The use of pH monitoring and esophageal manometry in the evaluation of results of surgical therapy for gastroesophageal reflux disease.

BACKGROUND/PURPOSE: Surgery is indicated for the treatment of gastroesophageal reflux disease (GERD) when medical treatment fails or complications are encountered in children. However, it has not been fully established how the results after surgery can be evaluated. A prospective study was performed to evaluate the results of surgical therapy for GERD by pH monitoring (PM) and esophageal manometry (EM) in children. METHODS: Patients who were candidates for anti-reflux surgery between 2003 and 2004 were evaluated for symptoms, growth and results of PM and EM both in the pre- and postoperative periods. RESULTS: Thirteen patients were included (mean age = 6.65 +/- 3.28 years, male/female ratio = 10/3). Most frequently occurring symptoms were recurrent respiratory infections (RRI) (n = 11) and vomiting (n = 8). Nissen fundoplication was performed because of unresponsiveness to treatment (n = 10), RRI (n = 9), failure to thrive (n = 7) and esophagitis (n = 2) after medical treatment (2 - 36 months). Symptoms were resolved in 83.9 % of patients and were not changed in 16.1 % following surgery. Weight percentiles had significantly improved (pre: 12.38, post: 25.4, p < 0.05) during a short follow-up period (1 - 4 months). Mean reflux index (pre: 24.73 +/- 21.07 %, post: 0.93 %, min: 0 - max: 3.6, p < 0.05), reflux time (pre: 368 +/- 313 min, post: 17.1 +/- 15.9 min, p < 0.05), number of episodes (pre: 344.7 +/- 343.6, post: 19.53 +/- 11.13, p < 0.05) and number of reflux episodes longer than 5 minutes (pre: 4.3, min: 0 - max: 58, post: 0.61, min: 0 - max: 3, p < 0.05) were found to be reduced after surgery by PM. Lower esophageal sphincter pressure (pre: 55 +/- 27 cmH (2)O, post: 64.46 +/- 30.85 cmH (2)O), contraction amplitude (pre: 141.92 +/- 69.11 cmH (2)O, post: 130.69 +/- 45 cmH (2)O) and contraction velocity (pre: 1.94 cm/s, min: 0.1 - max: 7.5, post: 4.29 cm/s, min: 0.2 - max: 10) did not differ postoperatively (p > 0.05). However, contraction times were decreased postoperatively (pre: 73.6 +/- 52.9 s, post: 27.67 +/- 20.1 s, p < 0.05) and were found to be correlated with reflux time and the number of reflux episodes longer than 5 minutes. CONCLUSION: Nissen fundoplication is effective for the treatment of GERD. It supports the anti-reflux mechanism without affecting esophageal motility except for contraction times. The decrease in contraction time after surgery can be explained by the decreases in reflux time and in the number of reflux episodes longer than 5 minutes. PM and EM confirmed the clinical improvement and can be used for the evaluation of results of NF.

Sigmoid colon vaginoplasty in children.

BACKGROUND: Vaginal construction is necessary for the patients with aplasia of Mullerian ducts, testicular feminisation and androgen insensitivity syndromes. Many methods of vaginal construction have been described. We report here the outcomes of six adolescent patients who underwent sigmoid colon vaginoplasty with special emphasis on the surgical technique and outcomes. PATIENTS AND METHODS: Between 1990 and 2003, six patients underwent sigmoid vaginoplasty after a diagnosis of 5alpha-reductase deficiency (n = 3), testicular feminisation (n = 2) or vaginal atresia (n = 1). The mean age was 16 years (13 to 18). Wide spectrum antibiotics and whole-gut preparation were used in all cases. A 15-20 cm segment of sigmoid colon was pulled through the retrovesical tunnel. The proximal end was closed in two layers in patients with 5alpha-reductase deficiency and with testicular feminisation. A distal anastomosis was carried out to the opening made on the vaginal plate (5alpha-reductase deficiency) or on the tip of the shallow rudimentary vagina (testicular feminisation). The sigmoid segment was interposed between the blind end of the atretic vagina and the perineum in the patient with vaginal atresia. Patients were instructed to perform daily vaginal irrigation. The neovagina was examined and calibrated under anaesthesia. No routine vaginal dilatation was recommended. RESULTS: All but one patient had an uneventful postoperative period and were discharged within 7-8 days. All patients had an excellent cosmetic result with an appropriate vaginal length. One of the patients experienced late stenosis of the introitus which responded to dilatations. Mucus discharge was not a significant problem. The patient with vaginal atresia (Bardet-Biedl syndrome) experienced deep vein thrombosis, renal failure and sepsis, resulting in death. CONCLUSION: Sigmoid colon vaginoplasty is a special procedure which appears appropriate for the construction of a new vagina in children. A sigmoid colon neovagina meets all necessary criteria after a vaginoplasty. It provides an adequate diameter and length, and produces less scar tissue in the perineum. It is self-moistening, easily adaptable to the uterus, cervix and rudimentary atretic vaginal segments and does not require routine dilatation. Mild stenosis of the introitus can be treated by dilatations and revision can be easily performed in severely stenotic cases. On the other hand, the patient may face morbidity after laparotomy and other serious complications may occur due to accompanying diseases.

