Bile duct injury complicated by bilioma after blunt liver trauma in a child.

Nonoperative management with close observation represents the standard of care for blunt liver injury, unless vital signs deteriorate or an associated injury requires emergency operation. Injuries of the biliary tract remain important concomitant lesions following liver trauma. Posttraumatic extraductal biliary collections or biliomas are rare complications of blunt abdominal traumas and only a few cases have been reported in the pediatric age group. We report a 5-year-old boy who suffered from blunt abdominal trauma that resulted in liver laceration and, eventually, bilioma formation. The patient was managed nonoperatively for liver injury. The diagnosis was confirmed by computed tomography (CT)-guided needle aspiration and percutaneous catheter drainage, which also allowed nonoperative management. The patient was symptom-free with normal liver function tests and a normal liver appearance on ultrasound examination six months after the accident. The possibility of missed bile duct injury should be considered when nonoperative management is used and close observation of the patient is necessary over a prolonged period.

Computed tomography evaluation of cavitary necrosis in complicated childhood pneumonia.

The purpose of the present study was to retrospectively investigate the chest radiograph (CR) and CT findings of childhood pneumonia complicated by cavitary necrosis, and to evaluate the role of CT in decision-making for surgical intervention. Chest CT was performed in 51 patients presenting with persistent or progressive pneumonia, respiratory distress and sepsis despite 7-10 days of appropriate antibiotic treatment and closed tube drainage. Chest radiograph and CT findings were retrospectively evaluated in 23 patients (45%) with cavitary necrosis. Chest radiographs showed consolidation in 19 of 23 patients, cavitation in five patients, parapneumonic effusions in 17 patients and air-fluid levels in the pleural space in one patient. The CT scans demonstrated consolidation and cavitary necrosis in all patients. There were parapneumonic effusions in all patients with concomitant loculated collections in six patients. Twenty-two of 23 patients had pleural thickening. In seven patients there were air-fluid levels in the pleural space. In five of these patients, CT scans demonstrated bronchopleural fistulae. On the basis of the CT and clinical findings, 11 patients underwent surgical intervention. Computed tomography is superior to CR for demonstrating cavitary necrosis complicating pneumonia, and other parenchymal and pleural complications. It also has a crucial decision-making role for surgery.

Injection sclerotherapy of rectal prolapse in children with 15 percent saline solution.

PURPOSE: A wide variety of sclerosing agents have been used in the treatment of rectal prolapse (RP) in children. We have used 15 % saline solution for the first time in the treatment. The aim of this study is to review the results of a 15 % saline solution and other sclerosing agents. PATIENTS AND METHODS: A total of 16 children with RP were treated by injection of 15 % saline solution. Under general anesthesia, the patient was placed in the lithotomy position. The left index finger was inserted into the rectum to control the position of the needle, a 20-gauge spinal needle was introduced through the perianal skin and was advanced. The saline was slowly injected, the needle was then withdrawn slightly, and the injection was continued until 2 - 3 ml of 15 % saline were injected. The injection was made into the submucosal tissue, the right perirectal area, the left perirectal area, and posterior to the rectum at 5 points. RESULTS: Conservative treatment had previously failed in all patients. Prolapse ceased in 15 (93.7 %) of the 16 children after the first injection. Only one patient required a second injection. There were no complications. CONCLUSIONS: The success rates and complications of the treatment reported in the literature differ for each sclerosing agent. 15 % saline is preferable because of the high cure rate, the safety of the procedure, the easy injection, and the lack of complications.

Oophoropexy in children with ovarian torsion.

