Is ultrasound guidance necessary to avoid complications in the implantation of venous access ports?

BACKGROUND

The aim of this study was to present demographic information of patients undergoing totally implantable venous access port (TIVAP) implantation and to investigate the rates of early and late complications, assessing the benefits of performing the procedure underUS guidance.

METHODS

From May 2018 to December 2023, the outcomes of a total of 537 TIVAP implantation procedures were analyzed retrospectively. Data of the surgeons' experiences for both puncture methods (anatomical landmarks and ultrasound guidance) are presented in the study.

RESULTS

The average age of the patients was 53.1±11.9 years, and 261 (48.6%) were female. The right subclavian vein was the preferred insertion site. Fourteen patients developed early complications and 11 developed late complications. Arterial puncture was the most common early complication, while catheter-related infection was the most common late complication. The age, sex, and body mass index of the patients were not independent risk factors for developing complications. Early complications increased as the number of puncture attempts did (p=0.034) and developed significantly less when ultrasound guidance was used during insertion (p=0.011).

CONCLUSION

The risk of developing complications was not affected by patient's age or sex. In addition, body mass index was not shown to be an independent risk factor for patients developing complications. It may be concluded from the study that early complications in particular can be reduced with ultrasound-guided implantation.

Foley catheter technique for the extraction of coins lodged in the upper esophagus of children

INTRODUCTION

Coins are the most commonly ingested foreign bodies in children. They usually become lodged in the upper oesophagus and should be managed immediately. The aim of the present study was to evaluate the characteristics and outcomes of patients with coins lodged in the upper oesophagus, who underwent coin removal using a silicone Foley balloon catheter without fluoroscopy or anaesthesia and evaluate the safety of the procedure.

MATERIALS AND METHODS

Patients who were admitted from January 2007 to December 2022 for coins lodged in the oesophagus and extracted with silicone Foley balloon catheter without anestehesia were evaluated retrospectively. We focused on the patient characteristics and clinical presentations, and the treatment safety, efficacy, and outcomes.

RESULTS

773 patients (416 male, 357 female), with a mean age of 3.5 years (range 6 months to 16 years), who ingested coin and extracted with Foley catether is included. The majority of patients (n = 728, 94.17%) were successfully managed by silicone Foley balloon catheter extraction. Our overall success was 94.17%, with 88.30% of coins retrieved and 5.9% pushed into the stomach. Patients who were successfully treated with Foley catheter were discharged on the same day except for 7 (0.90%) who had minimal bleeding. Only 45 (5.82%) patients required oesophagoscopy in the operating room and these patients were kept overnight for clinical follow-up, without any further interventions.

CONCLUSION

A Foley balloon catheter can be used to safely and effectively remove coins that are lodged in the upper oesophagus avoiding the risk of general anesthesia.

Is the increased ozone dosage key factor for its anti-inflammatory effect in an experimental model of mesenteric ischemia?

BACKGROUND

Ischemia/reperfusion injury of the intestines is a severe surgical condition. This study aimed to reveal ozone therapy effects with relatively increased ozone dosage in a created ischemia/reperfusion injury model.

METHODS

In this study, 24 albino Wistar rats were examined in three groups. Rats in the control group (CG, n=8) underwent only a laparotomy. In the sham group (SG, n=8) and ozone group (OG, n=8), the superior mesenteric artery (SMA) of the rats was occluded for 1 h. After deoccluding the SMA, the abdomen was closed, physiological saline was infused intraperitoneally in the SG, and an increased ozone/oxygen mixture dose (from 0.7 mg/kg to 1 mg/kg) was infused intraperitoneally in the OG. Small intestine samples were obtained at the 24th h for histopathological examination of intestinal mucosal injury and evaluated according to the Chiu score. In addition, Malondialdehyde and Myeloperoxidase levels were evaluated for oxidant levels, whereas, Glutathione (GSH) enzyme activity was measured to evaluate the tissue antioxidant system.

RESULTS

Histopathologically, the Chiu score was the lowest in the CG. It was lower in the OG compared to the SG showing the ameliorating effect of ozone on the intestinal mucosa. Chiu score in the OG was higher compared to that in the CG, but not statistically significant. A significantly higher GSH level was observed in the OG compared to the SG, proving antioxidant activity.

