Common pediatric surgical diseases of refugee children: health around warzone.

PURPOSE: We aim to evaluate the sociodemographic and medical features of child-aged refugee patients and identify their health-related problems. METHODS: Refugee children admitted to pediatric surgery department of a teaching hospital during the years 2012-2017 were included. Patients' files were reviewed retrospectively for sociodemographic and medical features. RESULTS: A total of 254 patients with the mean age of 4.6 ± 4.15 years (0-16 years) were treated. Male-to-female ratio was 1.7. Most common diagnosis were inguino-scrotal pathologies (n = 50, 19.7%) followed by foreign body ingestion (n = 37, 14.6%) and corrosive esophagitis (n = 22, 8.7%). The cause of admission was a potentially preventable trauma in 24.4% of cases. Comorbid medical conditions were present in 49 patients (19.3%). Anemia was detected in 23.2% of cases. Weight according to age and gender were < 3 percentile in 29.1% of patients. Difficulties in communication, lack of former medical history and advanced presentation of disease were the challenges faced by caregivers. CONCLUSION: The primary diagnoses for admission of refugee children were different from the routine practice and a significant part were from preventable causes. Comorbidities were common potentially having a negative influence on treatment processes. This can be a result of unfavorable living conditions and lack of medical care during migration.

Clinical Presentation, Prognostic Factors, and Outcome in Neutropenic Enteropathy of Childhood Leukemia.

Leukemia patients are at risk for neutropenic enteropathy (NEP) because of the effects of intensified chemotherapy. Medical records of 18 patients having 20 episodes of NEP were reviewed retrospectively. Primary diagnosis was acute lymphoblastic leukemia in 12 and myeloblastic leukemia in 6 cases. According to prognosis, 3 patients were in the standard-risk group, 6 in the moderate-risk group, and 9 in the high-risk group. Ultrasonography detected increased bowel wall thickness in 6 patients. Abdominal x-ray revealed air-fluid levels (n=8), pneumatosis intestinalis, pneumoperitoneum (n=1), and portal venous gas (n=1). All patients received medical treatment, and 1 with unrelieved hematochezia required resection of the cecum. Two cases with appendicitis and another 1 with pneumoperitoneum responded to antibiotics and recovered without surgery. The mortality rate was 30% and related to sepsis-induced complications. The presence of hypokalemia, hypoalbuminemia, metabolic acidosis, and admission to the intensive care unit were more common in patients with mortality (P=0.01). In conclusion, NEP should be kept in mind as a treatable but potentially lethal complication of childhood leukemia. Radiologic findings should be interpreted in conjunction with clinical picture. A conservative approach should be used in all cases but surgery can be considered in some situations.

Posterior sagittal anorectoplasty in vestibular fistula: with or without colostomy.

PURPOSE: The aim of this study is to compare the results and complications of one- and three-stage repairs in females with vestibular fistula (VF) and make contribution to the discussion of whether the disadvantages outweigh the protective effect of a colostomy from wound infection and wound dehiscence following posterior sagittal anorectoplasty (PSARP). METHODS: Patients with a diagnosis of VF who underwent PSARP between October 2009 and November 2015 were retrospectively reviewed. The patients were divided into two groups: Group 1-patients treated by one-stage procedure (n = 30); Group 2-patients treated by three-stage procedure (n = 16). RESULTS: There were no statistically significant differences between the groups with respect to wound infection, recurrence of fistula and rectal mucosal prolapse. Minor wound dehiscence occurred slightly more common in Group 1, even if p value is not significant. No wound dehiscence has been observed since we switched to the protocol of keeping the child nil per oral for 5 postoperative days and loperamide (0.1 mg/kg) administration for 7 postoperative days. The mean time before resuming oral intake was 2.87 ± 1.7 and 1.19 ± 0.4 days in Group 1 and Group 2, respectively (p = 0.001). None developed major wound disruption or anal stenosis in either group. There were no statistical differences between the groups in terms of voluntary bowel movements, soiling and constipation. CONCLUSIONS: PSARP performed without a protective colostomy in patients with VF has low morbidity, good continence rates and obvious advantages for both the patients and their parents.