Bannayan-riley-ruvalcaba syndrome from the point of view of the pediatric surgeon.

Bannayan-Riley-Ruvalcaba syndrome (BRRS) is an overgrowth syndrome and polyposis condition, which carries an increased risk for development of benign and malignant tumors of various tissues and organs. A 9-year-old boy with BRRS who had multiple subcutaneous mesenchymal tumors and follicular adenoma of the thyroid and a 14-year-old boy with multiple subcutaneous mesenchymal tumors and gastrointestinal polyposis are presented, with special emphasis on the surgical management of these patients.

Clinical predictors for differential diagnosis of acute scrotum.

Accurate and early diagnosis of acute scrotum is of the utmost importance to avoid testicular loss and/or needless surgery. The aim of this study is to analyze the clinical presentation and physical examination parameters together with the results of imaging studies in order to find out predictors for the differential diagnosis of acute scrotum with special emphasize on testicular torsion (TT). Patients who were treated for acute scrotum in our unit from 1970 up to and including 2000 were reviewed retrospectively. The study group was subdivided into three groups: "testicular torsion (TT)", "torsion of testicular appendage (TTA)", and "epididymoorchitis (EO)" group according to the diagnosis confirmed by radiologic and surgical findings. Presence and/or absence of various parameters related to clinical presentation, physical examination, and results of imaging studies were analyzed by statistical means in each group. One hundred and sixty children with a mean age of 12.2 years formed the study group. The mean duration of symptoms was 15 hours. No significant difference was noted between the three groups with regard to mean age and duration of symptoms. Nuclear scintigraphy and Doppler ultrasound were used as diagnostic aids in 50 and 66 children, respectively. Clinical presentation parameters including the presence of a) previous trauma, b) pain attacks, and c) nausea and vomiting, had the highest sensitivity, specificity, positive and negative predictive values in the TT group and the lowest values in the EO group. In contrast, the EO group had the highest statistical values with regard to presence of dysuria and micturition disorders. Physical examination parameters consisting of a) elevation, b) transverse location of testis, c) anterior rotation of epididymis, and d) absence of cremasteric reflex had the highest statistical values in the TT group. Contrary to this, imaging studies had the highest specificity and positive predictive values in the TTA group and the lowest values in the TT group. Previous history of trauma and pain attacks, presence of nausea and vomiting, and absence of urinary complaints are the main predictors of TT. Elevation and transverse location of testis with an anteriorly rotated epididymis associated with loss of ipsilateral cremasteric reflex strongly indicate TT. Although accuracy of imaging studies is higher for the differential diagnosis of TTA and EO, there is a considerable risk of misdiagnosis. Therefore, differential diagnosis of acute scrotum, particularly TT, still remains a clinical diagnosis, and clinical parameters deserve more importance in surgical decision making.

Evaluation of pelvic contractility in ureteropelvic junction obstruction: an experimental study.

