Does hyperbaric oxygen therapy reduce the effects of ischemia on colonic anastomosis in laparoscopic colon resection?

BACKGROUND: An increase in intra-abdominal pressure causes a decrease in the splanchnic blood flow and the intramucosal pH of the bowel, as well as increasing the risk of ischemia in the colon. The aim of the present study is to evaluate the effect of hyperbaric oxygen therapy (HBOT) on the ischemia caused by laparoscopy in colonic anastomosis in an experimental model of laparoscopic colonic surgery. MATERIALS AND METHODS: We divided 30 male Wistar albino rats into three groups: Group A was the control (open colon anastomosis); Group B received LCA (laparoscopic colon anastomosis); while Group C received both LCA and HBOT. Each group contained ten animals. We placed Group C (LCA and HBOT) in an experimental hyperbaric chamber into which we administered pure oxygen at 2.1 atmospheres absolute 100% oxygen for 60 min for ten consecutive days. RESULTS: The anastomotic bursting pressure value was found to be higher in the open surgery group (226 ± 8.8) (Group A). The result for Group C (213 ± 27), which received HBOT, was better than that for Group B (197 ± 27). However, there was no statistically significant difference between Group B and Group C. Group A showed better healing than the other groups, while significant differences in the fibroblast proliferation scores were found between Groups A and B. In terms of tissue hydroxyproline levels, a significant difference was found between Groups A and B and between Groups A and C, but not between Groups B and C. CONCLUSIONS: HBOT increases the oxygen level in the injured tissue. Although HBOT might offer several advantages, it had only a limited effect on the healing of colonic anastomosis in rats with increased intra-abdominal pressure in our study. KEY WORDS: Anastomosis, Colon, Hyperbaric Oxygen Treatment, Oxidative Stress.

Effect of Tadalafil on Prevention of Urethral Stricture After Urethral Injury: An Experimental Study.

OBJECTIVE: To evaluate the preventive effect of phosphodiesterase type 5 inhibitor (tadalafil) on the formation of urethral stricture after urethral injury. MATERIALS AND METHODS: A total of 28, 4-month-old male New Zealand rabbits were included and divided into 3 groups. Group 1 was a sham group with 8 rabbits that underwent only urethroscopy. Group 2 was a nontreatment group with 10 rabbits that underwent urethral electrocoagulation without any treatment. Group 3 was the treatment group with 10 rabbits that underwent urethral electrocoagulation with systemic tadalafil treatment. After 30 days of follow-up, urethroscopy and retrograde urethrography were performed to evaluate the morphological changes in the urethra. The urethra tissues were examined with standard light microscopy by a histologist, and apoptosis was evaluated by the terminal dUTP nick end-labeling assay. RESULTS: Urethral diameters in group 1, group 2, and group 3 were 9.14 ± 0.73 mm, 3.52 ± 1.2 mm, and 7.68 ± 1.14 mm, respectively. The differences in urethral diameters were statistically significant between groups (P < .01). Collagen deposition in submucosal connective tissue was significantly less in the tadalafil group vs the nontreatment group. The numbers of apoptotic cells in submucosal connective tissue were also quantitatively higher in urethral stricture groups compared to the sham group. CONCLUSION: Tadalafil treatment had a protective effect against the formation of urethral stricture in rabbit model. This treatment can be a promising opportunity for urethral stricture and must be supported by clinical studies.

Mannitol has a protective effect on testicular torsion: An experimental rat model.

OBJECTIVE: Testicular torsion is an emergency condition that causes testicular injury. Any treatment opportunity reducing the destructive effect of testicular torsion is important for the future life of patients. In this experimental study we investigated the protective effect of mannitol on ischemia-reperfusion (I/R) injury in a rat testes torsion model. METHOD: In total, 32 male Sprague Dawley rats were included. Four experimental groups included eight rats each. Group A was a sham group in which the right testis was brought out through a scrotal incision and then replaced in the scrotum without torsion. In Group B, the right testis was torsioned, by rotating 720° clockwise and fixed to the scrotum with no treatment. In Group C, the same testicular torsion process was performed with saline infusion just after testicular torsion. In group D, mannitol infusion was used just after testicular torsion. Testicles were detorsioned after 3 h and left inside for more than 2 h before orchiectomy. Histopathological, immunohistochemical, and biochemical analyses were performed. RESULTS: Testicular architecture was disturbed significantly in the torsion groups without mannitol infusion. However, testicular tissue structure was significantly better in the mannitol-treated group, demonstrating a protective effect. Similar findings were also shown for the proliferating cell nuclear antigen (PCNA) index and antioxidant activity; both were higher in the mannitol group than in the no-treatment and saline groups (p < 0.01). The apoptotic index was also significantly lower in the mannitol-treated group compared with the no treatment and saline groups (p < 0.01). CONCLUSIONS: The seminiferous tubule structure in testicular torsion without mannitol treatment was significantly disturbed, whereas the structural disruption was considerably less in the mannitol group. Mannitol treatment also decreased reactive oxygen radical levels significantly and was able to decrease apoptosis. These results were consistent with other organ model studies that evaluated the protective effects of mannitol treatment in I/R injury. Mannitol infusion had a protective effect against I/R injury in testicular torsion in rats. This experimental study may guide clinicians to evaluate the effectiveness of mannitol in human testicular torsion.