Delayed diagnosis: An important prognostic factor for oesophageal atresia in developing countries.

AIM: The aim of this study is to analyse the effect of delayed diagnosis on mortality rates, and evaluate the role of delayed diagnosis as a new prognostic factor in patients with oesophageal atresia (OA), especially in developing countries. METHODS: The records of 80 consecutive patients with OA (2008-2013) were reviewed. Patients were divided into two groups according to the time of diagnosis. As we demonstrated the effect of delayed diagnosis on mortality, we decided to develop a new classification that will be utilised to predict the prognosis of OA. The discrimination ability of the new prognostic classification was compared with those of the Waterston, Montreal and Spitz classifications using the area under the curve. RESULTS: The parameters of the new prognostic classification were birth weight less than 2000 g, the presence of major cardiac/life-threatening anomalies and delay in diagnosis. Class I consisted of patients with none or one of these parameters. Class II consisted of patients with two or three of these parameters. The area under the curve of the new classification was better than those of the other classifications in determining the prognosis of patients with OA. CONCLUSIONS: Delayed diagnosis of OA significantly led to morbidity and mortality. Although delayed diagnosis is not a characteristic of newborn or a marker of severity for OA and is a health care system issue in developing countries, we here point out that it is a prognostic factor in its own right. Our new classification has a superior discriminatory ability compared to the above-mentioned classifications.

Congenital anterior urethrocutaneous fistula: 3 new cases and review of literature.

OBJECTIVE: Congenital anterior urethrocutaneous fistula, is a rare anomaly characterised by fistulisation of penile urethra to skin and presence of a concomitant normal or hypospadiac external urethral meatus. It may be seen as an isolated anomaly or may accompany genitourinary or anorectal malformations. We aim to present 3 new cases and define the common properties of patients stated in literature. METHOD: Information of 3 patients aged 2, 3 and 6 with this diagnosis were reviewed retrospectively and features of 51 patients in 25 articles with literature search. RESULTS: From the patients we operated, 2 had midpenile and 1 had subcoronal fistula. Urethral meatus was at tip of glans in all with 1 stenotic meatus. Two-layered primary repair was performed in 3 patients and deep ventral incision on urethral plate with meatotomy were added to fistula repair in one with stenotic meatus. Fistula recurred in this patient but resolved spontaneously after dilatations. In literature, most common fistula site was subcoronal in 27 (52.9%). Hypospadias was in 11.8% and associated genitourinary anomaly was detected in 21.5% of patients. Fistula recurrence ratio was 7.8% using different surgical techniques. CONCLUSION: Congenital anterior urethrocutaneous fistula is frequently located in subcoronal level and usually a normal urethra distal to it. Physical examination is important to detect additional anomalies. Success rates are high with primary repair techniques.

The comparison of dextranomer/hyaluronic acid and polyacrylate-polyalcohol copolymers in endoscopic treatment of vesicoureteral reflux.

BACKGROUND: Dextranomer/hyaluronic acid (Dx/Ha;Dexell®) and polyacrylate-polyalcohol copolymer (PPC;Vantris®) are the popular tissue-augmenting substances using for the endoscopic injections of vesicoureteral reflux (VUR). The aim of the study is to evaluate and compare Dx/Ha and PPC in terms of effectiveness, injection techniques and complications with special emphasis on vesicoureteral junction obstruction (VUJO). METHODS: A total of 95 patients who underwent endoscopic VUR treatment between 2009 and 2015 were retrospectively reviewed. The patients were divided into two groups: group 1: Patients underwent endoscopic treatment with PPC (n=50 patients, 70 renal refluxing units) group 2: Patients underwent endoscopic treatment with Dx/Ha (n=45 patients, 74 renal refluxing units). RESULTS: The overall resolution rates based on the number of renal refluxing units studied was 88.6% and 70.3% in group 1 and group 2, respectively. Resolution rates were significantly better in group 1 compared to group 2. VUJO requiring ureteral reimplantation or stent insertion developed in 7 patients in group 1. No VUJO was observed in group 2. VUJO in group 1 was markedly higher than that in group 2. CONCLUSIONS: Endoscopic treatment of VUR with PPC promises better resolution rates but higher VUJO rates compared to Dx/Ha.