AIM: Children who have suffered from ovarian torsion may be at increased risk for a repeat event, and after unilateral ovarian loss, the contralateral ovary is at risk for future torsion. Oophoropexy has not been emphasized enough in the literature. We present our experiences with oophoropexy in children. METHODS: The medical records of 10 patients with ovarian torsion, who underwent oophorectomy and contralateral oophoropexy between April 1992 and April 2003, were reviewed retrospectively. The ovary was connected to the peritoneum of the posterior abdominal wall avoiding a disturbance of the tubo-ovarian anatomic relationship. RESULTS: The ages of patients ranged from 5 days to 14 years, with a mean age of 7.7 years. The period from onset of symptoms to hospital admission was ranged from 2 hours to 11 months. Only 1 ovary was salvaged after detorsion and bilateral oophoropexy was performed. In the other patients, the torsion caused necrosis, and oophorectomy or salpingo-oophorectomy and contralateral oophoropexy were carried out. Ovarian torsion occurred in 4 previously normal ovaries, in 5 cystic ovaries, and in 1 ovary containing a mature cystic teratoma. Two out of 10 patients had thrombus formation within the vessels of the twisted ovaries. An embolic phenomenon did not develop in any of the cases. At follow-up, all pubertal girls had normal menstrual periods. CONCLUSIONS: Failure to protect ovaries from subsequent torsions can result in castration, and we performed oophoropexy in both retained detorsed and contralateral ovaries without any postoperative complication. We performed medial oophoropexy to avoid tubo-ovarian disturbance. Oophoropexy is an easy and reversible procedure, and should be done in all cases of ovarian torsion.

Gallbladder dyskinesia: a cause of chronic abdominal pain in children.

PURPOSE: Gallbladder dyskinesia (GD) is a well-established disorder in adults, but it is not clearly defined in the paediatric population. Therefore, the aim of this study was to review our experience in a group of children with chronic abdominal pain associated with impaired gallbladder emptying in the absence of cholelithiasis. METHODS: The records of sixteen patients who underwent cholecystectomy with the diagnosis of GD were evaluated retrospectively. Clinical presentation, symptoms, diagnostic studies, and the effect of cholecystectomy in alleviating abdominal complaints were investigated. RESULTS: All patients had symptoms of upper abdominal pain in the absence of other attributable causes associated with low gallbladder ejection fractions (GEF) < 35 %, during cholecystokinin-stimulated hepatobiliary scan (CCK-HBS), and free of gallstones on ultrasound (USG). Abdominal pain and nausea were the most common presenting symptoms. Mean GEF was 15.3 %. All patients underwent cholecystectomy. The histopathological diagnoses of all operated patients were consistent with chronic cholecystitis. Symptoms were completely relieved in all except two patients. CONCLUSION: GD should be considered in the differential diagnosis of recurrent abdominal pain in children. Patients with this condition present with biliary-type pain and investigations show no evidence of gallstones in the gallbladder. Performing a CCK-HBS establishes the diagnosis. Patients with an abnormal GEF (< 35 %) should undergo cholecystectomy. This procedure has been shown to be effective in curing the symptoms in over 80 % of patients. To avoid late diagnosis, CCK-HBS should be employed early in the evaluation of biliary colic with negative sonographic findings.

A treatment for biliary hypoplasia: tube cholecystostomy and irrigation.

PURPOSE: Biliary Hypoplasia (BH), characterised by a small ductal system and reduction in the number of interlobular bile ducts, has a bad prognosis. It has been claimed that other treatment methods apart from liver transplantation are not effective. Seven patients with BH underwent tube cholecystostomy, decompression and saline irrigation of the biliary tree via tube cholecystostomy. We present our treatment method, together with the early and late biochemical and histopathological results of these patients. PATIENTS AND METHODS: The records of seven patients with BH were reviewed retrospectively. BH was proved by operative cholangiography. Irrigation was performed intermittently with warm saline to the biliary tract via tube cholecystostomy over two to three months. SGOT, SGPT, alkaline phosphatase (AP) and bilirubin levels were evaluated preoperatively and postoperatively. Histopathological findings were also evaluated. RESULTS: Median age at operation was 46 days (range 20 - 90 days). There were six males and one female. Five patients recovered completely. There was a statistical difference between preoperative and postoperative SGOT, SGPT, AP, and bilirubin levels of patients who recovered (p < 0.05). CONCLUSION: Similar to biliary atresia, many factors such as the patient's age, postoperative bilirubin level, histopathology of liver, treatment method, and cholangitis as a complication of the surgical procedure affect the prognosis of BH. Operation before the age of 70 days, normal bilirubin levels after operation, no cholangitis attack, intracellular and intracanalicular cholestasis, and mild mixed cellular infiltration are favourable factors. We believe that decompression and irrigation of the biliary tract is an effective treatment method for suitable cases of BH.