It is not "Just Circumcision".

OBJECTIVE: Circumcision is one of the most commonly performed operations during childhood. The procedure is often underestimated in areas where it is frequently executed due to social and religion-based indications. In fact it might be an opportunity to detect and to correct any existing penile anomaly. The aim of the study was to retrospectively evaluate the boys who were admitted to a hospital for circumcision and the outcome of the procedure. METHODS: The boys who were brought to outpatient clinics for circumcision between 2009-2015, were retrospectively evaluated. The indications for hospital admission and the presence of associated penile anomalies were searched. All the boys were examined and operated by a single surgeon of the institution. RESULTS: Nine hundred forty four boys were brought to pediatric surgery outpatient clinics in order to be circumcised. The operation was performed in 318 of them. The physical examination revealed penile anomalies in 29 of the 318 cases. The detected anomalies were webbed penis, penile torsion, hypospadias, chordee without hypospadias and meatal stenosis. CONCLUSIONS: The proper examination of the boys by a physician prior to circumcision provides the detection of penile anomalies which can be corrected at the same session. The arrangements for performing circumcision in hospitals by the medical staff should be favored. The misleading perception of underestimation of the procedure where it is ritually performed, should be corrected.

How did the surgeons treat neonates with imperforate anus in the eighteenth century?

Anorectal malformations (ARMS) are one of those challenging topics of pediatric surgery. The developments in assessing and approaching patients with these anomalies have been made in the last decades and the methods described in older textbooks functioned as a guide in planning these attempts (Kiely and Peña in Pediatric surgery, Mosby, Missouri, pp 1425-1449, 1998; Grosfeld in Anorectal malformations in children, Springer-Verlag, Berlin, pp 3-15, 2006). The aim of this study is to present the attitude of a surgeon of eighteenth century to the treatment of anorectal malformations, and the evolution in the history of the anomaly. The part about imperforate anus in a textbook of surgery, found in a second-hand bookstore, was translated. The description and the classification of the anomaly, the methods of approaching these cases together with some case reports were presented and compared with today's practice. The historical background of the anomaly was evaluated not only with regard to the book of Heister specifically but also to the other data obtained in the literature. The anomaly was reported to be "not rarely" observed. The obstetricians were warned to examine a newborn baby completely for early diagnosis. The classification of the anomaly was made according to the properties of the membrane covering the anus but prompt treatment, initiating with its simple excision, was suggested in all types. Better results in cases whose anus was covered with a thin, delicate membrane were reported. The results show that routine neonatal examination for all babies was recommended in this Textbook of Surgery which had been published 260 years ago. The physical deterioration due to delay was well described. A broad classification of imperforate anus was made and successful outcome in low-type anomalies of today was reported with some case samples. It is clear that all the efforts starting from Soranus until today improved the understanding of the anomaly. Combining previous information with today's practice in the meetings focused totally on anorectal malformations, where the leading surgeons shared their experiences and re-evaluated the problems encountered, enlightened the future status of this interesting topic of pediatric surgery.

Pyloric stenosis in in vitro fertilized triplets--is it a coincidence?

Infantile hypertrophic pyloric stenosis was previously reported in multiple births, but there were only 3 triplets in the literature and all were naturally conceived. Assisted reproductive technologies, such as in vitro fertilization, are accused for increasing the risk for some anomalies in children. Triplets of in vitro fertilization, all of whom were operated on because of pyloric stenosis, are presented.

Quo vadis? Ureteric reimplantation or ignoring reflux during augmentation cystoplasty.

