Neonatal perforated appendicitis in incarcerated inguinal hernia in the differential diagnosis of testis torsion.

Appendicitis in newborns is uncommon and difficult to diagnose. Reports on neonatal appendicitis subsequent to inguinal hernia incarceration are exceptionally rare. We present the case of a 26-day-old infant with perforated appendicitis due to incarceration of a right inguinal hernia, mimicking right testicular torsion.

Breast Metastases in Children and Adolescents With Rhabdomyosarcoma: A Large Single-Institution Experience and Literature Review.

INTRODUCTION: Breast metastasis is rare in childhood malignancies. Soft tissue sarcomas, especially rhabdomyosarcomas (RMS), and hematologic neoplasms, such as lymphomas, are the most common tumors that metastasize to the breast, albeit rare. MATERIALS AND METHODS: All cases with breast metastasis within a cohort of 200 RMS patients followed in our institution during 1990 to 2014 were assessed retrospectively and the literature was reviewed. RESULTS: There were 3 adolescent female patients with breast metastasis. All had alveolar histology. The primary tumors were in the parameningeal sites, extremities, and the perineum, respectively. Two patients had breast metastasis at diagnosis, and 1 during follow-up. In 1 breast lesion, there was a complete response to chemotherapy, and in another there was no response to chemotherapy, and the patient underwent radical mastectomy. In the third patient, there was partial response, and lesions progressed. All patients died with recurrent/progressive disease, 2 with no recurrence in the breast. In the English literature, there are 70 cases including our cases. All but 1 involve female patients, all adolescents, most have alveolar histology and poor prognosis. All had chemotherapy, whereas some had surgery and/or radiotherapy for local treatment. CONCLUSION: Breast metastasis should be considered in adolescent female patients with RMS. Optimal management is not clear. Besides chemotherapy, mastectomy and radiotherapy should be considered on a case basis.

The Value of Mitotic Count and Ki67 Proliferation Index in Congenital Mesoblastic Nephroma.

OBJECTIVE: We aimed to define the histopathologic features and proliferative rate of congenital mesoblastic nephroma (CMN) as a risk factor for recurrence. METHODS: Fourteen cases of CMN among 138 registered pediatric renal tumors were retrospectively reviewed. The prognostic impact for mitotic rate and Ki67 index was investigated. RESULTS: There were four (28.6%) classic, six (42.9%) cellular, and four (28.6%) mixed type CMNs, with average Ki-67 counts of 16.75% in the classic CMN, and 53.2% in the tumors with cellular components (both mixed and cellular CMNs). Twelve patients (85.7%) were aged less than six months. Tumors with cellular component showed significantly larger tumor diameter and higher Ki-67 index (p = 0.015 and p = 0.016, respectively). The patient with cellular CMN, whose tumor showed the highest mitotic rate (4.9/HPF), but not the highest Ki67 index (57.4%), died of recurrent disease with distant metastasis. CONCLUSION: Proliferative markers-mitotic count and Ki67 index-have limited value to predict recurrence or metastasis in CMNs with a cellular component.

Early myotomy and fundoplication in achalasia in childhood: a single-centre experience for 22 years.

Introduction The aim of this study was to review a single institution's experience with surgical interventions in children with achalasia and to determine treatment strategies for this rare disorder. Patients and methods This study is a retrospective analysis of 22 cases of childhood achalasia from 1991 to 2013. The patients were evaluated in terms of age, symptoms, interventions, intraoperative complications, and recurrent dysphagia. Results There were 13 boys and nine girls (7 months to 17 years old). The clinical symptoms were vomiting (68%), dysphagia (36%), wheezing (18%), coughing (13%), and weight-loss (13%). The mean duration of symptoms was 2.4 years (1 month to 6 years). A barium contrast X-ray study was performed in all of the patients. Oesophageal manometry was performed in eight patients. Six patients underwent multiple oesophageal dilatations (ED) as a first intervention. A Heller myotomy (HM) and fundoplication were performed in all the patients except two patients who recovered with dilatation. In the long term, one patient had a stricture due to the operation and had to undergo a reoperation. Of the Heller myotomy patients, one had a recurrent stricture that responded to dilatation. No other complications were present. All the patients are now asymptomatic. Conclusion Early diagnosis and prompt surgical treatment is important to prevent growth impairment in childhood achalasia cases. A Heller myotomy followed by a partial anti-reflux procedure is an effective treatment for achalasia in children. Based on our experience, it is superior to oesophageal dilatation therapy.

