Childhood splenic hemangiopericytoma: a previously unreported entity

The first childhood case of splenic hemangiopericytoma in a 10-year-old boy is presented. The clinicopathologic features of this unique entity are discussed with special emphasis on differential diagnosis and treatment by comparing with the previously reported adult cases. There are no specific presumptive clinical and laboratory findings, including tumor markers and imaging techniques that distinguish hemangiopericytoma from other splenic masses. The most important diagnostic aid is to bear this entity in mind when a child presents with an unexplained splenic mass. Splenectomy associated with chemotherapy or radiotherapy in the presence of systemic or local recurrences is mandatory for the appropriate treatment.

Ectopic gastric mucosa causing dysphagia due to strictures in a boy

Ectopic gastric mucosa in the upper esophagus has been reported previously in neonatal autopsy series and encountered in adult esophagoscopies. Despite the usual asymptomatic course of the disease, symptomatic adults have been reported. However there is no report of a symptomatic child with ectopic gastric mucosa in the literature. A 12-year-old boy presenting with dysphagia due to strictures resulting from circular patches of ectopic gastric mucosa located in the mid esophagus is reported.

Four different hernias are encountered in the anterior part of the diaphragm

A retrospective clinical study was performed to evaluate the hernias encountered in the anterior part of the diaphragm. Twenty patients (14 males, 6 females; aged 7 days-7 years) with hernias located in the anterior part of the diaphragm who were treated surgically formed the study group. The exact locations, contents and additional malformations were evaluated. The locations were parasternal in 14 and retrosternal in six. Parasternal locations were the right side in 11, left side in two and bilateral in one patient. Three patients had trisomy 21 syndrome. A sac was presented in all cases and included the colon in 12 patients. A patient with retrosternal location also had trisomy 21 syndrome. The patients with retrosternal hernias also presented with sacs, and the colon was the most commonly included viscus. In the presented series, no intrapericardial herniations or anteromedial defects were encountered. Comparison of previously reported patients and the present series suggests that the anterior part of the diaphragm hosts various hernias of congenital origin in its different locations. According to the exact location and the presence or absence of sacs, four different types of hernias occur in this area: retrosternal hernias with a sac, intrapericardial herniation, and parasternal and anteromedial hernias with either unilateral or bilateral involvements. Since four different hernias were distinguished, the term Morgagni hernia does not include or define all the hernias of the anterior part of the diaphragm. We believe they should, therefore be designated according to the location and presence or absence of a sac.

Epigastric heteropagus: a case report with review of the literature

Incomplete conjoined twinning or heteropagus attached at the autosite's epigastrium is an extremely rare form of conjoined twinnings. We report a case of epigastric parasitic twinning in which the parasite has a well developed lower trunk and pelvis with rudimentary lower limbs, and well developed upper extremities without shoulder girdles and thoracic cage. The clinical features of this rare entity are discussed with a literature review. We emphasize that in spite of monstrous appearance, autosite component of epigastric heteropagus can be treated successfully with minor surgery. This fact should be kept in mind during the intrauterine evaluation of these type of anomalies in order to avoid needless terminations.

Colorectal carcinoma in children

BACKGROUND/PURPOSE

Colorecta I carcinoma is extremely rare in children and presents with a poor prognosis. Surgical management and long-term follow-up of this entity are still obscure because of lack of data. Therefore, a retrospective clinical trial was performed to evaluate the clinical characteristics of childhood colorectal carcinoma and to determine the predictors of poor outcome.

METHODS

Records of children who had colorectal carcinoma and were treated at our unit between 1972 and 1997, inclusive, were reviewed retrospectively. Information recorded for each patient included age, sex, clinical characteristics, diagnostic procedures, extent of disease, treatment methods, histological types, and outcome. A modified Dukes staging scheme was used.

