Extrahepatic metabolism and renal effects of sevoflurane in a case of liver transplantation.

In a case of liver transplantation, sevoflurane metabolism was studied to investigate if sevoflurane has an extrahepatic metabolism or possible nephrotoxicity in the presence of chronic liver disease. Plasma blood urea nitrogen (BUN) and creatinine and urine levels of N-acetyl glycosaminidase (NAG) and beta2 microglobulin were assessed intraoperatively and for 11 days postoperatively. We observed a close relation between urine NAG excretion and urine inorganic fluoride levels in the intraoperative period and early postoperative days. The NAG levels were greater than normal despite the peak serum inorganic fluoride concentration of 18.94 micromol/L. No impairment was observed in serum BUN or creatinine levels in these periods.

Preliminary pediatric transesophageal echocardiography experiences.

With transesophageal echocardiography (TEE), a new echocardiographic window is obtained which enables cardiologists to explore the heart from the esophagus and stomach. However, the procedure, when first undertaken, may present certain difficulties for the cardiologist in interpreting the anatomical findings and approaching a diagnosis. We thus convey our first experiences and results of TEE in 107 pediatric patients. Transesophageal echocardiography (TEE) was performed in 107 pediatric patients at our institution between December 1998-February 2001, using the standard techniques and following the standard criteria suggested by the American heart Association. The mean age of 54 male (50.5%) and 53 female (49.5%) patients was 7.8 years. Intubation difficulty was experienced in four cases. In one case, while drawing the transducer back from the esophagus, it kinked at the hypopharynx. None of the cases had major hemorrhage or esophageal rupture, and only a few cases had minor pharyngeal injuries or hemorrhages. We used TEE in detecting vegetations in patients with possible endocarditis, and evaluating the prosthetic valves and abnormal pulmonary venous return. We also used TEE to clarify preooperative anatomical details, postoperative complications and residual defects of complex congenital cardiac anomalies. Transcattheter closure of 47 secundum atrial septal defects (ASD)'s and a muscular ventricular septal defect (VSD) (both during patient selection and during the procedure) were accomplished under TEE guidance. As the pediatric cardiologists gain more experience in performing TEE, this technique will have a wider and more effective use in the pediatric population.

Fiberoptic flexible bronchoscopy via the laryngeal mask airway in children.

The laryngeal mask airway (LMA) is a new device for controlling the airway during many procedures. Aside from its use in different kinds of surgical procedures, fiberoptic flexible bronchoscopy can also be performed easily with this mask in children under sedation. This procedure was performed via LMA in 36 children (aged 2-16 years) who suffered from different kinds of respiratory diseases and were seen at Hacettepe University Ihsan Dogramaci Children's Hospital, Pediatric Chest Disease Unit, during a seven-month period. The procedure was performed with success and no complications occurred. To the best of our knowledge, this is the first report from Turkey on flexible bronchoscopic evaluation via LMA in children with different kinds of respiratory diseases. We suggest that this technique can be used safely.

Transcatheter closure of secundum atrial septal defects, a ventricular septal defect, and a patent arterial duct.

We report our clinical experience with the newly developed Amplatzer device in transcatheter closure of nine atrial septal defects (ASDs), one ventricular septal defect (VSD), and one patent arterial duct (PDA). Eleven patients with ASD (age range 2.5-18 years) selected according to the location and size of the defect by transesophageal echocardiography (TEE), a five-year-old patient with muscular VSD and a one-year-old patient with PDA were considered for transcatheter closure with Amplatzer devices. All procedures were performed under general anesthesia with fluoroscopic and TEE guidance, following a routine hemodynamic evaluation in the catheter laboratory. The optimal device size was selected after the balloon sizing of the ASDs. The sizes of the VSD and PDA were measured on TEE and angiography. The patients were discharged at 24 hours, after an evaluation with x-ray, electrocardiogram (ECG), and echocardiography; they were on 3-5 mg/kg/day aspirin and infective endocarditis prophylaxis for six months after the procedure. They were reassessed at six to eight weeks and Holter monitoring was done in addition. Devices were used for nine ASD patients, and for the VSD and the PDA patients. Mean ASD size was 14.3 +/- 5.3 mm at TEE and 18.3 +/- 4.3 mm at balloon sizing (p=0.02). The mean size of the device was 18.7 +/- 4.2 mm. The procedure time and the fluoroscopy time were 46.1 +/- 12.3 and 12.9 +/- 1.6 minutes, respectively. Immediately after the procedure, four patients (44%) had trivial shunts (TS). TS remained in only two during discharge, and no shunt was observed at second evaluation. The devices were similarly applied to VSD (12-7 mm) and PDA (8-6 mm) patients. Both cases had TS immediately, which disappeared at 24 hours. None of the patients had major complications. Junctional rhythm developed in one patient, and another patient had frequent supraventricular extrasystoles. Amplatzer is an effective and safe device for transcatheter closure of ASD, VSD, or PDA, especially in pediatric patients.

