Laparoscopic myotomy for oesophageal achalasia--adding an antireflux procedure is not always necessary.

Laparoscopy is the access of choice for functional surgery of the gastroesophageal junction, and oesophagocardiomyotomy, as the conventional surgical treatment of achalasia, is one of the favourable indications for laparoscopic surgery. Laparoscopic anterior myotomy technique is highly effective and secure for relieving dysphagia with minimal risk of gastroesophageal reflux. Fifteen patients with the diagnosis of achalasia were treated with laparoscopic anterior face oesophagocardiomyotomy without a concomitant antireflux procedure. There was not any perioperative complication and no procedure was converted to open operation. Oesophageal cineradiography, manometry and 24-h pH monitoring were repeated postoperatively. Manometry showed a significant reduction of the resting tone (48-34.4 to 18-3.2 mmHg), and patients were free of symptoms for reflux and dysphagia at the follow-up between 8 and 96 (median 42) months. Only one patient needed pneumatic dilation, 1 year after the operation for mild dysphagia, and one patient had moderate reflux, which was managed by medication. Thanks to minimal invasive technique of laparoscopic surgery and intraoperative endoscopy, oesophagocardiomyotomy can safely be performed in a length needed without dividing lateral and posterior phrenoesophageal ligamentous attachments. Consequently, adding an antireflux procedure routinely is not necessary. We advocate laparoscopic anterior oesophagocardiomyotomy alone as the first-line treatment for achalasia.

Results of the Mutaf procedure in patients with gastroesophageal reflux disease.

Operations to treat complicated gastroesophageal reflux disease (GERD) have become the third most commonly performed general surgical procedure in large pediatric centers, and many surgical techniques have come into use to prevent gastroesophageal reflux. This paper presents our experience with gastric tube cardioplasty, a new procedure described by Oktay Mutaf (Mutaf procedure). Eleven children with GERD were successfully operated on. The postoperative period was uneventful, and all patients were symptom-free.

Nipple and areola diameter in Turkish pubertal girls.

The nipple and areola diameter of 498 girls aged 8-17 years were studied with the aim of finding measurable criteria for sexual maturation, including breast and pubic hair development during female puberty. All measurements were made holding a transparent ruler on both sides by the same observer. The smaller of the two measurements was used in the analysis. Significantly nipple and areola development occurred between breast stages B1 (2.56 and 14.35 mm), B2 (3.32 and 20.26 mm), B3 (5.21 and 28.84 mm), and B4 (6.28 and 32.03 mm). The nipple and areola diameter were also significantly greater in pubic hair stage (PH)3 (5.05 and 25.24 mm) with respect to PH2 and PH1 (3.46, 2.62 mm and 19.32, 15.37 mm, respectively), in PH5 (6.79 and 35.62 mm) with respect to PH4 (6.55 and 32.56 mm). A significant increase in nipple and areola diameter occurs between premenarchal girls and girls older than 0-2 years postmenarche. Sexual maturation staging by nipple size and by areola size appears to be feasible for female adolescent. However, staging by nipple size does not appear to be feasible for B4 and B5 stage, because the incremental gradations are small.

The effect of iatrogenic vas deferens injury on fertility in an experimental rat model.

The long-term result of accidental crushing of the vas deferens during inguinal surgery is unpredictable. It is stated that even a slight disturbance in the muscular layer or mucosa may endanger fertility. This study was designed to investigate the early and late histopathologic changes of iatrogenic injury on the vas and its effect on fertility in a rat model. Both vasa deferentia of 54 male rats, divided into three groups (n = 18 each), were subjected to an operative manipulation. These manipulations consisted of digital compression for 45 seconds in group A, grasping with a mosquito clamp for 2 seconds in group B, and grasping with a mosquito clamp for 2 minutes in group C. In five rats from each group, the vasa were removed on the third and 21st postoperative day for histological evaluation. The remaining 13 rats in each group were allowed to mate for a period of 4 months. Bilateral vasa were analyzed for patency and histology. A spermatic granuloma was observed in 79% of the fertile and 80% of the infertile rats. Statistical analysis showed no significant fertility difference among the three groups. There was no statistical difference between groups B and C (P > .05) in terms of high and low flow patency rates in vitro, whereas a statistical significance was present between these two groups and group A (P< .001). It can be said that type rather than time of injury is important in this experimental model, because the results of the patency test alone are sufficient to prove the possibility of functional damage in vas deferens. The authors conclude that inguinal contents should be handled carefully and contralateral exploration in asymptomatic cases older than 1 year with inguinal pathology should be avoided.

Omphalitis in term and preterm appropriate for gestational age and small for gestational age infants.

