[Testicular microlithiasis and Leydig cell proliferation in Wistar rats underwent Fowler-Stephens procedure]. / Microlitiasi testicolare e proliferazione delle cellule Leydig nei ratti Wistar sottoposti a procedure tipo Fowler-Stephens.

OBJECTIVES: The present study investigates the outcome of Fowler-Stephens operation in prepubertal Wistar rats focused on microlithiasis and Leydig cell hyperplasia development. METHODS: Thirty-eight (38) animals underwent laparoscopic Fowler-Stephens operation on the right testis (8 of them formed the control group) and 6 of them additional contra-lateral orchectomy. The testes were examined histological 9,30,70 and 90 days later, while ultrasound study was perfomed a day earlier. RESULTS: Initially, atrophic signs were visible as early as 9 days after the operation. Signs of intratubular calcification were obvious 30 days after the operation, in severe atrophic testes. Another important point was that in the animals that underwent orchectomy, testicular microlithiasis co-existed with lesions of Leydig cell hyperplasia. CONCLUSIONS: Microlithiasis and Leydig cell hyperplasia seem to have causative relation in operated undescended testis and present serious postoperative complications, with a review in the literature.

Complete testis-epididymis nonfusion anomaly: a typical association with cryptorchid testis.

INTRODUCTION: Fusion anomalies of the testis and epididymis are associated with cryptorchidism. We present an analysis of the fusion anomalies of the epididymis in cryptorchid boys. PATIENTS AND METHODS: We performed a retrospective review of patients presenting with undescended testes between 1986 and 1993. Patients were stratified among four groups based on the degree of testis-epididymis nonfusion. RESULTS: A total of 880 testes were eligible for review, of which 93% (815/880) had normal fusion, 3.6% (32/880) had epididymal head nonfusion, 2% (19/880) had epididymal tail nonfusion, and 1.6% (14/880) had complete nonfusion. Increasing degree of nonfusion was associated with higher perioperative testes position. Head and tail nonfusion were observed together with a contralateral descended testis, but less frequently than in bilateral undescended testes (p = 3.89 × E-10). Complete nonfusion was not observed in the contralateral descended testes in unilateral cryptorchid boys. CONCLUSIONS: Different degrees of fusion anomalies of the epididymis are associated with unilateral and bilateral undescended testis, indicating that nonfusion anomalies interact with epididymal-testicular descent because of impaired epididymal function.

Benign cystic lesions in the testis of children.

Cystic lesions in the testis of children are rare and in most cases benign tumors. However, a preoperative diagnostic work-up could contribute to planning the surgical procedure: orchiectomy in the case of potential malignancy or otherwise a testis-sparing approach. In this study we reviewed our recent cases of benign cystic testicular tumors and the corresponding literature. The different entities are presented with details of the diagnostic work-up, pathology and treatment of these lesions. In all presented cases, organ-preserving treatment was performed. This practice is to be recommended in the case of all prepubertal cystic testicular lesions.

Impact of Lodox Statscan on radiation dose and screening time in paediatric trauma patients.

INTRODUCTION: As part of the primary investigation, polytrauma patients arriving at our emergency department are examined in accordance with the Advanced Trauma Life Support (ATLS) rules, using the new Lodox Statscan (LS) digital low-radiation imaging device. The aim of this study was to establish whether entrance and effective radiation doses using LS in children were comparable to those of paediatric Computed Radiography (CR) and to evaluate the duration of scanning for both techniques in young polytrauma patients. METHODS: 19 consecutive polytrauma patients aged <16 years who had LS imaging were included in this prospective analysis. For a comparison of our results, we put together an age-, size-, injury type- and ISS-matched group of young patients screened using paediatric Conventional Radiology (CR). Entrance, effective doses and mean duration of diagnostic imaging were recorded for both groups. RESULTS: Effective and entrance doses were higher in the LS group compared to the paediatric CR group (p<0.001). This might be partly due to the higher radiation dose necessary for lateral LS spine imaging, and also because with conventional radiography, only selected parts of the spine are imaged compared to the standard full spinal view with LS. Diagnostic imaging with LS required less time than paediatric CR (p=0.117). CONCLUSION: LS scanning will probably be a useful diagnostic tool for a range of paediatric clinical indications in the future. But only the future will show whether LS will survive in the face of low-dose radiation CT scanners and magnetic resonance imaging devices that may eventually completely replace conventional radiography.