CONCLUSION

In this experimental model of ischemia/reperfusion in rats, treatment with an increased ozone level decreased the inflammatory process through antioxidant mechanisms and reduced intestinal mucosal damage. However, the effectiveness of ozone therapy depends on its dosages.

Laparoscopic Repair of Morgagni Hernia in Children

PURPOSE

This study aimed to evaluate our patients who underwent laparoscopic-assisted transabdominal repair for Morgagni hernia (MH).

METHODS

We retrospectively reviewed patients who underwent laparoscopy-assisted transabdominal repair using loop sutures for MH between March 2010 and April 2021. Demographic data, symptoms, operative findings, operation methods, and postoperative complications of the patients were reviewed.

RESULTS

A total of 22 patients with MH were treated with laparoscopy-assisted transabdominal repair using loop suture. There were 6 girls (27.2%) and 16 boys (72.7%). Two patients had Down syndrome, and two patients had cardiac defects (secundum atrial septal defect, patent foramen ovale). One patient had a V-P shunt due to hydrocephalus. One patient had cerebral palsy. The mean operation time was 45 min (30-86 min). The hernia sac was not removed, and a patch was not used in any of the patients. The mean hospitalization time was 1.7 days (1-5 days). One patient's defect was very large, and another patient's liver was densely attached to the liver sac, causing bleeding during dissection. In total, two patients were converted to open surgery. There was no recurrence during the follow-up.

CONCLUSION

Laparoscopy-assisted transabdominal repair is an efficient and safe choice for the repair of MH. Leaving the hernia sac does not increase the recurrence, so there is no need to dissect the sac.

A rare cause of intestinal obstruction in children: signet-ring cell adenocarcinoma of the colon

BACKGROUND

Signet-ring cell adenocarcinoma of the colon is well-recognized in adult patients who are extremely rare and not well-documented in children. Our study aims to raise awareness about this rare disease and its long-term outcomes.

METHODS

We retrospectively evaluated patients with signet-ring cell colon adenocarcinoma.

RESULTS

Six patients, three boys and three girls, with a mean age of 14.83 (range, 13-17 years), presented with signs of intesti-nal obstruction and were diagnosed with signet-ring cell colon adenocarcinoma. All patients had air-fluid levels on abdominal X-ray. Abdominal ultrasonography of all patients revealed subileus. Abdominal computed tomography was performed in five patients, and pre-operative colonoscopy was conducted in two patients before the emergency intervention. All of the patients underwent emergent exploratory laparotomy with the preliminary diagnosis of acute abdomen. In two patients, debulking surgery followed by a stoma was performed. The remaining four patients were treated with anastomosis following intestinal resection. All girls had metastases on the ovary. One of the patients died due to the burden of multiple metastases in the early period, and three died in the sixth post-operative year. We have been following the remaining two patients since then.

CONCLUSION

Although signet-ring cell carcinomas (SRCCs) are rare, they should be considered in the differential diagnosis of acute abdomen and intestinal obstruction in pediatric patients. Despite early diagnosis and treatment, SRCC has a poor prognosis in the pediatric population.

Long-term 10-year comparison of girls with congenital adrenal hyperplasia who underwent early and late feminizing genitoplasty

OBJECTIVES

The appropriate time to perform feminizing genitoplasty in patients with congenital adrenal hyperplasia (CAH) with the 46, XX genotype is still debatable. The aim of our study was to evaluate the relationship between age at surgery and long-term surgical outcomes of patients who underwent feminizing genitoplasty.

METHODS

We retrospectively analyzed 14 patients with CAH and 46, XX genotypes with feminizing genitoplasty (clitoroplasty + vaginoplasty) between 2005 and 2022. The patients were divided into two groups. Group 1 consisted of seven girls (n = 7/14) who have been operated before the age of 2 years. Group 2 consisted of seven girls (n = 7/14) who have been operated after the age of 2 years. The two groups are compared regarding anatomical assessments, overall cosmetic results, need for additional intervention using Creighton's criteria. Additionally, the cosmetical satisfaction of the patients/parents is questioned.

