Spontaneous regeneration of bone following mandibular ramus bone harvesting: a CBCT analysis.

The aim of this study was to evaluate healing at the donor site following autogenous block graft harvesting from the mandibular ramus. In this retrospective study, cone beam computed tomography images taken at different time-points were examined, and the volumes of preoperative and postoperative regions of interest were calculated in the software. Images were classified into four groups: 0-3 months, 4-6 months, 7-12 months, and >12 months post-surgery. To characterize the healing process over time, statistical analyses were conducted for both the 70% and 80% healing thresholds. Nearly half (n = 15, 47%) of the 32 patients included in this study achieved 70% bone healing within 4-12 months post-surgery. At the end of the 28-month period covered by this study, 21 patients (66%) had achieved 70% bone healing. The median time to achieve 70% healing was 9 months, while the median time to achieve 80% healing was 28 months. The findings of this study validate the feasibility of reutilizing the mandibular ramus area for additional bone augmentation when other intraoral sites are unavailable.

Spiral-medial butterfly fractures (AO-12-B1) in distal diaphysis of humerus with rotational forces: preliminary results of open reduction and plate-screw fixation.

OBJECTIVE: Humerus shaft fractures are frequent injuries in orthopedic practice and generally occurs with direct and indirect traumas. While the most of these fractures can be managed with conservative methods, in some situations surgery is needed. The aim of this study is to define a different mechanism and treatment result of  humerus spiral fractures with medial butterfly fragment (AO-12-B1). PATIENTS AND METHODS: Between 2010 and 2013, 11 patients who had undergone surgery for spiral humerus shaft fracture with medial large butterfly fragment (AO type 12-B1) resulting from a motor vehicle accident were enrolled to the study. All data was retrieved from the hospital's database retrospectively. All fractures were closed type and all of the patients were treated with open reduction and plate osteosynthesis through lateral approach. Elbow and shoulder ROMs were examined for functional outcomes. The DASH (Disabilities of the Arm, Shoulder and Hand) scoring system was applied at the final follow-up visit. RESULTS: There were 7 male and 4 female patients with a mean age of 36 years (range, 28-50 years). All of the fractures occurred with same mechanism resulting from motor vehicle accident. Conservative treatment was not considered for any of the cases. The mean time to surgery was 2 days (1-3 days). The mean postoperative follow-up period was 14 months (6-24 months). All fractures had healed completely at 3 months postoperatively. At the final follow-up visit the mean DASH score was 4.2 (3.3-6.7). CONCLUSIONS: Humerus spiral shaft fractures with a large medial butterfly fragment can be seen in dashboard injuries. It is important to fix the medial large fragment anatomically and minimal invasively in order to achieve union and not to disturb the vascular supply.

Management of bilateral Wilms tumor over three decades: The perspective of a single center.

