Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis.

AIM: Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease. METHOD: The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019. RESULTS: Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study. CONCLUSION: FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.

The role of Apigenin in testicular damage in experimental ischemia-reperfusion injury in rats.

BACKGROUND: Testicular torsion is an acute urologic emergency occurring in male newborns, children or adolescents. Prolonged ischemia for more than six hours can lead to irreversible testicular damage. Surgical detorsion allows reperfusion and is the only treatment currently available. The aim of this study was to evaluate the antioxidant effect of apigenin (APG) on the testicular ischemia-reperfusion (I/R) injury. METHODS: Forty-two Wistar rats were randomly divided into five groups. Sham group underwent operation of the left testis. In the torsion-detorsion groups C15 and C120, the left testis was rotated 1080(o) for three hours. The treatment groups Ap15 and Ap120 received the same surgical procedure as groups C15 and C120, but APG was administered intravenously at the same time of detorsion via the right femoral vein. Left orchiectomy was performed 15 min after detorsion at groups C15 and Ap15, and at 120 min at groups C120 and Ap120 for histopathologic and immunohistochemical evaluation. RESULTS: In I/R-untreated groups C15 and C120, there was a moderate to severe distortion of the tubules with lesions that varied between grades III and IV according to histopathological finding. In APG-treated groups Ap15 and Ap120, most of the lesions showed injuries of grades II and III with mild and moderate histopathological features. In Terminal deoxynucleotide transferase dUTP Nick End Labeling (Tunel) assay, APG-treated animals showed a statistically significantly decreased number of apoptotic cells compared to groups C15 and C120. CONCLUSION: Intravenous administration of APG seems to have a protective effect on testicular ischemia-reperfusion injury after testicular torsion and detorsion. Hippokratia 2015; 19 (3): 225-230.

Pott's disease in a two-year-old girl.

Fractures in children require a specific treatment depending on age. While obstetric fractures usually heal well even in case of significant dislocations and conservative therapy, the proportion of operative interventions among all pediatric fractures is increasing with age. Though the vast majority of fractures in childhood are still treated non-operatively, a trend towards early operative interventions and cast-free mobilization has been noticeable in the recent years. The methods of operative stabilization differ between the respective age groups: While K-wire osteosynthesis and a minimal invasive approach using elastic stable intramedullary nailing (ESIN) are common in the group of school aged children, the use of external fixation and plate osteosynthesis has been accepted for the treatment of fractures in adolescents. Bioresorbable implants do not yet play a decisive role in the management of pediatric fractures. This review is focusing on the current indications and concepts for stabilization of frequent pediatric fractures.

Inflammatory myofibroblastic tumor of the liver due to Mycobacterium tuberculosis in an immunocompetent girl.

The case of a 9-year-old girl with a Mycobacterium tuberculosis inflammatory myofibroblastic tumor (IMT) of the left lobe of the liver is reported. The tumor was surgically excised and had histological features diagnostic of IMT, a positive Ziehl-Nielsen staining for acid-fast bacilli and a positive polymerase chain reaction for Mycobacterium tuberculosis. Surgical excision of the tumor followed by anti-tuberculosis treatment for 9 months resulted in full recovery. The patient had no apparent immune disorder, and there was no evidence of extrahepatic tuberculosis. These findings make this case exceptional because IMTs, due mostly to atypical mycobacteria, have been described only in immunocompromised patients.

Muesothelial cyst of the spermatic cord as a cause of acquired cryptorchidism.

Mesothelial cysts of the spermatic cord (MCSC) are a rare entity. A 2-year-old cryptorchid boy with an inguinal mass was found to have a MCSC which was confused with undescended testis. The testis was readily placed into the hemiscrotum after excision of the cyst. MCSC may present as undescended testis and may be an unusual cause of acquired cryptorchidism. It should be excised and the inguinal canal should be explored for the existence of an undescended testis.

Treves' field congenital hernias in children: an unsuspected rare cause of acute small bowel obstruction.

The Treves' field congenital hernias (TFCH) are an unusual cause of bowel obstruction that may result in irreversible damage of the small bowel or a fatal outcome, unless treated timely and properly. We analyzed retrospectively the medical records of four patients who underwent surgery for TFCHs over a period of 9 years. The types of TFCHs, only diagnosed at surgery, were identified as transmesenteric through a defect in Treves' field in three patients, and as hernia into Treves' field pouch in one patient. Patients had non-specific clinical manifestations, and imaging findings demonstrated only small bowel obstruction. Delay in accurate preoperative diagnosis, and especially patient-related delay, led to a primary enterectomy-anastomosis for necrotic small bowel in the patients with transmesenteric hernias. One infant with necrotic bowel died postoperatively. It may be difficult to diagnose TFCHs in children preoperatively. Misdiagnosis of bowel obstruction caused by this type of internal hernia might lead to small bowel necrosis or death. The risk of this complication seems to be more influenced by pre-hospital delay. Awareness of the severe consequences of delay in diagnosis, high clinical suspicion, early recognition, and proper surgical intervention are essential in the successful management of TFCHs.

Congenital patent urachus associated with incomplete urethral duplication: a rare association.

Congenital patent urachus (CPU) is an uncommon anomaly. Blind incomplete urethral duplication is encountered more frequently than other types of urethral duplication (UD) in clinical practice. We describe a child with CPU in association with distal blind incomplete UD. A possible pathogenesis of this extremely rare coexistence is discussed.