BACKGROUND/PURPOSE: Ureteropelvic junction (UPJ) obstruction causes adaptive and/or compensatory alterations in renal pelvic contractility. As these alterations directly affect the outcome after renal damage, definition of these alterations is of the utmost importance from a clinical point of view. Thus, an experimental study was designed to determine the alterations of renal pelvic contractility in response to partial and complete UPJ obstruction. METHODS: Fifteen adult female New Zealand white rabbits were randomly assigned into three groups (each containing 5 rabbits) according to the degree of unilateral UPJ obstruction. Group I: sham operation was performed and served as the control group; group II: partial UPJ obstruction was made; group III: complete UPJ obstruction was made. The animals in groups I and II were sacrificed after three weeks and the rabbits in group III were sacrificed after two weeks. Muscle strips from the renal pelvis were prepared. Spontaneous mechanical activity and contractile responses to phenylephrine (PE), serotonin (5-HT), and KCl were recorded isometrically and compared in all groups. RESULTS: Both the frequency and amplitude of spontaneous mechanical contractions were significantly (p < 0.05) increased in partial (group II) and complete UPJ obstruction (group III) groups. PE and 5-HT-induced tonic contractions, which were more prominent in the complete and partial obstruction groups when compared with the control group (p < 0.05). PE and 5-HT also increased the frequency of spontaneous contractions in both partial and complete obstruction groups. KCl induced long lasting tonic contractions in the control muscles. The duration of contraction to reach the maximum amplitude was shortened in the obstruction groups and the amplitudes of the contractions were significantly augmented when compared to control preparations. CONCLUSION: UPJ obstruction alters the contractile properties of renal pelvis smooth muscle. Increased frequency of spontaneous mechanical activity suggests that pacemaker cells of the renal pelvis change their activities in response to UPJ obstruction. Increase in tonic contraction amplitudes in response to PE and 5-HT suggests an increased sensitivity of smooth muscle cells to these agents. Potentiation of the contractile response to KCl suggests that adaptive changes take place at the level of excitation-contraction coupling in the smooth muscle of the renal pelvis following UPJ obstruction.

An experimental study of choleretic effect and histopathologic alterations in the gastrointestinal system after whole-bowel irrigation.

BACKGROUND/PURPOSE: Whole-bowel irrigation (WBI) has been used for different purposes. It has been the preferred method of bowel cleansing before large bowel surgery and colonoscopy. There are some studies about histopathologic alterations in the gastrointestinal system caused by WBI. It was reported that large quantities of bile-stained intraluminal fluid were seen after WBI with lactated Ringer's solution. In light of all these studies, the authors have decided to inspect whether WBI is choleretic and whether the histopathologic findings in the gastrointestinal system are caused by this choleretic effect. METHODS: During the experimental procedures, animals at first were divided into 2 major groups of A and B; A consisted of the animals whose bile was not collected, and B consisted of animals whose bile was collected. Later, these 2 groups were divided into 4 subgroups consisting of 6 animals each. Sham operations were performed on the animals in group SH-A and SH-B. The animals in group saline-A and saline-B were given 0.9% of sodium chloride (isotonic sodium chloride). The animals in group LR-A and LR-B received lactated Ringer's solution. The last group (PEG-A and PEG-B) underwent WBI by using polyethylene glycol solution (PEG). After completing WBI, animals were rested for 4 hours, and at the end of resting time, laparotomy was performed to take biopsy specimens from stomach, small bowel, and large bowel. All of the specimens were evaluated and graded for congestion, edema, and inflammation by the individual blinded pathologist. RESULTS: According to the results, WBI has been shown to affect biliary secretion and to have a choleretic effect (P <.05, Tuckey-Kramer). The choleretic effect has also been shown to be responsible for histopathologic alterations in some groups (P <.05, Tuckey-Kramer). The most severe changes of congestion, edema, and inflammation have been detected in isotonic sodium chloride solutions in all groups. The least alterations have been seen in lactated Ringer's and PEG solutions. CONCLUSIONS: In light of these findings, it might be concluded that the use of WBI can cause different degrees of histopathologic changes in gastrointestinal system depending on the type of solutions. WBI has been shown to have choleretic effect, and it was found that there is a connection between histopathologic changes in gastrointestinal system and choleretic effect of WBI.

Sclerotherapy for lymphangioma in children.

Although surgical excision has been considered to be the treatment of choice by most of the surgeons, sclerotherapy of lymphangioma has gained popularity during recent years. A prospective clinical trial was conducted to evaluate the efficacy of bleomycin and OK-432 sclerotherapies for treating lymphangioma in children. Fifteen patients were enrolled in the study conducted between 1998 and 2002. All patients were hospitalized. Bleomycin or OK-432 was injected into the lesion. Patients were observed in the hospital for 1 day. The response was considered as excellent in cases with total disappearance of the lesion. If the lesion was regressed more than 50% of the original size, the response was considered as good. Little or no change in the size of lesion was considered to be a poor response. Ten girls and five boys with ages ranging from 4 days to 12 years were treated. Five patients had been operated previously for lymphangioma. Most of the lesions were located only in the cervical region (n=13). Other cases revealed extensions into the mediastinum (n=1) or axilla (n=1). Bleomycin (n=8, 2.87+/-2.03 inj.), OK-432 (n=5, 2+/-1 inj.) or both in order (n=2, 6 and 16 injs.) were injected. No allergic reaction, scar formation or pulmonary complication was encountered. Fever (11%), local reactions (4%) and vomiting (2%) were encountered following a total of 55 injections. After a follow-up period of 6-36 months, the responses were excellent in 53.4%, good in 26.7% and poor in 6.6%. Macrocysts disappeared in the remaining 13.3% of patients who had mixed cervicofascial lymphangioma. Lower success rates were encountered among patients who had undergone prior surgery. Sclerotherapy with bleomycin and OK-432 is effective in the treatment of lymphangioma in children. Adverse effects are minor and rarely encountered. However, the surgeon should be alert for the possible serious complications. Sclerotherapy can be also used as an adjunctive therapy in the treatment plan of widespread or mixed forms of lymphangiomas. In the light of our results, sclerotherapy should be preferred as the primary mode of treatment in childhood lymphangiomas.