Excessive sac pressures: the pathogenesis and innocence of hydroceles in children.

OBJECTIVE: To determine whether paediatric hydroceles result entirely from a small-calibre patent processus vaginalis, allowing free communication between the abdominal cavity and hydrocele sac, or whether there are other mechanisms. PATIENTS AND METHODS: Twenty-five hydroceles were studied prospectively in 24 boys (aged 18-132 months). Consent for the intraoperative measurements was obtained before surgery. The hydrocele was repaired under general anaesthesia with endotracheal intubation, using a standard approach, taking care not to open the sac during mobilization. Intra-abdominal pressures during surgery were measured indirectly via a nasogastric tube after gastric decompression. The pressure in the sac was measured via a 20 G intravenous cannula inserted via a purse-string suture. The relative pressure was then calculated by subtracting the intra-abdominal from the sac pressure. The effects of age and laterality were evaluated. RESULTS: The median (range) intra-abdominal, sac and relative pressures were 8 (2-18), 11 (3-30) and 4 (3-30) cmH2O, respectively. The sac pressure in the sac was greater than the intra-abdominal pressure in 17 of 25 (68%; P = 0.004) patients. Age or laterality had no significant influence on any of the pressures. CONCLUSIONS: These results suggest that in a significant proportion of hydroceles in children the pressures are higher than the intra-abdominal pressure. Therefore, they cannot be explained simply as a freely communicating, narrow-calibre processus. In addition, the pressures may reach levels which are potentially damaging to the testis.

Alimentary tract duplications in children: report of 26 years' experience.

Duplications of the alimentary tract are one of the rare anomalies of the gastrointestinal system. Because of the wide spectrum of the signs and symptoms, preoperative diagnosis frequently cannot be made. A close familiarity with clinical and surgical characteristics provides appropriate management and treatment of duplications. A retrospective clinical study was conducted to evaluate clinical and surgical characteristics and the treatment of duplications of the alimentary tract. During a 26-year period between 1971 and 1997, 38 patients with duplications of alimentary tract underwent operation at the Hacettepe University Department of Pediatric Surgery. Forty-two duplications in 38 patients (20 male, 53%; 18 female, 47%) were encountered. Sixty-nine percent of the patients were symptomatic under the age of one year, with 24 percent presenting with symptoms in the neonatal period. There were one sublingual, nine intrathoracic (including 2 thoracoabdominal) and 32 intraabdominal duplications. Abdominal mass, abdominal distention, constipation, vomiting and respiratory distress were the most frequently encountered signs and symptoms. Plain thoracic and abdominal X-rays, ultrasonography, and computed tomography of the chest and abdomen were the most commonly used diagnostic radiological methods. Thirty-three duplications (79%) were spherical and nine (21%) were tubular. Multiple duplications were encountered in two patients (5.3%). Fourteen duplications (33%) contained heterotopic mucosa, mostly gastric type. More than one type of heterotopic mucosa in the same duplication was encountered in four duplications (10%). Additional malformations were encountered in 26 percent of patients. Six patients (15.8%) died from unrelated causes. The signs and symptoms vary among duplications. Signs and symptoms leading to diagnosis and surgery varied according to the age of patient, location of the duplication, type of mucosal lining, duration of disease and presence of complication. The ideal surgical treatment of duplication is complete excision. However, the other treatment options should be well known.

Individual and associated effects of length of inguinal canal and caliber of the sac on clinical outcome in children.

