Antegrade continence enema--an analysis of 20 children with faecal incontinence.

AIM OF THE STUDY: We present our experience with the Malone antegrade continence enema technique in children suffering from severe anal incontinence. METHODS: The Malone antegrade continence enema technique was performed using the appendix, caecum or ileum in 20 children with faecal incontinence. The stoma was kept catheterised for three weeks after the operation in all patients and irrigation with saline was initiated after that period. Tap water was used for irrigations after discharge from hospital. The functional success was evaluated according to the classification defined by Curry et al. RESULTS: The mean age and the mean follow-up period was 11 years and 5 years, respectively. Strictures developed in five of the 20 cases (25 %) in this series. Four of these patients underwent revisional surgery, but in one case with appendiceal tube the stricture and catheterisation difficulty resolved spontaneously. Full continence was achieved in 13 of the children (65 %). CONCLUSIONS: The Malone procedure is an effective procedure in children with faecal incontinence. It should be performed after confirming that the patient is completely clean using Peña's programme and aften ensuring that both the child and the parents will properly follow the recommendations.

Caroli's disease in children: is it commonly misdiagnosed?

AIM: Caroli's disease is a simple form of intrahepatic bile duct ectasia. It can be complicated with the involvement of liver parenchyma and portal hypertension. Herein, the difficult management of delayed presentation of Caroli's disease is reported. METHODS AND RESULTS: We report on four different forms of clinical presentation of Caroli's disease: an infant with fulminant liver failure, a teenager with persistent biliary fistula, a boy with hypersplenism in the face of portal hypertension and a girl with variceal bleeding. CONCLUSIONS: Caroli's disease must be included in the differential diagnosis of cystic lesions in the liver. Delayed diagnosis of Caroli's disease is difficult to manage and appropriate investigations are warranted before planning a surgical approach.

Modified Barcat technique in distal hypospadias repair.

AIM: A modified Barcat operation, when carried out properly, provides an anatomically and cosmetically successful result in distal hypospadias repair in each glans configuration. We retrospectively evaluated our experience with this technique in the last five years. PATIENTS AND METHODS: 78 children with primary distal type hypospadias were operated between 1998 - 2003, using a modified Barcat technique. RESULTS: The mean age of the patients was 3 years (6 months - 14 years). The mean follow-up period was 2 years (1 month - 60 months). Nesbit plication was performed in four cases with chordee. Fistula developed in five (6.5 %) cases and required reoperation. Stenosis which did not require surgical intervention occurred in 5 children and resolved with self-dilatations. CONCLUSION: The Barcat technique is an appropriate operation for distal type hypospadias cases but should be modified by creating second tissue layers over the neourethra and a wide meatus.

Hypospadias reoperations.

AIM: To retrospectively evaluate the experience of a single surgeon (YS) with hypospadias reoperations. PATIENTS AND METHOD: 105 hypospadias patients were reoperated by the same surgeon between 1994 - 2003. The patients were classified into three groups according to the surgical technique employed. Urethral plate tubularisation was performed in Group I. Repair with genital skin or mucosa was carried out in Group II and repair with extragenital tissues was performed in Group III. RESULTS: Mean age at operation was 6.5 years (range: 1.5 - 23 yrs). Mean number of operations performed was 2 (1 - 7). Group I consisted of 33, Group II of 64, Group III of 8 cases. Reasons for reoperation were complete or partial neourethral loss in 71 cases; big and multiple fistulas in 29; neourethral or meatal stenosis in 11 children. One had diverticula. Two had partial corpus cavernosal loss. Residual or secondary fibrotic ventral flexion was detected in 31/105. Complication rates were 15%, 25% and 0% in Group I, II and III, respectively. Overall complication rate was 20% (21/105). CONCLUSION: Severe complications can develop not only in proximal but also after distal hypospadias repairs. Local supportive tissues can be provided more easily in proximal reoperations. Repair with buccal mucosa had no complications in our series as it was only used in well selected cases. If urethral plate is present and wide enough, its tubularisation should lead to better results in reoperations. If it is absent or narrow, meatal based or onlay island flaps should be employed. Though the onlay island flap is known to be well vascularised theoretically, our results with meatal based flaps were better. We preferred using the tunica vaginalis when urethral plate was absent and penile skin was not appropriate. We suggest using the onlay technique for large penile defects of the shaft and not in the glanular area. But its use as local supportive tissue in reoperations can be very helpful.

Sugiura procedure in portal hypertensive children.

Bleeding from esophageal varices is an important cause of morbidity and mortality in children with portal hypertension. The treatment protocol is planned according to the etiologic factors underlying the portal hypertension, which may be either intrahepatic or extrahepatic. Although portasystemic venous shunt operations were common previously, they are now regarded as nonphysiologic and are rarely used because of their unexpected results and complications. Today, in many centers, endoscopic procedures have become the first-step treatment modality in bleeding esophageal varices. More complicated surgical procedures, such as devascularization procedures in extrahepatic portal hypertension, and liver transplantation in patients with failing liver, should be performed when conservative measures fail. We followed up 69 patients with portal hypertension with endoscopic sclerotherapy in our department. Here we present a retrospective evaluation of the effect of the Sugiura operation on the prognosis of 12 children (6 with extrahepatic and 6 with intrahepatic portal hypertension) who were not responsive to the sclerotherapy program. No rebleeding was seen in 9 of the 12 (75%) patients after the procedure, and the mortality rate in this series was 1 of 12 (8.3%); this patient died of hepatic failure.