Sleeve resection for bronchial carcinoid tumour in two children under six years old.

BACKGROUND: Paediatric tracheobronchial tumours are very rare, and pneumonectomy and lobectomy procedures are rarely indicated due to their surgical difficulties and high sequelae. Bronchoplastic techniques preserving lung parenchyma allow the resection and reconstruction of the main bronchi and carina. CASE PRESENTATION: Here, we present a 6-year-old boy suffering from a carcinoid tumour of the right main bronchus which was successfully managed with a right upper sleeve lobectomy and a 4-year-old girl with an endobronchial carcinoid tumour narrowing the left main bronchus that received a sleeve resection of that bronchus. CONCLUSION: Bronchoplastic techniques are widely used in adults, can be very successful in paediatric patients where the preservation of the lung parenchyma is more important.

Pulmonary metastasectomy in pediatric patients.

BACKGROUND: This study aims to evaluate the outcomes of pulmonary metastasectomy resections in pediatric patients. METHODS: We retrospectively reviewed the medical records of 43 children who were operated on in the Pediatric Surgery Clinic between January 1988 and 2014. Forty-three children (26 boys; 17 girls; mean age 10±4.24 years, range 6 months-18 years) who underwent pulmonary metastasectomy resection were included in the study. The patients were evaluated based on age, gender, history of disease, surgical procedures, complications, duration of hospitalization, duration of chest tube placement, and procedure outcome. RESULTS: Indications for pediatric resections were oncological. Metastasis was secondary to Wilms' tumor in 14 patients, osteosarcoma in 7 patients, Ewing's sarcoma in 5 patients, rhabdomyosarcoma in 5 patients, lymphoma in 3 patients, hepatoblastoma in 2 patients, and other tumors in 7 patients. A total of 59 thoracotomies were performed. Approaches utilized included unilateral posterolateral thoracotomy (n=33), bilateral posterolateral thoracotomy (n=8), and sternotomy (n=2). Wedge resection was the procedure of choice (n=44). In selected cases, 11 segmentectomies, 3 lobectomies, and 1 pneumonectomy were performed. There was no perioperative mortality. One patient suffered prolonged air leak and three patients from fever. All patients received chemotherapy. Radiotherapy was administered to 16 patients (37.2%). Of those 16 patients, 7 had Wilms' tumor, 6 had Ewing's sarcoma/PNET, and 3 were rhabdomyosarcoma patients. During a median follow-up of 3 years, the overall survival was 74.4%. CONCLUSIONS: Multidisciplinary treatment involving pediatric oncologists, surgeons, and radiation oncologists is necessary to obtain positive results in children who have pulmonary metastases of oncological diseases. Wedge resection is a suitable option for children because less lung tissue is resected.

The Role of Ozone Therapy in Hepatic Fibrosis due to Biliary Tract Obstruction.

PURPOSES: In this experimental study, we investigated the role of ozone therapy in hepatic fibrosis caused by biliary obstruction. MATERIALS AND METHODS: In this study, 21 male Sprague-Dawley rats were divided equally into three groups. In the control group, only laparotomy was performed and intraperitoneal cavity is washed with 1 mL of saline. In the sham group (SG), common bile duct is binded with laparotomy and no treatment is given afterward. In the experimental group (EG) after the binding of common bile duct with laparotomy, 1 mg/kg dose and 50 mg/mL concentration of ozone were applied rectally for 21 days. Hepatic tissue sample and intracardiac blood samples were collected from all animals at postoperative 21st day with relaparatomy. RESULTS: When we compared the experiment to SG, we detected a decrease in aspartate aminotransferase, alkaline phosphate (ALP), total bilirubin, and direct bilirubin levels in the EG, however, only the decrease in total bilirubin levels were statistically significant (p = 0.025). Histopathological examination of livers of rats in the EG showed lower level of hepatic fibrosis and inflammation. In the SG, incomplete cirrhosis was detected in 57.1% of the rats, whereas in the EG, no cirrhosis was detected. Immunohistochemically, periportal inflammation was 100% in the SG, whereas it was seen (3/7) 42.9% in the EG. A significant decrease in positive α-smooth muscle actin reaction was observed in ozone-treated group compared with SG. CONCLUSION: We suggest that ozone can decrease the hepatic destruction levels in experimental model of biliary obstruction.

Antioxidant Effects of Probiotics in Experimentally Induced Peritonitis.