INTRODUCTION: Outcomes of Wilms tumor improved in last 50 years and excellent survival rates can be achieved especially in case of non-metastatic disease and favorable histology. Nevertheless, bilateral cases still stand as a therapeutic challenge. Prognosis of bilateral Wilms tumor (BWT) is not as good as the unilateral tumors of similar stage and histology in terms of survival and renal function. OBJECTIVE: Management of BWT is constantly evolving and still stands as a therapeutic challenge. This study is designed to review and share our experiences on this topic from a surgical standpoint. STUDY DESIGN: The records of patients treated in our clinic between 1980 and 2013 according to Turkish Pediatric Group of Oncology protocol were analyzed retrospectively and clinical data, surgical details, pathology results, long term outcomes were analyzed. RESULTS: Thirteen girls and 7 boys with a mean age of 2,5 years were treated. There were 2 patients with Wilms tumor-Aniridia-Growth Retardation complex and one with isolated hemihypertrophy. Metastasis were detected in lungs of 4 patients; liver of 2 and in the cranium of one. All patients except one with the presumptive diagnosis of unilateral Wilms tumor were given preoperative chemotherapy. To sum up; 19 nephroureterectomies, 8 partial nephrectomies and 13 enucleations were performed to 36 kidneys without any major early or late postoperative complications. Pathologic results revealed positive surgical margins in 2 lesions with enucleation and in 2 with partial nephrectomies and anaplasia in 4 patients. Two patients were not operated due to parental disapproval. Two patients had the need of dialysis; one was anephric and the others' renal functions recovered over a year. Seven patients received radiotherapy for pulmonary metastasis, positive surgical margins or local recurrences. Overall, 13 patients survived and 7 died due to metastasis, recurrences, and complication of dialysis and refusal of surgical treatment. Survival among all patients was 65% and 72.2% among operated ones. Of the 7 patients with the partial nephrectomy, 2 died and 5 survived. Among enucleation group, 8 out of 10 survived and 2 died. Survival was slightly higher among enucleation group (80% vs 71.4%). Median time of follow-up for survivors of disease is 5.8 years (min: 6 months and max: 14 years). DISCUSSION: Outcomes of BWT management have changed dramatically during the last few decades from only survival, to a long life expectancy without the need of renal replacement therapy owing to improvements in treatment options. We argue that positive surgical margins do not necessarily lead to local recurrence. For this reason it may be wiser to favor on more nephron sparing surgery than to achieve negative surgical margins. Adjuvant chemotherapy and radiotherapy may be adequate to prevent local recurrence. Also, survival did not differ significantly between different ways of nephron sparing surgeries, so it may be wiser to choose enucleation over partial nephrectomy which preserves more nephrons. Nephron-sparing surgery should have utmost importance despite the risk of positive margins. On the other hand, there is not enough data to interpret if positive surgical margins have role on distant metastases or not. Presence of metastasis and recurrence seems to be an important determinant of prognosis given the fact that none of the survivors had any metastasis or recurrence. CONCLUSION: Nephron preservation should be the aim while taking positive surgical margin risk on nephron sparing surgery side relying on postoperative chemotherapy and carefully planned radiotherapy to avoid recurrence. However, there is significant diversity on the management BWT in different centers and a certain validated guideline or protocol to provide the optimal treatment is still lacking.

Sigmoid colon vaginoplasty in children.

BACKGROUND: Vaginal construction is necessary for the patients with aplasia of Mullerian ducts, testicular feminisation and androgen insensitivity syndromes. Many methods of vaginal construction have been described. We report here the outcomes of six adolescent patients who underwent sigmoid colon vaginoplasty with special emphasis on the surgical technique and outcomes. PATIENTS AND METHODS: Between 1990 and 2003, six patients underwent sigmoid vaginoplasty after a diagnosis of 5alpha-reductase deficiency (n = 3), testicular feminisation (n = 2) or vaginal atresia (n = 1). The mean age was 16 years (13 to 18). Wide spectrum antibiotics and whole-gut preparation were used in all cases. A 15-20 cm segment of sigmoid colon was pulled through the retrovesical tunnel. The proximal end was closed in two layers in patients with 5alpha-reductase deficiency and with testicular feminisation. A distal anastomosis was carried out to the opening made on the vaginal plate (5alpha-reductase deficiency) or on the tip of the shallow rudimentary vagina (testicular feminisation). The sigmoid segment was interposed between the blind end of the atretic vagina and the perineum in the patient with vaginal atresia. Patients were instructed to perform daily vaginal irrigation. The neovagina was examined and calibrated under anaesthesia. No routine vaginal dilatation was recommended. RESULTS: All but one patient had an uneventful postoperative period and were discharged within 7-8 days. All patients had an excellent cosmetic result with an appropriate vaginal length. One of the patients experienced late stenosis of the introitus which responded to dilatations. Mucus discharge was not a significant problem. The patient with vaginal atresia (Bardet-Biedl syndrome) experienced deep vein thrombosis, renal failure and sepsis, resulting in death. CONCLUSION: Sigmoid colon vaginoplasty is a special procedure which appears appropriate for the construction of a new vagina in children. A sigmoid colon neovagina meets all necessary criteria after a vaginoplasty. It provides an adequate diameter and length, and produces less scar tissue in the perineum. It is self-moistening, easily adaptable to the uterus, cervix and rudimentary atretic vaginal segments and does not require routine dilatation. Mild stenosis of the introitus can be treated by dilatations and revision can be easily performed in severely stenotic cases. On the other hand, the patient may face morbidity after laparotomy and other serious complications may occur due to accompanying diseases.

Bannayan-riley-ruvalcaba syndrome from the point of view of the pediatric surgeon.

Bannayan-Riley-Ruvalcaba syndrome (BRRS) is an overgrowth syndrome and polyposis condition, which carries an increased risk for development of benign and malignant tumors of various tissues and organs. A 9-year-old boy with BRRS who had multiple subcutaneous mesenchymal tumors and follicular adenoma of the thyroid and a 14-year-old boy with multiple subcutaneous mesenchymal tumors and gastrointestinal polyposis are presented, with special emphasis on the surgical management of these patients.

