Transhiatal isoperistaltic colon interposition without cervical oesophagostomy in long-gap oesophageal atresia.

BACKGROUND: Oesophageal colonic interposition in oesophageal atresia (OA) patients is almost exclusively done as a staged operation with an initial oesophagostomy and gastrostomy followed by the definitive surgery months later. This study presents a series of patients in whom a cervical oesophagostomy was not performed before the substitution surgery. PATIENTS AND METHODS: Records of EA patients were evaluated for those who underwent colon interposition without cervical oesophagostomy. RESULTS: There were five patients: three with pure EA and two with proximal tracheo-oesophageal fistula. A delayed primary repair could not be performed because of intra-abdominally located distal pouch. The mean age at the time of definitive operation was 5.54 (±2.7) months and the mean weight was 6.24 (±1.3) kg. A right or a left colonic segment was used for interposition keeping the proximal anastomosis within the thorax. The post-operative results were quite satisfactory within a median follow-up period of 33.2 months. CONCLUSION: Avoiding cervical oesophagostomy and its inherent complications and drawbacks is possible in a subset of patients with long-gap EA who underwent colonic substitution surgery. This approach may be seen as an extension of the consensus that the native oesophagus should be preserved whenever possible, because it uses the native oesophagus in its entirety.

Assessment of ovarian reserve using serum anti-Müllerian hormone after ovarian torsion surgery.

BACKGROUND: The aim of this study was to determine ovarian reserve using serum anti-Müllerian hormone (AMH) level in children who had undergone either ovarian-preserving surgery or oophorectomy because of ovarian torsion. METHODS: Patients aged > 10 years who had undergone surgery for unilateral ovarian torsion were contacted for the study with ethics committee approval. Seventeen patients agreed to be included. RESULTS: A total of 10 patients had undergone ovarian detorsion and seven had undergone oophorectomy. Mean age at operation was 11.6 ± 2.23 years (range, 8-15 years) and 13.2 ± 2.17 years (range, 10-16 years), respectively (P = 0.46). Ovarian torsion was isolated in four patients in the first group, and in three in the second. The remainder had associated benign masses. At the time of this study, mean patient age was 18 ± 2.11 years (range, 14-21 years) with a mean postoperative follow up of 5.9 ± 2.8 years (range, 2-10.5 years). Echogenicity of all preserved ovaries was normal on pelvic Doppler ultrasonography, with presence of antral follicles in six. Three ovaries were smaller than expected for age, although two of these had antral follicles. Mean AMH was 5.54 ± 2.25 ng/mL in the detorsion group and 2.70 ± 2.11 ng/mL in the oophorectomy group (P = 0.04). CONCLUSIONS: The presence of follicles in preserved ovaries after detorsion has been reported previously. AMH is expressed in granulosa cells of growing follicles and its serum level is valuable in assessing the quantitative aspects of ovarian reserve. Preservation of the ovary in children with torsion is justified in terms of future ovarian reserve.

A Very Unlikely Finding in a Male Child: Urethral Prolapse.

Urethral prolapse is a disease of prepubertal black girls and postmenopausal women with an unknown cause. It may be congenital in origin or an acquired condition. It has never been reported in males. We report a 10-year-old Caucasian boy who presented because of recurrent right undescended testis. He had been operated on for bilateral undescended testes 7 years ago in another hospital, and circumcision was done during the same operation. The boy complained of a weak urinary stream during voiding. The physical examination was consistent with recurrent right undescended testis. Penile examination showed a circumferential urethral prolapse around the meatus. The urethral meatal appearance was apparent right after the circumcision. An orchiopexy operation as well as circumferential excision of the perimeatal urethral tissue with primary repair was done. The pathological examination of the specimen revealed keratinized stratified squamous epithelium consistent with urethral mucosa. The postoperative course was uneventful, and the patient urinates normally at the 8 postoperative month with a normal uroflowmetry study. This is the first report of urethral prolapse in a male. Because circumcision is a widely employed practice in many cultures, it is unlikely to be a predisposing factor. It is a benign condition that can be cured with simple resection and anastomosis.

The Prevalence of Malnutrition and Effectiveness of STRONGkids Tool in the Identification of Malnutrition Risks among Pediatric Surgical Patients.

