Indirect inguinal hernia repair conducted with single conventional port intracorporeal conventional equipment-endoscopic surgery

PURPOSE

Laparoscopic or laparoscopy-assisted inguinal hernia repair (IHR) can be performed using one port plus two stab wounds. We herein present our experience with laparoscopic IHR conducted using a single conventional port and a single working instrument.

METHODS

The records patients who underwent single conventional port intracorporeal IHR during November 2013-December 2018 were evaluated. The main outcome measurements were patient's demographic characteristics, hernia side, presence of incarceration, operative time, and complications.

RESULTS

A total of 132 inguinal hernias (52 right, 40 left, and 20 bilateral) were repaired in 112 patients (76 boys, 36 girls). The mean ages of the patients were 69.8 ± 53.4 months (3 months to 17 years). In six patients, contralateral processus vaginalis was found to be patent during operation. Incarcerated inguinal hernia was present in two patients. Mean operative time was 17.9 ± 3.8 min (9-30 min) in unilateral hernias and 28.9 ± 6.5 min (24-45 min) in bilateral hernias. No intraoperative and postoperative complications were encountered. The mean hospital stay of the patients was 8.8 ± 5.0 h (4-36 h). Postoperative follow-up was 16.5 ± 5.1 months (6-24 months). No recurrent inguinal hernias were detected during follow-up.

CONCLUSION

Single conventional port intracorporeal IHR obviates additional stab wounds. Additionally, present technique eliminates the risk of skin puckering, subcutaneous granuloma, infection, nerve, and muscle damage development induced by the subcutaneously placed knot in laparoscopy-assisted IHR. Single conventional port intracorporeal IHR in children is a feasible and safe operative technique with low complication rates.

Tubularized incised plate urethroplasty for the treatment of penile fistulas after hypospadias repair

OBJECTIVE

Urethrocutaneous fistula is the most common complication of hypospadias repair. Tubularized incised plate urethroplasty (TIPU) has been used for the management of distal fistulas. This study reports the usage of TIPU in the treatment of large penile fistulas.

MATERIALS AND METHODS

Between April 2002 and September 2012, 15 patients with large penile fistulas who were managed with TIPU were included in the study. The fistulas were sited along the penile shaft from proximal to distal penile localization. Glanular and coronal fistulas were excluded. The surgical technique was completed according to the standard TIPU technique. The surrounding scar tissue of the fistula was circumferentially excised, and the urethral plate at the level of the fistula was incised to provide performance of loose urethral tubularization. A urethral stent was kept for 5-7 days.

RESULTS

The mean age of the patients was 7.3 ± 3.1 years. Primary operation of these patients was tubularized preputial island flap (n = 6), on-lay preputial island flap (n = 4), and TIPU (n = 5). The sites of the hypospadias fistulas were as follows; penoscrotal (three), mid-penile (eight) and subcoronal (four). Fistulas recurred in two patients after fistula repair. The postoperative follow up of the patients was 12.4 ± 7.7 months.

CONCLUSION

TIPU may be used safely for the treatment of fistulas after hypospadias repair.

Induction of fetal diuresis with intraamniotic furosemide injection reduces intestinal damage in a rat model of gastroschisis

BACKGROUND/PURPOSE

Contact with amniotic fluid causes intestinal damage (ID) in fetuses with gastroschisis. Intraamniotic meconium has been shown to be responsible for ID, and ID has been shown to correlate with intraamniotic meconium concentrations. ID can be prevented by lowering the intraamniotic meconium concentration. A new method to lower intraamniotic meconium concentration might consist in the induction of fetal diuresis with intraamniotic diuretic injection. This hypothesis was tested in a rat model.

MATERIALS AND METHOD

There were 4 experimental groups.

CONTROL GROUP

Rat fetuses without any manipulation. Fetuses were harvested by cesarean section for examination at E21.5 (Term). SHAM GROUP: On E18.5, the hind limb of the rat fetuses were exteriorized by hysterotomy and replaced in the uterus. GASTROSCHISIS GROUP: Gastroschisis was surgically created in rat fetuses on E18.5, under a dissection microscope (16×). GASTROSCHISIS+FUROSEMIDE GROUP: After surgical creation of gastroschisis on E18.5, intraamniotic furosemide (5 mg/kg) was administered to the fetuses on E20. All fetuses were harvested on E21.5.