Anti-androgen induced inhibition of testicular descent is associated with a decrease in sympathetic tonus.

BACKGROUND/AIMS: Responses of cremaster muscles and sacs from boys with undescended testis suggested less exposure against sympathetic, but more exposure against parasympathetic tonuses. Since the sympathetic tonus is androgen dependent, it has been suggested that androgens control the descent by influencing the sympathetic tonus. Therefore an experimental study was planned to evaluate the contractile responses of cremaster muscles according to locations of associated testes in rats subjected to intrauterine steroidal or non-steroidal anti-androgen exposure. METHODS: Time-mated pregnancies were started in 18 rats. They were divided into three groups and each group was given physiologic saline, flutamide or cyproterone acetate (Androcur Depot). Flutamide was administered from day 15 to day 19, cyproterone acetate on day 15 of intra-uterine life. At twelve weeks of age the localization of testes was evaluated, cremaster muscles were removed, and contractile properties were studied. Twitch and tetanic contractions were recorded isometrically at 37 degrees C. Effects of verapamil and isoprenaline were investigated. Results were compared by ANOVA and p values less than 0.05 were considered significant. RESULTS: Both testes of all available male offspring in the saline (n = 22) and cyproterone acetate-treated (n = 19) groups were in the scrotum. Sixty percent of males in the flutamide-treated group (n = 20) had undescended testes. Cremaster muscles of rats exposed to flutamide had a lower sensitivity to voltage sensitive Ca+2 channel blockade by verapamil (3 x 10(-4) mol/L, p < 0.05) and displayed greater contractile response to isoprenaline (10(-5) mol/L, p < 0.05). Alterations in contractile properties of the muscles did not differ according to localization of testes in rats subjected to flutamide exposure. CONCLUSIONS: CM in rats subjected to non-steroidal anti-androgen exposure revealed alterations that indicate a decrease in sympathetic tonus. Since non-steroidal anti-androgen also inhibits the descent, the present study provides experimental support for the involvement of sympathetic tonus in the androgenic control of testicular descent.

Evaluation of pelvic contractility in ureteropelvic junction obstruction: an experimental study.

BACKGROUND/PURPOSE: Ureteropelvic junction (UPJ) obstruction causes adaptive and/or compensatory alterations in renal pelvic contractility. As these alterations directly affect the outcome after renal damage, definition of these alterations is of the utmost importance from a clinical point of view. Thus, an experimental study was designed to determine the alterations of renal pelvic contractility in response to partial and complete UPJ obstruction. METHODS: Fifteen adult female New Zealand white rabbits were randomly assigned into three groups (each containing 5 rabbits) according to the degree of unilateral UPJ obstruction. Group I: sham operation was performed and served as the control group; group II: partial UPJ obstruction was made; group III: complete UPJ obstruction was made. The animals in groups I and II were sacrificed after three weeks and the rabbits in group III were sacrificed after two weeks. Muscle strips from the renal pelvis were prepared. Spontaneous mechanical activity and contractile responses to phenylephrine (PE), serotonin (5-HT), and KCl were recorded isometrically and compared in all groups. RESULTS: Both the frequency and amplitude of spontaneous mechanical contractions were significantly (p < 0.05) increased in partial (group II) and complete UPJ obstruction (group III) groups. PE and 5-HT-induced tonic contractions, which were more prominent in the complete and partial obstruction groups when compared with the control group (p < 0.05). PE and 5-HT also increased the frequency of spontaneous contractions in both partial and complete obstruction groups. KCl induced long lasting tonic contractions in the control muscles. The duration of contraction to reach the maximum amplitude was shortened in the obstruction groups and the amplitudes of the contractions were significantly augmented when compared to control preparations. CONCLUSION: UPJ obstruction alters the contractile properties of renal pelvis smooth muscle. Increased frequency of spontaneous mechanical activity suggests that pacemaker cells of the renal pelvis change their activities in response to UPJ obstruction. Increase in tonic contraction amplitudes in response to PE and 5-HT suggests an increased sensitivity of smooth muscle cells to these agents. Potentiation of the contractile response to KCl suggests that adaptive changes take place at the level of excitation-contraction coupling in the smooth muscle of the renal pelvis following UPJ obstruction.