PURPOSE: The caliber of processus vaginalis is accepted to define the clinical outcome to be an inguinal hernia or hydrocele not based on any evaluation. The caliber of sacs and length of inguinal canals of boys and girls were evaluated to define the relation of sex, age, and the diagnosis with caliber of the sac and the length of inguinal canal. METHODS: A total of 217 inguinal canals in 24 girls and 112 boys with inguinal hernia, 30 boys with hydrocele or hydrocele of the cord, and 31 boys with undescended testis have been evaluated. Twenty patients had bilateral involvement. The length of inguinal canal, and the circumference of the sac were measured. A formula was developed to predict the length of inguinal canal according to the age and sex. The circumferences of the sacs, length of inguinal canals, and the ratios of the circumference to the length were compared according to the clinical pictures. RESULTS: The regression model of the relationship between the age and the length of the inguinal canal is an equation of third degree (inguinal canal in millimeters) = 0.0000119 x age 3 (months) - 0.00292 x age 2 (months) + 0.3168 x age (months) + 19.979 (r2 = 0.47). Inguinal canal is longer in boys (25.133 and 27.996 mm; P = .018), and length does not differ among diagnoses but differs according to age showing a linear growth after 24 months. Although the circumference as a sole parameter could classify only 55.3% of boys correctly, the ratio of length of inguinal canal to circumference of the sac has been the significant parameter in classifying boys into 1 of 3 groups including inguinal hernia, undescended testis, and hydrocele with a 70.2% success rate. CONCLUSIONS: Inguinal canal that shows a linear growth after 24 months of age is longer in boys. Caliber is not the unique factor that determines the clinical outcome. Although the ratio of length of inguinal canal to the circumference of the sac defines the clinical picture best, even this parameter cannot classify the cases correctly. Therefore, some factors in addition to the caliber and length of inguinal canal might have roles in determining the clinical outcome.

Inadvertent placement of pulmonary artery catheter into right carotid artery.

PURPOSE: To report a case of misplacement of a pulmonary artery catheter (PAC) into the carotid artery after open heart surgery. CLINICAL FEATURES: A 20-mo-old boy underwent open heart surgery (VSD repair). On the first day postoperatively, he had severe pulmonary hypertension and a PAC was inserted via the left internal jugular approach without complication. Two hours later, chest radiography showed the PAC in the right internal carotid artery which it had reached via the right and left ventricles and aorta. The PAC was withdrawn and a new PAC was inserted and its position was confirmed by chest radiography. Two years later echocardiography failed to demonstrate the second VSD or a residual leak through the patch although a PAC could be passed from the right ventricle to the left ventricle and subsequently into the aorta and right carotid artery. CONCLUSION: Correct placement of a PAC should be confirmed by chest radiography or other techniques to prevent complication.

Intraabdominal pressure: a parameter helpful for diagnosing and predicting a complicated course in children with appendicitis.

BACKGROUND/PURPOSE: The intraabdominal pressure (IAP) of children presenting with acute, perforated, or suspected appendicitis were determined and compared to define if the IAP has any diagnostic value or helps to predict a complicated course. METHODS: Eighty-four patients with a initial diagnosis of appendicitis were evaluated. In addition to preoperative measurements, IAP of each patient was determined repeatedly on the postoperative first, second, and third days. The patients were grouped according to the final diagnoses as acute, perforated, or suspected appendicitis or negative exploration. The preoperative and postoperative IAP of the patients were compared among the groups. Postoperative complications were recorded, and IAP of those patients were additionally compared with the others in the same group. RESULTS: Whereas a normal appendix was found in 4 of the operated patients, 27 and 38 patients had acute and perforated appendicitis, respectively. The mean preoperative values of IAP for acute, perforated, or suspected appendicitis and negative exploration were 6.2 +/- 0.4, 9 +/- 0.3, 0.3 +/- 0.4, and 3 +/- 0.4 cm H2O, respectively (P< .001). Postoperative first day and second day values of the IAP for acute appendicitis, perforated appendicitis, and negative laparotomy groups were 2 +/- 0.2 and 0.6 +/- 0.1,3 +/- 0.1 and 1.5 +/- 0.1,0.5 +/- 0.6 and -0.2 +/- 0.6 cm H2O, respectively. The difference between acute and perforated appendicitis groups was significant (P< .05). Wound infection was encountered in 7 among 38 patients with perforated appendicitis. The preoperative and first postoperative day IAP values of patients with perforated appendicitis who experienced a wound infection and who were without a wound infection have been 11.8 +/- 0.4 and 4.8 +/- 0.2, and 8.4 +/- 0.2 and 3.1 +/- 0.3 cm H2O (P< .001). Discriminant analysis has shown that 93.3%, 70.4%, and 73.3% of patients with suspected, acute, and perforated appendicitis have been within the expected groups. IAP less than 1.39 cm H2O has excluded appendicitis with a 95% confidence interval. Although the interval has been between 5.40 and 7.04 cm H2O for acute appendicitis, it has varied between 8.46 and 9.70 cm H2O for perforated appendicitis. CONCLUSIONS: Although the IAP does not increase in conditions mimicking appendicitis, it increases among children with appendicitis. A further increase is encountered among children with perforated appendicitis. Complicated course is encountered among children with highest IAP values. Therefore, IAP may be used both as a diagnostic parameter and a predictor of a complicated course associated with appendicitis in children.

