Sentinel lymph node biopsy in pediatric Wilms tumor.

INTRODUCTION: Although the sentinel lymph node Biopsy (SLNB) is well stablished in solid tumors among adults but the experience on SLNB in pediatrics is still limited. In this article we report our experience of sentinel lymph node detection that is applied on pediatric solid renal tumors. MATERIAL AND METHODS: Twenty 1-16 year old children with non-metastatic primary Wilms tumor regarding the radiological studies were enrolled. Radio tracer injection was carried out after renal vein, artery and ureter ligation, at the time of radical nephrectomy. Sentinel node detection and sampling was performed in every location with radiotracer count of 3 times more than background. Finally lymph node sampling was completed following the standard current discipline in Wilms tumor surgery. RESULTS: A single SLN was detected in 16 patients. 4 patients had more than one SLN. The most common site of SLN was inter aortocaval space. Histopathologic studies revealed tumor involvement in 3 sentinel nodes (15%). All other lymph node samples were also studied histologically and LN involvement was not detected in any of the cases with tumor free sentinel lymph node (no false negative case). Multiple LN involvement was reported in two patients with positive SLN in which, other involved lymph nodes were removed with the tumor during radical nephrectomy. CONCLUSION: Intraoperative SLNB is a safe and feasible tool to improve the accuracy of staging in pediatric Wilms' tumor. We suggest to ligate renal artery and vein prior to radiotracer injection to diminish the background confounding effect. LEVEL OF EVIDENCE: Level II (development of diagnostic criteria in a consecutive series of patients and a universally applied "gold standard") TYPE OF STUDY: Study of Diagnostic Test.

Bioavailability of rectal acetaminophen in children following anorectal surgery.

BACKGROUND: Acetaminophen is widely used as an analgesic and antipyretic agent in pediatrics. Although bioavailability of rectal acetaminophen is unpredictable, rectal route is a usual and acceptable method of prescription. Major anorectal surgery may alter the normal structure of the surgical site, especially the vascular elements and the normal connections between port and systemic vessels. As a result the pharmacokinetics of rectal medications might also be altered. Based on this hypothesis, we decided to study acetaminophen plasma concentration among children who underwent these types of surgeries to determine the pharmacokinetic of absorption, plasma concentration, safety, and efficacy of rectal acetaminophen. MATERIALS AND METHODS: The study included 20 cases with previous history of pull-through procedure owing to Hirschsprung's disease (HD), 20 cases with imperforate anus (IA) reconstructive surgeries who were admitted for colostomy closure, and 20 otherwise healthy cases of inguinal herniotomy. Venus blood sampling was done 4, 8 and 12 hrs after a single loading dose of rectal acetaminophen (40 mg/kg), and plasma acetaminophen concentration was compared between groups. RESULTS: Mean serum acetaminophen levels of the HD group were significantly higher than those of the herniotomy group (36.3 ±â€¯6.79, 27.4 ±â€¯8.42, 16.8 ±â€¯7.62 versus 25.9 ±â€¯9.12, 16.7 ±â€¯6.74, 8.1 ±â€¯5.79 (µg/ml) at 4, 8 and 12 hrs after drug administration and P < 0.05). The IA group had higher concentrations of plasma acetaminophen compared to the herniotomy group; however, the p values were not statistically significant. (31.4 ±â€¯10.39, 21.5 ±â€¯9.12, 13.3 ±â€¯6.79 versus 25.9 ±â€¯9.12, 16.7 ±â€¯6.74, 8.1 ±â€¯5.79 (µg/ml) at 4, 8 and 12 hrs after drug administration). Serum concentrations of acetaminophen in IA and HD patients were above the therapeutic range four hours after administering the loading dose (31.4 ±â€¯10.39 and 36.3 ±â€¯6.79 versus 5-20 µg/ml). CONCLUSION: Bioavailability of rectal acetaminophen might get altered after major anorectal surgery in children. Rectal acetaminophen should be administered with special caution among infants with history of anorectal operations. Repeated dose of rectal acetaminophen may cause the drug blood concentration to reach toxic levels in these patients. TYPE OF STUDY: Prospective comparative study. LEVEL OF EVIDENCE: Level II.

Pre-operative hormone stimulation in hypospadias repair: A facilitator or a confounder.