RESULTS

The mean age of the girls was 32.42 months (10-96 months) during operation time. The mean age of Group 1 patients (n = 7/14) who have been operated before the age of 2 years was 11.71 months (10-19 months). The mean age of Group 2 patients (n = 7/14) who have been operated after the age of 2 years was 53.14 months (36-96 months). The mean follow-up time was 10.57 years (3-18 years). There was no statistically significant difference between those operated on before and after two years in terms of anatomical assessments, overall cosmetic results and patient/parent satisfaction except the need for additional intervention (p = 0.049). In Group1 (operation age < 2 years old), five out of seven (71.42%) patients needed additional major surgery (four urogenital sinus re-mobilization, one redo-clitoroplasty). Those who received additional major surgery were the ones who were not satisfied. In Group 2 (operation age > 2 years old), two patients out of seven patients (28.57%) received major surgery (two redo-urethroplasties) and those patients were not satisfied. When patient/parent satisfaction was compared with additional surgical intervention, as expected, patients'/parents' satisfaction increased as major surgical intervention decreased. This was statistically significant (p = 0.007). The main source of dissatisfaction was repeated surgery among the parents.

CONCLUSIONS

The possibility of this additional surgical intervention increases, and patient/parent satisfaction decreases in patients below the age of 2 years. The corrective surgeries can be differed until the gender identity of the patient matures and the patient autonomy in deciding whether this surgery should occur.

Can serum soluble urokinase plasminogen activator receptor be an effective biomarker in comparing the inflammatory response between laparoscopic and open appendectomy?

Introduction

The inflammatory response after laparoscopy and laparotomy has been compared in studies in adults, but only a few studies have compared the immune response between laparoscopy and laparotomy in children.

Aim

To compare open and laparoscopic appendectomies regarding a new biomarker, suPAR, to evaluate the inflammatory response.

Material and methods

Patients between 3 and 17 years of age who were admitted to the pediatric surgery department and scheduled for appendectomy due to appendicitis were enrolled in the investigation. The patients were randomized to receive either laparoscopic (n = 20) or conventional open appendectomy (n = 20). The primary outcome was a change in preoperative and postoperative suPAR levels. The secondary outcomes were the white blood cell count, lymphocytes, neutrophils, platelets, C-reactive protein level, appendix diameter, symptoms, symptom duration, surgical complications, operative time, rescue analgesics, hospital stay, and family satisfaction.

Results

The mean age of the patients undergoing laparoscopic appendectomy was 10.55 ±2.743 (3-17) years. The mean age of the patients undergoing open appendectomy was 11.40 ±3.515 (3-17) years. A statistically significant difference was found when the postoperative suPAR values between the two groups were compared (p = 0.048). The operative time and hospital stay in the laparoscopic group were significantly shorter than those in the open group (p = 0.001, p = 0.047).

Conclusions

Laparoscopic appendectomy is associated with a shorter operative time, a shorter hospital stay, and a smaller inflammatory response caused by surgical stress than open appendectomy. suPAR is an effective marker for comparing postoperative inflammatory stress between open and closed appendectomies.

Trichobezoar presenting as an acute abdominal obstruction in a 17-year-old girl

Trichobezoars are hairballs that combine with food residue in the digestive tract as a result of ingesting hair. A 17-year-old girl was admitted to the emergency department with abdominal pain and vomiting for 3 days. She had been having digestive difficulty and bloating for the previous 2 months. An abdominal radiograph demonstrated air-fluid levels consistent with ileus, and an ultrasound showed hyperechoic material in the stomach and ileum. Computed tomography demonstrated images of trapped air which was considered diagnostic of a bezoar. At laparotomy, a large mass was removed from the stomach. As the bezoar extended through the pylorus and duodenum and there were mobile masses palpable in the ileum, it required a second incision to remove them. For some years she had had a habit of swallowing hair which she found on her pillow and there was a history of an obsessive personality trait and hyperactivity for which she agreed to attend a psychiatric clinic.Abbreviations: BMI: body mass index; CT: computed tomography; Hb: haemoglobin; IV: intravenous; WHO: World Health Organization.

The effect of hydrogen sulfide on ischemi̇a /reperfusion injury in an experimental testicular torsion model

INTRODUCTION

Testicular torsion is an acute pediatric surgical emergency requiring rapid diagnosis to prevent the permanent ischaemic damage of the testicles. Hydrogen Sulfide (H2S) have shown to cure tissue damage and has a role in the prevention of I/R damage. We aimed to evaluate the effect of H2S in testicular torsion.

