Neurological results of the modified treatment of epilepsy by stimulation of the vagus nerve.

INTRODUCTION: The vagus nerve stimulation (VNS) is used for treatment of drug-resistant epilepsy but laryngeal side effects are common. We tried to improve VNS by modifying the implantation procedure. The aim was to reduce the rate of side effects that have prevented using VNS to its full capacity. METHODS: We operated on 74 pediatric patients for VNS device implantation using a modified surgical protocol incorporating lower neck incision for electrode placement and 36 patients who were operated by standard technique were used for control group. We retrospectively analyzed reduction in frequency of seizures, reduction in severity of seizures (assessed by the shortened Ictal/post-ictal subscale of the Liverpool Seizure Severity Scale that included falling to the ground, postictal headache and sleepiness, incontinence, tongue biting, and injury during attack). RESULTS: Using the new implantation technique, side effects related directly to VNS therapy occurred in six cases (8.1%) showing statistically sound improvement over the standard implantation technique (p Ë‚ 0.05). To achieve good results, the maximum stimulation (3.5 mA) was used in 24 patients (32.4%), with no laryngeal side effects detected. Twelve patients (16.2%) were seizure-free after the first year of VNS treatment. 74.3% of patients experienced a 50% reduction in seizure frequency and improved ictal or postictal activity. CONCLUSION: To minimize laryngeal complications in implantation surgery for VNS devices, the surgical technique may be modified, and lower neck incision could be used. A low rate of laryngeal side effects allows using the VNS device to its full electrical capacity.

Ecthyma gangrenosum versus ecthyma-like lesions: should we separate these conditions?

INTRODUCTION: We analyzed cases of ecthyma gangrenosum (EG) and "ecthyma-like" or "ecthyma-mimicking" cases of necrotic lesions of the skin to improve current definitions of these conditions. METHODS: The retrospective analysis compared 28 cases of lesions (from 2001 to June 2015) that were identified as EG. Age, sex, lesion location, time from macule to ulcer, underlying diseases, number of lesions per patient, wound bacterial culture, blood culture, and immune status served as variables for analysis and comparison. RESULTS: Only in 20 cases (71.42%) was Pseudomonas aeruginosa the etiology of the lesion. The etiology of eight cases was various bacterial species (five cases, 17.85%) and fungal species (three cases, 10.73%). In 21 cases (75%), the lesion appeared in immunocompromised patients. In four cases (14.28%), the patients suffered from Pseudomonas sepsis. In four cases (14.28%), the lesion appeared in healthy individuals. There was no difference in clinical picture, lesion location, number of lesions per person, and treatment strategy between Pseudomonas and non-Pseudomonas cases. CONCLUSION: Necrotic lesions resembling EG can have various microbiological etiology and can occur in immunocompetent or healthy persons. With no difference in clinical picture, two separate definitions should not be applied to Pseudomonas and non-Pseudomonas cases. We suggest accepting a broader definition of EG.

Treatment of epilepsy by stimulation of the vagus nerve from Head-and-Neck surgical point of view.

OBJECTIVES/HYPOTHESIS: The current article is dedicated to the surgical aspect of the vagus nerve stimulation (VNS) and our efforts to improve the surgical technique. The aim was to reduce the side effect/surgical complication rate as well as the time needed for this surgery. STUDY DESIGN: A case series. METHODS: The surgical data of 72 consecutive patients (age 4-14) who were operated for VNS device implantation from 2007 to 2014 were collected and analyzed. We designed the new surgical protocol that was implemented in all 72 cases and analyzed postsurgical side effects/complication rates. This protocol suggests low neck incision, detecting the vagus between the heads of the sternocleidomastoid muscle, a submuscular pocket for the device, and a short tunnel between it and the vagus electrodes. RESULTS: The implantation took about 40 minutes; 4.2% of the patients (n = 3) were afflicted by complications related to surgery; and one patient (1.4%) suffered from hardware malfunctions. Side effects related to VNS therapy itself occurred in seven cases (6.9%). CONCLUSION: To minimize laryngeal complications in implantation surgery for VNS devices, the surgical technique should be significantly modified, and lower neck incision could be implemented together with a submuscular pocket for the battery. LEVEL OF EVIDENCE: 4.