INTRODUCTION: Preoperative hormone stimulation (PHS) is popular in hypospadias reconstructive surgery. While still controversial, it is performed to have a more developed gross anatomy of the glans and penis for improvement of the surgical condition and outcome. OBJECTIVE: In this study we assessed morphometric and histologic effects of pre-operative testosterone therapy on the penis and prepuce in patients with hypospadias. STUDY DESIGN: 18 patients with hypospadias who received 3 monthly doses of 25 mg testosterone injections were compared with 23 patients with hypospadias who were managed without pre-operative androgen therapy. Penile morphometry and hormone side effects were assessed in monthly pre-operative visits. Intra operative observations and preputial histopathology were also compared between the groups. RESULTS: Glans diameter enlarged significantly after the first dose of testosterone. (P < 0.001) while morphologic changes were not significant by further injections. 72.2% showed one or more hormone related side effects that were mostly mild. Severe side effects such as thick pubic hair growth, frequent erections or considerable penis hyper-sensation were observed in 27.8%. Glans to corpus ratio was 0.2 ± 0.75 in PHS group compare to 0.3 ± 0.17 in control group. (P < 0.001). Hemorrhage needing tourniquet placement was reported in 44.4% of the PHS patients compared to 26.1% among the control group. Histopathologic studies revealed increased vascularity and less inflammation of the prepuce in PHS group compared to controls. DISCUSSION: The glans and penis enlargement wasn't significant in 22.2% of patients who underwent PHS. We identified the first dose of testosterone as the most effective one. This finding supports the idea of close clinical monitoring to stop PHS when a significant response is observed and the expected goals are reached. Androgen side effects were not uncommon among our patients although they were mainly mild. Intraoperative assessments showed a decreased glans wing thickness to corporal body ratio in PHS group compared to controls. This finding caused more complex glanuloplasty while wrapping the glans wings over neo urethra and enlarged corporal bodies. CONCLUSION: We suggest limiting PHS to carefully selected cases considering the observed anatomical and histological changes and the side effects. Monthly monitoring during PHS is recommended to stop androgen therapy as soon as the minimum defined targets are reached. This may decrease the rate of androgen side effects while providing better surgical conditions.

Pediatric Vaginal Leech Infestation with Severe Bleeding: A Case Report and Review Article.

BACKGROUND: Vaginal leech infestation is a rare event with vaginal bleeding being its prominent sign. Few cases have been reported in young children. CASE: In this article, we present a case of vaginal leech infestation in a 2-year-old girl who presented with significant vaginal bleeding that caused severe acute anemia, prompting transfusion. On examination, she appeared anemic, but healthy, without any signs of pubertal development. The leech was seen during examination with the patient under anesthesia and was removed. With removal of the leech, bleeding decreased significantly and stopped completely after 2 hours. She was discharged the next day in good condition. SUMMARY AND CONCLUSION: The important concern in vaginal leech infestation is early diagnosis to prevent severe acute anemia and shock.

Thoracoscopic Esophageal Atresia with Tracheoesophageal Fistula Repair: The First Iranian Group Report, Passing the Learning Curve.

BACKGROUND: Thoracoscopic treatment of esophageal atresia and tracheoesophageal fistula (EA+TEF) is accepted as a superior technique at least in cosmetic point of view but it is considered as an advance endoscopic procedure that needs a learning curve to be performed perfectly. This is the first report of Iranian group pediatric surgeons in thoracoscopic approach to EA. METHODS AND MATERIALS: Since 2010, twenty four cases with EA+TEF underwent thoracoscopic approach in Sarvar Children Hospital (Mashhad -Iran). During the first 6 months, thoracoscopic approach to 6 cases of EA+TEF was converted to open procedure because of technical and instrumental problems. The first case of successful thoracoscopic EA repair was accomplished in 2010 and since then, 10 cases of EA+ TEF among 18 patients were treated successfully with thoracoscopic approach RESULTS: Overall conversion rate was 58.3% but conversion rate after the primary learning curve period, was 35.7%. The main conversion causes include difficulties in esophageal anastomosis, limited exposure and deteriorating the patient's condition. Anastomotic leak and stenosis were observed in 20% and 40% respectively. Overall mortality rate was 4.2%. CONCLUSION: Thoracoscopic repair of esophageal atresia seems feasible and safe with considerable superiorities to the conventional method although acceptable results needs a prolonged learning curve and advanced endoscopic surgical skill. Clear judgment about the best surgical intervention for EA according to all cosmetic and functional outcomes needs further studies.