MATERIALS AND METHODS

Eighteen male, Wistar albino rats were divided into 3 groups. The sham group which is applied surgical stress. The ischemia/reperfusion group (I/R) which detorsion performed 1 h later than testicular torsion application. I/R + NaHS treatment group, NaHS solution was injected intraperitoneally for 1 week. On the 7th day of the detorsion all left testes were fixed in Bouin solution and sent to Pathology Department for histopathological examination. All right testes were washed with normal saline, dried in a sterile way and stored in - 80 °C deepfreeze up to the date of biochemical processes. Testicular tissues were obtained for the detection of myeloperoxidase (MPO), malondialdehyde (MDA), AOPP (advanced oxidation protein product) for oxidant markers and ferric reducing antioxidant power (FRAP) levels, superoxide dismutase (SOD),glutathione peroxidase (GSH-Px) activities for antioxidant markers and histopathological exploration.

RESULTS

The effects of NaHs administration on oxidation were evaluated by determination of testicular MPO, MDA and AOPP levels. Increased testicular MPO (58.6%) activity was observed in the I/R group compared to the sham group. Following NaHS treatment, MPO (26.7%) activity was significantly decreased in rats exposed to I/R injury (Figure 1). MDA levels did not alter. Increases in AOPP (20.9%) levels were observed in the I/R group. NaHS treatment resulted in significant decreases in AOPP (25.1%) levels in testes tissues of rats exposed to I/R injury. The effects of NaHS treatment on antioxidant system FRAP, SOD, GSH and GSH-Px activities were evaluated. GSH levels were significantly increased in the IR + NaHS group compared to the I/R group. In histopathological examination degeneration of seminiferous tubules and spermatogenic cells were observed in the I/R group. After NaHS treatment, normal spermatogenic activity with many spermatozoa in the lumen of most seminiferous tubules were observed in the I/R injured rats. According to Johnsen's scoring (JS), the I/R group was significantly decreased compared to the sham group. JS values for the I/R + NaHS group were significantly increased compared to the I/R group.

CONCLUSION

Our study supports that ischemia/reperfusion injury plays an important role in the testicular torsion injury, and it is a pioneer study showing that H₂S may have a potential for therapeutic effect. The limitation of this work is this is an experimental study with limited number of animals. According to the results of our study, hydrogen sulfide treatment has beneficial effects on biochemical and histopathological results of testicular injury in testic torsion.

Long-term outcomes of six patients after partial internal biliary diversion for progressive familial intrahepatic cholestasis

BACKGROUND

Partial internal biliary diversion (PIBD) is an alternative approach for the treatment of devastating pruritus in patients with progressive familial intrahepatic cholestasis (PFIC). In these patients quality of life can be improved and progression of liver disease can be delayed while waiting for liver transplantation. The aim of our study was to evaluate six patients with PFIC who have undergone PIBD in long-term follow-up.

METHODS

Retrospective review of the records of six patients who underwent PIBD for PFIC between 2008 and 2010 was conducted to evaluate age, growth, clinical and laboratory studies for long-term outcome.

RESULTS

Serum postoperative bile acid levels were reduced from a mean 340.1μmol/L (range 851-105) preoperatively to a mean of 96.3μmol/L at postoperative fifth year. The difference between pre- and postoperative bile acid levels was statistically significant (p=0.018). AST decreased from 79.1U/L (range 43-150U/L) to 64.6U/L (range 18-172U/L), ALT decreased from 102.8U/L (range 35-270U/L) to 84.6U/L and total bilirubin decreased from 2.9μmol/L (range 0.35-6.4μmol/L) to 1.53μmol/L (range 0.3-2.4). Again, the decrease in total bilirubin levels was significant (p=0.043). Pruritus was diminished from a mean of +4 (range 4-4) preoperatively to a mean of +2 (4-0). One patient who underwent liver transplantation owing to relapsing pruritus died from postoperative sepsis in the early postoperative period at the fifth year after PBID. Five symptom-free patients have not required liver transplantation at a mean period of 6.1±0.83years (5.1-7.0years) follow-up.

CONCLUSION

PBID is an effective surgical procedure in the long-term and can delay the need for liver transplantation in children with PFIC by reducing jaundice and pruritus.

Neonatal perforated appendicitis in incarcerated inguinal hernia in the differential diagnosis of testis torsion

Appendicitis in newborns is uncommon and difficult to diagnose. Reports on neonatal appendicitis subsequent to inguinal hernia incarceration are exceptionally rare. We present the case of a 26-day-old infant with perforated appendicitis due to incarceration of a right inguinal hernia, mimicking right testicular torsion.