AIM: An experimental study was performed to evaluate the protective effects of probiotics on gut mucosa in peritonitis through antioxidant mechanisms. METHODS: Thirty-two male Wistar albino rats were divided equally into four groups. The rats in Group 1 (control group) underwent laparotomy only. In group 2 (peritonitis group), peritonitis was induced in the rats by the cecal ligation and puncture (CLP) model. In group 3, the rats were treated with probiotics for five days after CLP-induced peritonitis. The last group of rats (group 4) were fed probiotics for five days before the CLP procedure and five days after the surgery. On the fifth day after surgery, all rats were killed, and tissue samples from the terminal ileum were obtained to evaluate the activities of myeloperoxidase (MPO), malondialdehyde (MDA), and glutathione (GSH). Histopathologic examinations were also performed to evaluate the grade of intestinal injury. RESULTS: Myeloperoxidase and MDA activities were increased, GSH concentrations were decreased in group 2, compared with group 1. Intestinal MPO activities in group 4 were decreased compared with group 1 and group 2, indicating a reduction in oxidant activity. Malondialdehyde decreased in group 3 and decreased even more in group 4, compared with the peritonitis group (group 2). Glutathione concentrations were increased in group 4 compared with group 2 and group 3 (p < 0.05). The Chiu scores of the probiotics groups, groups 3 and 4, were lower than those in group 2, indicating reduced mucosal damage in the probiotically fed groups. CONCLUSION: Probiotics have protective effects in peritonitis, which may be related to antioxidant mechanisms. This antioxidant effect of probiotics might occur when pre-conditioning with probiotics before peritonitis because there is sufficient time to prepare the tissues for oxidative damage.

Effect of probiotic supplementation on bacterial translocation in common bile duct obstruction.

OBJECTIVE: To investigate the effects of probiotics on bacterial translocation in the obstructive common bile duct with comparison to an enteral product containing arginine and glutamine. MATERIAL AND METHOD: In our study, 40 Sprague-Dawley rats each weighing 250-300 g were used. Animals in Group 1 (sham) were laparatomized and fed standard chow supplemented with physiologic saline at daily doses of 2 ml through orogastric tube for 7 days. Common bile ducts of the animals in the other groups were ligated with 3/0 silk sutures. Group 2 (control group) was fed standard chow supplemented with daily doses of 2 ml physiologic saline. Group 3 (probiotic group) was fed standard chow supplemented with a probiotic solution (Acidophilus plus) containing strains of Lactobacillus acidophilus, Bifidobacterium bifidum and Lactobacillus bulgaricus at a daily doses of 2 × 10(9) colony forming units (CFU). Group 4 (formula group) was fed only an enteral solution (Stresson Multi Fiber) containing glutamine, arginine and a medium-chain fatty acid at daily doses of 2 g/kg. At the end of the 7th day, all animals were relaparatomized, and to determine bacterial translocation, aerobic, and anaerobic cultures were obtained from the specimens of mesenteric lymph nodes, intestinal mucosa, and blood samples. Smear cultures prepared from caecum were examined to determine the number of CFU. Finally, for histological examination specimens were excised from terminal ileum, and oxidative damage was assessed in liver tissues. Afterwards all animals were killed. RESULTS: Moderately lesser degrees of bacterial translocation, and mucosal damage were seen in Groups 3, and 4 relative to Group 2 (p < 0.05). In Group 4, any difference was not seen in the number of cecal bacteria relative to baseline values, while in Group 3, significant decrease in cecal colonization was seen. Among all groups, a significant difference between levels of malondialdehyde, and glutathione was not observed. CONCLUSION: At the end of our study, we have concluded that both probiotics, and enteral diets which contain immunomodulators such as glutamine, and arginine alleviate bacterial translocation, and impairment of intestinal mucosa.

Effects of tissue plasminogen activator in experimentally induced peritonitis.

