of R2 was longer than those of the patients with DT and RT. The differences between patients with RT and DT regarding the latency and duration of R1 and R2, although similar to those differences between UT and DT, were not significant. There were no significant differences of the latencies of R3 between groups. In patients with RT and UT, response latency and duration in the descended and retractile-undescended sides were similar. CONCLUSIONS: Defined by shortened latency and prolonged activity of cremasteric responses, which probably reflect a diminished neuronal inhibitory control, CR is hyperactive in UT. Disinhibited motor neurons leading to overactivity of cremaster muscle might have hampered the descent of testis. Our results do not provide a definite support for or against the hypothesis of CR hyperactivity in RT.

Changes in bladder of rabbits subjected to elevation of intraabdominal pressures.

BACKGROUND/PURPOSE: An experimental study has been conducted to evaluate the effects of increased intraabdominal pressure (IAP) on the morphology of the bladder of rabbits. METHODS: Experiments were performed on 20 adult male New Zealand rabbits. Six rabbits served as the control group (group I). Seven rabbits were subjected to increased IAP of 7 cm H2O for 10 days through installing air into the abdominal cavity (group II). Increased IAP was maintained for 60 days in another group of 7 rabbits (group III). Bladders were removed and fixed in 10% formalin for routine process. Paraffin sections of 5 to 7 microm were stained with H & E for light microscopic evaluation. Histopathologic parameters were scored, and the mean scores according to groups were compared by 1-way analysis of variance (ANOVA). The mean values of groups were compared separately by Tukey-Kramer multiple comparison test. In these tests, P value less than.05 was considered statistically significant. RESULTS: All of the bladder strips obtained from animals subjected to 10 days of pressure increase (group II) showed mild to severe degree of vacuolation and desquamation of urothelium. Both vacuolation and desquamation of urothelium were present in all of the strips obtained from rabbits with 60 days pressure increase (group III). Additionally, there were infiltration and congestion of the urothelium together with vacuolation, suburothelial edema, and desquamation in 4 group III rabbits. Moderate or severe congestion in the lamina propria was present in bladder strips of group II rabbits. The congestion of the lamina propria was advanced, and additional moderate to severe inflammation was present in 4 rabbits of group III. Mean histopathologic scores of urothelium (P <.00001) and lamina propria (P =.002) differed significantly among groups. When the groups were compared one by one, the differences between the group I and group II and group II and III were significant (P <.05). Although serosa appeared normal in both group I and II, moderate congestion and infiltration of the serosa was present in the bladder strips of group III (P <.05). CONCLUSION: Increases in IAP for even 10 days show damaging effects on the bladder. Extended period resulted in augmentation of the damage.

Intraabdominal pressure: a parameter helpful for diagnosing and predicting a complicated course in children with appendicitis.

BACKGROUND/PURPOSE: The intraabdominal pressure (IAP) of children presenting with acute, perforated, or suspected appendicitis were determined and compared to define if the IAP has any diagnostic value or helps to predict a complicated course. METHODS: Eighty-four patients with a initial diagnosis of appendicitis were evaluated. In addition to preoperative measurements, IAP of each patient was determined repeatedly on the postoperative first, second, and third days. The patients were grouped according to the final diagnoses as acute, perforated, or suspected appendicitis or negative exploration. The preoperative and postoperative IAP of the patients were compared among the groups. Postoperative complications were recorded, and IAP of those patients were additionally compared with the others in the same group. RESULTS: Whereas a normal appendix was found in 4 of the operated patients, 27 and 38 patients had acute and perforated appendicitis, respectively. The mean preoperative values of IAP for acute, perforated, or suspected appendicitis and negative exploration were 6.2 +/- 0.4, 9 +/- 0.3, 0.3 +/- 0.4, and 3 +/- 0.4 cm H2O, respectively (P< .001). Postoperative first day and second day values of the IAP for acute appendicitis, perforated appendicitis, and negative laparotomy groups were 2 +/- 0.2 and 0.6 +/- 0.1,3 +/- 0.1 and 1.5 +/- 0.1,0.5 +/- 0.6 and -0.2 +/- 0.6 cm H2O, respectively. The difference between acute and perforated appendicitis groups was significant (P< .05). Wound infection was encountered in 7 among 38 patients with perforated appendicitis. The preoperative and first postoperative day IAP values of patients with perforated appendicitis who experienced a wound infection and who were without a wound infection have been 11.8 +/- 0.4 and 4.8 +/- 0.2, and 8.4 +/- 0.2 and 3.1 +/- 0.3 cm H2O (P< .001). Discriminant analysis has shown that 93.3%, 70.4%, and 73.3% of patients with suspected, acute, and perforated appendicitis have been within the expected groups. IAP less than 1.39 cm H2O has excluded appendicitis with a 95% confidence interval. Although the interval has been between 5.40 and 7.04 cm H2O for acute appendicitis, it has varied between 8.46 and 9.70 cm H2O for perforated appendicitis. CONCLUSIONS: Although the IAP does not increase in conditions mimicking appendicitis, it increases among children with appendicitis. A further increase is encountered among children with perforated appendicitis. Complicated course is encountered among children with highest IAP values. Therefore, IAP may be used both as a diagnostic parameter and a predictor of a complicated course associated with appendicitis in children.

A comparative histopathologic evaluation of the effects of three different solutions used for whole bowel irrigation: an experimental study.