Successful treatment with interferon alfa in infiltrating angiolipoma: a case presenting with Kasabach-Merritt syndrome.

We report a case of infiltrating angiolipoma who presented with a large mass on the shoulder and the signs of Kasabach-Merritt syndrome. She improved dramatically within one month and the mass completely disappeared after six months of interferon treatment.

Pulmonary metastases in children: an analysis of surgical spectrum.

Pulmonary surgery is frequently used for the treatment of metastasis or nodules in children with various types of malignancies. However, the indications and effectiveness of pulmonary metastatectomy have not been evaluated recently. Therefore, a retrospective study was conducted to analyse the results of pulmonary metastatectomy in children. Children who underwent pulmonary metastatectomy at our department between 1990 and 2000 were reviewed. Eighteen children consisting of 11 boys and 7 girls (age range, 3 to 18 years) underwent thoracotomy for pulmonary metastasis excision. The primaries were osteosarcoma (n = 2), synovial sarcoma (n = 1), fibrosarcoma (n = 1), Ewing's sarcoma (n = 2), mesenchymal chondrosarcoma (n = 1), Wilms' tumour (n = 4), clear-cell sarcoma (n = 1), Hodgkin lymphoma (n = 3), hepatoblastoma (n = 1), hepatocellular carcinoma (n = 1) and haemangioendotheliosarcoma (n = 1). Pulmonary metastases were encountered either at the time of initial diagnosis (22 %) or occurred within 6 months to 5 years. They were frequently nodular (94 %), unilateral (94 %) and located in the right lung (70 %). The number of metastases were frequently one (56 %) or two (28 %). Excision was done by means of wedge resection (88 %), segmentectomy (6 %), and lobectomy + wedge resection (6 %). The nodules contained tumour cells in most cases (n = 14) (78 %), mature nephrogenic elements (6 %) and no tumour tissue (16 %) in the remaining cases. Histology was similar to that of the original tumour in 12 cases. However, synovial sarcoma was encountered in metastasis in one case with fibrosarcoma primary. Re-thoracotomy was performed in 22 % of cases for the recurrent lesion, which in only one case was a true local recurrence. Overall disease-free survival rate was 56 % during the follow-up period (mean, 36.4 +/- 31.8 months). Pulmonary metastatectomy may increase survival in carefully selected children, though it is unlikely to cure the patient. Therefore combined therapies such as chemotherapy and/or radiotherapy should be continued in the postoperative period.

Xanthogranulomatous pyelonephritis in children: diagnostic and therapeutic aspects.