Vaginal müllerian cyst: an unusual cause of vaginal bleeding in a 16-month-old girl.

BACKGROUND: Vaginal bleeding in premenarchal girls is always abnormal and its source must be identified for appropriate management. Examination under anesthesia and vaginoscopy are commonly employed for evaluation of the vagina as a source of bleeding, and the examination may occasionally reveal vaginal pathology. CASE: A 16-month-old otherwise healthy girl presented with spotting. Exam under general anesthesia and vaginoscopy revealed a 1-cm polypoid-like lesion overlying the posterior vaginal wall which was excised using the hysteroscope. Pathology revealed a benign Müllerian cyst. SUMMARY AND CONCLUSION: Vaginal findings of causes of premenarchal bleeding such as Mullerian cysts may be diagnosed and treated with the vaginoscopic approach.

Blunt pancreatic trauma in children.

PURPOSE: To report our experience with blunt pancreatic trauma in pediatric patients and evaluate several various management strategies. METHODS: Ten children admitted over the last 10 years with pancreatic blunt trauma were included in the present series. RESULTS: The average time from injury to hospital admission was 2.4 days. All injuries resulted from accidents: bicycle handlebar injuries (5), being kicked by a horse (2), falls from a height (2), and injury sustained during closure of an electric gate (1). Additional systemic and abdominal injuries were recorded in 7 patients. The amylase levels at the time of patient admission were normal in 3 patients, mildly raised in 4 patients, and elevated in 3 patients. Abdominal computed tomography was performed in 10 patients, ultrasonography in 5, and endoscopic retrograde cholangiopancreatography (ERCP) in 4. Pancreatic injuries comprised 4 grade I, 3 grade II, and 3 grade III injuries. Grade I and II injuries were successfully managed by conservative treatment. The 3 children with grade III trauma and pancreatic ductal injury in the neck (1), body (1), and tail (1) of the gland were surgically treated, having an uneventful postoperative stay of 8-14 days and no complications during the 1-year follow-up period. CONCLUSION: The present study supports early ERCP as an essential part of the initial patient evaluation when pancreatic transection is highly suspected.

Management of primary spontaneous pneumothorax in children.

OBJECTIVE: To examine the role of CT scans and early surgical intervention in the management of pediatric patients with primary spontaneous pneumothorax (PSP). METHODS: Retrospective cohort study. RESULTS: The authors identified 46 cases with 70 episodes of pneumothorax. The recurrence rate among conservatively treated patients was 50% both after the first and the subsequent episode. Recurrence rate in cases with and without blebs on CT was comparable. Initial episodes were treated with supplemental oxygen (n = 18) and chest tube drainage (n = 18), and 10 patients underwent video-assisted thoracoscopic surgery (VATS). The recurrence rate was significantly lower following surgical intervention compared with other therapy, and morbidity was comparable with that in patients who needed chest tube drainage. CONCLUSIONS: Recurrence after the first episode of PSP in children is frequent and is difficult to predict by CT findings. VATS is safe and effective in preventing recurrences. Surgical intervention may be an attractive alternative in patients who require chest tube drainage for the first episode of PSP.

Fibrous hamartoma of infancy.

Fibrous hamartoma of infancy is a rare benign soft tissue tumor that usually occurs within the first 2 years of life. We report 3 cases of fibrous hamartoma of infancy seen over a 10-year period. Treatment is curative by local excision with a low local recurrence rate. Fibrous hamartoma of infancy should be considered in the differential diagnosis of soft tissue masses in children because it is always benign and subject to nonaggressive treatment.

The contribution of intraoperative transinguinal laparoscopic examination of the contralateral side to the repair of inguinal hernias in children.