OBJECTIVE: To decide whether antireflux surgery should be used in the presence of vesico-ureteric reflux (VUR) in children, in whom an augmentation procedure is needed, because secondary VUR in children with a neurogenic bladder, infravesical obstruction and primary VUR in the exstrophy-epispadias complex is expected to resolve after augmentation, which decreases the intravesical pressure and increases capacity. PATIENTS AND METHODS: Between 1987 and 2001, the bladder was augmented in 38 children, using no antireflux surgery in group 1 (15 patients) and antireflux surgery in group 2 (23 patients). RESULTS: VUR was detected in all patients on cysto-urethrography before surgery; reflux resolved after augmentation cystoplasty in 97% and 93% of refluxing units in groups 1 and 2, respectively. The increase in the expected bladder capacity was from 35% to 86% in group 1 and from 38% to 90% in group 2. No patient had any deterioration in renal function. CONCLUSIONS: We recommend using only augmentation in patients with low- or high-grade VUR and a neurogenic bladder, infravesical obstruction and exstrophy-epispadias. Combining antireflux surgery with cystoplasty has no significant effect on either the resolution of VUR or renal function.

Do patch procedures prevent complications of the Mathieu technique?

PURPOSE: The effects of V-incision sutured (MAVIS) and dartos patch reinforcement techniques in reducing side effects and complications of the Mathieu procedure and improving the appearance of the meatus are evaluated. MATERIALS AND METHODS: A total of 74 patients with distal shaft hypospadias without chordee or with minimal chordee were operated on by a single surgeon using Mathieu's technique. While only the classic Mathieu repair was performed in group 1, MAVIS and dorsal dartos patch reinforcement was included with the procedure in group 2. A silicone urethral catheter and foam silicone dressing were used in both patient groups. RESULTS: There were 32 cases in group 1 and 42 in group 2. Median patient age at operation was 3.2 and 3.4 years in groups 1 and 2, respectively. Mean postoperative period for the silicone catheter was 4.9 days in both groups. Followup ranged from 52 to 128 months (mean 76) for group 1 and 13 to 43 months (25.4) for group 2. Five fistulas and 1 meatal stricture developed in group 1 and all the children in this group required meatal calibration with dilatation in some. Neither fistula nor stricture occurred in group 2 and there was no need for calibration. A slit-like meatus was achieved in all children in group 2 but in only 12 in group 1. CONCLUSIONS: The MAVIS technique and dorsal dartos patch reinforcement may prevent complications of the classic Mathieu procedure. A slit-like meatus was obtained in all cases with this approach.

Extrathoracic liver hamartoma.

Mesenchymal hamartoma is a benign tumor of the liver that often presents because of a palpable abdominal mass or respiratory distress. An unusual protrusion of this tumor through the chest wall of a neonate with Poland's syndrome is reported.

Management of portal hypertension in children: a retrospective study with long-term follow-up.

OBJECTIVES: Data regarding the management of the portal hypertensive haemorrhage in the paediatric patients have yielded conflicting results. The purpose of this study was to evaluate the efficacy of beta-blocker (propranolol) alone, sclerotherapy alone and beta-blocker + sclerotherapy combination in the management of portal hypertension in the paediatric population. METHODS: Medical information was retrieved from the records of 62 children with portal hypertension who were under treatment during at least two years of follow-up period. Data collected included diagnosis, type of portal hypertension, age at initiation of therapy, bleeding episodes before and during therapy. RESULTS: Sixteen of 62 patients were diagnosed as extrahepatic portal hypertension, 46 as intrahepatic portal hypertension. The mean age of study population was 7.6 +/- 4.2 years, 45 percent being females. The mean duration of follow-up under therapy was 5.2 +/- 2.5 years. Among the patients with intrahepatic portal hypertension, 29 received propranolol + sclerotherapy, 12 received only propranolol and 5 received only sclerotherapy. There was no significant decrease in bleeding episodes during propranolol or sclerotherapy. However patients under propranolol + sclerotherapy, showed significant decrease in bleeding episodes during therapy (23/29 before therapy, 15/29 during therapy, p < 0.05). Rebleeding index in patients with IHPH was significantly long in the group treated by propranolol + sclerotherapy (p = 0.0001) compared with before therapy. Because the numbers of patients in the groups are small, Kaplan Meier estimation suggest that propranol treatment is more effective. But there isn't significant difference when the results were compared with those of before therapy, except in the combined treatment group. CONCLUSION: The monotherapy is not sufficient for longterm follow-up of portal hypertensive patients. The combination therapy with propranolol + sclerotherapy appears more encouraging in the prevention of portal hypertensive haemorrhage, but this needs to be assessed in randomized trials.