To determine whether there is a difference on the historical and clinical characteristics of omphalitis among term and preterm appropriate for gestational age (AGA) and small for gestational age (SGA) infants, we prospectively investigated 85 newborns with bacteriologically proved omphalitis. Study groups were based on gestational age and being SGA. Preterm AGA infants had significantly lower mean age and neutrophil counts. Risk factors such as septic delivery including unplanned home delivery, and bacterial spectrum were similar in the groups. Staphylococcus aureus and Escherichia coli were the most frequent micro-organisms. Mortality rates for the study groups were similar and overall case fatality rate was 13 per cent. Immunological immaturity of preterm newborns may explain the earlier occurrence age of omphalitis and lower absolute neutrophil count. The following features such as early-onset infection, septic delivery including unplanned home delivery and abnormal temperature may be considered as determinants of poor prognosis. However, further studies are needed.

Penopubic flaps technique for the repair of epispadias with or without exstrophy: a preliminary report.

Six patients (average age, 2 1/2 years; range, 4 months to 8 years) with the exstrophy-epispadias complex and isolate epispadias were treated using an alternative method. An inverted U-shaped incision (with a length of approximately 3 to 5 cm and a width of approximately 0.7 to 1.0 cm) was prepared, extending from the penopubic urethral meatus toward the umbilicus. The two incisions were extended along the urethral plate toward the ventral face of the glans. The pubic flap was prepared from the skin or scar tissue on the pubic area. The neourethra was reconstructed using penopubic flaps. A fistula occurred in one patient, which healed spontaneously. The penopubic flaps enabled us to form a wide-enough urethral tube and to perform a better dissection on the pubic area.

Pubertal development of Turkish boys in Elazig, eastern Turkey.

Data on pubertal development in 462 healthy, well-developed schoolboys from the cross-sectional study in Elazig, Eastern Turkey, are reported. Genital and pubic hair development are classified according to Marshall and Tanner, and Winter criteria. The initiation of genital development (the onset of puberty) was 11.6 +/- 0.15 (mean +/- SEM) years and that of pubic hair development was 12.2 +/- 0.16 years. The completion of genital and pubic hair development occurred at the same age, namely at 15.7 +/- 0.11 years. On average the genitalia and pubic hair reached the adult stage 4.2 and 3.6 years after they began to develop, respectively. As a general comment Eastern Turkish boys' pubertal data are in good agreement with English, North American and South African data.

Low levels of selenium in mothers and their newborns in pregnancies with a neural tube defect.

OBJECTIVE: Very few data are presented in the literature about selenium (Se) in human fetal development. The aim of this paper was to study the relationship between maternal and neonatal Se status and neural tube defects (NTDs). PATIENTS AND METHODS: Serum and hair samples were obtained from 20 nonpregnant women, 32 healthy mothers with normal newborns, and 28 mothers who had a newborn with NTD, and their newborns at delivery. Serum Se levels, as ng/mL, and hair Se levels, as microgram/g, were determined on a Perkin-Elmer 1000 spectrophotometer (United Kingdom) by fluorometry. RESULTS: The mean maternal serum and hair Se concentrations in the NTD group (42.9 +/- 1.75 ng/mL, 277 +/- 7.73 ng/g, respectively) were significantly lower than those of the control healthy mothers (50.2 +/- 2.35 ng/mL, 300 +/- 6.10 ng/g, respectively) and the nonpregnant women (58.1 +/- 3.12 ng/mL, 315 +/- 7.64 ng/g, respectively). A significant decrease in concentrations of Se in serum and hair was observed in newborns with a NTD (26.0 +/- 1.55 ng/mL, 181 +/- 3.71 ng/g, respectively) compared with healthy newborns (32.6 +/- 1.70 ng/mL, 204 +/- 4.43 ng/g, respectively). CONCLUSIONS: Maternal Se deficiency during pregnancy was thought to be one of the factors responsible for NTDs. However, the lowered serum and hair Se concentrations may be secondary manifestations of an abnormal pregnancy and did not contribute to its production. More studies on maternal Se status during the antenatal period, especially early gestation and neonatal Se status including normal newborns and NTD infants, are needed.

Prune-belly syndrome associated with omphalocele in a female newborn.

The authors report on a female newborn with prune-belly syndrome (PBS) in association with omphalocele. This case raises the total of omphalocele associated with PBS to seven. The authors suggest that this case lends support to the concept of PBS being caused by an early disturbance of mesodermal development in both the abdominal wall and the urinary tract.

Hydronephrotic type of bilateral multicystic dysplastic kidney. An unusual case.

25 year-old pregnant woman was admitted at week 29 of fetal development for routine ultrasonic evaluation of growth. Sonography of the fetal body revealed two cystic anechoic septated structures bilaterally. At autopsy of the stillborn neonate pathology confirmed congenital multicystic dysplastic kidney. We believe this is the first case reported.

Maternal carriage and neonatal colonisation of group B streptococci in labour are uncommon in Turkey.

