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.

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.

Laparoscopic splenectomy for haematological diseases.

PURPOSE: To show the utility of laparoscopic splenectomy for hematologic diseases. PATIENTS AND METHODS: Ten patients with hematologic diseases who were operated between February 1997 and October 1998 were analysed retrospectively. TECHNIQUE: The operations were performed by four trocars, hilar vessels were divided by clips and bag was used for splenic retrival. RESULTS: All operations were completed successfully. No accessory spleens were found. Intraoperative complication, other than a bag tear in one operation did not occur. Postoperative complications occurred in two patients. The first one was a portal vein thrombosis and the second one was a peritonitis. All patients responded hematologically to the operation. CONCLUSION: With appropriate surgical technique and patient follow up, laparoscopic splenectomy is a safe, adventageous and efficaceus operation for hematologic diseases.

Xanthogranulomatous pyelonephritis in children: diagnostic and therapeutic aspects.

BACKGROUND: Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic, inflammatory disease of the kidney. Etio-pathogenesis, diagnosis and management of pediatric XGP is still obscure due to the limited number of cases. Therefore, a retrospective clinical study was carried out to present an updated picture of the entire spectrum of pediatric XGP based on our 30 years' experience covering one of the largest non-collected series treated in a single medical center. METHODS: Records of children who were treated for XGP in our unit from 1970 to 1999, inclusive, were reviewed retrospectively. Information recorded for each patient included age, sex, past medical history, clinical characteristics, diagnostic procedures,treatment methods, histopathologic findings and outcome. RESULTS: 17 children with a mean age of 6.6 +/- 0.8 years, consisting of 15 males and 2 females, were treated for XGP. Eight patients had a urological disease history and 4 of them underwent surgery for urinary calculi and exstrophia vesica repair. The most common presenting symptoms were abdominal pain, fever,weight loss and anorexia. Palpable flank mass was the most common physical examination finding. Left and right kidneys were involved in 10 and 7 patients, respectively. Diagnostic procedures were intravenous pyelography, retrograde pyelography, ultrasound scan and computerized tomography (CT). Renal calculi and/or calcifications and non-functioning kidney were the most frequent findings in radiologic investigations. By combining all these investigations, the preoperative diagnoses were XGP (n = 2), renal and/or perirenal abscess (n = 5), psoas abscess(n = 2), non-functioning kidney due to recurrent pyelonephritis(n = 4), Wilms' tumor and/or renal clear-cell carcinoma (n = 4). XGP was correctly diagnosed in only two patients based on cr findings. Drainage of the renal or psoas abscess was performed in 8 patients as an initial procedure (surgical drainage in 6 and ultrasound-guided percutaneous drainage in 2 patients). Surgical procedures included nephrectomy (n= 13), partial nephrectomy (n=2), nephrectomy and diversion of reno-colic fistula(n= 1), and renal biopsy and nephrostomy (n= 1). Operative and postoperative complications were colonic perforation (n= 3) and wound infection (n = 3). Complications were noted only in patients who underwent nephrectomy without initial drainage procedures. Histopathologic examinations showed diffuse and focal XGP in 14 and 3 patients, respectively. CONCLUSION: XGP should be included in the differential diagnosis of all children presenting with perirenal or psoas abscess, renal mass and/or non-functioning kidney associated with/or without urolithiasis. Clinical awareness and a high index of suspicion is required to achieve the correct preoperative diagnosis and appropriate management. CT seems to be the most valuable imaging method for the diagnosis. We strongly recommend percutaneous drainage of the abscess and adjunctive antibiotic therapy prior to nephrectomy to avoid complications. Complete nephrectomy is the proper treatment for the diffuse form whereas frozen section biopsies followed by partial nephrectomy are mandatory for the proper treatment of focal disease.

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.

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.

Testicular tumors in children.

