The most commonly cited articles in pediatric surgical journals.

AIM: This study aimed to investigate the characteristics of the most frequently cited articles published in 3 main journals dedicated to the field of pediatric surgery (Journal of Pediatric Surgery, Pediatric Surgery International and European Journal of Pediatric Surgery). MATERIAL AND METHODS: A search was initiated using the database (1985 - 2006) of the Science Citation Index of the Institute for Scientific Information. The total number of publications and their citation numbers were found and the most cited articles were investigated in detail. A total of 600 (200 from each journal) most cited articles were identified and chosen for further analysis. RESULTS: The total number of citations in these 3 journals was 20 271. The citations of the most cited articles ranged from 10 to 224. The articles were published between 1985 and 2003 and the mean number of citations/article was 33.78. Articles originated from 39 counties and 256 institutions. The leading countries were the United States (203 articles from 75 institutions), Germany (50 articles from 21 institutions), Japan (34 articles from 17 institutions), Switzerland (34 articles from 8 institutions), United Kingdom (32 articles from 19 institutions), and Canada (28 articles from 7 institutions). Of the institutions with the highest number of cited articles, four institutions were from the USA followed by Switzerland with two institutions. The leading topics were the gastrointestinal system (n = 239), respiratory system (n = 94), urology (n = 61) and oncology (n = 56), and diaphragmatic hernia (n = 41) was the most common special topic. There were 42 case reports (7 %) and 75 experimental research articles (12.5 %). Thirty-four authors from 14 countries and 30 institutions had articles in more than one journal. The most cited author was N. S. Adzick from the USA with 224 citations. CONCLUSION: In this study, we found that the Journal of Pediatric Surgery predominated with the greatest number of cited articles. The most cited articles, authors and institutions originated from the USA and English-speaking countries. The gastrointestinal system, respiratory system, urology and oncology were the leading topics and diaphragmatic hernia was the most common special topic.

Expression of estrogen and androgen receptors in children with hypospadias: preliminary report.

This investigation was conducted to evaluate the presence of estrogen and androgen receptors in penile tissues of patients with hypospadias. The biopsy specimens from prepuce, glans, and urethral plate were sampled during the hypospadias surgery in five patients and were analyzed immunohistochemically. Twelve specimens were investigated for the presence of estrogen or androgen receptors (n: 24); the result was negative in 9 (37%) and positive in 15 (63%). Estrogen receptors were present in 10 specimens (42%) (prepuce: 5, glans: 3, and urethral plate: 2). Androgen receptors were present in 5 specimens (21%) (prepuce: 3, glans: 1, and urethral plate: 1). There was expression of both estrogen and androgen receptors in 5 specimens and only estrogen receptors in the remaining 5. Dominant expression of estrogen receptors in penile tissues of children with hypospadias may be the postnatal finding of disrupted estrogen and androgen receptor interaction during the intrauterine development of external genitalia.

Plasma testosterone and estradiol levels in unilateral cryptorchidism.

This research was conducted to investigate the relationship between plasma hormone level during activation of hypothalamic-pituitary-testicular axis at the postnatal period and at puberty in unilateral cryptorchidism. Plasma testosterone and estradiol levels of 80 patients with unilateral cryptorchidism at different ages (range: 6 months-12 years) were measured. The mean plasma testosterone level is 40 (15-60) pg/ml at 6 months of age, 55 (30-120) at ages between 9 and 12 years, and 20 (11-22) at ages between 1 and 9 years. The mean plasma estradiol level is 12, 11 and 11 (5-24) pg/ml, respectively, in these groups. The patients with unilateral cryptorchidism do not have similar peaks of plasma estradiol level as plasma testosterone level at the postnatal period and at puberty. Peak of plasma testosterone at puberty occurs if the patients were not operated on.

Estrogen receptor beta type in the rat urinary bladder.