RESULTS

There was no significant difference between intestinal serosal thicknesses of the control and sham groups. The serosal thickness was significantly higher in the gastroschisis group compared to the control group. In the gastroschisis+furosemide group, the intestinal serosal thickness was found significantly decreased compared with the gastroschisis group.

CONCLUSION

Intraamniotic furosemide injection caused a substantial decrease in ID encountered in gastroschisis. The induction of fetal diuresis with intraamniotic furosemide injection seems promising as a prenatal treatment modality.

Can pulse oxymetry be used for measuring intestinal blood flow?

AIM

When studying intestinal blood flow (IBF) using radiolabeled erythrocytes in the rabbit intestinal volvulus model, we also evaluated whether a pulse oxymeter (POX) could be used for the measurement of intestinal blood flow.

METHODS

IBF was measured with radiolabeled erythrocytes and POX in the rabbit intestinal volvulus model. The study was performed on 3 groups: 1) baseline, 2) volvulus, 3) volvulus plus devolvulus.

RESULTS

The POX and scintigraphic measurements were in correlation and showed that IBF stopped for 6 hours following volvulus. IBF was significantly decreased in the volvulus plus devolvulus group compared to the baseline group (p < 0.01). IBF measured with POX correlated with scintigraphic measurements.

CONCLUSION

POX is useful for the measurement of IBF and thus may be a cheap and reliable alternative to other intestinal blood flow measurement methods.

A unique opportunity for the operative treatment of high anorectal malformations: laparoscopy

BACKGROUND/PURPOSE

Georgeson et al. have reported a new operative technique for the treatment of high anorectal malformations (ARM) instead of posterior sagittal anorectoplasty (PSARP). With this new operative technique, anorectal pull-through is performed without a posterior sagittal incision with laparoscopic assistance. Herein we report our experience with laparoscopy-assisted anorectal pull-through (LAARP).

METHODS

The hospital and the digital video records of 4 high ARM male patients who underwent LAARP between January 2002 and June 2004 were evaluated retrospectively. The LAARP procedure was accomplished as described by Georgeson et al. Dilatation of the neoanus was started on the 15th postoperative day and was continued twice daily until the desired anal diameter had been reached. The colostomies were closed thereafter.

RESULTS

LAARP was performed in the presence of colostomy in four patients. The first two patients are passing stools two or three times a day. A bowel management program has been initiated for the third patient, who is 4 years old. The last patient still has a colostomy.

CONCLUSIONS

The laparoscopically excellent visualization of the pelvic musculature, especially of the pubococcygeal muscles, provides a great opportunity for accurate placement of the rectum in its anatomically precise place, without dividing the sphincteric muscle complex. Although there is not enough data regarding fecal continence after LAARP, we think that LAARP provides a unique opportunity for the operative treatment of high ARM and should be the first choice procedure for the operative treatment of high ARM.

Is induction of fetal diuresis with intraamniotic furosemide effective for the removal of intestinal waste products from amniotic fluid?

AIM

In gastroschisis, contact with amniotic fluid (AF) causes intestinal damage. Intraamniotic meconium has been shown to be responsible for the intestinal damage, and intestinal damage has been shown to correlate with intraamniotic meconium concentrations. Intraamniotic meconium below a threshold level does not cause intestinal damage. Intraamniotic meconium concentrations can be lowered by AF exchange. Can induction of foetal diuresis by an intraamniotic injection of furosemide be used as an alternative method for the same purpose?

METHOD

Pregnant rabbits on the 23rd - 25th gestational days (normal gestation time: 31 - 33 days) were divided into two groups, the control group and the furosemide group. Initial AF samples were taken, then either 5 mg/kg furosemide or a placebo was injected into the amniotic cavity. Final AF samples were obtained 6 hours later. AF urea nitrogen, creatinine, amylase, alkaline phosphatase and bilirubin levels were determined.

RESULTS

There was no significant difference between the initial and final levels of AF urea nitrogen, creatinine, bilirubin, amylase, and alkaline phosphatase in the control group, while the final AF urea nitrogen and creatinine levels of the furosemide group were not significantly different from the initial levels (p > 0.05). Final AF bilirubin, amylase and alkaline phosphatase levels of the furosemide group were significantly decreased compared with initial levels (p < 0.01).

CONCLUSION

Induction of foetal diuresis with intraamniotic furosemide is effective for the removal of intestinal waste products from amniotic fluid.