RESULTS

There were 12 boys and 8 girls who were treated for colorectal carcinoma (range, 7 to 16 years). Predisposing conditions were encountered in 2 patients (10%), one with Bloom's syndrome and another with familial occurrence of colonic carcinomas. Predominant symptoms were abdominal pain, vomiting, and rectal bleeding. Barium enema, ultrasonography, computerized tomography, and endoscopic procedures were used for the diagnosis. Rectosigmoid region was the most common site for the primary tumor (65%). All patients presented with advanced stages of disease (stage C, 7; stage D, 13). Surgical procedures were incisional biopsy (n = 4), palliative permanent colostomy (n = 4), segmental resection (n = 5), complete resection (n = 6), and rectal biopsy (n = 1). Peritoneum was the most common site of extensive intraabdominal disease followed by omentum majus and liver. The lung also was involved in 2 patients. Predominant histological type was mucinous adenocarcinoma (80%). All patients but one received adjuvant chemotherapy, and 2 received palliative radiotherapy. Thirteen patients died of disease in a period ranging from 1 day to 1 year after initial surgery. The fate of 4 patients who were discharged in a very ill status was unknown. Three patients were alive for 2 years to 4 years postoperatively, and one of them presented with end stage disease.

CONCLUSIONS

Delayed diagnosis, advanced stages of disease at presentation, and, most importantly, mucinous type of histology are the major determinants of poor outcome in childhood colorectal carcinoma. We emphasize that possibility of a malignant colorectal tumor should be considered for any childhood case with signs and symptoms of intestinal obstruction, intractable abdominal pain, alteration in bowel habits and gastrointestinal bleeding. Colorectal malignancy should not be excluded only on the basis of the patient's age. Because of the steadily increasing incidence of precancerous bowel diseases and poor prognosis of colorectal carcinoma, childhood cases of bowel disorders should receive the same detailed and vigorous diagnostic evaluation and appropriate treatment as given to adult cases. Contrast studies, ultrasonography, computed tomography, and endoscopy are essential procedures for both confirming the diagnosis and detecting the extent of the disease.

Congenital lobar emphysema: diagnostic and therapeutic considerations

BACKGROUND/PURPOSE

Congenital lobar emphysema (CLE) is characterized by overinflation of a pulmonary lobe and may present as a diagnostic and therapeutic dilemma. The authors have reviewed their experience to clarify the controversies about the diagnosis and management of CLE in children.

METHODS

Children who had CLE and were treated at our department between 1991 and 1998, inclusive, were reviewed.

RESULTS

Fourteen children consisting of 8 boys and 6 girls (age range, 25 days to 2.5 years) had CLE. Eight children (57%) were symptomatic at birth. Major presenting symptoms were dyspnea (n = 8, 57%), cyanosis (n = 6, 43%) and recurrent respiratory tract infection (n = 4, 28.5%). Chest x-rays and computerized tomography scans showed hyperaeration of the affected lobes in 14 and 12 patients, respectively. Pulmonary perfusion scan was performed in 8 patients and showed loss of perfusion in the affected lobe in 7 cases. The affected sites were left upper lobe (n = 8, 57%), right middle lobe (n = 4, 28.5%) and right upper lobe (n = 2, 14.5%). Congenital cardiac anomalies were encountered in 2 patients (14.5%). Ten children underwent lobectomy, and postoperative course was uneventful. Nonoperative management was performed in 4 cases (28.5%) presenting at older age with milder symptoms. In the latter, although symptoms subsided, radiological abnormalities persisted during the follow-up period of 3 months to 4 years. No mortality was encountered in the series.

CONCLUSIONS

The diagnosis of CLE is established by combined radiological and scintigraphic imaging methods. Surgical excision of the affected lobe is the appropriate treatment in all infants under 2 months of age and in infants older than 2 months presenting with severe respiratory symptoms. Infants older than 2 months presenting with mild to moderate respiratory symptoms associated with normal bronchoscopic findings can be treated conservatively. In conservative management, the children should be under close follow-up, and the family should be alarmed about the disease. Further studies are required to determine the long-term outcome of conservative management.

Lack of carbachol response indicates the absence of cholinergic receptors in sacs associated with undescended testis

BACKGROUND/PURPOSE

The mechanism of testicular descent remains controversial. The processus vaginalis (PV) contains smooth muscle and should have contractile activity that may contribute to descent. This study was designed to evaluate the smooth muscle of PVs associated with incomplete obliteration for spontaneous activities and responses to various stimuli, to determine if differences exist according to sex, diagnostic source, or location of the testis.

MATERIALS

Peritoneal samples (n = 4); sacs from girls (n = 8) and boys with inguinal hernia (n = 12); and sacs from boys with hydrocele (n = 3), hydrocele of the cord (n = 2), or undescended testis (n = 7) were used for the current study. Tissues were attached to the isometric force displacement transducer in an organ bath containing mammalian Ringer's solution at 37 degrees C. Spontaneous mechanical activity and contractile responses of tissues to the electrical field stimulation, phenylephrine, carbachol, and serotonin were recorded. The values obtained from boys and girls with inguinal hernia and from boys with either undescended or descended testis were compared through Fisher's Exact test.