Traumatic subarachnoid-pleural fistula in children. Report of 2 cases and review of the literature.

Traumatic subarachnoid-pleural fistula (TSAPF) is a rare complication of thoracic trauma. Late diagnosis is a problematic dilemma in these cases. Patients with thoracic injury have persistent pleural leakage, thoracic vertebral injury, pneumocephalus, urinary retention and paraplegia should alert the surgeon for TSAPF. Two cases of TSAPF due to gunshot injury are reported.

Tracheobronchial rupture due to blunt trauma in children: report of two cases.

Tracheobronchial tree injuries occur in a small number of patients after blunt chest trauma, and their occurrence is uncommon in the pediatric trauma population. The authors report two male children, one with a tracheal rupture, and the other with disruption of the main right bronchus. Mediastinal and subcutaneous emphysema resulting in airway obstruction were noted in Case 1 and soft-tissue emphysema, pneumomediastinum and tension pneumothorax were evident in Case 2 at the time of presentation. In the child with bronchial disruption, a major airway injury was suspected early on, because of a massive air leak despite two properly placed chest tubes. The definitive diagnosis was established bronchoscopically, and thoracotomy and primary repair were performed. The child with rupture of the posterior tracheal wall was diagnosed at an early stage by bronchoscopy and he was successfully managed without surgery.

The effect of ATP-MgCl(2) on prevention of reperfusion injury after unilateral testicular torsion.

This study was designed to investigate the effect of ATP-MgCl(2) administered before and after detorsion on the prevention of reperfusion injury after unilateral testicular torsion. The rats were divided into six groups, each containing six rats. Torsion was created by rotating the left testes 720 degrees in a clockwise direction. Group 1 functioned as a control group. Torsion only was carried out in Group 2. Detorsion was carried out in Group 3. ATP-MgCl(2) (100 micromol/kg) was injected intravenously immediately before detorsion in Group 4. ATP-MgCl(2) (100 micromol/kg) was injected intravenously immediately after detorsion in Group 5. Saline was injected intravenously immediately after detorsion in Group 6. The effect of ATP-MgCl(2) on reperfusion injury was investigated by determining the levels of thiobarbituric acid-reactive substances (TBAR) and resulting lipid peroxidation in the bilateral testicular tissue. Testicular torsion and detorsion caused a significant increase in the TBAR levels in the bilateral testicular tissue. TBAR levels decreased to approximately normal levels in Groups 4 and 5. It is concluded that if reperfusion injury has occurred in both testes after unilateral testicular torsion, ATP-MgCl(2) administered before or after detorsion may prevent reperfusion injury in testicular torsion.

Morgagni hernia: an unexpected cause of respiratory complaints and a chest mass.

Morgagni hernia (MH) is the least common type of congenital diaphragmatic hernias. Although its course is often asymptomatic, it may be associated with various respiratory and gastrointestinal symptoms. We describe 7 children with MH during a 5-year period in three pediatric centers in Turkey. All children had acute or chronic respiratory symptoms; cough was the most frequent. The diagnosis was made by posterior-anterior (PA) and lateral chest X-rays. The PA chest X-rays showed a homogenous mass in 2 and a gas-filled cystic image in 3 children in the right cardiophrenic angle. A retrocardiac homogeneous density in one child, and bilateral consolidation in lower lung areas in another child were also seen. All lateral chest X-rays showed gas-filled bowel loops above the diaphragm. The diagnosis was confirmed by barium-contrast radiograph. Four patients had five additional anomalies, i.e., ventricular septal defect, right inguinal hernia, congenital hip dislocation, pectus carinatum, and obstruction of the uretero-pelvic junction. All of the hernias were repaired by an abdominal approach. There were no complications or recurrences during follow-up. In conclusion, MH should be considered in the differential diagnosis of cases of long-standing respiratory symptoms and/or when an unexplained radiological image, especially on the right cardiophrenic area, is present.

Effects of caudal block on cortisol and prolactin responses to postoperative pain in children.