[The role of thoracoscopy in paediatric spontaneous pneumothorax]. / Die Rolle der Thorakoskopie beim kindlichen Spontanpneumothorax. 12-jähriger Knabe mit akuter Luftnot.

Spontaneous pneumothorax in children is an emergency. A rapid and structured treatment is necessary. Indicating clinical signs are dyspnoea with unilateral reduced breath sounds and hypersonic percussion note. Chest x-ray confirms diagnosis. CT scan shows detailed information's of pathological changes in lung tissue and offers important considerations for the therapy. Today video assisted thoracoscopic surgery (VATS) takes a central role in the treatment of spontaneous pneumothorax. Thoracoscopy completes diagnosis detecting the pathologies, which were missed in imaging procedures. Definitive surgical treatment is performed simultaneously in the same anaesthesia.

A simple presurgical necrotizing enterocolitis-mortality scoring system.

OBJECTIVE: To assess the relationship between early laboratory parameters, disease severity, type of management (surgical or conservative) and outcome in necrotizing enterocolitis (NEC). STUDY DESIGN: Retrospective collection and analysis of data from infants treated in a single tertiary care center (1980 to 2002). Data were collected on disease severity (Bell stage), birth weight (BW), gestational age (GA) and pre-intervention laboratory parameters (leukocyte and platelet counts, hemoglobin, lactate, C-reactive protein). RESULTS: Data from 128 infants were sufficient for analysis. Factors significantly associated with survival were Bell stage (P<0.05), lactate (P<0.05), BW and GA (P<0.01, P<0.001, respectively). From receiver operating characteristics curves, the highest predictive value resulted from a score with 0 to 8 points combining BW, Bell stage, lactate and platelet count (P<0.001). At a cutoff level of 4.5 sensitivity and specificity for predicting survival were 0.71 and 0.72, respectively. CONCLUSION: Some single parameters were associated with poor outcome in NEC. Optimal risk stratification was achieved by combining several parameters in a score.

Impaired absorption of marked oligopeptide Glycine-I Tyrosine-Glycine after successful autologous-allotopic ileal mucosa transplantation in beagles.

PURPOSE: After establishing a method for ileal mucosa transplantation in an animal model, the authors investigated the absorptive capacity for oligopeptides of the transplanted mucosa. METHODS: In 14 beagle dogs the authors transplanted ileal mucosa in a vascularized demucosed segment of the transverse colon. The colonic wall-ileal mucosa complex then was integrated in the ileal continuity. Six animals were lost owing to operative complications. Absorptive capacity for oligopeptides was measured in the remaining 8 animals with the iodine 131 (131I)-marked tripeptide glycine-tyrosine-glycine before and 4 weeks after transplantation. The results were compared and analyzed with the Student's t test for matched pairs. Blood concentrations of the marked tripeptide with P value less than .05 were considered as a significant reduction in the absorptive capacity of the transplanted ileal mucosa. After fixation with glutaraldehyd graft, uptake of the colonic wall-ileal mucosa complex was evaluated histologically in 8 animals. RESULTS: In all 8 animals, a 100% graft uptake was verified in all sections. Fifteen minutes after application of 15 MBc Glycine-131I-Tyrosine-Glycine there was no significant difference in the absorption between normal and transplanted ileal mucosa. After 30 minutes, the absorption of the transplanted ileal mucosa showed a tendency (P < .1) for an impaired uptake of the marked tripeptide. However, 60 minutes after application the difference in the absorptive capacity of the transplanted ileal mucosa was significant (P < .05). CONCLUSIONS: Autologous allotopic ileal mucosa transplantation is feasible; however, an impaired absorption of oligopeptides of the transplanted mucosa 4 weeks after transplantation could be observed.