PURPOSE: The aim of this study was to present an updated picture of surgical management of pediatric testicular tumors based on our 30 years' experience, which consisted of one of the largest noncollected series treated in a single medical center. METHODS: Records of children who were treated for testicular tumor in our unit from 1970 to 1999, inclusive, were reviewed retrospectively. Information recorded for each patient included age, sex, past medical history, clinical characteristics, diagnostic procedures, treatment methods, histopathologic findings, and outcome. RESULTS: Fifty-one patients with a mean age of 3.8 +/- 0.5 years were treated for testicular tumors. Of these, 35 (69%) had germ cell testis tumor (GCT) and 16 (31%) had non-germ cell testis tumor (NGCT). Endodermal sinus tumor and paratesticular rhabdomyosarcoma were the dominant histologic subtypes in each group, respectively. The most common mode of presentation was painless scrotal mass. At initial presentation, retroperitoneal (n = 5), both retroperitoneal and lung (n = 2), and retroperitoneal and liver (n = 3) metastases were recorded in 10 (19%) patients. Initial operative procedures were radical inguinal orchiectomy (RIO) (n = 29), scrotal orchiectomy (SO; n = 9), bilateral RIO (n = 2), both RIO and unilateral retroperitoneal lymph node (RPLN) excision (n = 6), testis-sparing enucleation of the tumor (n = 5). SOs were performed elsewhere, and these patients underwent high ligation (n = 4) and both high ligation plus RPLN excision (n = 5) in our unit. Histopathologically, spermatic cord invasion and RPLN involvement were present in 10 patients. Scrotal recurrences were encountered in 2 patients who had scrotal orchiectomy initially. Retroperitoneal recurrences were noted in a patient presenting with stage I embryonal carcinoma and in 2 patients presenting with group IV paratesticular rhabdomyosarcoma. The mean follow-up period was 89 +/- 10 months. Four patients with stage IV embryonal carcinoma (n = 2) and group IV paratesticular rhabdomyosarcoma (n = 2) died of progression of the disease. All remaining patients were alive and disease free at their last outpatient appointment. No significant difference was noted with regard to 5-year survival rates between (1) malignant GCT and paratesticular rhabdomyosarcoma patients (91% v 80%) and (2) patients treated by RIO (88%), SO plus high ligation (87%), and RIO plus RPLN excision (80%). Five-year survival rates were 100% for stage I, II, III patients and 33.3% for stage IV and group IV patients presenting with malignant testicular tumors (P <.05). CONCLUSIONS: Childhood testicular tumors deserve special attention from the therapeutic point of the view. A solid scrotal mass should be considered malignant until proved otherwise. Any suspicion of the testicular tumor warrants an inguinal approach to prevent scrotal violation by the tumor. Current trends emphasize that testis-sparing surgery should be performed for benign lesions such as teratoma, leydig cell tumor, and epidermoid cyst based on frozen biopsy findings. Literature findings and our experience suggest that RIO is the accurate treatment for stage I malignant GCT and group I and IIa paratesticular rhabdomyosarcoma. RPLN excision is not of benefit either as a staging or therapeutic procedure in stage I and group I and IIa diseases of these tumors. RPLN excision should be reserved for (1) malignant GCT patients who have persistent elevation of alpha-fetoprotein after orchiectomy in the presence of normal total body CT scan, and for patients presenting with stage II and III disease with definitive abnormality on CT scans, and (2) group IIb, IIc, and III paratesticular rhabdomyosarcoma patients with radiologic evidence of retroperitoneal involvement on CT scans. High ligation should be done as a complementary procedure after SO to increase the survival rates. J Pediatr Surg 36:1796-1801.

Capsaicin in albino rats prevents contralateral testis from the damaging effects posed by ipsilateral testis that underwent torsion.

OBJECTIVE: To evaluate the effect of capsaicin, a powerful neurotoxin selective to afferent nerves, on contralateral testicular damage in ipsilateral testicular torsion. METHODS: Forty male albino rats were randomly allocated into five groups. No operation was performed in group one. After intraperitoneal administration of 0.9% NaCl, rats underwent a sham operation in group 2 and testicular torsion in group 3. In groups 4 and 5 rats underwent sham operation and testicular torsion, respectively after intraoperitoneal capsaicin injection. Contralateral testes were harvested on the fifteenth day of the experiment and mean seminiferous tubular diameters and mean testicular biopsy scores were recorded for each testis. The values were compared through analysis of variance (ANOVA) with Turkey-Kramer multiple comparisons test and p values less than 0.05 were considered to be significant. RESULTS: Mean testicular biopsy scores and mean seminiferous tubular diameters of group 5 was significantly higher than the group 3. There was no difference between the groups 1, 2, 4, and 5 when these two parameters are concerned. CONCLUSION: Capsaicin effectively prevents contralateral testicular damage encountered following ipsilateral testicular torsion. The inhibition of afferent impulses from the ipsilateral testis under distress prevents contralateral testicular injury, and provides additional data to support the role of an autonomic reflex arc in contralateral testicular injury.

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.

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.

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.

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.

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.

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.