This study was conducted to localize estrogen receptor beta (ERbeta) in the rat urinary bladder respect to gender. The bladder dome and trigone of 16 Sprague Dawley rats (Male: 8, Female: 8) were evaluated utilizing the reverse transcriptase-polymerase chain reaction technique (RT-PCR) to detect ERbeta signal. Chi square test was used for statistical analysis. ERbeta was present in the bladder of 13 rats and absent in 3. The side of expression was bladder trigone in 13 rats and besides ERbeta (M: 1, F: 2) was also present in the bladder dome of 3. The relationship between the distribution of ERbeta in the bladder and gender was not different. ERbeta is present in the bladder trigone of rats independent of gender. Estrogen action in the bladder trigone is also important in males besides females.

The sex hormone receptors in the bladder in childhood - I: preliminary report in male subjects.

The sex hormone receptors (oestrogen, androgen, progesterone) in the bladder were demonstrated in clinical studies by various authors in adult patients. But the presence of these receptors in childhood had not been investigated. The aim of this study was to assess the presence of sex hormone receptors in the bladder of male subjects in childhood. The study included 20 bladder biopsies from a total of 15 children. Biopsies were taken during open surgery and/or cystoscopic procedures for various indications from the bladder dome, trigonum and in the region of the bladder neck. All biopsies were routinely fixed and processed for histopathological assessment and investigated immunohistochemically to determine the sex hormone receptors in the bladder. The sex hormone receptors were demonstrated with different densities and locations. In particular, sex hormone receptors were found very frequently in biopsies taken from the bladder neck. Overall receptor positivity in the specimens was 90 % for progesterone, 65 % for androgen and 25 % for oestrogen. There was no receptor expression in the deeper tissues of the bladder wall. This preliminary study demonstrated: 1. Sex hormone receptors are present in children; 2. There was a female sex hormone (progesterone, oestrogen) receptor expression in male subjects; 3. The receptors are mainly localised at the bladder neck and in transitional epithelium of the bladder wall. We think that the sex hormone receptor map may be useful in the evaluation of lower urinary tract and specially bladder neck disorders in childhood in the future.

Albendazole therapy in the treatment of hydatid liver disease.

Hydatid disease, a common health problem in Turkey as in many countries, should be included in the differential diagnosis of all patients presenting with a cystic mass in the abdominal or thoracic cavity. Previously, surgery had been the main form of treatment. But with the introduction of preoperative medication with albendazole, treating this disease medically is now growing in popularity. We report herein the findings of ten patients with two lung and 20 liver hydatid cysts ranging from 3 to 20 cm in diameter, who were successfully treated with medical therapy. Multiple organ involvement and multiple cysts in an organ are the main indications for medical treatment with albendazole, but the indications should not be limited to certain situations such as small-sized cysts, since even huge-sized cysts responded well to the therapy in this series.

Effects of male sex hormones on urodynamics in childhood: intersex patients are a natural model.

The effects of sex hormones on bladder function have been evaluated in adult females, especially in regard to postmenopausal incontinence and bladder irritability syndromes. These have not been investigated in children in regard to urodynamic findings. An intersex patient whose bladder is under the influence of androgens is a natural model to investigate the effects of male sex hormones on bladder function in females. To evaluate the urodynamic findings and clinical symptoms in a group of intersex patients and to determine how androgens influence bladder function in female children, clinical and urodynamic records of 12 intersex patients with adrenogenital syndrome were investigated retrospectively. The mean age was 9 +/- 5.7 years (1.5-18) and the mean follow-up period was 5.1 +/- 4.4 years (1-12). Congenital adrenal hyperplasia (CAH) was present in all cases. Only 3 patients had urinary symptoms and incontinence, but these findings did not correlate with their urodynamic findings. None of the patients required medications for their urinary symptoms. Nine are still being treated medically by the pediatric endocrine team with hydrocortisone for CAH. The upper urinary tract was found to be normal with no hydronephrosis. The mean bladder capacity (269 +/- 122 ml) was lower (86.7%) than the estimated capacity for age. The mean compliance was 20 +/- 13.7 ml/cmH2O. No unstable detrusor contractions were encountered. The most remarkable finding was this reduced bladder capacity of androgenized female patients for age, which shows the antagonistic effect of androgens on bladder urodynamics in females.

The relation between human leukocyte antigen (HLA) distribution and intestinal obstruction and adhesions in childhood: preliminary report.