We have performed a randomized controlled study in 60 children (ASA 1.8 month to 10 yrs) undergoing lower abdominal and genitourinary surgery, to assess the effects of caudal anaesthesia on plasma cortisol and prolactin concentrations during early postoperative period. After induction of anaesthesia by inhalation or intravenously, thirty children received a standardized general anaesthetic (control group) while the remaining children received caudal anaesthetics with 0.25% bupivacaine in addition to a similar general anaesthetic (caudal group). Blood samples for cortisol and prolactin were taken after induction and 1 hour after surgery. Postoperative analgesia was assessed by modified pain objective scale and side effects were noted. Children in the caudal group had significantly smaller plasma cortisol and prolactin concentrations at 1 hr postoperatively, compared with those in the control group. Plasma cortisol concentration after induction was higher than after one hour of surgery in the caudal group. These results were correlated with pain scores. No serious side effects were recorded. In conclusion, caudal anaesthesia attenuated the postoperative cortisol and prolactin responses to surgery and pain in children.

Congenital malformation of the lung.

Congenital malformations of the lung are rare and vary widely in their presentation and severity. However, frequently they present with dramatic symptoms resulting in the need for prompt diagnosis and treatment. Five patients with congenital lung malformations were treated in Karadeniz Technical University Farabi Medical School Pediatric Surgery Department between June 1992 and January 1997. There were one girl and four boys. The mean age was 42 days (range 1 to 120 days) and the mean weight was 3.9 kg (range 2.4 to 5.4 kg). The following cases were included; one pulmonary agenesis, two congenital lobar emphysema, one pulmonary sequestration, and one cystic adenomatoid malformation. Respiratory distress was the most common presenting symptom. The diagnosis was performed by chest X-ray with postero-anterior and lateral view and thoracic computed tomography (CT). Associated congenital anomalies were detected in one patient and the following anomalies were found; esophageal atresia, tracheo-esophageal fistula, short distal esophagus, and small intrathoracic stomach Posterolateral thoracotomy was used for all patients and complete surgical resection was performed in four patients. Corrective surgery was delayed in one patient in whom extended respiratory support was required and he died on the ninth day due to respiratory failure. In four patients prognosis was excellent. In this article, diagnosis and treatment of congenital lung malformations are discussed.

Congenital splenic cyst--a report of two cases.

We report on two girls with large epidermoid splenic cysts. They presented with abdominal pain, fever, and non-bilious vomiting. In both cases the cyst was diagnosed by means of computer tomography and ultrasonography. One of the patients was successfully treated with partial splenectomy. In the other case percutaneous drainage was initially carried out, but this treatment was insufficient. Splenectomy was then performed.

Gastric perforation presenting as bilateral scrotal pneumatoceles.

Although processus vaginalis is patent in the majority of newborn infants, the expression of an intraabdominal pathology such as gastrointestinal perforation or bleeding in the scrotum is very rare. In a large percentage of neonates with the gastrointestinal perforation, pneumoperitoneum is absent. In any case, it may not be detected in early radiographs. We report a newborn baby who presented with bilateral scrotal pneumatoceles as a first sign of pneumoperitoneum due to gastric perforation. Plain x-ray of the abdomen was normal except for pneumoscrotum, but contrast study revealed gastric perforation.

Pediatric safety pin ingestion.

Fifteen consecutive children with ingested safety pins were evaluated retrospectively. Eight patients were males and seven were girls. The mean age of the patients was 5.4 years ranging from 7 months to 16 years. Two of 15 patients were mentally retarded Seven safety pins ingestion were noted by parents, three older children applied with safety pin swallowing. Three infants referred with hypersalivation and swallowing difficulty. One of two mentally retarded patients had recurrent aspiration pneumonia, the other had neck abscess. These patients' lesions were detected incidentally by thoracic X-ray. Nine safety pins were at the level of the cricopharyngeus, one at the level of the aortic arch and five at the esophagogastric junction. A right esophagoscopy was used for extraction of safety pins under general anesthesia and endotracheal intubation were used. Before esophagoscopy control plain X-ray was obtained for location of safety pin. Nine safety pins were extracted by esophagoscopy. Three safety pins spontaneously and three during anesthesia induction passed through the esophagus falling down the stomach. Five of these six safety pins were spontaneously extracted without complication. However one open safety pin lodged at the duodenum and laparotomy was required. In this article, etiology and management of safety pin ingestion in children are discussed.