Inflammatory myofibroblastic tumor in children: diagnosis and treatment.

BACKGROUND/PURPOSE: Inflammatory myofibroblastic tumor (IMT) is a rare benign neoplasm. Although it is commonly seen in children, the number of childhood cases in the current literature is limited. Furthermore, malignant degeneration or transformation to lymphoma in the recurrent or residual IMT have directed attention to this interesting entity. Herein, the authors present their experience with IMT with special emphasis on diagnosis and treatment. METHODS: All records of children treated with diagnosis of IMT between 1977 and 1999 inclusive were evaluated retrospectively. RESULTS: Seven children were treated for IMT with the mean age of 9.14 +/- 2 years (range, 6 to 12 years). Male to female ratio was 5:2. Respiratory symptoms and clubbing were present in a patient with pulmonary IMT (n = 1). Abdominal pain (n = 3), fever (n = 2), and weight loss (n = 4) were encountered in intraabdominal IMTs. The most frequent physical finding was palpable intraabdominal mass (n = 4). Plain films showed nonspecific findings such as radiodense area in the hemithorax (n = 1), displacement of bowel segments (n = 2), air-fluid levels (n = 1), and amorphous calcification (n = 4). Ultrasonography and CT showed calcified masses in 4 cases. Except the case with intrathoracic IMT, all the tumors were located in the abdomen at various sites such as cardioesophageal junction (n = 1), left hepatic lobe (n = 1), mesentery of the small bowel (n = 2), and antimesenteric wall of the descending colon (n = 1), gastrosplenic region and porta hepatis (n = 1). Tumor sizes ranged from 3 x 2 x 2 cm to 15 x 15 x 13 cm. The masses were excised totally in all but one case. Infiltrated organs (esophagogastric junction, a segment of jejunum, and spleen, stomach wall, and renal capsule) were resected in 3 cases. Total surgical excision of IMT was considered adequate for treatment in 6 cases. One patient with aggressive IMT required further treatments such as immunomodulation and chemotherapy and died of neutropenic sepsis. CONCLUSIONS: IMT is a benign neoplasm rarely presented with malignant features such as local invasiveness, recurrence, distant metastasis, or malignant transformation. IMT can be suspected preoperatively through some hematologic abnormalities and radiologic findings, but precise diagnosis should be made on the basis of histologic findings. Complete surgical resection and close follow-up are all necessary for appropriate treatment to avoid recurrences as well as unnecessary and potentially harmful therapy. The optimal management of locally aggressive and recurrent forms should be decided individually for each patient. J Pediatr Surg 36:908-912.

A comparative histopathologic and immunohistopathologic evaluation of cremaster muscles from boys with various inguinoscrotal pathologies.

AIM: It has been hypothesized that the cremaster muscle (CM) might play a part in the pathogenesis of various inguinoscrotal pathologies such as undescended testis and hernia. A prospective study was carried out to determine if CM of boys with hydrocele, inguinal hernia, and undescended testis reveal any histopathological and immunohistopathological alterations. METHODS: Samples of CM from 29 patients presenting with inguinal hernia (15), undescended testis (9), and hydrocele (5), and CM from autopsies of boys without inguinal pathology (2), and samples of internal oblique muscles from patients undergoing laparotomy (3) were obtained. The biopsies were frozen in isopentane-cooled liquid nitrogen, cut in 6 micron sections and stored at -80 degrees C until processed. Sections were stained by hematoxylin-eosin, modified Gomori-trichrome, PAS, Oil Red-O, NADH, SDH and COX. All specimens were evaluated for seven parameters including variation in fibre size, presence of central nucleus, endomysial fibrosis, inflammation, presence of basophilic fibres, increase in perimysial connective tissue, and variation in fibre size between fascicules. The specimens were also evaluated for beta-spectrin, laminin alpha-1 chain, laminin alpha-2 chain, 43 kd distroglycan, and fetal myosin by immunofluorescence. The presence of each parameter was compared, individually and in combination, according to the ages and underlying pathologies. RESULTS: None of the internal oblique muscles were positive for any of the seven parameters. Only one of the two CM obtained during autopsy revealed a slight variation in fibre size. However, fibre size variation and increase in perimysial connective tissue were found in all but one CM from a patient with hernia. The presence or absence of parameters did not differ according to age. Comparison of the groups with inguinal hernia and undescended testis for each of the individual parameters did not reveal significant differences. However, the presence of four or more parameters in each CM was more commonly encountered among patients with undescended testis compared to patients with hernia (p < 0.05). The CM of patients with hydrocele suggested similar findings to patients with inguinal hernia. All of the specimens, regardless of origin, revealed normal sarcolemmal and basal laminal stainings, and fetal myosin was expressed in only two specimens which were obtained from an internal oblique muscle and the CM of a patient with an inguinal hernia. CONCLUSION: The CM of patients with inguinal hernia, hydrocele, and undescended testis reveal histopathological alterations. Furthermore, CM from patients with undescended testis reveal more profound alterations. Whether these alterations reflect a primary muscle pathology or a defect in innervation or changes secondary to inguinoscrotal pathology requires further study.