RESULTS

There were no statistically significant differences in patient age between groups. Among the parameters studied, only the carbachol response of the sacs associated with undescended testis showed a significant difference compared with the others (P = .001). None of the sacs associated with undescended testis responded to carbachol, whereas all of the sacs from boys and girls with inguinal hernia responded to carbachol.

CONCLUSIONS

Lack of carbachol response suggests the absence of cholinergic receptors within the sacs associated with undescended testis. The lack of cholinergic receptors may play a role in the failure of the process of testicular descent by hindering either PV elongation into the scrotum or a possible propulsive activity of the PV on the testis.

Spectrum of complicated intestinal amebiasis through resected specimens: incidence and outcome

BACKGROUND/PURPOSE

Entamoeba hystolytica (EH) is an enteric protozoan that may cause serious complications that require operative management in children. A retrospective clinical trial was performed to find out the incidence and outcome of complicated intestinal amebiasis (IA) by means of surgically resected specimens in children.

METHODS

The histopathologic evaluation of 554 intestinal specimens (including appendix and polyp) of 482 patients between 1980 and 1997, inclusive, were reviewed. Intestinal biopsy specimens taken from successfully medically treated patients with uncomplicated IA were excluded.

RESULTS

Complicated IA was noted in 18 children (3.7%) consisting of 7 girls and 11 boys with a mean age of 9.2+/-2.3 years. EH was present in the (1) appendices of 4 patients with perforated appendicitis and 3 patients with normal appendix who underwent negative exploration; (2) juvenile polyps of 4 patients presenting with hematochesia; (3) colonic wall of 1 patient presenting with intussusception and treated by resection and anastomosis; (4) cecum of 1 patient presenting with right lower quadrant mass and underwent exploration with the presumptive diagnosis of lymphoma; (5) colonic wall of 5 patients who underwent ileostomy followed by subtotal colectomy and endorectal pull-through with the presumptive diagnosis of chronic inflammatory bowel disease (n = 3), toxic megacolon + peritonitis (n = 1), and total colonic polyposis (n = 1). All above-mentioned patients are alive and free of symptoms.

CONCLUSIONS

The diagnosis of IA should be considered in a very wide spectrum of clinical appearances. IA may be associated with colonic polyps and perforated appendicitis, may act as a leading point for intussusception, and may mimic the clinical picture of appendicitis and lymphoma resulting in negative explorations. The diagnosis and treatment of complicated IA in patients who received a misdiagnosis of inflammatory bowel disease is a great challenge and requires major and emergency surgery.

Abnormal prostatic utricle configuration in hypospadias and intersex patients

A retrospective clinical trial was performed to evaluate the incidence, clinical characteristics, diagnosis and treatment methods of abnormal prostatic utricle configuration (APUC) in hypospadias and intersex patients. Forty-five hypospadias and 72 intersex patients in whom the configuration of prostatic utricle (PU) was evaluated by radiological and endoscopic investigations formed the study group out of 380 hypospadias and 160 intersex patients who were treated between 1975 and 1996. Enlargement of PU (EPU) was classified into four grades based on the radiological configuration. The term vagina masculina (VM) was used to define the presence of unregressed müllerian duct structures. The incidence of APUC (either enlarged PU: EPU or VM) was 13.3% (n = 6) and 16.6% (n = 12) in hypospadias and intersex patients, respectively. The incidence and grade of EPU increased significantly with the severity of hypospadias. Urinary infection, obstruction and enuresis were the most common symptoms in both groups. Medical treatment consisting of appropriate antibiotics associated with follow-up of the APUC by means of radiological and endoscopic investigations was carried out in 4 patients with Grade I EPU successfully. Surgical excision of the Grade II, III and/or VM through perineal (n = 5), transabdominal extravesical (n = 5) and perineal plus transabdominal extravesical (n = 3) approaches was done while one patient was lost for follow-up before treatment. We emphasize that surgical treatment of EPU and VM must aim at complete excision without damaging continence and sexual potency mechanisms. The selection of the surgical treatment method should be individualized according to the grade of APUC which must be defined by preoperative radiological and endoscopic investigations. The optimal surgical method is the one which allows the best visualization of the involved anatomy, facilitates accurate suture placement with complete removal of the EPU and VM and avoids inadvertent injury to the adjacent tissues. Guidance by urethral and utricular catheters is essential for safe and elegant dissection in all surgical methods.