Intestinal damage in gastroschisis correlates with the concentration of intraamniotic meconium

BACKGROUND/PURPOSE

Contact with amniotic fluid (AF) causes intestinal damage in gastroschisis, which has been shown to be caused by intraamniotic meconium. However, whether this intraamniotic meconium-induced intestinal damage is concentration dependent has not been investigated previously. The purpose of this study is to investigate the effects of intraamniotic human meconium at various concentrations on the intestines of chick embryo with gastroschisis.

METHODS

Five-day-old fertilized chick eggs were used. Gastroschisis was created through the amniotic cavity without opening the allantoic cavity. Sterile meconium was obtained from newborn humans. Meconium suspensions at various concentrations were prepared using saline and instilled into the amniotic cavity.

RESULTS

Intraamniotic 1:200 and 1:400 meconium was found to cause intestinal damage. Meconium concentrations lower than 1:400 did not cause intestinal damage. Histopathologic examination of the intestines of the 1:200 and 1:400 meconium groups showed serosal thickening, inflammation, focal fibrin, and collagen deposits. Histopathologic features of the intestines of the 1:600 and 1:800 meconium groups did not differ from the intestines of the control group.

CONCLUSION

Intraamniotic meconium, which is responsible for intestinal damage in gastroschisis, must reach a threshold level to induce intestinal damage. J Pediatr Surg 36:1811-1815.

Experimentally prefabricated bladder

PURPOSE

Long life expectancy after augmentation cystoplasty increases the importance of late complications of augmentation cystoplasty. Many complications are related to the mucosa of the intestinal flap used for augmentation cystoplasty. We compared a new prefabricated enterocystoplasty flap with the classic techniques of enterocystoplasty using seromuscular flaps. For prefabrication the seromuscular flap was partially grafted with uro-epithelium before augmentation cystoplasty.

MATERIALS AND METHODS

The study consisted of 4 groups. In the first 2 groups seromuscular flaps were used for augmentation cystoplasty with different sides of the flap inside the bladder. The muscular and serosal surfaces were prefabricated in groups 3 and 4, respectively. Prefabricated seromuscular flaps were used for augmentation cystoplasty after remaining in situ for 2 weeks.

RESULTS

While mean augmented bladder capacity in groups 1, 2 and 4 was 18 to 20 ml. after 8 weeks, capacity in the prefabricated seromuscular enterocystoplasty group was 50 ml. Histopathological examination showed severe fibrosis in all except the prefabricated seromuscular enterocystoplasty group.

CONCLUSIONS

Prefabrication allows the avoidance of the complications caused by intestinal mucosa in the reservoir and results in good capacity when the raw surface of the seromuscular flap is partially grafted with uro-epithelium before use.

Persantine attenuates hemorrhagic shock-induced P-selectin expression

Ischemia/reperfusion (I/R), a phenomenon that is associated with conditions such as organ transplantation, trauma, vascular disease, and stroke, involves the recruitment of activated and adherent leukocytes that subsequently mediate tissue injury. Endothelial cell adhesion molecules such as P-selectin mediate I/R-induced leukocyte recruitment and allow the adherent leukocytes to damage the vascular wall and parenchymal cells. This study examines the influence of dypiridamole (persantine) on hemorrhagic shock (H/S)-induced P-selectin expression. H/S was induced in C57BL/6 mice by withdrawing blood to drop the mean arterial blood pressure to 30 to 35 mm Hg for 45 minutes. The mice were resuscitated by infusing the shed blood and Ringer's lactate (50% shed blood volume). In vivo P-selectin expression was determined using a dual monoclonal antibody technique in the heart, lung, liver, kidneys, stomach, small bowel, and colon of a control group, a hemorrhagic shock group, and a hemorrhagic shock group that was pretreated with Persantine (Boehringer, Ingelheim, Ingelheim, Germany). H/S significantly (P < 0.01) increased P-selectin expression in all regional vascular beds of untreated mice. Persantine treatment largely prevented the H/S-induced P-selectin expression in the same vascular beds. Persantine significantly attenuates the upregulation of P-selectin in the hemorrhagic shock model.