Long-term outcomes of children with transanal endorectal pull-through and a review of the literature

INTRODUCTION

The transanal endorectal pull-through (TERPT) procedure, the latest advancement in the surgical treatment of Hirschsprung's disease, has replaced most other surgical techniques in the last decade.

PATIENTS AND METHODS

Between October 2002 and March 2014, a total of 22 patients diagnosed with Hirschsprung's disease underwent a one-stage TERPT operation.

RESULTS

Resected segments included the rectosigmoid (seven patients), the descending colon (10 patients), and the transverse colon (five patients). The minimum length of the resected segments was 15 cm and the maximum length was 65 cm. The mean length was 39.18 ± 12.05 cm. Following surgery, the start of oral ingestion was 1-8 days (mean 3 ± 1.69 days) and the hospital stay after the operation lasted 4-11 days (mean 7.04 ± 2.05 days). The mean follow-up period was 48 ± 6 months (range of 24-166 months). Out of 22 patients, three patients had an anal stricture, which responded to anal dilatations; three patients had an enterocolitis episode that required hospitalization; two patients experienced constipation; and two patients had incontinence/soiling.

CONCLUSION

Our data suggest that the TERPT operation can be safely performed in terms of long-term complications.

Antioxidant Effects of Probiotics in Experimentally Induced Peritonitis

AIM

An experimental study was performed to evaluate the protective effects of probiotics on gut mucosa in peritonitis through antioxidant mechanisms.

METHODS

Thirty-two male Wistar albino rats were divided equally into four groups. The rats in Group 1 (control group) underwent laparotomy only. In group 2 (peritonitis group), peritonitis was induced in the rats by the cecal ligation and puncture (CLP) model. In group 3, the rats were treated with probiotics for five days after CLP-induced peritonitis. The last group of rats (group 4) were fed probiotics for five days before the CLP procedure and five days after the surgery. On the fifth day after surgery, all rats were killed, and tissue samples from the terminal ileum were obtained to evaluate the activities of myeloperoxidase (MPO), malondialdehyde (MDA), and glutathione (GSH). Histopathologic examinations were also performed to evaluate the grade of intestinal injury.

RESULTS

Myeloperoxidase and MDA activities were increased, GSH concentrations were decreased in group 2, compared with group 1. Intestinal MPO activities in group 4 were decreased compared with group 1 and group 2, indicating a reduction in oxidant activity. Malondialdehyde decreased in group 3 and decreased even more in group 4, compared with the peritonitis group (group 2). Glutathione concentrations were increased in group 4 compared with group 2 and group 3 (p < 0.05). The Chiu scores of the probiotics groups, groups 3 and 4, were lower than those in group 2, indicating reduced mucosal damage in the probiotically fed groups.

CONCLUSION

Probiotics have protective effects in peritonitis, which may be related to antioxidant mechanisms. This antioxidant effect of probiotics might occur when pre-conditioning with probiotics before peritonitis because there is sufficient time to prepare the tissues for oxidative damage.

Percutaneous internal ring suturing as a first choice laparoscopic inguinal hernia repair method in girls: a single-center study in 148 patients

INTRODUCTION

We sought to retrospectively assess the operative findings and clinical outcomes of 148 girls who underwent laparoscopic inguinal hernia repair with the percutaneous internal ring suturing (PIRS) technique.

METHODS

Between 2010 and 2014, girls with inguinal hernia underwent surgery using the laparoscopic PIRS technique described by Patkowski. Demographic and perioperative findings, complications, and recurrences were evaluated.

RESULTS

A total of 205 inguinal hernia repairs were performed in 148 children with a mean age of 5.83 years (1 month-16 years). In 57 girls (38.5 %), the hernias were bilaterally repaired, while in 91 girls (61.5 %) hernias were unilaterally repaired. The mean follow-up time was 3.6 years (range 2.5-6.1 years). No serious complications or recurrence were noted. Granuloma occurred in one patient.

CONCLUSION

The PIRS technique is a safe, simple and effective procedure for girls. Excellent cosmetic results and reduced recurrence rates are associated with this method. This procedure is particularly suitable for girls because they lack a spermatic cord and vascular structures that can cause complications with this technique in boys. Based on our experience and others in the literature, we suggest that the PIRS procedure might be considered a gold standard for inguinal hernia operations in girls.