Noradrenaline and nitrite-nitrate concentrations in the contralateral testes during ipsilateral spermatic cord torsion in the presence or absence of a testis and epididymis

OBJECTIVE

To determine the changes occurring during ipsilateral spermatic cord torsion either in the presence or absence of the ipsilateral testis and epididymis, by evaluating noradrenaline and nitrite-nitrate concentrations in the contralateral testes.

MATERIALS AND METHODS

Forty male albino rats were allocated randomly to one of four equal groups undergoing: group 1, a sham operation; group 2, ipsilateral spermatic cord torsion; group 3, epididymo-orchidectomy only; and group 4, spermatic cord torsion after epididymo-orchidectomy. The contralateral testes were harvested after 24 h and the noradrenaline and nitrite-nitrate contents determined. The levels in each group were compared using the Kruskal-Wallis and Mann-Whitney U-tests.

RESULTS

The noradrenaline content of testes from group 2 was significantly lower than in those of groups 1 and 3, but there were no significant differences in content between groups 1 and 3, 1 and 4, and 2 and 4. The content in group 4 was significantly less than that in group 3. There were no significant differences in nitrite-nitrate contents among any of the groups.

CONCLUSION

Spermatic cord torsion for 24 h, either in the presence or absence of a testis and epididymis, significantly decreased the noradrenaline content in the contralateral testis. This finding supports the suggestion that the sympathetic system is activated by exposure to noradrenaline in the contralateral testis during ipsilateral spermatic cord torsion, with no dependency on the presence of a testis and epididymis. As the nitrite-nitrate concentrations were unaffected, nitric oxide seems to have no role in contralateral testicular deterioration.

Inguinal hernia revisited through comparative evaluation of peritoneum, processus vaginalis, and sacs obtained from children with hernia, hydrocele, and undescended testis

BACKGROUND/PURPOSE

Histological structures of peritoneum, processus vaginalis, and sacs obtained from girls with inguinal hernia and boys with inguinal hernia, hydrocele, and undescended testis have been compared through immunohistochemical features to evaluate if any clue descriptive for the etiology of inguinal hernia exists.

METHODS

Parietal peritoneums (n = 6), processus vaginalises (n = 4), female hernia sacs (n = 5), male hernia sacs (n 12), and sacs from hydrocele (n = 5) and undescended testis (n = 9) were stained with indirect immunoperoxidase method. Anti-CD9, CD26, CD29, CD31, CD36, CD44, CD49a, CD49b, CD49c, CD49d, CD49e, CD49f, CD54, CD55, CD56, CD62E & P, CD71, CD98, CD102, CD106, CD146, CD151 monoclonals and NFL-NPH, S-100 antiserums were used. The histological structures of each group of samples were identified and compared.

RESULTS

Smooth muscle layers have been encountered within the walls of hernia sacs of both boys and girls. Although the hydrocele sacs have shown smooth muscle bundles distributed as patchy areas, smooth muscle bundles have been observed infrequently among sacs from patients with undescended testis. Peritoneum and processus vaginalis samples have been free of smooth muscle.

CONCLUSIONS

Inguinal hernia during childhood seems to be related to the presence of smooth muscle within the wall of the sac. The smooth muscle bundles may have played a role both in prevention of obliteration and clinical outcome. Because the sacs associated with undescended testis are without smooth muscles, and herniation is not a frequent association, they may not share the same etiologic basis with inguinal hernia.

Combined use of steroid, antibiotics and early bougienage against stricture formation following caustic esophageal burns

BACKGROUND

If an esophageal burn is diagnosed, the aim is to prevent stricture formation. The combined use of steroid, antibiotics and early bougienage (SAEB) is one of the currently used treatment protocols. The effect of SAEB treatment against stricture formation following caustic esophageal burn has been evaluated retrospectively.

METHODS

Forty-nine children of 282 admitted with a history of caustic substance ingestion were found to have esophageal burns. Forty-nine children underwent treatment against stricture formation. SAEB was begun within 48 hours of ingestion.

RESULTS

Eight children of 12 who ingested sodium hydroxide and five children of 20 who ingested acids developed strictures in spite of the therapy. Additionally two esophageal perforations were encountered in patients who ingested sodium hydroxide.