Corrosive injury-induced gastric outlet obstruction: a changing spectrum of agents and treatment.

METHODS: During the last 5 years, 61 children were admitted to the authors' hospital because of corrosive substance ingestion, and among them 6 patients were seen with gastric outlet obstruction. Two of them had ingested acid substances, and the other 4 had ingested alkali corrosives. The mean age was 2.9 years (range, 1.5 to 3). Their common complaint was postprandial vomiting, which had begun 3 weeks after the event (range, 1 week to 10 weeks). Endoscopic evaluation and barium contrast radiographies were performed at admission. Four patients had a pyloric stricture, 1 had an antral stricture, and another had an antropyloric stricture. Balloon dilatation of the pylorus (in 1 patient), pyloroplasty (in 3 patients), and Billroth I procedures (in 2 patients) were performed. The mean follow-up period was 22 months (range, 6 weeks to 48 months). One patient, who had undergone a Billroth I procedure, underwent reoperation because of intestinal obstruction 3 months later. On follow-up they are all free of symptoms. CONCLUSIONS: The treatment of gastric outlet obstruction caused by corrosive ingestion should be treated surgically. Although endoscopic and radiologic evaluation helps to determine the time and necessity, once the diagnosis is confirmed, early definitive surgical intervention should be performed, and the type of the surgery depends mostly on the findings of the surgeon at laparotomy. Endoscopic balloon dilatation of the pylorus maybe attempted in suitable cases. Special care should be given to prevent children from accidental corrosive ingestion.

Albendazole therapy in the treatment of hydatid liver disease.

Hydatid disease, a common health problem in Turkey as in many countries, should be included in the differential diagnosis of all patients presenting with a cystic mass in the abdominal or thoracic cavity. Previously, surgery had been the main form of treatment. But with the introduction of preoperative medication with albendazole, treating this disease medically is now growing in popularity. We report herein the findings of ten patients with two lung and 20 liver hydatid cysts ranging from 3 to 20 cm in diameter, who were successfully treated with medical therapy. Multiple organ involvement and multiple cysts in an organ are the main indications for medical treatment with albendazole, but the indications should not be limited to certain situations such as small-sized cysts, since even huge-sized cysts responded well to the therapy in this series.

Association of biliary atresia and urogenital sinus.

A case of an association of extrahepatic biliary atresia (EHBA) and urogenital sinus (UGS) anomaly that was diagnosed as an urachal remnant antenatally is reported. Diagnostic laparoscopy of the abdominal cavity in the postnatal period was the most helpful step for making the diagnosis. Biliary atresia and urogenital sinus, which was the cause of bladder outlet obstruction, were treated successfully. To the authors' knowledge, this is the first case of this type of association introduced to the literature. J Pediatr Surg 36:635-637.

Diagnostic laparoscopy in prolonged jaundice.

BACKGROUND: The early diagnosis of surgical jaundice in a neonate is an important step for the surgical success in extrahepatic biliary atresia. Diagnostic laparoscopy, as in many areas in surgery, is included in the conventional diagnostic methods of extrahepatic biliary atresia. METHODS: Since 1992, 24 infants with prolonged jaundice, in whom extrahepatic biliary atresia and neonatal hepatitis could not be differentiated with conventional diagnostic interventions, have been evaluated laparoscopically. RESULTS: A coarse, irregular, greenish-brown liver with some degree of fine angiomatous development and an atretic gallbladder are the findings of laparoscopic evaluation in an infant with extrahepatic biliary atresia. However, in neonatal hepatitis, the liver is smooth, sharp-edged, and chocolate brown in color, and simultaneously performed cholangiography should show the passage of the contrast material both into the proximal biliary tracts and the intestinal system. In this series, 10 of 24 cases were proved to be neonatal hepatitis diagnosed by laparoscopy, so unnecessary laparotomy was avoided in 42% of the cases. CONCLUSION: When the diagnostic laparoscopy, in which the liver and the gallbladder are directly visualized, is combined with the cholangiographic examination, the most accurate and earlier diagnosis in an infant with prolonged jaundice can be achieved, and the important period of time for the surgical success in extrahepatic biliary atresia will be minimally wasted.

A case of wandering spleen causing urinary symptoms after correction of a posterolateral diaphragmatic hernia.

A 12-year-old girl who had had an operation for a posterolateral diaphragmatic hernia was admitted to the hospital because of enuresis. Physical examination and radiologic studies revealed the spleen behind the urinary bladder, left-sided hydronephrosis, and a high volume of residual urine. The hydronephrosis and residual urine resolved immediately following splenectomy.

A case of mesenteric cysts caused by abdominal tuberculosis.

We report on a 10-year old boy suffering from chronic abdominal pain. Clinical examination and imaging modalities revealed that the patient had mesenteric cysts. Exploratory laparotomy revealed two mesenteric cysts of various size and multiple enlarged mesenteric lymph nodes. M. tuberculosis was identified and histology of the specimens proved the existence of abdominal tuberculosis.