Absorption of D(+)-xylose, cobalamin, and folic acid after autologic-allotopic ileum mucosa transplantation in beagles.

BACKGROUND/PURPOSE: Ileum mucosa transplantation in a demucosed colon coat was developed as a new method for small bowel elongation. In an animal model, the authors investigated the absorptive capacity of the transplanted mucosa for D(+)-xylose, cobalamin (vitamin B12), and folic acid. METHODS: Ileum mucosa was transplanted in a vascularized demucosed segment of transverse colon in 18 beagle dogs. The colon coat-ileum mucosa complex then was integrated in the ileal continuity. Absorptive capacity for D(+)-xylose, cobalamin, and folic acid was measured before and 4 weeks after transplantation. The results were compared and analyzed with the Students' t test for matched pairs. All determined blood values with P values less than.05 were considered to show a significant reduction in the absorptive capacity of the transplanted ileum mucosa. RESULTS: Fifteen minutes after application there was no significant difference in the absorption of D(+)-Xylose and cobalamin between normal and transplanted ileum mucosa (P >.1). Absorption of folic acid in the transplanted segment was lower but not significant (P <.1). After 30 minutes D(+)-xylose and cobalamin again showed no difference between the absorptive capacity of normal and transplanted ileum mucosa (P >.1), whereas folic acid continued with the tendency toward an impaired absorption (P <.1). However, after 60 minutes, the difference of the absorptive capacity of the transplanted ileum mucosa was significant (P <.05) for folic acid. D(+)-xylose showed a tendency for an impaired uptake (P <.1), whereas absorption of cobalamin did not differ significantly after transplantation (P >.1). CONCLUSIONS: Experimental autologic-allotopic ileum mucosa transplantation is a feasible new method for small bowel elongation in an animal model. Examination of the absorptive capacity of the transplanted ileum mucosa showed a normal uptake for cobalamin, while there was an impaired absorption of D(+)-xylose and folic acid.

Poor effect of glutamin and human-EGF on autologic-allotopic transplanted ileum mucosa.

INTRODUCTION: After establishing a new method of autologic-allotopic ileum mucosa transplantation as a therapy for short-bowel syndrome, the effects of glutamine and human epithelial growth factor (human EGF) on the transplanted ileum mucosa were evaluated. METHODS: Ileum mucosa was transplanted in 28 young beagle dogs in a demucosed vascularised transverse colon segment. The ileum mucosa was kept in place with silicone stents in all animals. Eight animals of the control group were irrigated with saline solution. In the second group with 10 animals, 100 mg/kg glutamine were administered daily in the lumen. The 10 animals of the third group were treated with 25 microg/kg human EGF per day subcutaneously and irrigated with saline solution. 4 weeks later, histological specimens were harvested from the colon coat-ileum mucosa complex, the normal ileum and normal colon. Lumen diameter, percentage ileum mucosa uptake as well as mucosa and colon muscle coat thickness were evaluated. RESULTS: In all groups, the diameter of the lumen was larger than 10 mm after fixation, due to the silicone stent. The group with glutamine irrigation showed the largest lumen diameter. A complete mucosa lining of the inner surface of the colon muscle coat was achieved in none of the animals. The highest percentage of ileum mucosa uptake was found in the group with glutamine irrigation. In most animals, the transplanted ileum mucosa was markedly thinner than normal ileum mucosa. Only in the group with glutamine irrigation did we find two animals with nearly normal mucosa thickness. The longitudinal muscle of the transplanted colon coat was thicker in all three groups compared to normal colon. There were no differences in thickness of the circular muscle in all animals compared to normal colon. CONCLUSIONS: Silicone stents maintain a lumen after autologic-allotopic ileum mucosa transplantation. However, additional irrigation with glutamine, as well as treatment with human EGF subcutaneously could not provide a complete lining of the colon muscle coat with transplanted ileum mucosa. A modification of the operative procedure is necessary to achieve a colon muscle coat that is completely lined with ileum mucosa before the absorptive capacity of the transplanted colon coat-ileum mucosa complex can be evaluated.