CONCLUSIONS

This protocol has been found to carry a risk of perforation without preventing stricture formation after strong alkali ingestion. Therefore other treatment modalities for preventing strictures should be evaluated especially in children who have ingested products containing strong alkalis.

Cremasteric reflexes of boys with descended, retractile, or undescended testes: an electrophysiological evaluation

BACKGROUND/PURPOSE

Retractile testis traditionally has been regarded as suprascrotal location of testis resulting from hyperactivity of the cremasteric reflex (CR). However, the activity of CR is evaluated poorly in the literature. Electrophysiological characteristics of CR in boys with various testicular localizations have been evaluated comparatively.

METHODS

Cremasteric responses that were evoked by electrical stimulation of the upper-inner aspect of thigh were recorded using a concentric needle electromyography (EMG) electrode inserted into the cremaster muscle. Evoked EMGs of groups, each consisting of 10 boys with bilateral descended (DT), unilateral retractile (RT), or unilateral undescended testes (UT) were compared for response latencies and durations.

RESULTS

Three components with different onset latencies (R1, R2, and R3) were identified in EMG responses. In patients with UT, the latency of the R1 was shorter than that of the patients with DT, and the duration of R2 was longer than those of the patients with DT and RT. The differences between patients with RT and DT regarding the latency and duration of R1 and R2, although similar to those differences between UT and DT, were not significant. There were no significant differences of the latencies of R3 between groups. In patients with RT and UT, response latency and duration in the descended and retractile-undescended sides were similar.

CONCLUSIONS

Defined by shortened latency and prolonged activity of cremasteric responses, which probably reflect a diminished neuronal inhibitory control, CR is hyperactive in UT. Disinhibited motor neurons leading to overactivity of cremaster muscle might have hampered the descent of testis. Our results do not provide a definite support for or against the hypothesis of CR hyperactivity in RT.

The use of eccentric circummeatal-based flap with combined limited urethral mobilization technique for distal hypospadias repair

We report a suitable approach to the correction of subcoronal meatus for any variants and report our experience with this method. An eccentric circummeatal-based flap was used to treat 42 patients with hypospadias during a 4-year period. The position of the meatus was coronal in 18 patients (43 percent) and subcoronal and distal penile in 16 (38 percent) and 8 (19 percent) patients, respectively. In addition, 19 patients had marked ventriflexion. The mean length of the urethroplasty was 1.1 cm (ranging from 0.6 to 1.7 cm). In no instance was residual ventral curvature noted nor did the neourethra restrict the phallus during erection. The functional and cosmetic results were excellent, and in many cases the glans penis assumed a nearly normal shape and appearance. No patient required a second procedure to improve cosmesis. This is a convenient procedure for correction of distal hypospadias in which the urethral gap is no longer than 2 to 2.5 cm. The surgical repair does not depend on glanular or meatal variations or even if the patient had a previous operation. It is particularly suitable in cases that have marked fibrous chordee.

The preventive effect of heparin on stricture formation after caustic esophageal burns

BACKGROUND/PURPOSE

Preventing thrombus formation after caustic esophageal ingestion has been proposed to have beneficial effects. Therefore, an experimental study was carried out to investigate the effects of heparin on the esophagus after caustic burns.

METHODS

Caustic esophageal burns were produced in rats by irrigation with 50% NaOH as described by Liu. Rats were divided into four groups as follows: group A, animals with esophageal burns, received placebo and underwent autopsy 48 hours after caustic injury; group B, animals with esophageal burns, received subcutaneous heparin treatment and underwent autopsy 48 hours after caustic injury; group C, animals with esophageal burns, received placebo and underwent autopsy 28 days after caustic injury; group D, animals with esophageal burns, received subcutaneous heparin treatment for 7 days and underwent autopsy 28 days after caustic injury. Histopathologic evaluation was performed in all groups, and collagen content of esophageal sections was analyzed by determination of hydroxyproline levels.

RESULTS

Submucosal vascular thrombosis was encountered in all group A animals but the submucosal venules and arterioles were patent in most of group B animals. Esophageal strictures did not develop in any of group D animals, although varying degree of esophageal stenoses were encountered in all animals of group C. The circumferences of the burned segment have been narrowed to 3+/-1 mm in group C rats. There was obvious collagen deposition in submucosa, and epithelial regeneration was not complete in group C rats. Submucosa and epithelial integrity seemed normal in group D animals. Hydroxyproline contents in group D were significantly lower compared with group C (P < .05).