To investigate the association between the human leukocyte antigen (HLA) system and adhesions causing intestinal obstruction in childhood in order to determine whether HLA profiles can be used to identify and screen individuals at risk for intestinal adhesions, clinical and laboratory evaluations were done in a total of 42 (F:M = 27:15) patients. The mean age was 6.11 +/- 3.2 years (0.6-13 years). The patients were tested for HLA phenotype in two groups; the HLA phenotype distribution and relative risk (RR) for adhesions were determined. The study patients were children operated upon due to acute abdominal emergencies. Group 1 included patients who needed readmission after the surgery due to intestinal obstruction (n = 19), group 2 patients had no readmission for any reason following surgery (n = 23). Of the 19 patients in group 1, 9 were treated only medically and 10 needed surgical intervention. Among the patients in whom medical treatment was initiated (n = 14), 5 needed surgery during follow-up. There was an increased RR for certain HLA subtypes (A24 [9], HLA11, DR11 [5], B22) in patients presenting with intestinal obstruction due to adhesions. Among these, A24 (9) and DR11 (5) were statistically significant (P < 0.05) compared with the control group. Several possible mechanisms could link the HLA system with disease, especially those in which the immune response is suspected to be involved, but the questions of how the inflammatory response is initiated and the role of proinflammatory cytokines remain unclear. Future research developments are likely to focus on increased understanding of the molecular biology of the major histocompatibility complex and its biological function in the immune response and adhesion formation and intestinal obstruction. It is possible that HLA profiles can be used to identify individuals at risk for intestinal adhesions in the future.

Duplicated exstrophy in one of identical twins.

The characteristic of duplicated exstrophy is the presence of a patch of exstrophic bladder mucosa in the infraumbilical region with a low-set umbilicus, in addition to the normal bladder. Musculoskeletal defects, diastasis pubis, and rectus abdominis can also be found in these patients. We report the first case of a female twin baby with appearance of a low-set umbilicus and diastasis pubis associated with a pubic sinus. The external genitalia and urinary continence were normal. Duplicated exstrophic mucosal remnant was excised, and the histopathologic study of the specimen confirmed urothelium.

Hydatid disease of the liver in childhood.

The records of 100 children with hydatid disease were reviewed retrospectively from 1978 to 1997; 43 were girls and 57 were boys. The mean age was 9.14 years; 61 patients had 124 hepatic cysts. Presenting symptoms were asymptomatic abdominal masses, found masses incidentally during ultrasonography (US), or acute abdomen. Plain X-ray films, US, or computerized tomography (CT) are sufficient for diagnostic evaluation in endemic areas. In the differential diagnosis, laboratory investigations such as the Casoni and Weinberg tests, indirect hemagglutination, eosinophilia, and ELISA were also used. These tests may give negative results, however, in some patients with hydatid disease. The mean follow-up time was 10.5 years (range 1-18 years), the mean duration of hospitalization 7 days. The complication rate was 3.6%. Mortality was 3.27% and occurred after the administration of formaldehyde and hypertonic scolicidal agents. Hydatid disease of the liver can be treated medically in selected patients; conservative surgical approaches that save as much parenchyma as possible, such as partial cystectomy and capitonnage, are indicated in the other cases.

The relationship between Helicobacter pylori infection and acid-hematuria syndrome in pediatric patients with gastric augmentation-II.