PURPOSE: Although whole bowel irrigation (WBI) is a widely used method of bowel preparation in daily surgical practice, almost nothing is known about the histopathologic alterations caused by WBI and whether these differences have any detrimental effect on the outcome of gastrointestinal surgical procedures. Therefore, an experimental study has been conducted to evaluate and compare the effects of WBI with various solutions on the histology of gastrointestinal tract. METHODS: During the experimental procedures animals were divided into 4 groups consisting of 8 animals each as follows: group A, WBI performed by using isotonic saline solution; group B, WBI performed by using an isoosmolar solution containing polyethylene glycol (PEG); group C, WBI performed by using Lactated Ringer's solution; group D, Animals that were not irrigated but sham operations that were performed served as controls. Four hours after WBI the animals underwent laparotomy and a segment of transverse colon with intact vascular peduncle was prepared. After waiting for 30 minutes, specimens from duodenum, small intestine, large bowel, colonic segment, and liver were obtained from each animal. Histopathologically, all of the specimens were evaluated and graded by 3 parameters including congestion, edema, and inflammation. RESULTS: Although varying degrees of congestion, edema, and inflammation were encountered from all of the specimens of group A, B, and C, only slight congestion was noted in all specimens of group D. The difference between group D and other groups was statistically very significant (P < .001). When the sections from duodenums of groups were evaluated, the degree of congestion, edema, and inflammation were found to be moderate in group B, mild-moderate in group A, and mild in group C. Histopathologic examinations of specimens of the small, large bowel, and isolated colonic segment showed severe congestion, edema, and inflammation in group A, moderate-mild in group B, and mild in group C. The difference between A and B, A and C, and A and D was statistically significant (P < .01). Although severe congestion was encountered in liver specimens of group A, only mild congestion was encountered in groups B and C (P= .0001). The matched durations of irrigations and total volume of irrigation solutions were found to be not related with the difference in histopathologic findings. CONCLUSIONS: WBI has induced varying degrees of histopathologic alterations from mild to severe in the rat gastrointestinal tract. Lactated Ringer's solution and PEG solution have induced the least alterations. Therefore, WBI with Lactated Ringer's solution and PEG solution seem to be safe alternatives of mechanical bowel preparation before elective large bowel surgery. Because saline solution has caused detrimental alterations in distal gastrointestinal tract histology, WBI with saline solution seems to be unadvisable.

Renal pelvic pressure responds with augmented increases to increments in intraabdominal pressure.

BACKGROUND/PURPOSE: Flow of a fluid through a collapsible tube is under the influence of various factors including the external compressing pressure. Because the intraabdominal pressure may compress the ureter, an experimental study has been planned to determine and compare the normal intraabdominal and renal pelvic pressures and the alterations in renal pelvic pressure in response to the increments in intraabdominal pressure in the rabbits. METHODS: Eight adult rabbits were used for the experiment. Under general anesthesia, an urethral catheter, a nasogastric tube, and an intraperitoneal catheter were placed to measure intravesical (IVP), intragastric (IGP), and intraabdominal pressures (IAP), respectively. Intracranial pressure monitorization catheter was placed into the renal pelvis to monitor intrapelvic pressure (IPP). Basal pressure measurements have been recorded. The pressures have been recorded in every 5 minutes, and IAP has been increased gradually about 3 to 4 cm of water pressure in every step for 30-minute periods. RESULTS: Increases in the intrapelvic pressure values have been significantly higher than the increases in the IAP (P < .001). A significant correlation has been found between IPP and IAP (P = .000, r = 0.866). By using linear regression analysis the relationship has been found to be IPP = 7.303 + 1.985 (IAP). Intragastric pressure values have been higher compared with IAP values (P < .001), whereas intravesical pressures have not differed from IAP (P > .05). CONCLUSIONS: Elevations in IAP results in augmented increases in the IPP. Poiseuille and Laplace Laws suggest this augmented increase to resemble proximal ureteric obstruction. Increases in IAP may simulate proximal ureteric obstruction and may take part in the pathogenesis of hydronephrosis. J Pediatr Surg 36:901-904.

Contractility and electrophysiological parameters of cremaster muscles of boys with a hernia or undescended testis.

BACKGROUND/PURPOSE: The cremaster muscle (CM) has been considered to participate in regulation of blood flow and temperature of the testis. Its contribution to testicular descent has been suggested. However, there is limited information about the CM in physiological and pathological states. Therefore, an experimental study has been conducted to evaluate and compare the contractile and electrophysiological properties of CM in boys with descended or undescended testes. METHODS: Identical CM strips were obtained from eight boys who underwent orchidopexy with a mean age of 3+/-2.2 years and from eight boys who underwent herniorrhaphy with a mean age of 4+/-1.3 years. Muscle strips of 3 x 8 mm were vertically attached to an isometric force displacement transducer, and direct muscle contractions were elicited by rectangular electrical pulses. Direct isometric muscle contractions were recorded in an organ bath containing mammalian Ringer's solution. In electrophysiological experiments, conventional microelectrode techniques were used. RESULTS: Direct electrical stimulation of CM strips obtained from patients with descended and undescended testes elicited muscle twitches and frequency-dependent contractile responses. Tetanic contractions of undescended testes at 100 Hz were 67% greater in amplitude than that of descended testes (P< .002). Muscle strips of both groups exhibited increased twitch amplitudes by 105%+/-37% when the temperature of the bathing solution was increased from 22 degrees to 37 degrees C (P< .001). The electrophysiological findings were similar. CONCLUSIONS: Contrary to other striated muscles, elevated temperature increases the contractility of CM. If the increased contractility by an increase in temperature is a property unique for CM, it should reflect the attempts at regulating testicular blood flow or temperature. The increased amplitude of contractions encountered among the CM of boys with undescended testis suggests the CM to have a role on the location of the testis.