CONCLUSIONS

Heparin has ameliorating effects on stricture formation after caustic esophageal burn. Those effects may occur through possible anticoagulant, antithrombotic, and endothelial protective effects, and modifying effects of heparin on wound healing.

Fetal distress does not affect in utero defecation but does impair the clearance of amniotic fluid

PURPOSE

An experimental study was performed to evaluate the effect of fetal distress on in utero defecation and clearance of amniotic fluid (AF).

METHODS

Sixteen pregnant New Zealand white rabbits underwent laparotomy at 25 days' gestation (full term, 31 to 32 days) as group A (n = 8) and B (n = 8). Uteroplacental ischemia was achieved by constriction of the aorta below the renal arteries to cause fetal distress in group B, whereas sham operation was done in group A. In both groups, 0.1 mL of technetium-99m (99mTc)-HIDA containing 1 mCi of radioactivity was injected into the gluteus muscle of each fetus, which had been exposed through the uterus. Beginning 2 hours after injection, a live fetus was killed every 2 hours for 48 hours in both groups. Tissue samples from the reference organs (lung, heart, stomach, kidney, bladder) and liver, meconium in proximal, mid and distal bowels, AF, and maternal blood were taken. The radioactivity of each sample was determined by a gamma counter and the percentage injected dose (uptake) per gram of tissue (%ID/g) was calculated. The total uptake and mean transit time (MTT) showing intestinal transport were calculated using the linear trapezoidal approximation and extrapolation. The peak concentration (Cmax, %ID/g) and time corresponding to the peak (tmax, h) were obtained.

RESULTS

(1) Significant difference was noted between the groups with regard to uteroplacental perfusion pressure and blood pH (51.0+/-2.6 mm Hg; pH, 6.9+/-0.1 in group B; 80.1+/-2.7 mm Hg, pH, 7.3+/-0.1 in group A; P < .05). (2) 99mTc-HIDA was predominantly trapped by the liver and excreted into the gastrointestinal tract and AF in both groups. (3) In liver and bowel, shape of the profile was bimodal because of fetal swallowing and similar in both groups, tmax was the same in both groups, Cmax was lower in group B than in group A, the total uptake was smaller in group B than in group A, and intestinal transport time was similar (44.2 hours in group A and 43.0 hours in group B). In amniotic fluid, shape of the profile was sigmoidal in group B and reached a Cmax value of 11.6% ID/g, whereas unimodal profiles were observed in group A with a Cmax value of 12.6% ID/g; radioactivity was eliminated from the AF with a rate constant of 0.48% ID/g h in group A (AUC, 273% ID/g h); whereas accumulation of radioactivity was noted in group B (AUC, 308% ID/g h). (5) In maternal blood, shape of the profile was sigmoidal in group A with a Cmax value of 2.9% ID/g and unimodal in group B (Cmax, 1.6% ID/g), accumulation of radioactivity was noted in group A (AUC, 93% ID/g h), whereas a rapid decline of radioactivity (k, 0.06% ID/g h) was noted in group B (AUC, 47% ID/g h).

CONCLUSIONS

Fetal distress did not affect the intestinal transport dynamics and in utero defecation but impaired the clearance of AF and the passage into the maternal circulation, which was shown by the accumulation of radioactivity in AF only in group B and in maternal blood only in group A without any elimination rate. This finding suggests that meconium-stained AF is not related to meconium passage after fetal distress; rather, it reflects impaired clearance of AF, which already has containing meconium caused by physiological in utero defecation.

Biochemical predictors for differentiating intraperitoneal and extraperitoneal bladder perforation

PURPOSE

A retrospective clinical study was performed to find out whether serum biochemistry alterations may serve to differentiate the traumatic bladder perforation to be either intraperitoneal or extraperitoneal.

METHODS

Thirty-two children treated for traumatic bladder perforation between 1970 and 1997, inclusive, formed the study group. Patients were divided into two groups: intraperitoneal bladder perforation (IBP) and extraperitoneal bladder perforation (EBP) groups. The groups were compared with regard to age, sex, mechanism of injury, and hemodynamic parameters (blood pressure, hematocrit) at presentation (each group was further subdivided into two subgroups according to the duration between trauma and presentation as early (duration <24 hours) and late (duration >24 hours) presentation groups). The subgroups were compared with each other with respect to serum concentrations of urea, creatinine, sodium, potassium, and chloride.