BACKGROUND: Bilateral inguinal hernias are relatively common in children. This fact has led to a controversy of more than 50 years concerning the necessity of bilateral surgical exploration during the repair of unilateral inguinal hernias in children. The advent of transinguinal laparoscopic visualization of the contralateral side is a turning point and a major contribution to the subject, offering the opportunity to reassess the systematic bilateral exploration and the "wait and see" policies currently in use at most services of pediatric surgery. DATA SOURCES: The current information concerning intraoperative transinguinal laparoscopic evaluation of inguinal hernias in children was summarized in a didactic way. A MEDLINE search (PubMed) from 1995 to the present days was conducted. RESULTS: A patent processus vaginalis (PPV) is not equal to a future symptomatic hernia. There is still no definitive evidence on which PPVs will become a hernia (5.8% to 11.6%) and which remain clinically insignificant. Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side is today the most simple and accurate way to reduce the incidence of negative explorations. CONCLUSION: Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side during pediatric inguinal hernia repair is a simple, accurate, fast, and effective method to assess the contralateral processus vaginalis, improving decision-making, reducing the number of negative explorations, and sparing the surgeon the embarrassment associated with the appearance of a metachronous hernia at a later date. It is easily learned and should be part of every pediatric surgeon's practice.

Riding a bicycle: do we need more than a helmet?

BACKGROUND: To assess pediatric bicycle-related traumatization in view of types of injuries, incidence and modes of prevention. METHODS: Retrospective study of pediatric cases admitted to the pediatric intensive care unit of a university-affiliated level II trauma hospital in Israel over 12 consecutive years. RESULTS: Forty-six patients (three girls, 43 boys) with bicycle-related injuries formed 1% of the total pediatric intensive care unit admissions during the study period. The number of patients with bicycle-related injuries increased significantly during recent years (1996-2001 vs 2002-07: P = 0.003). Most of the cases presented abdominal injuries (54.4%) followed by head (32.6%) and chest (13%) injuries. The median age of patients with abdominal trauma was significantly lower in comparison to patients with other types of injuries (P = 0.002). Abdominal cases required longer hospitalization compared with other patients (P = 0.003). Falling from a bicycle was the main mechanism of injury in abdominal cases (88%) (P = 0.003). Motor vehicle impacts were the main mechanism of injury in patients with head (60%) and chest (66.6%) trauma. CONCLUSION: The incidence of severe bicycle-related injuries requiring intensive care hospitalization is increasing and abdominal trauma forms the main portion of those injuries. We suggest introducing a trunk-protective measure for young bicyclists. Exact information on the mechanism of the injury is important for evaluating the injured patient more accurately.

Myringotomy knife for pyloromyotomy.

Laparoscopic pyloromyotomy is a common procedure for treating infantile hypertrophic pyloric stenosis. Since 2006, we have been using miniature otolaryngologic instruments for pyloromyotomy due to a shortage of arthroscopic blades in our Medical Center. The purpose of this study is to determine the safety, efficacy, and cosmetic results obtained from the use of fine otolaryngologic instruments in pyloromyotomy. We retrospectively reviewed the records of 10 male infants who underwent pyloromyotomy during the years 2006 to 2007, using a fine otolaryngologic knife (myringotomy knife). Median operation time was 23 minutes, no complications were observed, all patients were discharged within 24 hours, and the scars were barely visible in 4 weeks' time. We are proposing an alternative technique for the classic pyloromyotomy method that looks promising. Further studies are needed.

Diagnosis and treatment of pediatric vaginal and genital tract abnormalities by small diameter hysteroscope.

The vaginal speculum can be safely and efficaciously replaced by the less traumatic small diameter continuous flow hysteroscopic vaginoscopy for diagnosis and treatment of genital tract lesion in children and adolescents.

Urban paediatric trauma due to stab wounds: an Israeli hospital experience.