Laparoscopic repair in children with traumatic bladder perforation

Here, we report two patients with a traumatic intraperitoneal bladder dome rupture repaired by laparoscopic intracorporeal sutures. The first patient was a 3-year old boy was admitted with a history of road accident. He had a traumatic lesion on his lower abdomen and a pelvic fracture. Computed tomography (CT) scan revealed free intraabdominal fluid. The urethragram showed spreading contrast material into the abdominal cavity. Laparoscopic exploration revealed a 3-cm-length perforation at the top of the bladder. The injury was repaired in a two fold fashion. Post-operative follow-up was uneventful. The second case was a 3-year-old boy fell from the second floor of his house on the ground. He had traumatic lesion on his lower abdomen and a pelvic fracture. Due to bloody urine drainage, a cystography was performed and an extravasation from the dome of the bladder into the peritoneum was detected. On laparoscopy, a 3-cm long vertical perforation at the dome of the bladder was found. The perforation was repaired in two layers with intracorporeal suture technique. The post-operative course was uneventful. Laparoscopic repair of traumatic perforation of the bladder dome is a safe, effective and minimally invasive method. The cosmetic outcome is superior.

Sleeve resection for bronchial carcinoid tumour in two children under six years old

BACKGROUND

Paediatric tracheobronchial tumours are very rare, and pneumonectomy and lobectomy procedures are rarely indicated due to their surgical difficulties and high sequelae. Bronchoplastic techniques preserving lung parenchyma allow the resection and reconstruction of the main bronchi and carina.

CASE PRESENTATION

Here, we present a 6-year-old boy suffering from a carcinoid tumour of the right main bronchus which was successfully managed with a right upper sleeve lobectomy and a 4-year-old girl with an endobronchial carcinoid tumour narrowing the left main bronchus that received a sleeve resection of that bronchus.

CONCLUSION

Bronchoplastic techniques are widely used in adults, can be very successful in paediatric patients where the preservation of the lung parenchyma is more important.

Pulmonary metastasectomy in pediatric patients

Background

This study aims to evaluate the outcomes of pulmonary metastasectomy resections in pediatric patients.

Methods

We retrospectively reviewed the medical records of 43 children who were operated on in the Pediatric Surgery Clinic between January 1988 and 2014. Forty-three children (26 boys; 17 girls; mean age 10 ± 4.24 years, range 6 months–18 years) who underwent pulmonary metastasectomy resection were included in the study. The patients were evaluated based on age, gender, history of disease, surgical procedures, complications, duration of hospitalization, duration of chest tube placement, and procedure outcome.

Results

Indications for pediatric resections were oncological. Metastasis was secondary to Wilms’ tumor in 14 patients, osteosarcoma in 7 patients, Ewing’s sarcoma in 5 patients, rhabdomyosarcoma in 5 patients, lymphoma in 3 patients, hepatoblastoma in 2 patients, and other tumors in 7 patients. A total of 59 thoracotomies were performed. Approaches utilized included unilateral posterolateral thoracotomy (n = 33), bilateral posterolateral thoracotomy (n = 8), and sternotomy (n = 2). Wedge resection was the procedure of choice (n = 44). In selected cases, 11 segmentectomies, 3 lobectomies, and 1 pneumonectomy were performed. There was no perioperative mortality. One patient suffered prolonged air leak and three patients from fever. All patients received chemotherapy. Radiotherapy was administered to 16 patients (37.2 %). Of those 16 patients, 7 had Wilms’ tumor, 6 had Ewing’s sarcoma/PNET, and 3 were rhabdomyosarcoma patients. During a median follow-up of 3 years, the overall survival was 74.4 %.

Conclusions

Multidisciplinary treatment involving pediatric oncologists, surgeons, and radiation oncologists is necessary to obtain positive results in children who have pulmonary metastases of oncological diseases. Wedge resection is a suitable option for children because less lung tissue is resected.