RESULTS

There were 21 boys and 11 girls with a mean age of 8.7+/-4.9 years. Mechanisms of injury were motor vehicle accidents (75%), falls (19%), and gunshot wounds (6%). There was no significant difference between the IBP and EBP groups with regard to age, sex, mechanism of injury and hemodynamic parameters at presentation. The biochemical parameters were found to be within normal range in the EBP group, whereas significantly higher levels of creatinine, potassium, and lower level of sodium were noted in IBP group regardless of presentation time. Significantly higher level of serum urea was recorded in a late presentation group of IBP patients.

CONCLUSIONS

The authors emphasize that patients presenting with IBP are more likely to present with significantly higher levels of creatinine, potassium, and lower level of sodium compared with the patients with EBP regardless of presentation time. Increased level of serum urea concentration is a characteristic of IBP patients with late presentation. Biochemical alterations can be used to differentiate traumatic IBP and EBP in children with subtle physical examination and radiological findings.

Malignant hypertension and paraganglioma in a 14-year-old girl

A 14-year-old girl presented with malignant hypertension. Physical examination and abdominal computerized tomography revealed a paraaortic mass. Urinary catecholamines, serum renin, and aldesterone levels were high. The mass was totally excised and a paraganglioma of the organ of Zuckerkandl was confirmed. The hypertension resolved after surgery.

Gastric outlet obstruction due to corrosive ingestion: incidence and outcome

A retrospective clinical study was performed to determine the incidence, management, and outcome of gastric outlet obstruction (GOO) caused by caustic ingestion in children. Of 220 patients who sustained caustic substance ingestion and were treated at our unit between 1976 and 1996, 168 ingested alkaline substances; of these, 9 children (5.3%) developed GOO in addition to esophageal strictures. The remaining 52 patients ingested acid agents, and 2 of them (3.8%) presented with GOO without esophageal strictures. The overall incidence of corrosive GOO was 5% (n = 11). The mean age of the patients with GOO was 5.7 +/- 2.8 years (range 2-14) with a female:male ratio of 6:5. Sodium hydroxide (n = 6), potassium hydroxide (n = 3), and hydrochloric acid (n = 2) were the ingested caustic agents. The patients were subdivided into two groups according to serial endoscopic and radiologic findings: group I: moderate (dense superficial and spotty ulcerations with intact mucosa) mucosal injury with partial pyloric obstruction; and group II: severe (deep ulcerations, extreme hemorrhagic erosions, eschar formation with white plaques) mucosal injury with complete pyloric obstruction. Group I consisted of 5 patients who ingested alkali agents while group II included 6 who presented with ingestion of alkaline (n = 4) and acid (n = 2) agents. Surgical treatment included Billroth I (n = 6) operations performed in group II and Finney (n = 3) and Heineke-Mikulicz (n = 2) pyloroplasty procedures done in group I. All patients are alive without any complaints. Fiberoptic endoscopy should be the preferred method of evaluating a patient with ingestion of a corrosive agent. It determines the presence of injury and assesses the extent of damage, establishing the diagnosis and allowing therapy to be instituted immediately. Our experience revealed that substantial damage has occurred early after ingestion, and early surgical intervention has decreased the morbidity and mortality. The extent of the mucosal injury and status of the pylorus and antrum determined the type of surgical treatment. A Billroth I procedure recommended for severely injured mucosa with complete pyloric obstruction, and pyloroplasty for moderate mucosal injury associated with partially obstructed but still viable pylorus. In contrast to the current belief, alkali ingestion also has a high risk of corrosive gastric injury causing GOO, which should be considered during assessment of the injury. We emphasize that a detailed evaluation of radiologic and especially endoscopic findings is very important for determining the timing, necessity, and type of appropriate surgical treatment.

Acute scrotum due to edidymo-orchitis associated with vasal anomalies in children with anorectal malformations

Epididymo-orchitis, an uncommon cause of acute scrotum in prepubertal boys, is infection or inflammation of epididymis and testis. Epididymo-orchitis may be associated with urinary tract infections or reflux of urine predisposed by an underlying vasal anomaly. Two infants with anorectal malformations who presented with acute scrotum are reported. The surgical exploration of the testes showed findings consistent with epididymo-orchitis. Further radiological investigations of urinary tract showed vasal anomalies in both patients. If a patient with anorectal malformation presents with acute scrotum, epididymo-orchitis should be suspected initially. Evaluations should be directed toward defining predisposing vasal anomaly, and appropriate therapeutic measures should be undertaken to prevent recurrences.