BACKGROUND/PURPOSE: The acid-hematuria syndrome, which presents with dysuria, hematuria, and perineal pain still remains a problem in those patients who have undergone bladder augmentation using the gastrocystoplasty technique. Additionally, there is still a question regarding the explanation for postoperative metabolic problems such as metabolic alkalosis, hypocholoremia, hypergastrinemia, and various complications related to gastritis and peptic ulcer disease. The aim of this study was to investigate the relation of Helicobacter pylori (HP) infection in this patient group and the relationship between HP infection and the above-mentioned clinical problems and complications. METHODS: In this study, 10 children with a history of previous gastrocystoplasty (five girls, five boys; mean age, 6.75+/-2.53 years; range, 2.5 to 12 years) were evaluated. Blood samples for HP detection were analyzed by serological testing (ELISA technique). Histopathologic studies were performed for gastric tissue specimens, obtained by endoscopic procedures from the stomach and augmented bladder. Urine pH and serum gastrin levels were measured in all patients. RESULTS: Regarding the serological studies, four of ten patients had a positive ELISA test result (40%). The four patients with HP-positive serological test results, were the patients who had acid-hematuria syndrome. These patients also had low urine pH levels (mean, 4.5) when compared with those of HP-negative patients. HP-positive patients also had high serum gastrin levels in comparison with those of HP-negative patients. CONCLUSIONS: The relation between HP infection and problems such as hypergastrinemia, acid output, and ulcer disease is well known. Our study demonstrates a correlation between the HP-positive gastrocystoplasty patients and the above-mentioned symptoms and complications. Because of the potential risk of HP infection, we suggest that HP infection be investigated in patients with gastrocystoplasty or in candidates for a gastrocystoplasty operation. HP-positive patients should be treated, to reduce the risks of postoperative complications.

Bladder augmentation: urodynamic findings and clinical outcome in different augmentation techniques.

OBJECTIVE: To compare the urodynamic findings and clinical outcome in different bladder augmentation techniques. PATIENTS AND METHODS: From 1987 to 1996, 32 bladder augmentations were performed in 30 (M:F/18:12) patients. Mean age was 8.1 years (range: 1-15 years) and the mean follow-up period was 3.2 years (range: 6 months to 8 years). The following techniques were used for bladder augmentation: sigmoid colon in eleven cases, stomach in nine cases, ileum in six cases, ileocaecum in two cases and rectus abdominis muscle flap (RAMF) in four cases. Seven patients also underwent Mitrofanoff procedure to create a continent stoma. RESULTS: According to the urodynamic evaluation the mean capacity was 237 +/- 120 ml in the colonic group, 115 +/- 86 ml in the gastric group, 240 +/- 45 ml in the ileal group, 250 +/- 0 ml in the ileocaecal group and 30 +/- 10 ml in the RAMF group. The mean compliance was 20.6 +/- 14 ml/cm H2O in the colonic group, 10.7 +/- 10.4 ml/cm H2O in the gastric group, 21.6 +/- 9 ml/cm H2O in the ileal group, 25.5 +/- 5.5 ml/cm H2O in the ileocaecal group, 5.8 +/- 1.5 ml/cm H2O in the RAMF group. The upper urinary tract was normal without hydronephrosis in all but except two patients. These two patients are still treated medically for chronic renal failure by the pediatric nephrology team. The patients are using their Mitrofanoff or native urethra with clean intermittent catheterization (CIC) or self-CIC technique for continence. CONCLUSION: Comparing these five different techniques, ileal, ileocaecal and colonic groups were in advantage to achieve high volume reservoirs, followed by the gastric group. Regarding complications; in colonic cases, mucus problems, stone formation and surgical complications related to gastrointestinal tract (intestinal obstruction, perforation) were the most common ones. Perineal dermatitis was the main complication in gastric cases. In the ileal group, complication rate was low. Absence of mucus production and the low postoperative complication rates were the two major advantages of RAMF technique. However this technique is not recommended as an augmentation procedure due to its low capacity and compliance rates. Recently, ileal augmentation has became the most popular method in our institution.

Prenatally detected gastroschisis presenting as jejunal atresia due to vanishing bowel.

A case of gastroschisis complicated by vanishing bowel and presenting as jejunal atresia is reported that is uniquely different from previously reported cases. Following delivery, complete closure of the abdominal wall with a small fascial defect was observed. Complete healing of this fascial defect was observed at 1 month of age.

The effect of an H2-receptor antagonist on small-bowel colonization and bacterial translocation in newborn rats.