OBJECTIVE: To assess the incidence and types of stab wounds to hospitalized children and adolescents. SUBJECTS: The sample consisted of patients, age 6-18 years, who were admitted to our hospital with sustained injury between 1991 and 2007. RESULTS: In total, 83 patients were admitted as a result of penetrating (n = 51) and superficial (n = 32) injuries. Eighty-two were hospitalized, and one was declared dead upon arrival. Only 11 patients were hospitalized during the 1991-2000 period, and 71 during the 2001-2007 period. Ten patients were admitted to the intensive care unit (ICU); 23 patients were operated (hospital mortality = 0). Evacuation time (time from injury to hospital) was 10 min (mean time; maximum 35 min). CONCLUSION: This study found higher rates of hospitalization compared with those over a decade ago. These rates reflect not only changes in hospitalization trends and/or population growth in the hospital area but also an increase of urban violence. Israeli hospitalization system deals with paediatric trauma effectively, being well trained because of permanent terrorist activity.

Familial wandering spleen: a first instance.

We report on 2 sisters presenting with acute torsion of a wandering spleen within a 3-year interval. The diagnosis was made preoperatively by computed tomography (CT) in both cases. A high index of suspicion because of our experience with the first patient, who underwent splenectomy, enabled a correct early diagnosis in the sibling. On urgent surgery, reversible ischemic changes were found, and detorsion and splenopexy resulted in preservation of the spleen.

[Vagal nerve stimulation for refractory epilepsy in children].

Epileptic disease is defined as recurrent seizures not as a result of fever or acute cerebral insult. It is very common in all age groups. In the majority of cases, satisfactory control is being achieved, leading to normal life. However, in some cases, the disease is resistant to a variety of medications. In these cases, an attempt to decrease the number of epileptic episodes is done by trying other methods such as a ketogenic diet or neurosurgical interventions. Recently, a new modality of treatment with vagal nerve stimulation was introduced, particularly for cases resistant to medications and are not candidates for neurosurgical intervention.

Superior mesenteric artery syndrome after scoliosis repair surgery: a case study and reassessment of the syndrome's pathogenesis.

We carried out a retrospective analysis to investigate the prevalence of superior mesentery artery syndrome (SMAS) in children who underwent scoliosis surgical repair at our hospital between 1998 and 2006 and to reassess the syndrome's pathogenesis. Among 133 consecutive pediatric patients, two cases were identified, both 13-year-old girls with idiopathic scoliosis, undergoing surgery using third-generation instrumentation systems. Conservative management achieved resolution of the symptoms without recurrence. SMAS prevalence in our series was 1.6%. SMAS might occur after derotation and translation forces application, and even with nonextreme corrections. Low BMI and significant weight loss at presentation are not mandatory.

Adnexal torsion involving hydatids of Morgagni: a rare cause of acute abdominal pain in adolescents.

OBJECTIVE: Hydatids of Morgagni are common embryonal remnants of the müllerian duct and among the infrequent causes of adnexal torsion. The purpose of this study was to investigate the occurrence of adnexal torsion involving hydatids of Morgagni, as well as its possible mechanisms. METHODS: A database search was conducted for cases of adnexal torsion treated in our institution from January 2002 to July 2005. These cases were analyzed, focusing on a subgroup of adolescents with adnexal torsion involving the hydatids of Morgagni. RESULTS: There were 76 patients with adnexal torsion. The rate of hydatid of Morgagni torsion was 26% (4 of 15 cases, 95% confidence interval [CI] 0.15-0.51) in the adolescent subgroup (10-19 years old), compared with 0% (0 of 61 cases, 95% CI 0-0.048) in the adult subgroup. The difference between the hydatid torsion rates in the two subgroups was statistically significant (P = .01, 95% CI 0.001-0.532). The four patients with hydatid torsion (postmenarchal girls, aged 13-18 years) were managed with laparoscopic adnexal detorsion and cystectomy of the affected hydatid of Morgagni. At surgery, we noted three different mechanisms of hydatid torsion: torsion of the adnexa together with torsion of the hydatid of Morgagni, torsion of the hydatid of Morgagni with intact adnexa (n = 2), and entanglement of the hydatid's pedicle around the distal fallopian tube. The hydatids of Morgagni were observed on the preoperative transabdominal ultrasonogram in only one patient and appeared as a simple cyst. CONCLUSION: Adnexal torsion involving the hydatids of Morgagni appears to be more common in adolescents than previously thought. LEVEL OF EVIDENCE: III.