BACKGROUND: We aimed to evaluate the microbiological and immunological effects of tissue plasminogen activator (tPA) in a rat model of peritonitis. METHODS: Twenty-four male Wistar albino rats were divided equally into three groups. Peritonitis and thereafter laparotomy and partial omentectomy were performed in all rats. The control group (C) had no further treatment. The antibiotics group (A) received metronidazole and ceftriaxone. The antibiotic and tPA group (A+T) received the same antibiotics as well as tPA. For microbiological and immunological analysis, blood samples were obtained at the 24th hour, and peritoneal fluid samples were obtained at the 24th and 72nd hours. On the fifth day after surgery, all rats were sacrificed, and the macroscopic findings of the peritoneal cavity were recorded. RESULTS: The mean number of intraperitoneal abscesses was significantly higher in the control group and the lowest in the two treatment group (A+T). The levels of cytokines were not significantly different between groups. Giving tPA reduced the number and sizes of the abscesses with no significant difference in inflammatory response. CONCLUSION: In this experimental peritonitis model, it can be postulated that tPA decreased abscess formation without exaggerating the inflammatory response.

Multiple magnet ingestion resulting in small bowel perforation: a case report.

Foreign body ingestion is a common clinical situation that is primarily diagnosed by emergency clinicians. Most foreign bodies can be evacuated without difficulty. Although rare, magnets that reach the lower intestinal tract may cause complications such as intestinal fistula formation, perforation, volvulus or appendicitis. We report herein a two-year-old girl who was admitted to our department 3 days ago with abdominal pain and non-bilious vomiting. Upon admission direct abdominal roentgenogram revealed a foreign body consisting of multiple spheric parts bound together forming a circle in the lower quadrants of the abdomen. Her family, unaware of this ingestion, stated that a magnetic toy matching the object present on the plain radiograph was lost several days ago. Surgical intervention showed a magnetic toy in the proximal part of the ileum causing multiple perforations in the intestinal wall and the neighboring mesentery. The ileal portion containing the magnet toy was seen folded over itself forming a blind loop. The patient was discharged uneventfully in the 7th postoperative day. Our case highlights a well known fact that foreign body ingestion in children may not have eye witnesses and should be taken into consideration when evaluating children with abdominal pain.

Intrapericardial diaphragmatic hernia: report of 2 cases with prenatal diagnosis.

An intrapericardial diaphragmatic hernia is a very rare congenital abnormality, with only a few cases reported in the English literature. The triad includes a massive pericardial effusion, bilateral pulmonary compression with or without pulmonary hypoplasia, and herniation of part of the liver into the pericardium. We report 2 cases of intrapericardial diaphragmatic hernias diagnosed prenatally in our obstetrics and gynecology unit.

Mediastinal masses in children: experience with 120 cases.

Primary mediastinal malignancies are rare tumors and can originate from any mediastinal organ or tissue such as thymic, neurogenic, lymphatic, germinal, or mesenchymal. The authors reviewed all cases of primary pediatric mediastinal masses diagnosed over a 25-year period to determine the pattern of presentation, the histology, and the outcome of the surgical treatment. In this study, 120 primary pediatric mediastinal mass cases diagnosed between 1985 and 2011 are retrospectively evaluated according to their age, sex, symptoms, anatomical location, surgical treatment, and histopathological evaluation. The median age of the patients was 5.8 years. There were 34 benign and 86 malign tumors. Thirty patients were asymptomatic. Common symptoms in the patients were cough, dyspnea, fatigue, fever, abdomen pain, back pain, and neurological symptoms. According to their origins, they were presented as neurogenic tumors (38.3%), lymphomas (18.3%), undifferentiated sarcomas (15%), germ cell tumors (7.5%), and the other tumors (22%) thymic pathologies, lymphangiomas, rhabdomyosarcomas, lipomas, hemangiomas, and Wilms' tumor. Complete resection of the tumor was performed in 86 patients, partial resection of the tumor was the intervention in 11 patients. In 23 patients, biopsy was undertaken. Because of the high incidence of asymptomatic or nonspecific presentation such as the upper airway disease, the presentation of a mediastinal mass in children may be challenging. Neurogenic tumors or lymphomas are indicating surgery, if possible complete resection, for both benign and malignant conditions. Although surgery is the mainstay of therapy for most mediastinal tumors, an experienced multidisciplinary approach is necessary.

Gunshot wound of the fetus.

We report here a fetus, who was delivered via cesarean section in 32th gestational week from a 37-year-old mother and sustained multiple gunshots. Post-natal evaluation revealed eight entry-exit holes and the baby was transferred to our clinic.Upon admission, peripheral pulses were nonpalpable, appropriate fluid administration and blood transfusion were conducted and further examinations revealed bladder perforation. Bladder was repaired over a suprapubic catheter and bullet holes were primarily sutured. Left foot drop was observed on follow up and the patient was discharged with no further complication. Although the maternal and the fetal morbidity and mortality rates are high in intrauterine gunshot wounds, appropriate management may provide survival as seen in our case.