Bacterial translocation (BT) is defined as the passage of enteric bacteria from the gastrointestinal tract to extraintestinal tissues. Bacterial overgrowth is one of the main promoting factors of BT, which is thought to play an important role in the pathogenesis of sepsis and necrotizing enterocolitis. It is believed that small-bowel colonization is established by bacterial spread through the rectum. Gastric acid is also involved in this process. An experimental study was designed for investigating the effect of gastric acid inhibition with the use of an H2-receptor antagonist on intestinal colonization and BT in newborn rats. Animals were divided into two groups: the ranitidine group (n = 20) received ranitidine 10 mg/kg per day intramuscularly for 5 days; the control group (n = 30) received saline solution. Mesenteric lymph node, spleen, liver, stomach, small bowel/cecum, and large bowel specimens were obtained from each rat 5 days later and gram-negative and -positive aerobic bacteria identified by the use of chocolate and Endo agar. It is concluded that: (1) there was a strong correlation between gastric and small-bowel bacterial colonization in the ranitidine group; (2) no correlation between large-and small-bowel colonization could be demonstrated; and (3) BT occurred only in the ranitidine group.

Congenital short bowel syndrome associated with appendiceal agenesis and functional intestinal obstruction.

Congenital short bowel with functional intestinal obstruction and absence of appendix vermiformis is a very rare condition with poor prognosis. Seventeen cases of congenital short bowel have been reported previously in the literature. The etiology is unknown. In this report, a case of congenital short bowel, combined with functional intestinal obstruction, mal-rotation, and absence of the appendix vermiformis, is presented and the pathogenesis discussed.

Comparison of different bladder autoaugmentation techniques in a rabbit model.

OBJECTIVE: To compare the urodynamic, radiological and histopathological findings of a bladder autoaugmentation method combined with different seromuscular enterocystoplasty (mucosectomized) techniques and the rectus abdominis muscle-flap (RAMF) technique, and thus devise a method that may eliminate the potential risks of bladder autoaugmentation. MATERIALS AND METHODS: The study comprised 20 male New Zealand White rabbits in four groups. In group 1 (control), an autoaugmentation model was created by incising the detrusor muscle of the bladder, forming a large wide-mouthed bladder diverticulum. In group 2, a full-thickness RAMF with an intact vascular supply was used to cover the augmented bladder wall. In groups 3 and 4, besides the autoaugmentation procedure, a 5 cm ileal segment with an intact vascular supply was prepared and the muscosal layer of the segment removed. In group 3, the mucosectomized surface of the ileal graft was used to cover the autoaugmented bladder (seromuscular ileocystoplasty, SMEC) and in group 4, the serosal surface of the pedunculated ileal graft was used in reverse to cover the autoaugmented bladder wall (reversed SMEC, RSMEC). All groups were followed using intravenous pyelography (IVP), voiding cysto-urethrography (VCUG), urodynamic investigations and histopathological analysis for 2 months post-operatively. RESULTS: In all groups except 2 (RAMF), a diffuse bulging of the bladder wall was detected on IVP and VCUG. In groups 1, 3 and 4, there was a significant increase in mean bladder capacity and the compliance also increased. However, in group 2 there was a significant reduction in bladder capacity and compliance, and the histopathological analysis showed severe fibrosis. The fibrotic changes were moderate in groups 1 and 4 and mild in group 3. CONCLUSIONS: The urodynamic studies, IVP, VCUG and histopathology suggested that the SMEC technique decreased the potential risks of bladder autoaugmentation, had minimal side-effects and was the most appropriate coat over the uroepithelium after bladder autoaugmentation.

A modified Mitrofanoff procedure using the rectus abdominis muscle flap technique: a preliminary report in a rabbit model.

OBJECTIVE: To create a modified Mitrofanoff continent stoma in a rabbit model, using a rectus abdominis muscle flap (RAMF) with its intact vascular supply. MATERIALS AND METHODS: Fifteen New Zealand White male rabbits underwent an operation to create a 6 cm long tube using a RAMF with its vascular pedicle from the inferior epigastric vessels. The internal orifice of the tube was anastomosed to the anterior bladder wall with 5/0 polyglactin sutures. The external orifice was directly sutured to the skin to fashion a catheterizable Mitrofanoff stoma. A 6 F catheter was left in the tube as a stent for 2 weeks. Radiography and histopathological investigations were carried out for 8 weeks after surgery. RESULTS: Intravenous pyelography and voiding cystourethrography showed a normal looking urinary system; contrast studies showed an intact RAMF tube with no signs of stricture. Catheterization of the stoma was possible in each animal. Histopathologically, there was no evidence of severe fibrosis or inflammatory changes; the inner surface of the tube (proximal bladder side) was covered by transitional urinary epithelium in most of the animals. CONCLUSION: It is possible to create a Mitrofanoff tube using a vascularized RAMF in a rabbit model. Using this technique there is no need to perform a major operation in the gastrointestinal system. The technique may provide a good alternative treatment in those patients who need a combination of Mitrofanoff and antegrade continence enema surgery, and in patients with previous appendectomy.