IORT (intraoperative radiotherapy) in neuroblastoma: experience and first results.

Intraoperative radiotherapy (IORT) permits the application of a single large radiation dose to a malignant mass at the time of surgery sparing adjacent normal tissue from irradiation. Since 1996 we have used IORT to treat 13 children with neuroblastoma, stage 3 - 4. In all cases the tumour was not radically resectable at the first operation. Ultrasound, CT and MRI were performed and patients were treated with chemotherapy according to the NB90 protocol. The second-look operation was performed in the IORT operating room where the tumour was resected as completely as possible, while keeping the "no risk" principle in mind. Localised radiation of the residual tumour was 8 - 10 Gy. The child was monitored via 3 video cameras. No technical problems occurred during IORT application. The follow-up time was 6 - 69 months (May 2001). One patient died due to tumour progression, another in complete remission died after 9 months due to sepsis. The clinical course of 2 patients was complicated by a renal artery stenosis and a mesenteric artery occlusion. All other patients are in complete remission with regular follow-up examinations. Although the results are promising the number of patients is too small as yet for statistical analysis. However, IORT can be safely applied in patients with high-risk neuroblastomas, reducing the dose, side effects and resulting in remission.

Accessory liver in an infant with congenital diaphragmatic hernia.

Incidence of congenital diaphragmatic hernia (CDH) ranges from 1 in 2,400 to one in 5,000 live births. Associated anomalies in CDH are approximately 30% to 35%. The authors report on an infant with CDH and an accessory supradiaphragmatic liver with separate vascularization from the thoracic aorta. The pathogenesis of this malformation is discussed. The postoperative course and the follow-up of the child over 5 years was completely uneventful.

Paediatric surgical reality in Germany and visions for the future.

Over the past 2 centuries paediatric surgery has developed into a well-recognised, independent surgical speciality comparable to plastic surgery or thoracic and vascular surgery. About 550 members of the GAPS (German Association of Paediatric Surgery) annually treat about 2-3% of all 0-15-year-old children of the FRG and operate 32.5% of all children who need a surgical intervention in paediatric surgical centres. There are 83 paediatric surgical centres in the FRG. Most of them perform more than 2000 operations per year. Three newer developments are likely to influence the future of paediatric surgery in Germany: 1. demographic factors, particularly the massive reduction of the reproduction rate from factor 1 to 0.59; 2. the new German National Health Care System, called "Strukturreform 2000", which will introduce the Australian DRG system and a new administrative structure permitting only a restricted care of the patients under tight economic control; and 3. the European regulations of the UEMS/EBPS which the national Landesärztekammern will be required to adopt.

Total and superior sternal clefts in newborns: a simple technique for surgical correction.

The authors discuss six cases of superior and total sternal clefts treated in their department in the last 34 years and discuss the problems of this congenital malformation. The inferior sternal clefts including Cantrell's pentalogy and the total ventral clefts were excluded because in these cases severe associated anomalies require another approach. In superior and total sternal clefts, cardiac, vascular anomalies in lungs and abdomen and craniofacial dysgenesias are rarely present. In these cases a primary repair during the first weeks of life should be performed. Furthermore, the authors describe their own surgical approach, consisting of the conversion of the partial cleft into a total one. Then the rims are trimmed, and a complete approximation of the two segments is possible.

Autogenic allotopic small-bowel mucosa transplantation in beagles. A new perspective for treatment of small-bowel syndrome?