BACKGROUND: Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic, inflammatory disease of the kidney. Etio-pathogenesis, diagnosis and management of pediatric XGP is still obscure due to the limited number of cases. Therefore, a retrospective clinical study was carried out to present an updated picture of the entire spectrum of pediatric XGP based on our 30 years' experience covering one of the largest non-collected series treated in a single medical center. METHODS: Records of children who were treated for XGP in our unit from 1970 to 1999, inclusive, were reviewed retrospectively. Information recorded for each patient included age, sex, past medical history, clinical characteristics, diagnostic procedures,treatment methods, histopathologic findings and outcome. RESULTS: 17 children with a mean age of 6.6 +/- 0.8 years, consisting of 15 males and 2 females, were treated for XGP. Eight patients had a urological disease history and 4 of them underwent surgery for urinary calculi and exstrophia vesica repair. The most common presenting symptoms were abdominal pain, fever,weight loss and anorexia. Palpable flank mass was the most common physical examination finding. Left and right kidneys were involved in 10 and 7 patients, respectively. Diagnostic procedures were intravenous pyelography, retrograde pyelography, ultrasound scan and computerized tomography (CT). Renal calculi and/or calcifications and non-functioning kidney were the most frequent findings in radiologic investigations. By combining all these investigations, the preoperative diagnoses were XGP (n = 2), renal and/or perirenal abscess (n = 5), psoas abscess(n = 2), non-functioning kidney due to recurrent pyelonephritis(n = 4), Wilms' tumor and/or renal clear-cell carcinoma (n = 4). XGP was correctly diagnosed in only two patients based on cr findings. Drainage of the renal or psoas abscess was performed in 8 patients as an initial procedure (surgical drainage in 6 and ultrasound-guided percutaneous drainage in 2 patients). Surgical procedures included nephrectomy (n= 13), partial nephrectomy (n=2), nephrectomy and diversion of reno-colic fistula(n= 1), and renal biopsy and nephrostomy (n= 1). Operative and postoperative complications were colonic perforation (n= 3) and wound infection (n = 3). Complications were noted only in patients who underwent nephrectomy without initial drainage procedures. Histopathologic examinations showed diffuse and focal XGP in 14 and 3 patients, respectively. CONCLUSION: XGP should be included in the differential diagnosis of all children presenting with perirenal or psoas abscess, renal mass and/or non-functioning kidney associated with/or without urolithiasis. Clinical awareness and a high index of suspicion is required to achieve the correct preoperative diagnosis and appropriate management. CT seems to be the most valuable imaging method for the diagnosis. We strongly recommend percutaneous drainage of the abscess and adjunctive antibiotic therapy prior to nephrectomy to avoid complications. Complete nephrectomy is the proper treatment for the diffuse form whereas frozen section biopsies followed by partial nephrectomy are mandatory for the proper treatment of focal disease.

Colonic atresia: surgical management and outcome.

Colonic atresia (CA) is a very rare cause of intestinal obstruction, and little information has been available about the management and predictors of outcome. A retrospective clinical trial was performed to delineate the clinical characteristics of CA with special emphasis on surgical treatment and factors affecting outcome. Children with CA who were treated in our department between 1977 and 1998 were reviewed: 14 boys and 4 girls aged 1 day to 5 months. All but 2 referred patients and 1 with prenatal diagnosis presented with intestinal obstruction. Plain abdominal X-ray films showed findings of intestinal obstruction in 14 cases; a barium enema demonstrated a distal atretic segment and microcolon in 4. The types of atresia were IIIa (n=9), I (n=6), and II (n=3). Type IIIa atresias were located proximal to the splenic flexure (n=8) and in the sigmoid colon (n=1), type I atresias were encountered throughout the colon; and all type II atresias were proximal to the hepatic flexure. Associated anomalies were multiple small-intestinal atresias (MSIA) (n=4), gastroschisis (GS) (n=2), pyloric atresia (n=1), Hirschsprung's disease (n=1), and complex urologic abnormalities (n=1). The initial management was an enterostomy in 15 patients (83%), including 2 referred and 2 with GS, and primary anastomosis in the remaining 3 (17%). Secondary procedures were the Santulli operation (n=2), colostomy closure and recolostomy followed by a Swenson operation (n=1), sacroabdominoperineal pull-through (n=1), and colostomy closure (n=1). Leakage was encountered in all primarily anastomosed patients. The overall mortality was 61%. Deaths occurred in patients with associated major anomalies (GS 2, MSIA 3, pyloric atresia 1) (55%) and in 3 patients who were initially managed by primary anastomosis (27%). Two additional patients died of sudden infant death syndrome (18%). Type I atresia was more common than in previously reported series and was associated with proximal multiple atresias. The initial management of CA should be prompt decompression of the intestine by an ostomy procedure, preferably end- or double-barrel. The type of surgery (primary anastomosis without prior colostomy) and associated abnormalities are the major determinants of poor outcome.

Testicular tumors in children.