BACKGROUND: High prevalence of malnutrition along with the risk for the development of malnutrition in hospitalised children has been reported. However, this problem remains largely unrecognised by healthcare workers. AIMS: To determine the prevalence of malnutrition and effectiveness of STRONGkids nutritional risk screening (NRS) tool in the identification of malnutrition risk among pediatric surgical patients. STUDY DESIGN: Cross-sectional study. METHODS: A total of 494 pediatric surgical patients (median age 59 months, 75.8% males) were included in this prospective study conducted over 3 months. SD-scores <-2 for Body Mass Index (BMI) for age or weight-for-height (WFH) and height-for-age (HFA) were considered to indicate acute and chronic malnutrition, respectively. The STRONGkids NRS tool was used to determine risk for malnutrition. RESULTS: Malnutrition was detected in 13.4% in this group of pediatric surgical patients. Acute malnutrition was identified in 10.1% of patients and more commonly in patients aged ≤60 months than aged >60 months (13.4 vs. 6.6%, p=0.012). Chronic malnutrition was identified in 23 (4.6%) of patients with no significant difference between age groups. There were 7 (1.4%) children with coexistent acute and chronic malnutrition. The STRONGkids tool revealed that 35.7% of patients were either in the moderate or high risk group for malnutrition. Malnutrition, as revealed by anthropometric measurements, was more likely in the presence of gastrointestinal (26.9%, p=0.004) and inguinoscrotal/penile surgery (4.0%, p=0.031), co-morbidities affecting nutritional status (p<0.001) and inpatient admissions (p=0.014). Among patients categorized as low risk for malnutrition, there were more outpatients than inpatients (89.3 vs. 10.7%, p<0.001) and more elective surgery cases than emergency surgery cases (93.4 vs. 6.6%, p<0.001). CONCLUSION: Providing data on the prevalence of malnutrition and risk of malnutrition in a prospectively recruited group of hospitalised pediatric surgical patients, the data acquired in the present study emphasise the need to raise clinician's awareness about the importance of nutritional status assessment among hospitalised pediatric patients and the benefits of identifying patients at the risk of nutritional depletion before malnutrition occurs. Our findings support the use of the STRONGkids tool among pediatric surgical patients to identify patients at risk for malnutrition and to increase the physician's awareness of nutritional assessment among hospitalised patients upon admission.

Congenital diaphragmatic hernia: a 4-year experience in a single centre.

BACKGROUND: This study aimed to evaluate congenital diaphragmatic hernia (CDH) patients in our department during a 4-year period. PATIENTS AND METHODS: A retrospective study of 10 cases of CDH patients managed in the Neonatology and Pediatric Surgery Units of Goztepe Teaching Hospital from 2000 to 2004. RESULTS: The mean birth weight of the patients was 2,600 g and the mean gestational age was 37.6 weeks. The mean admission time for the patients was 10.4 h. The mortality rate was 50%, comprising two deaths before operation and one during operation. The surviving infants followed for 1 year are free of any symptoms and complications. CONCLUSION: Conventional ventilation is an other treatment modality, especially in order to gain time before surgical operation for newborns with CDH.

An audit on pediatric hydatid disease of uncommon localization: incidence, diagnosis, surgical approach, and outcome.

BACKGROUND/PURPOSE: Infestation of sites other than the liver and lungs by the parasite Echinococcusgranulosus is rarely encountered in clinical practice. The present study aims to determine the incidence of hydatid disease of uncommon localization in children and to document the clinical and radiologic findings, the types of the operations performed, and the postoperative course of the disease. METHODS: A retrospective review of the demographical data as well as preoperative and postoperative clinical findings of children who underwent surgical treatment of hydatid disease was done. RESULTS: Hydatid disease of uncommon localization was encountered in 15 (7%) of 207 children reviewed. The sites in which the cysts were located were as follows: spleen (n = 4, 1.9%), kidney (n = 4, 1.9%), retroperitoneum (n = 3, 1.4%), omentum (n = 2, 1%), anterior abdominal wall (n = 1, 0.5%), and anterior thigh (n = 1, 0.5%). Radiodiagnostic tools such as ultrasonography were used in all. Partial pericystectomy was the surgical procedure of choice in most cases. There was 1 recurrence in a patient with splenic disease, with no mortality. CONCLUSIONS: Pediatric hydatid disease can involve any body part. Radiologic imaging techniques are helpful in diagnosis. Surgery should aim to preserve as much tissue as possible while precautions to prevent recurrences are undertaken.

The effects of orchiopexy on serum anti-Müllerian hormone levels in unilateral cryptorchid infants.