Effects of Leptin on Intestinal Ischemia-Reperfusion Injury.

Many clinical conditions such as shock, sepsis, mesenteric thrombosis, necrotizing enterocolitis, and bowel transplantation can cause intestinal ischemia-reperfusion (IR) injury. This study was designed to determine the effects of leptin on intestinal IR injury. Thirty rats were divided into three groups, each containing ten rats: group A (IR group), group B (treatment group), and group C (sham group). After 1 h of intestinal ischemia, the clamp was removed in order to perform reperfusion. In group B, 100 mg/kg leptin was administered subcutaneously 30 min before reperfusion. In groups A and C, 0.1 ml physiologic saline was injected. In group A, serum and tissue nitric oxide (NO) levels were significantly decreased, and malondialdehyde levels were significantly increased compared to sham group (p < 0.05). Histopathologic injury was significantly lower in sham group compared to group A. In group B, serum and tissue malondialdehyde levels were significantly decreased (p < 0.05), but serum and tissue NO levels were significantly increased compared to group A (p < 0.05). Histopathologic injury was significantly lower in group B compared to group A (p < 0.05). The results of the present study demonstrated that leptin decreases intestinal IR injury by increasing NO production, rearranging mucosal blood flow, and inhibiting polymorphonuclear leukocyte infiltration.

The passage of meconium alone is not a sign of correctly positioned anus.

OBJECTIVE: The aim of this study is to determine the consequences of delayed presentation of anorectal malformations and emphasize the causes of delayed diagnosis of these malformations. METHODS: We retrospectively reviewed 54 neonatal patients with a diagnosis of anorectal malformations. Group 1 consisted of 35 patients diagnosed within the first 48 h of life and Group 2 included 19 patients diagnosed after 48 h of life. RESULTS: Obstructive symptoms at the time of diagnosis, overall complications and the mean postoperative hospitalization period in Group 2 were markedly higher than that of Group 1. A comprehensive neonatal examination within the first 48 h of life was performed in 32 (91.4%) patients in Group 1 and 5 (26.3%) of the patients in Group 2 (p < 0.001). CONCLUSIONS: The passage of meconium is not the only sign of correctly positioned anus. A careful physical examination and awareness of this anomaly are of great importance in making a timely diagnosis of anorectal malformations.

A bladder stone within a congenital paraureteral diverticulum: a case report.

Paraureteral diverticula are rare in pediatric population. We here present a bladder stone in the congenital paraureteral diverticulum presenting with vesicoureteral reflux. To the best of our knowledge, stone formation in paraureteral diverticulum has not been reported previously. A 5-year-old boy was admitted with the complaint of dysuria. Abdominal ultrasonography revealed a bladder stone in a diverticulum arising from right posterolateral wall and a small right kidney. Voiding cystourethrogram confirmed large bladder diverticulum with vesicoureteral reflux. Cystoscopy revealed a giant stone in the paraureteral diverticulum. The stone was removed with open diverticulectomy and right Cohen ureteroneocystostomy was performed.

Diseases mimicking intussusception: diagnostic dilemma.