Kasabach-Merrit syndrome in infants.

METHODS: Four infants with Kasabach-Merrit syndrome syndrome have been treated at the University Hospital, Trabzon. They had large varied-site cutaneous hemangiomas. Diagnosis was performed with clinical and laboratory studies. All patients has severe thrombocytopenia and anemia. Fibrinogen and fibrin split products were examined in two patients and lower fibrinogen and over fibrin split products levels were detected in them. All patients were admitted to the intensive care unit and they were treated with antibiotics, fresh blood transfusion and thrombocyte suspension. Two out of four patients were previously treated with steroids unsuccessfully and one patient died due to disseminated intravascular coagulopathy. Three patients were treated with interferon alfa-2a and compression. RESULTS: In two patients the lesions regressed 60-80% following the five months therapy and in the other patient the lesion was completely excised after one month therapy. CONCLUSIONS: Interferon alfa-2a and compression were found to be remarkably effective in the treatment of Kasabach-Merrit syndrome.

Mesenteric fibromatosis.

Two rare cases of mesenteric fibromatosis are presented. The first patient had a right upper quadrant mass and colicky abdominal pain. The tumor originated from the mesentery of the colon and it infiltrated the gallbladder, cystic duct, and the liver. The second patient had severe hematemesis and melena. The origin of the tumor, which infiltrated 3/4 part of the stomach, the gastrohepatic ligament, the first part of the duodenum, and the liver could not be determined. In the first patient, partial colectomy and cholecystectomy were performed and the liver lesion was completely excised. The second patient underwent subtotal gastrectomy and left lobectomy of the liver. The first part of the duodenum was excised. Gastrojejunostomy was performed. No recurrence was recorded in either patients during 16 and 13 months follow-up, respectively. In this report, diagnostic aids, differential diagnosis and treatment of this rare disease are discussed.

Nonoperative management of intra-abdominal bleeding due to blunt trauma in children: the risk of missed associated intestinal injuries.

Nonoperative management of intra-abdominal bleeding (IAB) from blunt injuries in children has been advocated for many years. Nonoperatively managed patients, however, are at risk for missed associated intestinal injuries. To evaluate this question, we reviewed the charts of 120 children who had traumatic IAB; 106 were initially managed nonoperatively and observation failed in 2. Fourteen underwent emergency operation. Forty patients had isolated liver and/or splenic injuries while the others had injuries associated with several organs. During observation peritonitis developed in 3 patients and further radiologic examinations failed to confirm an intestinal injury. Diagnostic peritoneal lavage demonstrated contaminated blood and fecal particles from injured intestines in 3 patients; they underwent emergency operation at 10, and 26 h after admission. There was no mortality or morbidity associated with delayed treatment. These data suggest that the majority of patients with IAB may be successfully treated nonoperatively, but associated intestinal injuries should be suspected in all cases.

Empyema in children.

Empyemas develop following bacterial pneumonias, thoracic trauma and surgery which are still among the common diseases, causing illness and death throughout the developing world. With the advent of potent antibiotics the mortality of empyema has been drastically reduced. In this study 52 patients (29 boys and 23 girls) with thoracic empyema were evaluated retrospectively. In this series the causes of empyema were postpneumonic in 50 patients, esophageal anastomotic leak in one patient, and thoracic trauma in one patient. The diagnosis was suspected clinically and by the finding of a pleural effusion on chest roentgenogram. Definitive diagnosis was confirmed by pleural aspiration which pus was obtained. Responsible organisms included; Staphylococcus aureus, Streptococcus pneumonia, Haemophilus influenza, pseudomonas, and Klebsiella. The most common is Staphylococcus aureus. The patients were treated in various ways; 14 patients were treated with antibiotics and thoracentesis, 38 patients were treated with a closed tube thoracostomy. Eight of 38 patients had the chest tube converted to an open empyema tubes for long term management. Fourteen of 38 patients developed abcess formation. Nine of 14 patients were treated with computed tomography guided catheter placement, five patients encountered thoracotomy and decortication. In this article, appropriate treatment and result of long-term follow-up of empyema were evaluated.