Early myotomy and fundoplication in achalasia in childhood: a single-centre experience for 22 years

Introduction The aim of this study was to review a single institution's experience with surgical interventions in children with achalasia and to determine treatment strategies for this rare disorder. Patients and methods This study is a retrospective analysis of 22 cases of childhood achalasia from 1991 to 2013. The patients were evaluated in terms of age, symptoms, interventions, intraoperative complications, and recurrent dysphagia. Results There were 13 boys and nine girls (7 months to 17 years old). The clinical symptoms were vomiting (68%), dysphagia (36%), wheezing (18%), coughing (13%), and weight-loss (13%). The mean duration of symptoms was 2.4 years (1 month to 6 years). A barium contrast X-ray study was performed in all of the patients. Oesophageal manometry was performed in eight patients. Six patients underwent multiple oesophageal dilatations (ED) as a first intervention. A Heller myotomy (HM) and fundoplication were performed in all the patients except two patients who recovered with dilatation. In the long term, one patient had a stricture due to the operation and had to undergo a reoperation. Of the Heller myotomy patients, one had a recurrent stricture that responded to dilatation. No other complications were present. All the patients are now asymptomatic. Conclusion Early diagnosis and prompt surgical treatment is important to prevent growth impairment in childhood achalasia cases. A Heller myotomy followed by a partial anti-reflux procedure is an effective treatment for achalasia in children. Based on our experience, it is superior to oesophageal dilatation therapy.

Management of a Wilms' tumor with intracardiac extension using extracorporeal circulation and deep hypothermic circulatory arrest: Case report and review of the literature

Wilms' tumor is a relatively common malignancy among childhood cancers. However, intracardiac extension of the lesion is rare and challenging. In this report, the authors present a successful management of intracardiac extension of Wilms' tumor in a 3-year-old child using cardiopulmonary bypass and deep hypothermic circulatory arrest. The authors also reviewed the published literature on Wilms' tumor with cardiac extension, which were managed by cardiopulmonary bypass and deep hypothermic circulatory arrest to provide an optimum management plan in this challenging condition.

The Role of Ozone Therapy in Hepatic Fibrosis due to Biliary Tract Obstruction

PURPOSES

In this experimental study, we investigated the role of ozone therapy in hepatic fibrosis caused by biliary obstruction.

MATERIALS AND METHODS

In this study, 21 male Sprague-Dawley rats were divided equally into three groups. In the control group, only laparotomy was performed and intraperitoneal cavity is washed with 1 mL of saline. In the sham group (SG), common bile duct is binded with laparotomy and no treatment is given afterward. In the experimental group (EG) after the binding of common bile duct with laparotomy, 1 mg/kg dose and 50 mg/mL concentration of ozone were applied rectally for 21 days. Hepatic tissue sample and intracardiac blood samples were collected from all animals at postoperative 21st day with relaparatomy.

RESULTS

When we compared the experiment to SG, we detected a decrease in aspartate aminotransferase, alkaline phosphate (ALP), total bilirubin, and direct bilirubin levels in the EG, however, only the decrease in total bilirubin levels were statistically significant (p = 0.025). Histopathological examination of livers of rats in the EG showed lower level of hepatic fibrosis and inflammation. In the SG, incomplete cirrhosis was detected in 57.1% of the rats, whereas in the EG, no cirrhosis was detected. Immunohistochemically, periportal inflammation was 100% in the SG, whereas it was seen (3/7) 42.9% in the EG. A significant decrease in positive α-smooth muscle actin reaction was observed in ozone-treated group compared with SG.

CONCLUSION

We suggest that ozone can decrease the hepatic destruction levels in experimental model of biliary obstruction.

The Value of Mitotic Count and Ki67 Proliferation Index in Congenital Mesoblastic Nephroma

OBJECTIVE

We aimed to define the histopathologic features and proliferative rate of congenital mesoblastic nephroma (CMN) as a risk factor for recurrence.

METHODS

Fourteen cases of CMN among 138 registered pediatric renal tumors were retrospectively reviewed. The prognostic impact for mitotic rate and Ki67 index was investigated.

RESULTS

There were four (28.6%) classic, six (42.9%) cellular, and four (28.6%) mixed type CMNs, with average Ki-67 counts of 16.75% in the classic CMN, and 53.2% in the tumors with cellular components (both mixed and cellular CMNs). Twelve patients (85.7%) were aged less than six months. Tumors with cellular component showed significantly larger tumor diameter and higher Ki-67 index (p = 0.015 and p = 0.016, respectively). The patient with cellular CMN, whose tumor showed the highest mitotic rate (4.9/HPF), but not the highest Ki67 index (57.4%), died of recurrent disease with distant metastasis.