PURPOSE: The aim of this study was to present an updated picture of surgical management of pediatric testicular tumors based on our 30 years' experience, which consisted of one of the largest noncollected series treated in a single medical center. METHODS: Records of children who were treated for testicular tumor in our unit from 1970 to 1999, inclusive, were reviewed retrospectively. Information recorded for each patient included age, sex, past medical history, clinical characteristics, diagnostic procedures, treatment methods, histopathologic findings, and outcome. RESULTS: Fifty-one patients with a mean age of 3.8 +/- 0.5 years were treated for testicular tumors. Of these, 35 (69%) had germ cell testis tumor (GCT) and 16 (31%) had non-germ cell testis tumor (NGCT). Endodermal sinus tumor and paratesticular rhabdomyosarcoma were the dominant histologic subtypes in each group, respectively. The most common mode of presentation was painless scrotal mass. At initial presentation, retroperitoneal (n = 5), both retroperitoneal and lung (n = 2), and retroperitoneal and liver (n = 3) metastases were recorded in 10 (19%) patients. Initial operative procedures were radical inguinal orchiectomy (RIO) (n = 29), scrotal orchiectomy (SO; n = 9), bilateral RIO (n = 2), both RIO and unilateral retroperitoneal lymph node (RPLN) excision (n = 6), testis-sparing enucleation of the tumor (n = 5). SOs were performed elsewhere, and these patients underwent high ligation (n = 4) and both high ligation plus RPLN excision (n = 5) in our unit. Histopathologically, spermatic cord invasion and RPLN involvement were present in 10 patients. Scrotal recurrences were encountered in 2 patients who had scrotal orchiectomy initially. Retroperitoneal recurrences were noted in a patient presenting with stage I embryonal carcinoma and in 2 patients presenting with group IV paratesticular rhabdomyosarcoma. The mean follow-up period was 89 +/- 10 months. Four patients with stage IV embryonal carcinoma (n = 2) and group IV paratesticular rhabdomyosarcoma (n = 2) died of progression of the disease. All remaining patients were alive and disease free at their last outpatient appointment. No significant difference was noted with regard to 5-year survival rates between (1) malignant GCT and paratesticular rhabdomyosarcoma patients (91% v 80%) and (2) patients treated by RIO (88%), SO plus high ligation (87%), and RIO plus RPLN excision (80%). Five-year survival rates were 100% for stage I, II, III patients and 33.3% for stage IV and group IV patients presenting with malignant testicular tumors (P <.05). CONCLUSIONS: Childhood testicular tumors deserve special attention from the therapeutic point of the view. A solid scrotal mass should be considered malignant until proved otherwise. Any suspicion of the testicular tumor warrants an inguinal approach to prevent scrotal violation by the tumor. Current trends emphasize that testis-sparing surgery should be performed for benign lesions such as teratoma, leydig cell tumor, and epidermoid cyst based on frozen biopsy findings. Literature findings and our experience suggest that RIO is the accurate treatment for stage I malignant GCT and group I and IIa paratesticular rhabdomyosarcoma. RPLN excision is not of benefit either as a staging or therapeutic procedure in stage I and group I and IIa diseases of these tumors. RPLN excision should be reserved for (1) malignant GCT patients who have persistent elevation of alpha-fetoprotein after orchiectomy in the presence of normal total body CT scan, and for patients presenting with stage II and III disease with definitive abnormality on CT scans, and (2) group IIb, IIc, and III paratesticular rhabdomyosarcoma patients with radiologic evidence of retroperitoneal involvement on CT scans. High ligation should be done as a complementary procedure after SO to increase the survival rates. J Pediatr Surg 36:1796-1801.

Capsaicin in albino rats prevents contralateral testis from the damaging effects posed by ipsilateral testis that underwent torsion.

OBJECTIVE: To evaluate the effect of capsaicin, a powerful neurotoxin selective to afferent nerves, on contralateral testicular damage in ipsilateral testicular torsion. METHODS: Forty male albino rats were randomly allocated into five groups. No operation was performed in group one. After intraperitoneal administration of 0.9% NaCl, rats underwent a sham operation in group 2 and testicular torsion in group 3. In groups 4 and 5 rats underwent sham operation and testicular torsion, respectively after intraoperitoneal capsaicin injection. Contralateral testes were harvested on the fifteenth day of the experiment and mean seminiferous tubular diameters and mean testicular biopsy scores were recorded for each testis. The values were compared through analysis of variance (ANOVA) with Turkey-Kramer multiple comparisons test and p values less than 0.05 were considered to be significant. RESULTS: Mean testicular biopsy scores and mean seminiferous tubular diameters of group 5 was significantly higher than the group 3. There was no difference between the groups 1, 2, 4, and 5 when these two parameters are concerned. CONCLUSION: Capsaicin effectively prevents contralateral testicular damage encountered following ipsilateral testicular torsion. The inhibition of afferent impulses from the ipsilateral testis under distress prevents contralateral testicular injury, and provides additional data to support the role of an autonomic reflex arc in contralateral testicular injury.

Mechanisms involved in contractile differences among cremaster muscles according to localization of testis.