A comparative histopathologic evaluation of the effects of three different solutions used for whole bowel irrigation: an experimental study.

PURPOSE: Although whole bowel irrigation (WBI) is a widely used method of bowel preparation in daily surgical practice, almost nothing is known about the histopathologic alterations caused by WBI and whether these differences have any detrimental effect on the outcome of gastrointestinal surgical procedures. Therefore, an experimental study has been conducted to evaluate and compare the effects of WBI with various solutions on the histology of gastrointestinal tract. METHODS: During the experimental procedures animals were divided into 4 groups consisting of 8 animals each as follows: group A, WBI performed by using isotonic saline solution; group B, WBI performed by using an isoosmolar solution containing polyethylene glycol (PEG); group C, WBI performed by using Lactated Ringer's solution; group D, Animals that were not irrigated but sham operations that were performed served as controls. Four hours after WBI the animals underwent laparotomy and a segment of transverse colon with intact vascular peduncle was prepared. After waiting for 30 minutes, specimens from duodenum, small intestine, large bowel, colonic segment, and liver were obtained from each animal. Histopathologically, all of the specimens were evaluated and graded by 3 parameters including congestion, edema, and inflammation. RESULTS: Although varying degrees of congestion, edema, and inflammation were encountered from all of the specimens of group A, B, and C, only slight congestion was noted in all specimens of group D. The difference between group D and other groups was statistically very significant (P < .001). When the sections from duodenums of groups were evaluated, the degree of congestion, edema, and inflammation were found to be moderate in group B, mild-moderate in group A, and mild in group C. Histopathologic examinations of specimens of the small, large bowel, and isolated colonic segment showed severe congestion, edema, and inflammation in group A, moderate-mild in group B, and mild in group C. The difference between A and B, A and C, and A and D was statistically significant (P < .01). Although severe congestion was encountered in liver specimens of group A, only mild congestion was encountered in groups B and C (P= .0001). The matched durations of irrigations and total volume of irrigation solutions were found to be not related with the difference in histopathologic findings. CONCLUSIONS: WBI has induced varying degrees of histopathologic alterations from mild to severe in the rat gastrointestinal tract. Lactated Ringer's solution and PEG solution have induced the least alterations. Therefore, WBI with Lactated Ringer's solution and PEG solution seem to be safe alternatives of mechanical bowel preparation before elective large bowel surgery. Because saline solution has caused detrimental alterations in distal gastrointestinal tract histology, WBI with saline solution seems to be unadvisable.

The factor V Leiden mutation: a possible contributor to the hepatic artery thrombosis encountered after liver transplantation in a child.

A 10-year-old girl has experienced 3 recurrences of hepatic artery thrombosis (HAT) after a liver transplantation. She responded to intraarterial administrations of urokinase after the first 2 attacks. However, the restoration of the arterial flow was not possible after the third attack. The child and her father were both heterozygous for factor V Leiden mutation. In addition to the technical factors, the factor V Leiden mutation should be considered as a factor that plays a role in HAT.

Thymic enlargement in childhood.

Thymic masses constitute one of the least common mediastinal masses in childhood. While producing symptoms of airway compromise, they also raise the suspicion of malignancy when detected. Radiological, operative and pathological findings of patients that have been operated for thymic masses in our institution is presented in this paper. Nine patients were operated in our institution during a 12-year-period between 1985-1997 for thymic masses. Ages of the patients ranged from four months to 13 years. With the exception of one, who was diagnosed with a routine chest x-ray, all the patients had respiratory complaints. All the patients had been evaluated with computed tomography preoperatively. In total, seven sternotomies and four thoracotomies were performed to reach the anterior mediastinum. The distribution of masses was as follows two malignant thymomas, three thymic hyperplasia, one lymphocyte-rich thymoma, one epithelial thymoma, one cystic thymoma and one lymphoblastic lymphoma. Although rare, thymic enlargement may be a cause of intractable respiratory complaints in childhood. Because of the high incidence of primary malignancy of the mediastinal neoplasms in childhood, thymic enlargement requires accurate pathological diagnosis and treatment. Median sternotomy with intensive anesthetical care allows proper tumoral exposure.

Comparison of endtidal CO2 and arterial blood gas analysis in paediatric patients undergoing controlled ventilation with a laryngeal mask or a face mask.