Turkish experience with rhabdomyosarcoma: an analysis of 255 patients for 20 years

Two hundred and fifty-five previously untreated patients (pts) with rhabdomyosarcoma (RMS) (age range 15 days to 17 years, median 5 years) were evaluated and treated in our institution. Head and neck primaries were seen in 125 patients (49%), abdominopelvic in 73 (29%), trunk and lung in 20 (5%) and extremity lesions in 37 (15%). The histology was: embryonal 137; alveolar 42; botryoid 18; pleomorphic 14. Forty-four patients could not be subclassified. The stage of the patients were as follows: 15 in state I, 74 in stage II, 139 in stage III and 27 in stage IV, according to the IRS grouping system. Patients were treated with a combination of surgery and radiation to doses of 35-55 Gy according to the patient's age and stage. All the patients received chemotherapy according to VAC or pulse-VAC (before 1988) and modified AVAC (after 1988) protocol. Survival curves were calculated by the Kaplan-Meier method. The statistical significance of each variable was tested by the log-rank test. Overall survival was 42 percent at 10 years. Three important predictors for survival time were clinical group (p < 0.001), age (p < 0.001) and primary site (p = 0.005). The best results involved clinical group I-II, age one to five years and orbital and genitourinary primary sites. An important predictor of survival time was also detected between those treated during the first ten years (1972-82) and last 10 years (1982-92), p < 0.005. Of the 96 deaths, 37 were from progressive disease, 24 from infection, 4 during postoperative period (first 7 days), 18 from unknown causes and 13 from other causes.

Contractility and electrophysiological parameters of cremaster muscles of boys with a hernia or undescended testis

BACKGROUND/PURPOSE

The cremaster muscle (CM) has been considered to participate in regulation of blood flow and temperature of the testis. Its contribution to testicular descent has been suggested. However, there is limited information about the CM in physiological and pathological states. Therefore, an experimental study has been conducted to evaluate and compare the contractile and electrophysiological properties of CM in boys with descended or undescended testes.

METHODS

Identical CM strips were obtained from eight boys who underwent orchidopexy with a mean age of 3+/-2.2 years and from eight boys who underwent herniorrhaphy with a mean age of 4+/-1.3 years. Muscle strips of 3 x 8 mm were vertically attached to an isometric force displacement transducer, and direct muscle contractions were elicited by rectangular electrical pulses. Direct isometric muscle contractions were recorded in an organ bath containing mammalian Ringer's solution. In electrophysiological experiments, conventional microelectrode techniques were used.

RESULTS

Direct electrical stimulation of CM strips obtained from patients with descended and undescended testes elicited muscle twitches and frequency-dependent contractile responses. Tetanic contractions of undescended testes at 100 Hz were 67% greater in amplitude than that of descended testes (P< .002). Muscle strips of both groups exhibited increased twitch amplitudes by 105%+/-37% when the temperature of the bathing solution was increased from 22 degrees to 37 degrees C (P< .001). The electrophysiological findings were similar.

CONCLUSIONS

Contrary to other striated muscles, elevated temperature increases the contractility of CM. If the increased contractility by an increase in temperature is a property unique for CM, it should reflect the attempts at regulating testicular blood flow or temperature. The increased amplitude of contractions encountered among the CM of boys with undescended testis suggests the CM to have a role on the location of the testis.

Redo operations of Hirschsprung's disease

The purpose of this study was to specify the indications, applicability and final outcome of the redo definitive operations of Hirschsprung's disease. Between 1976-1993, 213 patients had undergone definitive operations of Hirschsprung's disease. In this series, 5 who required a redo pull-through operation were investigated. The redo pull-through operations were performed in 5 patients because of severe anastomotic stricture or total closure of the anastomotic site, recto-urethral fistula, anastomotic stricture, and enterocolitis due to anastomotic disruption. The initial definitive procedures were in 4 patients the Swenson operation and in one patient the Boley operation. As redo pull-through operations, the following were performed with success: in 3 patients, the Duhamel operation; and in 2 patients, the Swenson operation. The final outcome of the redo pull-through alterations were satisfactory and it can be suggested that one should not hesitate to perform a redo pull-through operation in selected Hirschsprung patients.