BACKGROUND/PURPOSE: Evidence suggests differences in contractility in cremaster muscles (CM) associated with undescended testis caused by alterations of autonomic innervation. Contractile responses of CM to various pharmacologic agents were evaluated and compared according to the localization of testis. METHODS: Samples of CM from boys with undescended testis or inguinal hernia were obtained. Twitch and tetanic contractions were recorded isometrically at 37 degrees C. Effects of verapamil, isoprenaline, calcitonin gene-related peptide (CGRP), substance P (SP) and N(omega)-nitro-L-arginine (L-NNA) were investigated. Results were compared through 2-way analysis of variance, and P values less than.05 were considered to be different. RESULTS: Verapamil alone significantly (P <.05) decreased contraction amplitudes in CM from both sources; the decrease was more pronounced in CM from boys with inguinal hernia (P <.05). Although isoprenaline increased contraction amplitudes in CM associated with undescended testis (P <.05), CGRP and SP increased contraction amplitudes in CM associated with descended testis (P <.05). L-NNA increased contraction amplitudes in both groups (P <.05). The decrease of contraction amplitudes after verapamil displayed a similar pattern after isoprenaline, SP, and L-NNA. Verapamil-induced contractility decrease was more pronounced after CGRP in both groups (P <.05). CONCLUSIONS: Sensitivity of CM to verapamil differs according to localization of testis. Isoprenaline enhances contractility by stimulating Na(+)-K(+)ATPase in undescended testis without altering voltage-sensitive channel sensitivity to verapamil. CGRP and SP increase contractility in inguinal hernia, and CGRP increases the sensitivity of voltage-sensitive Ca(2+) channels to verapamil in CM from both groups. Nitric Oxide (NO) exerts inhibitory action on CM contractility, and it is less pronounced in undescended testis. These differences may contribute to pathophysiology of undescended testis.

Complications of the two major operations of Hirschsprung's disease: a single center experience.

This study was designed to determine and compare the results of the Duhamel and Swenson procedures. The hospital records of patients who had undergone the Swenson or Duhamel operation over a 17-year period were reviewed and the patients were contacted for a final evaluation. The early and late complications of these operations were defined and compared. It was determined that the Swenson operation had been performed in 138 patients and the Duhamel in 59. Among the various complications, such as wound infection, dehiscence, anastomotic leak, adhesive intestinal obstruction, pelvic abscess, intraabdominal abscess, mucosal prolapsus, anastomotic stricture and fistulas, only the anastomotic stricture showed significantly higher percentages in patients who had undergone the Swenson procedure. When urinary incontinence, enterocolitis, soiling and constipation were considered, there was no significant difference between these two groups. There was one death in the Swenson group and none in the Duhamel group. The authors suggest the Duhamel operation as a simpler and safer method for the treatment of Hirschsprung's disease.

The effects of flow rate, length and external pressure upon the pressure required for fluid to flow through a ureter.

OBJECTIVE: To determine in vitro the effects of increments of external pressure on the pressure required to conduct fluid through ureters of various lengths at different flow rates, as the flow of a fluid through a collapsible tube is influenced by various factors (e.g. external pressure, the pressure gradient between the ends, the length and diameter of the tube, and the viscosity of fluid). MATERIALS AND METHODS: Two in vitro systems were designed, composed of three parts, i.e. a perfusion line, an exit line and a container of two different widths in which short or long ureteric segments, obtained from cattle, could be placed; the ureter was connected to the perfusion and exit lines. Physiological saline was added to the container until the desired external pressure was applied to the ureter. The flow pressure (height of the perfusion line) was recorded when producing flows through ureters of varying length at 1.5 and 6 mL/min, and determined under various external pressures. The intra-ureteric pressure during flow was also monitored by a pressure transducer. The four combinations of long and short ureters with high and low flow rates were compared using analysis of variance, with the Pearson correlation coefficient used to evaluate the relationships between the various pressures. RESULTS: There were close relationships between flow pressure and external pressure (r = 0.727), intra-ureteric and external pressure (r = 0.766), and the flow pressure and intra-ureteric pressure (r = 0.940, all P < 0.001). Increments in external pressure resulted in greater flow and intra-ureteric pressure (P < 0.05). Increases in flow pressure were more pronounced than increases in intra-ureteric pressure at the same external pressure (P < 0.05) at high flow rates. A longer ureter and higher flow rates caused greater intra-ureteric pressure (P < 0.05). CONCLUSION: External pressure increases the pressure required to conduct fluid through a ureter and the effect is more pronounced at high flow rates. The length of the ureter also affects the flow pressure at high flow rates. Therefore, flow through the ureter follows the Poiseuille equation only at high flow rates. Thus, increases in intra-abdominal pressure may cause greater intrapelvic pressure and induce ureteric obstruction, contributing to the pathogenesis of hydronephrosis.