A rare neonatal testicular tumor: juvenile granulosa cell tumor of infant testis: a report of 3 cases.

SUMMARY: Juvenile granulosa, the cell tumor of testis are very rarely seen in children. Radical orchiectomy is sufficient for treatment. In this study, we presented 3 infants with juvenile granulosa cell tumor in testis.

Complete bronchial rupture in a child: report of a case.

Tracheobronchial rupture due to blunt chest trauma is a rare and serious injury in children. The diagnosis is usually difficult and may be overlooked because of the variability of symptoms and findings. Fiberendoscopy is useful in children with stable tracheal or bronchial ruptures. However, in the emergency situation, fiberendoscopy may not be appropriate, and thoracotomy and primary anastomosis may be the best option.

Bronchogenic cysts: a rare congenital cystic malformation of the lung.

PURPOSE: Bronchogenic cysts are rare congenital cystic malformations of the lung. We retrospectively analyzed ten cases of bronchogenic cyst (BC) to reinforce the importance of recognizing this malformation. METHODS: Between 1985 and 2000, ten pediatric patients with BC were treated surgically in our department. Their clinical presentation, radiological, operative, and pathological findings were analyzed retrospectively. RESULTS: There were five boys and five girls, ranging in age from 16 days to 6 years (mean 6.5 months). The clinical signs and symptoms included respiratory distress in seven patients (70%), cyanosis in four (40%), chronic cough and fever in five (50%), and dysphasia in two (20%). Routine chest X-ray revealed a pulmonary air-filled cyst in six patients (60%) and a pulmonary nodular opacity in four (40%). The diagnosis was supported by computed tomography in four patients and by ultrasonography in two. Eight of the patients were treated by cyst excision and two by lobectomy. The pathological diagnosis made from all specimens was bronchogenic cyst, with squamous metaplasia in two. CONCLUSION: In newborns, infants, and even children, the development of dyspnea, cyanosis, chronic cough, and fever should alert us to the suspicion of a cystic malformation in the lung, such as a bronchogenic cyst, especially if an air-filled cyst is seen on a plain chest X-ray.

The effect of pentoxifylline on intestinal anastomotic healing after ischemia.

The negative effects of ischemia-reperfusion injury (IRI) on intestinal anastomotic healing have been described in previous studies. To determine the effect of pentoxifylline (PTF) on small-bowel anastomoses performed after IRI, 20 male Wistar albino rats were studied. Under ketamine anesthesia, the superior mesenteric artery was occluded for 30 min and ileal resection-anastomosis was performed after 10 min of reperfusion. In group I, no medication was given. In group II, PTF 50 mg/kg was administered intraperitoneally before reperfusion and i.m. on the 1st, 2nd, 3rd and 4th postoperative days (POD). All rats were killed and anastomotic segments were removed on the 7th POD. Anastomotic bursting pressure (ABP) and hydroxyproline (HP) content were measured in the anastomotic segments; parameters were compared statistically with Student's t-test. In group I, the mean ABP was 225.5 +/- 38.18 mmHg the and mean HP level was 16.03 +/- 1.91 micro mol/g tissue. In group II, these levels were 277 +/- 41.1 mmHg and 19.85 +/- 1.81 micro mol/g tissue, respectively. The differences between the groups were significant (P < 0.005). Thus, PTF can improve anastomotic healing in an experimental model after IRI by promotion of collagen synthesis.

Safety-pin ingestion in children: a cultural fact.

Pediatric foreign-body (FB) ingestion is a common problem. Many of these FBs are sharp objects such as needles, toothpicks and safety pins (SP). This report reviews the management of SP ingestion in children. During a 16-year period, we recorded 49 pediatric cases of witnessed SP ingestion. In all children, SPs were used to attach the blue beads to the child's suits with the belief of averting the evil eye. The mean age was 8 months ranging from 4 months to 2 years, and 30 patients were males and 19 were females. SPs were most commonly sited in esophagus (37%) and stomach (37%). In the remainder, the SPs have already reached the duodenum and intestine. In this series, 20 (41%) children passed SPs spontaneously, 14 (28.5%) required endoscopic removal and 15 (30.5%) underwent surgery. The outcome of all patients was uneventful. All of the esophageal SPs require endoscopic intervention, however, after passing into stomach the patients can be observed with keeping the surgical intervention in mind if the SP displays a fixed position for more than three days.