CONCLUSION

Proliferative markers-mitotic count and Ki67 index-have limited value to predict recurrence or metastasis in CMNs with a cellular component.

Management of a Benign Phyllodes Tumor in a 13-Year-Old Girl with Trans-position of the Nipple Areola Complex and Breast Reconstruction

Phyllodes tumor is a rare primary tumor of the breast. In children and adolescents, it is even rarer with only 20 cases, treatment of which vary in the literature. Herein we report the case of a 13-year-old female patient with a giant benign phyllodes tumor eroding the bottom of the breast skin and causing nipple retraction. We performed breast conservative surgery by mobilizing the areola, using skin flaps and inserting an implant. Breast malignancy, including phyllodes tumor (PT), is very rare in adolescents. PT, previously called cystosarcoma phylloides, consists of leaf-like fronds, from which the tumor gets its name (1, 2). Although PT is most often seen in the fourth decade of life, almost 20 cases have been reported in the adolescent period, most of which are benign. The histologic types are benign, borderline, and malignant, depending on the mitotic rate of the tumor (3, 4).

A Cystic Mass does not Always Mean Hydatid Cyst in Endemic Areas

Within the medical community, there is a tendency to describe all cystic lesions in the liver and lungs as Hydatid disease (HD) in areas with HD endemics. This approach may sometimes cause a misdiagnosis. We have three cases with children aged between seven, seven and ten year old, all of whom had been diagnosed, via radiologic imaging, with HD cysts and started on treatment without confirmation. The true diagnoses of these cases were undifferentiated embryonal sarcoma (UES) in two and oesophageal duplication in one case, respectively. The indirect haemagglutination assays (IHA) were obtained in two of them. Although their results were negative, albendazole treatment was started in all cases. Confirmatory tests should be run in dubious cases. An IHA test can aid the diagnosis, although its effectiveness is limited. The possibility of false positive and negative results always exists, especially in lung cysts. A percutanous biopsy is strongly advised for differential diagnosis.

Proteus syndrome: report of intra-abdominal lipomatosis

Proteus syndrome (PS) is an extremely rare sporadic disorder that manifests as an asymmetric, disproportionate overgrowth of any connective tissues, such as bone, fat, or epidermal nevi, in a mosaic or patchy pattern. This hamartoneoplastic syndrome was first described by Cohen and Hayden. Its prevalence is approximately 1 per 1,000,000 live births, and intra-abdominal expansion has been reported in no more than 20 cases in the literature. The phenotypes of the patients differ because of the variation in the pattern of the overgrowths, making diagnosis difficult. Extremely large subcutaneous lipomas and internal lipomas, which occur rarely, are one of the presentation phenotypes. Here, we present the second patient in the literature with PS involving the epiploon.

Mediastinal masses in children: experience with 120 cases

Primary mediastinal malignancies are rare tumors and can originate from any mediastinal organ or tissue such as thymic, neurogenic, lymphatic, germinal, or mesenchymal. The authors reviewed all cases of primary pediatric mediastinal masses diagnosed over a 25-year period to determine the pattern of presentation, the histology, and the outcome of the surgical treatment. In this study, 120 primary pediatric mediastinal mass cases diagnosed between 1985 and 2011 are retrospectively evaluated according to their age, sex, symptoms, anatomical location, surgical treatment, and histopathological evaluation. The median age of the patients was 5.8 years. There were 34 benign and 86 malign tumors. Thirty patients were asymptomatic. Common symptoms in the patients were cough, dyspnea, fatigue, fever, abdomen pain, back pain, and neurological symptoms. According to their origins, they were presented as neurogenic tumors (38.3%), lymphomas (18.3%), undifferentiated sarcomas (15%), germ cell tumors (7.5%), and the other tumors (22%) thymic pathologies, lymphangiomas, rhabdomyosarcomas, lipomas, hemangiomas, and Wilms' tumor. Complete resection of the tumor was performed in 86 patients, partial resection of the tumor was the intervention in 11 patients. In 23 patients, biopsy was undertaken. Because of the high incidence of asymptomatic or nonspecific presentation such as the upper airway disease, the presentation of a mediastinal mass in children may be challenging. Neurogenic tumors or lymphomas are indicating surgery, if possible complete resection, for both benign and malignant conditions. Although surgery is the mainstay of therapy for most mediastinal tumors, an experienced multidisciplinary approach is necessary.