Endtidal CO2 (PECO2) and arterial blood gas tensions were compared between laryngeal mask (LMA) and face mask (FM) ventilation in paediatric outpatients. Following premedication with midazolam, anaesthesia was induced with either thiopentone or isoflurane and atracurium. Anaesthesia was maintained with N2O, O2 and isoflurane. Manually controlled ventilation was applied with a nonrebreathing system. Both PECO2 and arterial blood gas tensions were measured at 5 and 15 min after skin incision. The mean PaCO2 values in the LMA group were 36.6+/-7.4 and 37.5+/-6.4 mmHg and PaCO2 -PECO2 were 1. 8+/-2.4 and 2.5+/-3.3 mmHg, respectively. The mean PaCO2 values in the FM group were 41.3+/-8.1 and 43.4+/-8.9 mmHg; and PaCO2 -PECO2 were 5.3+/-3.6 and 8.8+/-7.0 mmHg, respectively. These values were lower in the LMA group (P< 0.05). We have concluded that monitoring of PECO2 is more reliable for estimating blood gas values during controlled ventilation with a LMA than a face mask.

Intraarticular morphine administration provides pain relief after knee arthroscopy.

This present study investigated the effects of intraarticular morphine administration in 1 mg and 5 mg doses on post-operative pain relief and analgesic requirements for patients undergoing arthroscopic procedures. At the end of the operation patients were randomly allocated in a double-blinded fashion into three groups. The control group (Group 1) received normal saline 20 mL intraarticularly. The patients in the second and third groups received intraarticular morphine sulphate 1 and 5 mg in saline 20 mL, respectively. Post-operative pain was assessed on the 1st, 6th and 24th hour by visual analogue scale (VSA). Supplementary analgesic requirement and possible complications were also followed. The intensity of pain and analgesic requirement were reduced more in the morphine 5 mg group than in the control group. It is concluded, that the administration of intraarticular morphine 5 mg provides long-lasting and effective analgesia after knee arthroscopy.

p53 Protein expression in squamous cell carcinomas from sun-exposed and non-sun-exposed sites.

BACKGROUND: In sun-exposed nonmelanoma skin cancers, observation of specific p53 gene mutations implicate the role of UV radiation-induced mutations in the pathogenesis of these tumors. Immunohistochemical p53 protein overexpression and p53 gene mutation have been frequently considered related events. OBJECTIVE: We investigated the differences in p53 immunostaining in squamous cell carcinomas (SCCs) with varying degrees of differentiation, from both chronically sun-exposed and sun-protected sites of the skin. METHODS: Twenty-six SCCs (15 UV-related and 11 UV-unrelated) and five specimens of Bowen's disease (in situ SCC) from sun-exposed skin were examined by means of BP53-12-1 monoclonal antibody immunohistochemistry. RESULTS: p53 Immunoreactivity was observed in 66.7% of sun-exposed, 54.5% of non-sun-exposed invasive SCCs (Fisher's exact test, p = 0.689), and 80% of Bowen's disease specimens. In 50% of all samples, p53 positivity was more prominent in the proliferating periphery of the tumor with gradual loss of positivity as the cells differentiated. CONCLUSION: The reliability of p53 immunohistochemistry needs further molecular genetic studies.

Effect of 5-methoxytryptophan and 5-methoxytryptamine on the reproductive system of the male golden hamster.

S.c. injection of 25 microgram of methoxytryptamine (5-MT) in oil into adult male hamsters given between 4.30 and 5 p.m. (light on from 5 a.m. to 7 p.m.: 14 L/10 D) for 51 consecutive days caused involution of the testes. Similar injections of 5-MT given between 8.30 and 9.30 a.m. completely failed to cause regression of the gonads. Under the same conditions, 5-methoxytryptophan (5-MTP) did not induce gonadal atrophy, neither in the morning nor in the late afternoon. These results indicate that, like malatonin, 5-methoxytryptamine is implicated in the control of the reproductive function.

The independency of an intact pineal gland of the inhibition by 5-methoxytryptamine of the reproductive organs in the male hamster.

Subcutaneous injections fo 25 micrograms of 5-methoxytryptamine (5-MT) in oil into intact and pinealectomized male hamsters given between 4.30 p.m. and 5 p.m. (light on from 5 a.m. to 7 p.m.; 14 L/10 D) for 54 consecutive days caused involution of the testes. 5-MT, however, is more effective when the pineal is present. These results indicate that melatonin is not the only pineal factor inducing gonadal atrophy in the hamster. 5-MT seems even more effective than melatonin in so far as it is, contrary to melatonin under the same experimental conditions, also effective in the absence of the pineal. Like melatonin, 5-MT appears to be implicated in the control of the reproductive function.