Group B streptococcus infection is an important cause of neonatal morbidity and mortality. We studied 114 women and their newborns to determine the relationship between maternal carriage and neonatal group B streptococcal colonisation. Rectal, cervical and vaginal swabs were taken at delivery. Within a few minutes of birth, swab specimens were also taken from throat, ear, umbilicus, conjunctiva and skin of the newborns. Group B streptococcus was isolated in 10 (8.7%) of the 114 pregnant women studied and in five (4.3%) of the 114 newborns. Vertical transmission rate was found to be 50%. Neonatal group B streptococcus colonisation has not reached a high level in Turkey, and consequently does not warrant intrapartum screening at the moment.

Changing trend of neural tube defects in eastern Turkey.

STUDY OBJECTIVE: The aim was to study the relationship between birth prevalence of neural tube defect (including anencephaly) in Eastern Turkey before and after the Chernobyl disaster. DESIGN: This was a prospective study of time trends in live births and stillbirths over the years 1985-1990. Medical and sociodemographic data were recorded for the mothers. SETTING: Elazig, Eastern Turkey. SUBJECTS: There were 5240 live births and stillbirths during the study period, 24 of whom had neural tube defect and of these 20 had anencephaly. MAIN RESULTS: Of the 5240 newborns, 24 had a neural tube defect, giving a birth prevalence of 4.5 per 1000 total births. Of these, 20 were anencephalic (3.8 per 1000). In all, of the 2355 conceptions estimated to have occurred prior to the Chernobyl disaster in May 1986, the birth prevalences of total neural tube defect and anencephaly were the same (1.7 per 1000). This contrasts with the years following after Chernobyl, when the birth prevalence of total neural tube defect was 6.9 per 1000 (5.5 per 1000 for anencephaly). The differences were statistically significant (p < 0.001). These two increased rates reached a peak of 12.4 (for total neural tube defects) and 8.9 (for anencephaly) in 1988. In 1989 the rate of total neural tube defects decreased to 10.0 and that of anencephaly to 8.6 per 1000. In 1990 the rate of total neural tube defects fell to 5.6 and that of anencephaly fell to 4.2. CONCLUSIONS: The changes in birth prevalence of neural tube defects might be due to the Chernobyl disaster. However, the increases observed occurred mainly in infants conceived well over a year after the Chernobyl disaster, suggesting that other factors may be responsible.

Comparison of children and adults with tuberculous meningitis in Elazig, Turkey.

Retrospective evaluation of 16 cases of tuberculous meningitis revealed that BCG vaccination and tuberculin positivity were rare in pediatric as well as adult patients. Children with disease had developmental retardation and a high rate of maternal illiteracy as compared to normal controls.

Neonatal omphalitis is still common in eastern Turkey.

88 newborns with omphalitis diagnosed at a University Hospital in Eastern Turkey from January 1988 to December 1990 were reviewed. The yearly incidence was 7.7% in inpatient newborns. Risk factors including septic delivery (especially home delivery), prematurity, and being small for gestational age appeared to be important. Clinical manifestations, white blood cell and absolute neutrophil counts were non-specific and non-pathognomonic. Bacteriologic analysis revealed that Gram-positive bacteria (68%) predominated over Gram-negative isolates (60%). Staphylococcus aureus and Escherichia coli were the most frequent microorganisms. Mortality rate was 15%; all deaths occurred in patients presenting with systemic symptoms. The following poor prognostic factors were identified: septic delivery (particularly at home), prematurity, being small for gestational age and the development of systemic symptoms.

Serum gonadotropins and estradiol levels in Turkish pubertal girls.

Serum follicle stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2) levels were measured by radioimmunoassay in the sera of 37 healthy Turkish pubertal girls. The data show that FSH levels significantly increased from stage 2 to 3, and tented to plateau during stages 3,4 and 5, and LH and estradiol levels constantly rises with advances in sexual development and significantly correlates with pubertal stages. When the serum FSH level was compared in pre and postmenarcheal girls of the same age the level was almost identical. Adversely, LH and estradiol levels were higher in postmenarcheal girls than in premenarcheal girls.

Subclinical amnionitis in patients with intact membranes in preterm labour.

Preterm delivery is the major obstetric and paediatric problem, being responsible for much perinatal morbidity and mortality. Subclinical amnionitis may cause preterm labour and delivery. The rate of subclinical bacterial infection of amniotic fluid was studied in 25 afebrile pregnant women with intact membranes in preterm labour. Specimens of amniotic fluid were collected by transabdominal amniocentesis. Serum and amniotic fluid lactic dehydrogenase (LDH) levels were assessed to determine their usefulness in making the diagnosis of subclinical amnionitis. Aerobic bacteria were isolated from 48% (12/25) of the specimens. Thus, subclinical amnionitis may play a substantial role in patients with intact membranes in preterm labour. However, transabdominal amniocentesis is not routinely indicated in similar asymptomatic patients because microbiological and especially LDH studies require further evaluation.