An experimental study of the effect of two distinct surgical techniques of orchiopexy on spermatogenesis and testicular damage in cryptorchid testes.

OBJECTIVE: To compare the effect of two different techniques of testicular fixation on testicular function. DESIGN: Experimental study. SETTING: Surgical animal laboratory at an academic medical center. PATIENT(S): Sixteen mature golden hamsters underwent classic transfixation orchiopexy and true dartos pouch orchiopexy. INTERVENTION(S): Classic transfixation orchiopexy (CTO) involved transfixation of the testicular wall at two different points and fixation of the dartos fascia. True dartos pouch orchiopexy (TDPO) involved creating a window in the dartos fascia, passage of the testicle, and closure of the window from both sides of the testicle. MAIN OUTCOME MEASURE(S): Flow cytometric separation of testicular cells into haploid, diploid, and tetraploid fractions for histogram analysis. RESULT(S): A significant decrease in testicular weight was observed in 6 out of 16 animals undergoing CTO. Diploid cells comprised the main cell fraction, and almost no haploid or tetraploid cells were observed, while in the 16 animals undergoing TDPO no change from the control pattern was observed. CONCLUSION(S): This experimental work supports our clinical impression that TDPO should replace CTO as the method of choice for the treatment of an undescended testicle in children.

Total endoscopic vaginal reconstruction in a case of Mayer-Rokitansky-Kuster-Hauser syndrome.

The congenital absence of the vagina is an uncommonly encountered malformation, known as Rokitanski- Kuster-Hauser syndrome. These patients may enjoy an improved quality of sexual life once a neovagina is constructed. Surgical and nonsurgical (Frank's autodilatation) methods of creating a neovagina by recurrent dilatations require long and often embarrassing self-catheterization which is often painful, and yield a vagina with limited length. The developing ability to perform complicated surgery by laparoscopy has revived interest in colonic and ileal interposition procedures for formation of a neovagina. We report a case of sigmoid colpoplasty for neovagina creation in a 15-year-old girl, performed completely by laparoscopy, with a favorable outcome and an easier recovery.

Transinguinal laparoscopic examination: an end to the controversy on repair of inguinal hernia in children.

BACKGROUND: Contralateral exploration of the groin has been common practice among pediatric surgeons for nearly 50 years, based on the high incidence of patent processus vaginalis on the contralateral side with the potential for the subsequent development of a hernia. OBJECTIVES: To evaluate transinguinal laparoscopic examination of the contralateral side during repair of inguinal hernia in children in order to reach a decision regarding exploration of the contralateral side. METHODS: Over a 21 month period 124 children with unilateral inguinal hernia underwent laparoscopic evaluation of the contralateral groin. The operations were performed under general anesthesia as ambulatory procedures. RESULTS: Transinguinal contralateral laparoscopic exploration was positive (patent processus vaginalis) in 26 children (21%) and negative (closed processus vaginalis) in 88 (71%). Failure to introduce the telescope occurred in 10 patients (8%) due to a friable or narrow hernia sac. Twenty-five children below 2 years of age were spared exploration of the contralateral side as a result of the negative laparoscopic examination. On the other hand, 15 children aged 2-17 had their contralateral groin explored because of a positive finding at laparoscopy. CONCLUSIONS: Transinguinal laparoscopic examination of the contralateral side during repair of inguinal hernia in children is a simple, safe and quick method to avoid systematic bilateral explorations and should be part of every pediatric surgeon's experience.