Strangulated low Spigelian hernia in children: report of two cases.

Low Spigelian hernia (LSH) in children is considered an extreme surgical rarity. This clinically deceptive hernia is difficult to diagnose preoperatively and has a real risk of strangulation. Strangulated LSH may be misdiagnosed as strangulated inguinal hernia. Early recognition and timely surgical repair are important to avoid strangulation.

Irreducible inguinal hernia due to crossed testicular ectopia in an infant.

The usual presentation of crossed testicular ectopia (CTE) is that of inguinal hernia with contralateral absent testis. We report on a 10-month-old infant with CTE, which presented as irreducible inguinal hernia. Diagnosis was made during surgery, as the child underwent an emergency operation for repair of his irreducible right inguinal hernia. A normal-sized and normal-shaped testis was found in the hernial sac with its blood vessels and vas deferens. A herniotomy with fixation of the ectopic gonad to the opposite hemiscrotum was done. The child remained asymptomatic 1 year postoperatively. Crossed testicular ectopia in infancy may present as irreducible hernia, requiring urgent surgery.

Uterus didelphys with an obstructed hemivagina and ipsilateral renal agenesis: a rare cause of acute abdomen in pubertal girls.

The unique clinical syndrome of uterus didelhphys with an obstructed hemivagina and ipsilateral renal agenesis, presenting as acute abdomen in three pubertal girls, is reported. Accurate preoperative diagnosis and appropriate treatment will offer relief of symptoms and decrease morbidity and unnecessary procedures.

Quantitative assessment of the stage of neuronal maturation in the developing human fetal gut--a new dimension in the pathogenesis of developmental anomalies of the myenteric plexus.

There are two main theories of the normal development of the enteric nervous system: the classical theory suggests that the enteric neuroblasts migrate along the alimentary tract in a single cranio-caudal direction. However, the second theory postulates a dual gradient of neuronal development. The present study aims to support the second theory and contribute to the understanding of the pathogenesis of Hirschsprung's disease and its allied gut motility disorders. Using a histomorphometric method, quantitative estimation of the myenteric intraganglionic neuronal development was made in tissues from various selected levels of the gut in 32 normal human fetuses of 11 to 24 weeks ovulation age. A parallel study with special chromatin staining was carried out from these materials to investigate different neurons in the myenteric plexus. Development of intraganglionic neurons was shown to be more advanced in the esophagus, less so in the rectosigmoid and least so in the ileocecal region: the mean values of neuronal and nuclear volume were found in the esophagus greater than in rectosigmoid and ileocecal region as ovulation age progressed. Intraganglionic mitotic figures were detected at all the selected levels of the gut. A decrease of the mitosis index as age progressed was observed. We showed that myenteric neurons followed a dual gradient of development proceeding from both ends to the middle of the gut in mid-trimester human fetuses. Our findings are compatible with the suggestion that any alterations in the fetal gut microenvironment may affect seriously the normal development of a multipotential precursor cell population resulting in various congenital anomalies of the myenteric plexus.

Anatomic evidence for coexistence of cholinergic and adrenergic neurons in the developing human intestine: new aspects in the pathogenesis of developmental neuronal abnormalities.

In order to interpret the interrelation of cholinergic and adrenergic myenteric neural elements in the developing human, histochemical methods were used to demonstrate cholinergic and adrenergic activity independently in consecutive cryostat sections of the esophagus, ileocecal region, and colon of fetuses of 9 to 22 weeks ovulation age. At least some of the neural cells remained plastic, with respect to their transmitter choice, and showed both cholinergic and adrenergic function. These cells were shown to be present first in the ileocecal region (11 weeks) then in the esophagus (12 weeks) and lastly in the colon (14 weeks). Our findings support the hypothesis of a dual gradient of maturation of enteric neurons. The choice of transmitters is influenced by a "microenvironmental" factor, which may also arrest the maturation or cause the death of neurons.

Elastic fibers in musculature of rectosigmoid colon: normal findings in children and changes in Hirschsprung's disease--a preliminary report.

In order to determine the possible implication of elastin in spasticity of the aganglionic segment in Hirschsprung's disease the elastic fibers in the colon at rectosigmoid level were studied in seven surgical specimens of aganglionic bowel and in seven normal controls. Elastic fibers in both the muscle layers of normal bowel are thin, tend to be straight, and follow the line of muscle fasciculi. In aganglionic bowel, however, the fibers are more numerous and thicker in both layers, and in the longitudinal layer they are laid down in spirals. The total elastin content is increased by approximately 100% as compared with controls. These structural and quantitative changes in the elastin may contribute both to the spasticity and to the increased elasticity of the aganglionic segment.

Lymphedema as the first manifestation of Hodgkin's disease.

Two cases of Hodgkin's disease are described, initially manifested with unilateral lymphedema of the lower extremity. The appearance of pronounced lymphedema of a lower extremity, as the first clinical manifestation and presenting sign of Hodgkin's disease is extremely rare. The surgical treatment of this condition consisted in removal of the involved lymph nodes of the inguinofemoral area and at the same time in omental transposition of a lymphatic communication of the afflicted area with the peritoneal cavity. The procedure was successful in ameliorating the lymphedema. No episodes of postoperative cellulitis occurred and good functional capacity of the extremity was achieved.