BACKGROUND: Intussusception is a common abdominal emergency in early childhood. The aim of this study was to describe the diseases mimicking intussusception and to discuss the causes and management of these conditions. METHODS: Seven patients who were initially diagnosed as having intussusception on abdominal ultrasonography but who had a final diagnosis of diseases other than intussusception were reviewed retrospectively. RESULTS: Two patients with ileocolic intussusception underwent ultrasonography-guided reduction with a hydrostatic method but the ultrasonographic findings persisted. At surgery, only edematous ileocecal valve and mesenteric lymphadenopathy were observed. In three patients with Henoch-Schönlein purpura, initial abdominal ultrasonography showed intussusception. The patients with no sign of obstructive symptoms were managed conservatively with a diagnosis of intramural hemorrhage and on follow up the ultrasonographic findings of intussusception was resolved. One patient with the target sign on computed tomography and ultrasonography of the abdomen underwent ileocolic resection and end-to-end anastomosis due to a tumor in the cecum. There was no evidence of intussusception. One patient with a cyst in the right lower quadrant accompanying intussusception on ultrasonography of the abdomen underwent ultrasonography-guided reduction but the ultrasonographic findings persisted. On exploration, only cecal duplication cyst without intussusception was detected. Cecal resection including the cyst and end-to-end ileocolic anastomosis were performed. CONCLUSIONS: Ultrasonography, color Doppler ultrasonography, barium or hydrostatic enema and computed tomography are helpful in diagnosing intussusception, but patients with radiologic findings of intussusception should be evaluated on symptoms and clinical findings before surgical intervention. Also, other diseases mimicking intussusception should be kept in mind in the differential diagnosis.

Perforation of Meckel's diverticulum by a button battery: report of two cases.

Ingested button battery perforation of Meckel's diverticulum is extremely rare, with only two reported cases in the recent literature. Two additional preschool children who accidentally swallowed an alkaline button battery and developed a perforated Meckel's diverticulum are reported. Surgeons should be aware of this rare complication. Careful clinical, radiologic and laboratory monitoring of children who ingest a button battery is advisable.

Gastric perforation after corrosive ingestion.

PURPOSE: To describe a series of children with gastric perforation (GP) after corrosive ingestion. METHODS: Case notes of children treated for GP complicating corrosive ingestion between May 2001 and April 2010 were retrospectively reviewed. RESULTS: Seventy-six children with corrosive ingestion were treated during the study period of which 5 (6.6%) developed GP. This complication was evident on admission in one case and developed within 48 h in the others. The major clinical findings were abdominal pain, tenderness, and distension with radiologic evidence of pneumoperitoneum. Associated pathology included necrosis of the abdominal esophagus in one case and duodenal perforation in another. Two cases have died during surgery while three survived with free of complications related to GP repair. Two patients developed gastric outlet obstruction (one with an esophageal stricture) on follow-up. CONCLUSIONS: GP is a rare but major complication of corrosive ingestion. Children who swallow corrosives should be closely monitored and pediatric surgeons should be aware of this potential early complication. The possibility of associated pathology should be considered when undertaking surgical repair.

Relationship between release of beta-endorphin, cortisol, and trauma severity in children with blunt torso and extremity trauma.

PURPOSE: To determine the levels of beta-endorphin and cortisol in children with multiple injuries and to determine whether there is any difference between and compare the severity of trauma and beta-endorphin and cortisol release as calculated using Pediatric Trauma Score (PTS). METHODS: During a 10-month period, 80 children with multiple injuries admitted to a University Hospital's Pediatric Surgery Department were studied. Blood samples were obtained immediately at admission and a PTS of each patient was calculated. The correlation between PTS and hormonal values were searched. The children were classified into two groups according to their PTS. Group 1 had PTS >8 and group 2 had PTS < or =8. The two groups were also compared with respect to their beta-endorphin and cortisol values. RESULTS: There was a linear correlation between beta-endorphin and cortisol values and the injury severity. The levels were higher in the patients with more severe injuries. There were 60 patients in group 1 and 20 patients in group 2. Their ages were 9.2 +/- 4.1 and 9.7 +/- 4.2 years, respectively (p > 0.05). The mean PTS for group 1 patients was 11 +/- 0.8 and for group 2 patients was 7.4 +/- 1.2 (p < 0.001). The mean plasma beta-endorphin concentrations were 124.4 +/- 114.4 pg/mL in group 1 patients and 261.6 +/- 231.2 pg/mL in group 2 (p < 0.001). The respective plasma cortisol concentrations in the two groups were 22.5 +/- 10.3 microg/dL and 30.8 +/- 17.2 microg/dL (p < 0.05), respectively. CONCLUSIONS: The results of this study show that the plasma beta-endorphin and cortisol levels are elevated in children after blunt trauma and the degree of elevation is related to the injury severity.