Achalasia in childhood: surgical treatment and outcome.

Achalasia is a rare disorder of the esophagus in children. From 1971 to 1999, 20 children with achalasia of the esophagus have been treated at our institution including two patients who were referred to us after esophagomyotomy. There were 13 boys and 7 girls (average age, 8.2 years; range 2 to 15 years). Presenting symptoms were vomiting (n = 18), dysphagia (n = 11), loss of weight (n = 5), recurrent respiratory infections (n = 3), cough (n = 2) and noisy respiration (n = 1). Barium swallow established diagnosis in all patients. Esophagoscopy was used as a supportive investigation in some patients (n = 10). Nineteen patients underwent Heller-Zaiger operation (modified Heller esophagomyotomy) either by transabdominal (n = 16) or transthoracic approach (n = 3) with (n = 6) or without concomitant antireflux procedure. The postoperative period was uneventful in all patients. Follow-up ranged from 2 months to 16 years. Decreased or absent peristalsis persisted in initial control esophagograms in all patients. Gastroesophageal reflux was encountered in only one patient. Complete relief of symptoms was noted in 14 patients. Mild to moderate dysphagia was encountered in 5 patients and all of them were evaluated by endoscopy and upper gastrointestinal series. Dysphagia resolved spontaneously in one child and following two dilations in another child. One child has moderate dysphagia after a short follow-up period. Esophageal stenosis was seen in the remaining two and subsequently treated by esophagocardioplasty (Heyrowsky and Wendel operations). Achalasia should be considered in the differential diagnosis in any children with persistent dysphagia, recurrent respiratory tract infections and vomiting, including children treated for clinically suspected gastroesophageal reflux. The obvious mode of treatment is surgical myotomy in children. Modified Heller esophagomyotomy is the procedure of choice, which can be performed either by an abdominal or a thoracic approach. The need to carry out a concomitant antireflux procedure remains controversial. The most frequent postoperative problem is persistent dysphagia. It may be self-limited in some cases and disappear during follow-up. Resistant stenosis following esophagocardiomyotomy can be treated by esophagocardioplasty procedures such as Heyrowsky and Wendel operations.

Changes in bladder of rabbits subjected to elevation of intraabdominal pressures.

BACKGROUND/PURPOSE: An experimental study has been conducted to evaluate the effects of increased intraabdominal pressure (IAP) on the morphology of the bladder of rabbits. METHODS: Experiments were performed on 20 adult male New Zealand rabbits. Six rabbits served as the control group (group I). Seven rabbits were subjected to increased IAP of 7 cm H2O for 10 days through installing air into the abdominal cavity (group II). Increased IAP was maintained for 60 days in another group of 7 rabbits (group III). Bladders were removed and fixed in 10% formalin for routine process. Paraffin sections of 5 to 7 microm were stained with H & E for light microscopic evaluation. Histopathologic parameters were scored, and the mean scores according to groups were compared by 1-way analysis of variance (ANOVA). The mean values of groups were compared separately by Tukey-Kramer multiple comparison test. In these tests, P value less than.05 was considered statistically significant. RESULTS: All of the bladder strips obtained from animals subjected to 10 days of pressure increase (group II) showed mild to severe degree of vacuolation and desquamation of urothelium. Both vacuolation and desquamation of urothelium were present in all of the strips obtained from rabbits with 60 days pressure increase (group III). Additionally, there were infiltration and congestion of the urothelium together with vacuolation, suburothelial edema, and desquamation in 4 group III rabbits. Moderate or severe congestion in the lamina propria was present in bladder strips of group II rabbits. The congestion of the lamina propria was advanced, and additional moderate to severe inflammation was present in 4 rabbits of group III. Mean histopathologic scores of urothelium (P <.00001) and lamina propria (P =.002) differed significantly among groups. When the groups were compared one by one, the differences between the group I and group II and group II and III were significant (P <.05). Although serosa appeared normal in both group I and II, moderate congestion and infiltration of the serosa was present in the bladder strips of group III (P <.05). CONCLUSION: Increases in IAP for even 10 days show damaging effects on the bladder. Extended period resulted in augmentation of the damage.