Equality of the left and right renal venous flow predicts the severity of variceal bleeding in portal hypertensive children.

Portasystemic collaterals develop as a result of portal hypertension. The collaterals in the cardioesophageal region is the leading cause of bleeding from esophageal varices. Some of the portal hypertensive patients present with bleeding episodes but the others do not, and some of the bleeders do not respond to endoscopic sclerotherapy procedure, although the underlying pathology is the same. The capacity of the natural collateral vessels might be a determining factor about the hemorrhagic events. Since the first step of portasystemic collateralization takes place in the naturally existent vascular channels, the present study, with its anatomic and clinical parts, was focused on these venous structures.

Nonsurgical diagnosis and management of an inflammatory pseudotumor of the spleen in a child.

Primary splenic tumors in children are rare and usually benign. We report the case of a 7-year-old boy with a splenic mass that initially resembled an infectious process. Histopathologic examination of a specimen obtained using sonographically guided Tru-cut needle biopsy, performed after angiography, revealed an inflammatory pseudotumor of the spleen, an extremely rare benign lesion. The lesion has been managed conservatively with clinical and sonographic follow-up. This case shows that benign lesions of the spleen can easily be diagnosed using current radiologic and histopathologic techniques without the need for surgery, thus allowing total or even partial splenectomy to be reserved for patients in whom a mass cannot be diagnosed or in whom clinical progression is evident.

Arterial carbon dioxide markedly increases during diagnostic laparoscopy in portal hypertensive children.

UNLABELLED: Several factors are responsible for hypercarbia during laparoscopic procedures. This study was undertaken because we observed a sudden increase in PaCO(2) in children with portal hypertension (PHT), which was unusual in healthy children undergoing laparoscopic procedures. Fifty-seven children underwent laparoscopic procedures under general anesthesia and were mechanically ventilated. Arterial blood samples were obtained 5 min after intubation (T(0)), 15 min and 30 min after CO(2) pneumoperitoneum (T(15) and T(30)), 5 min after desufflation (T(end)), and 10 min after extubation (T(ext)) for blood gas analysis. The changes in PaCO(2), pH, and ETCO(2) were statistically significant during the study periods in both groups (P < 0.05). The percentage of PaCO(2) increase between T(0) and T(15) was 11.5% and 20.1%, respectively, in the control group and the PHT group (P < 0.05). This increase reached 36.8% at T(30) in the PHT group, whereas the control group had a 17.2% increase (P < 0.05). ETCO(2) presented similar changes. The variability in base excess, bicarbonate, PaO(2), arterial oxygen saturation, and SpO(2) was not significant in either group (P > 0.05). The PaCO(2) increased remarkably in children with PHT undergoing laparoscopy, with no difference in intrahepatic or extrahepatic origin. Limiting the duration of CO(2) pneumoperitoneum and intraabdominal pressure and adjusting ventilatory variables to accommodate hypercarbia are of the utmost importance for such cases. IMPLICATIONS: We compared children with portal hypertension with systemically healthy children during laparoscopy. The increase in arterial and end-tidal CO(2) was remarkable in children with portal hypertension, regardless of bicarbonate changes. Managing ventilation to accommodate hypercarbia is of the utmost importance for such cases.

Esophageal variceal bleeding secondary to portal hypertension: endoscopic sclerotherapy as the first-step treatment.

BACKGROUND: Variceal bleeding from the esophagus is an important cause of mortality and morbidity in children with portal hypertension (PHT). PATIENTS AND METHODS: A series of 69 PHT cases (41 intrahepatic, 28 extrahepatic) have been evaluated in our department since 1990. According to the Child-Pugh classification, 49 cases were in class A, 16 cases were in class B, and 4 cases were in class C at admission. In our protocol, endoscopic sclerotherapy is performed in all patients, and the diagnosis is achieved directly by diagnostic laparoscopy and fine-needle liver biopsy. The procedure is applied under general anesthesia, and 1% aethoxysclerol (polidocanol) is injected paravariceally and intravariceally with the use of a flexible endoscope. RESULTS: The Sugiura procedure was performed in nine patients who presented with recurrent bleeding episodes despite the strict sclerotherapy protocol. Liver transplantation was performed in two patients who were in Child class C. The total mortality rate in this series was 7% (5/69). CONCLUSION: Endoscopic sclerotherapy, as presented herein, decreases the need for additional surgical interventions in children with PHT.