Effects of maternal nicotine exposure during lactation on breast-fed rat pups.

BACKGROUND: Nicotine is known to be associated with adverse effects in infants and children. It is concentrated in breast milk and is absorbed by the infant. The aim of this study was to investigate the effects on breast-fed rat pups of maternal nicotine exposure during lactation. METHODS: In the experimental group (n = 6), nicotine was given to lactating dams (2 mg/kg/day) after delivery and continued for 10 days during lactation. Control animals (n = 4) received saline for the same duration. The suckling rats were weighed and killed on postnatal day 10, and samples were taken from the lung, liver, kidney, spleen and small intestine for histopathological examination. Superoxide dismutase (SOD), catalase (CAT) activities and malondialdehyde (MDA) levels were measured in the liver of the dam and the offspring. RESULTS: Histopathological changes in the liver of the nicotine-exposed group showed portal inflammatory infiltrate, ballooning degeneration of hepatocytes, and focal necrosis in the parenchyma. Thickening of alveolar walls because of interstitial inflammation was noted in the lungs. Histopathological examination of kidney, spleen and small intestine tissue did not reveal any abnormality. In the experimental group, SOD and CAT activities were significantly decreased (p <0.001) but MDA levels were significantly increased (p <0.001) compared with the control group. CONCLUSION: These results indicate that maternal nicotine exposure induces oxidative stress and causes detrimental histopathological changes in the lung and liver of lactating offspring.

Congenital scaphoid megalourethra: report of two cases.

Congenital megalourethra is a rare congenital malformation of the penile urethra. It is defined as the diffuse dilatation of the anterior urethra due to the absence of development of the erectile tissue of the penis. Since the initial description, nearly 80 cases with megalourethra have been reported in English literature. Congenital megalourethra has been classified into scaphoid and fusiform types and is usually associated with additional urinary tract and other system anomalies, irrespective of its type and severity. We report two rare cases of scaphoid megalourethra without any associated anomaly. A 13-year-old boy and an 8-month-old boy were admitted to the Department of Pediatric Surgery with complaints of penile swelling and dysuria since birth. Physical examination and retrograde cystourethrogram confirmed the diagnosis of congenital scaphoid megalourethra. Both patients underwent a reduction urethroplasty. They did well postoperatively and voided with a normal stream without any abnormality of the penile shaft.

Psychological evaluation of children with idiopathic constipation and their parents.

BACKGROUND: Constipation is one of the most common problems in childhood. In idiopathic constipation it is not possible to identify primary cause in every case. Child behavioral problems and disturbances in parent-child relationships have been cited as causes of constipation. Constipation is a source of anxiety to the child and to the family. The purpose of the present study was to evaluate psychological characteristics of constipated children and their parents. METHODS: Thirty-two otherwise healthy children with idiopathic constipation over 4 years old were prospectively evaluated between January 2002 and June 2003. The Child Behavior Checklist (CBCL) and Symptom Checklist-90 revised (SCL-90-R) were used to assess the psychological profiles of the children and the parents, respectively. Thirty children with inguinal hernia who had no constipation or other problems, and their parents were asked to complete the checklists as controls. The scores of the constipation group were compared statistically with those of the control group. RESULTS: In the constipation group there were 19 boys and 13 girls with a mean age of 7.3 years (4-14 years). All the patients responded to medical treatment. Constipated children and their parents were not found to have more behavior problems than the control group (P > 0.05). CONCLUSIONS: Children with idiopathic constipation and their parents do not show significant behavioral and emotional problems. Their psychological profiles are not different from the general population.

Ascended testis in three brothers with Pelizaeus Merzbacher syndrome.

Ascended testis is a rare clinical entity. The mechanism involved in testicular ascent is still not understood completely. Spasticity of cremaster muscle may cause secondary ascent of testis. The authors present 3 brothers with Pelizaeus Merzbacher syndrome, a rare, x-linked leukodystrophy in whom the testes bilaterally ascended from the normal scrotal position to an undescended position after onset of spasticity.