Hepatic duct stone associated with chlamydia sepsis: a rare condition in childhood.

Stone formation in the biliary system is a rare condition in infants. A few cases of bile stones in the biliary tree have been reported with underlying predisposing factors, such as sepsis and antibiotic usage. This article describes a surgically treated 16-week-old infant with recurrent cholangitis who had a bile stone in the hepatic duct after chlamydia sepsis.

Urodynamic investigations in reversed ileal seromuscular enterocystoplasty: an experimental study in a rabbit model.

OBJECTIVE: To investigate the efficacy of the reversed ileal seromuscular enterocystoplasty (RISMEC) technique and assess the urodynamic findings. MATERIALS AND METHOD: A large bladder defect was created in 12 New Zealand White rabbits: in six the bladder was closed primarily (control group) and in the remaining six the bladder was augmented using the RISMEC technique combined with omentoplasty. The results were assessed using intravenous pyelography (IVP), voiding cysto-urethrography (VCUG), histopathological investigations and urodynamic studies after 4 and 12 weeks. RESULTS: The IVP and VCUG revealed an apparently normal urinary system and voiding pattern in both groups. Histopathologically, in all rabbits undergoing RISMEC, the serosal surface of the reversed ileum was lined with transitional urinary epithelium; there was no evidence of severe fibrosis, inflammation, stone or mucus-production. Urodynamic studies showed a significant decrease in the mean bladder capacity in the controls, but no significant change in the RISMEC group. The mean bladder compliance decreased from 5.85 to 1.36 mL/cmH2O in the controls (P < 0.02) but there was no significant decrease in compliance in the RISMEC group. CONCLUSION: The results suggest that in this rabbit model, the RISMEC technique combined with omentoplasty increases bladder capacity with minimal graft shrinkage; the peritoneal surface is rapidly covered with transitional epithelium and the integrity of the kidneys preserved. Urodynamic investigations showed neobladders with adequate storage capacity, low intravesical pressures and improved compliance rates.

Rectus abdominis muscle flap (RAMF) technique for the management of bladder exstrophies: late clinical outcome and urodynamic findings.

OBJECTIVE: To investigate the efficacy of the rectus abdominis muscle flap (RAMF) technique for the closure and augmentation of small, non-compliant bladder exstrophies. PATIENTS AND METHODS: The RAMF technique was used in two girls and two boys (mean age at operation, 31.7 months, range 3-72) with bladder exstrophy. The clinical outcome and urodynamics were assessed during a follow-up of 29 months to 6 years (mean 49.2 months) and included imaging, cystoscopy, biochemical and microbiological studies. RESULTS: There were no urinary tract infections, metabolic problems or electrolyte disturbances and kidney function remained normal in all patients. Radiography confirmed intact function and anatomy of the urinary tract and cystoscopy showed complete coverage of the inner peritoneal layer of RAMF with uroepithelium. No stone formation or mucus production were detected. Currently, three patients void using clean intermittent catheterization through the native urethra and the fourth through an appendiceal Mitrofanoff valve. However, the bladder volume was insufficient at the late follow-up and three patients required bladder augmentation. CONCLUSIONS: The RAMF technique is a good alternative for closing bladder exstrophies and achieves an increase in bladder capacity; however, although there is a mild improvement in bladder capacity and compliance. RAMF should not be used as a bladder augmentation procedure. The technique is indicated in the closure of large bladder defects, bladder exstrophies with small, inelastic, non-compliant bladder remnants and failed primary closures.