There is no standard treatment for the short-bowel syndrome. The aims of surgical therapy are based on: slowing the intestinal transit, increasing the absorbing intestinal area and small-bowel transplantation. Searching for a new surgical treatment we developed an alternative for increasing the absorbing small-bowel area by means of autogenic allotopic small-bowel mucosa transplantation in beagle dogs. In young animals we isolated the transverse colon leaving the blood supply intact. Colonic continuity was reestablished and two abdominal stomata were performed at the ends of the isolated transverse colon. A week thereafter the colonic mucosa of the isolated transverse colon was surgically removed and autologous small-bowel mucosa was transplanted in the demucosed colon. The animals were then sacrificed 2, 4 and 6 weeks after transplantation and the colon-coat-ileal-mucosa complex (CIC) was histologically examined. The ileal mucosa could be transplanted in the demucosed colon showing histological characteristics of ileal mucosa. The circular muscle of the colon coat developed a hypertrophy which was present even 6 weeks after transplantation. In this study we could show that autogenic allotopic small-bowel mucosa transplantation is feasible in beagle dogs and may prove a novel method of small bowel expansion in cases of small-bowel syndrome.

Impalement and anorectal injuries in childhood: a retrospective study of 12 cases.

BACKGROUND/PURPOSE: Because of the small numbers of impalement and anorectal injuries in childhood, a standardized therapeutic approach is necessary to avoid major complications. On the basis of a retrospective analysis of 12 children with such injuries treated from 1986 to 1996 in our department, the authors tried to establish guidelines for their treatment. METHODS: Additional therapeutic problems and main complications are elucidated after meticulous analysis of three selected cases. RESULTS: In two cases of anorectal impalement and a primary colostomy, no complications occurred. However, in three cases involving anorectal injury a primary fecal diversion was not performed, making a secondary colostomy necessary afterwound infection. CONCLUSIONS: The current standard principles in the treatment of severe anorectal injuries in children are fecal diversion, wound drainage, and broad spectrum antibiotics. A primary reconstruction in cases of impalement can be recommended only after exclusion of anorectal injury.

Continuous extracorporeal stool-transport system: a new and economical procedure for transitory short-bowel syndrome in prematures and newborns.

Between May 1994 and June 1995, nine newborns underwent surgery due to mechanical ileus or intrauterine perforation of the small bowel. Three were very-low-birth-weight infants weighing between 520 and 1,200 g. Surgery was performed in the first 2 days of life and split ileo- or jejunostomas were implanted. Early oral nutrition was initiated. To avoid non-use of the distal bowel and short-bowel syndrome, the aboral stoma was irrigated a few days later with the proximal feces. A new technique was applied to transport the chyle continuously from the oral to the aboral stoma: the stool was collected in an especially constructed stoma bag and transported distally by a roller pump. No major complications were seen. The general outcome was excellent in all cases, and reanastomosis under optimal bowel conditions was achieved in all patients without further problems.

Amniotic membranes as prosthetic material: experimental utilization data of a rat model.

BACKGROUND/PURPOSE: Prosthetic materials are applied for closing big tissue defects, the repair of traumatized organs, or hernias. Because nonabsorbable synthetic materials are rigid, possess a defined and unchangeable size, and foreign body reaction (FBR) may occur, biological materials may be an alternative. METHODS: In experimental studies in rats the authors implanted the fetal parts of the human amniotic membranes and examined the utilization and FBR induced in a standardized model. In addition amnion (AM) was combined with vicryl-net (VN) for higher implant stability. Fifteen, 30 and 90 days after implantation, macroscopic appearance was examined, and light microscopy and immunohistology testing of the specimens were performed. RESULTS: Adhesions to parenchymal organs and omentum were present irrespective of the side facing the abdominal cavity. AM induced a rapid FBR, which diminished with time. Chorion (CH) and parts of the AM were resorbed within the examined period after infiltration with recipient cells and neovascularisation. The combined implant, AM, and VN showed best results because disadvantages of one material could be compensated for by the advantages of the other. CONCLUSION: The studies show that AM, in its anatomic definition, combined with VN proves to be a safe and reliable prosthetic material for the use in tissue defects.