BACKGROUND/PURPOSE: In males, serum anti-Müllerian hormone (AMH) reflects Sertoli cell function and provides an estimate of seminiferous tubular integrity. It has been suggested that comparison of AMH levels before and after surgery could be useful to determine effectiveness of the treatment. In this study, we determined the serum AMH levels in infants with unilateral cryptorchidism before and after orchiopexy procedure and compared these data with the AMH values in age-matched controls. METHODS: The study population was 20 cryptorchid children with unilateral palpable testes who underwent orchiopexy as a cryptorchid group, and 20 healthy children who underwent circumcision as a control group. All children are 12 months of age. Serum AMH levels were measured at just before surgery (at 12 month old) and 6 months after surgery (at 18 month old). RESULTS AND CONCLUSIONS: All undescended testes were found to be normal in size and in the superficial inguinal pouch or subcutaneous region of the groin at surgery. With regard to the preoperative serum AMH levels, there was a significant difference between the cryptorchid and the control groups (40.04 +/- 4.97 ng/ml versus 53.46 +/- 7.51 ng/ml) (P < 0.05). Similarly, the postoperative serum AMH levels were lower in cryptorchid children than in controls (39.27 +/- 4.58 ng/ml versus 52.79 +/- 6.27 ng/ml) (P < 0.05). In cryptorchid children, serum AMH levels measured at 6 months after orchiopexy were similar with preoperative basal levels (40.04 +/- 4.97 ng/ml versus 39.27 +/- 4.58 ng/ml) (P > 0.05). AMH levels in children with unilateral palpable undescended testes remain unchanged 6 months after orchiopexy performed at 1 year of age. This is the first report in literature regarding the effect of orchiopexy on the serum AMH levels.

An evaluation of individual plain abdominal radiography findings in pediatric appendicitis: results from a series of 424 children.

BACKGROUND: This study was conducted to collect the results of the plain abdominal radiography (PAR) signs, to determine their individual diagnostic values, and to discuss them under a brief literature review. METHODS: Eight predetermined PAR signs were individually interpreted in a series of 424 consecutive children (278 males; 146 females; median age 10 years; range 11 months to 17 years) who underwent an operation for appendicitis. The sensitivity, specificity, and positive and negative predictive values for the signs were determined. RESULTS: Appendicitis was confirmed in 378 (89%) patients. Among the remaining 46 (11%) patients with a normal appendix, 20 (5%) had other intraabdominal pathologies. Calcified fecalith, mass image in right-lower-quadrant (RLQ), psoas obscuration, and localized extraluminal air signs were all highly specific and therefore, unlikely to be present if the appendix is normal. On the other hand, the sensitivity values were low, in general, for all the PAR signs investigated. Yet, presence of dilated transverse colon and/or single air fluid level in the RLQ has the highest percentage occurrence with appendicitis. CONCLUSION: Although the there is no single PAR finding capable of ruling the diagnosis of appendicitis out, basic knowledge on PAR findings could have an impact on decision making process for clinicians dealing with pediatric acute abdominal pain.

Teratoma arising from anomalous common bile ducts: a case report.

Teratoma arising from extrahepatic common ducts is very rare entity. The authors found 2 teratoma cases originating from common bile duct in the literature. As a third case, the authors report on a 4-month-old girl with benign cystic teratoma arising from distal common hepatic bile duct and with anomalous common bile ducts. Surgical management of the patient also is discussed.

Regional anesthesia is a good alternative to general anesthesia in pediatric surgery: Experience in 1,554 children.

BACKGROUND/PURPOSE: Although caudal and spinal blocks are modern and safe techniques, in many centers children still are operated on under general anesthesia (GA), or the blocks are used for postoperative analgesia after GA in infraumbilical operations. The authors aimed to document the results and the complications of 1,554 regional anesthesia cases, thereby assessing their validity. METHODS: The analysis of 1,459 caudal and 95 spinal blocks cases collected until January 2001 in children from newborn to 12 years of age are documented retrospectively. The types of anesthesia analyzed in the study were caudal block (CB) only, CB plus GA, GA plus CB, GA plus spinal block, and spinal block only. RESULTS: There were 1,338 caudal and 95 spinal block cases that clinically were satisfactory. Because the duration of CB was not sufficient in 39 cases, GA was used. Failure to produce a CB occurred in 82 cases (5.57%). There were 257 of 1,338 patients operated on under GA and supported by caudal block for postoperative analgesia. CONCLUSIONS: Caudal anesthesia seems to be an inexpensive, simple, and effective technique not only as a supplement for postoperative analgesia, but also as a single method of anesthesia. and the authors recommend its use in a wider setting of clinical entities in infraumbilical surgical procedures of children.