Validation of MPI and PIA II in two different groups of patients with secondary peritonitis.

BACKGROUND/AIMS: There are several scoring systems designed to predict mortality in patients with peritonitis, which need validation in different patient populations. Our aim was to evaluate Mannheim Peritonitis Index (MPI) and Peritonitis Index of Altona (PIA II) in patients with postoperative peritonitis and other causes of secondary peritonitis. METHODOLOGY: The records of patients operated for intraabdominal infection between 1987-1996 in Hacettepe University Department of General Surgery, were reviewed retrospectively. A total of 473 patients were included in the study; 75 of them had postoperative peritonitis (POSTOP group) and the remaining 398 had secondary peritonitis due to other causes (OTHER group). Using multiple logistic regression, MPI and PIA II were combined in an equation and this new variable was called combined peritonitis score (CPS); CPS = -9 + (0.3 x MPI) + (-1.2 x PIA II). All patients were scored according to MPI, PIA II and CPS. Receiver-operator characteristic (ROC) curves and sharpness of scores were compared. Also mean scores in both groups, proportions of correct predictions of outcome according to scores and correlation of scores with mortality were compared. RESULTS: Overall mortality was 17.8% in OTHER group and 33.3% in POSTOP group (P = 0.0018). Higher MPI scores, lower PIA II scores and higher CPS scores were associated with higher mortality in both groups (P < 0.0001). Mean MPI values were higher, mean PIA II values were lower and mean CPS values were higher in POSTOP group (P < 0.001). The areas under ROC curves of CPS were bigger than MPI and PIA II in both groups. Sharpness of CPS was higher in both groups compared to MPI and PIA II (P < 0.05). Proportion of correct predictions of outcome was highest in CPS among the three scores (P = 0.0074). CPS had the best correlation with observed mortality. CONCLUSIONS: POSTOP group patients had higher MPI, lower PIA II and higher CPS values ending up with higher mortality. This may be because of the delay in diagnosis and treatment, resulting with higher organ failure rates. Generally the results of evaluations for MPI and PIA II are similar. When these two peritonitis scores are combined and used together in the form of CPS, all the parameters improve.

Effect of 5-lipoxygenase inhibition on Kupffer cell clearance capacity in obstructive jaundiced rats.

BACKGROUND: Obstructive jaundice is a common surgical problem. It may cause hepatic and Kupffer cell dysfunction. Previous studies demonstrated that 5-lipoxygenase inhibition prevents hepatic injury. However, its effect on Kupffer cell clearance capacity has not been determined yet. MATERIALS AND METHODS: Rats were divided into four groups. In group 1 (sham control group), only bile duct dissection was performed. In other groups bile ducts were ligated and divided. In groups 1 and 2 saline, in group 3 ethanol, and in group 4 a 5-lipoxygenase inhibitor AA-861 was given intraperitoneally to the animals. Rats were sacrificed 14 days after the operations. Serum alkaline phosphatase, total bilirubin, and alanine aminotransferase levels were determined. Kupffer cell clearance capacity was measured using an in situ isolated hepatic perfusion technique. Hematoxylin-eosin-stained liver samples were evaluated under light microscope for histopathologic scoring. RESULTS: Rats in the sham control group had significantly lower serum ALP and bilirubin values than those in the experimental groups with biliary obstruction. AA-861 administration significantly decreased serum ALT levels and histopathologic scores. There was no significant difference in ALT levels and histopathologic scores between the sham control and AA-861 groups. Kupffer cell clearance capacity was found to be significantly increased in the AA-861 group compared to other experimental groups with obstructive jaundice. CONCLUSIONS: This study shows that leukotriene synthesis inhibition using AA-861 prevents hepatic damage and improves Kupffer cell clearance capacity in obstructive jaundiced rats. This may have significant implications for the management of patients with obstructive jaundice.