Amniotic fluid exchange for the prevention of neural tissue damage in myelomeningocele: an alternative minimally invasive method to open in utero surgery

OBJECTIVE

Experimental studies have shown that neural tissue damage in myelomeningocele (MMC) is acquired, resulting from exposure of neural tissue to amniotic fluid (AF). Similar to neural tissue damage in MMC, in gastroschisis, intestines exposed to AF are damaged. In gastroschisis, intestinal damage can be prevented by changing the composition of the AF with partial AF exchanges. An experimental study was performed to investigate whether the neural tissue damage in MMC can be prevented by AF exchange.

METHODS

Thirteen-day-old fertilized chick eggs were used. In group 1, the amnio-allantoic membrane was opened to create a common cavity, and MMC was created (MMC-only group). In group 2, after creation of MMC, amnio-allantoic fluid exchange was performed (MMC-plus-exchange group). Chicks were extirpated for histopathologic examination 5 days later.

RESULTS

While edema, focal calcification, fibrosis, capillary cell proliferation and scattered mononuclear cells were observed in the MMC-only group, histopathologic changes were mild in the exchange group. The number of neuron-specific enolase stainings (+) neural cell count was significantly higher in the exchange group compared to the MMC-only group (p < 0.01).

CONCLUSION

Exposure of MMC to AF causes structural neural tissue damage that can be prevented by AF exchange. AF exchange is minimally invasive compared to open in utero surgery for the closure of MMC. By AF exchange, neural tissue damage that occurs during the gestational period may be prevented.

Bilateral asynchronous perinatal testicular torsion: a case report

Bilateral perinatal testicular torsion (PTT) is an extremely rare condition. A baby boy at the postnatal 28th hour presented with right scrotal erythema and swelling, and left hydrocele were detected. There were no systemic symptoms. Right hydrocele had been detected during prenatal ultrasonography at the 34th week of gestation. Emergency technetium Tc 99m pertechnetate scintigraphy showed hypoperfusion in both sides suggesting testicular torsion. The patient underwent surgery immediately. Right necrotic testis was removed, left testis was judged as viable, and thus was treated with detorsion. Bilateral PTT in the neonate is a true emergency because of the risk of anorchia. Controversy still exists regarding the treatment of unilateral PTT. Some investigators suggest delayed operation regarding the anesthetic risk imposed on the neonate and the reality that operative salvage of the prenatally torsed testicle is a remote possibility. However, although asynchronous bilateral PTT is rare, the patient with unilateral PTT is at risk of contralateral testicular torsion in the waiting period of delayed operation. Therefore, the authors recommend early surgical intervention.

Role of superoxide in hemorrhagic shock-induced P-selectin expression

Superoxide has been implicated in the regulation of endothelial cell adhesion molecule expression and the subsequent initiation of leukocyte-endothelial cell adhesion in different experimental models of inflammation. The objective of this study was to assess the contribution of oxygen radicals to P-selectin expression in a murine model of whole body ischemia-reperfusion, i.e., hemorrhage-resuscitation (H/R), with the use of different strategies that interfere with either the production (allopurinol, CD11/CD18-deficient or p47(phox)-/- mice) or accumulation [intravenous superoxide dismutase (SOD), mutant mice that overexpress SOD] of oxygen radicals. P-selectin expression was quantified in different regional vascular beds by use of the dual-radiolabeled monoclonal antibody technique. H/R elicited a significant increase in P-selectin expression in all vascular beds. This response was blunted in SOD transgenic mice and in wild-type mice receiving either intravenous SOD or the xanthine oxidase inhibitor allopurinol. Mice genetically deficient in either a subunit of NADPH oxidase or the leukocyte adhesion molecule CD11/CD18 also exhibited a reduced P-selectin expression. These results implicate superoxide, derived from both xanthine oxidase and NADPH oxidase, as mediators of the increased P-selectin expression observed in different regional vascular beds exposed to hemorrhage and retransfusion.

Sacrococcygeal extraspinal ependymomas: the role of coccygectomy

BACKGROUND

Ependymomas, the common glial tumors of the spinal cord, occur occasionally outside the central nervous system and are called exstraspinal ependymomas (EEP). EEPs are found primarily in sacrococcygeal region during childhood. The pathogenesis and the treatment of the sacrococcygeal (SC) ependymomas are still controversial. Therefore, we present our case with metaanalysis of other case reports to determine the optimal treatment modality for SC EEPs.

METHODS

A metaanalysis of case reports of SC EEPs, including the current case, was conducted. Also all available case reports of EEPs, without age limit, were analyzed to determine the distribution of EEPs localization.

RESULTS

EEPs usually are found in teratoma localizations such as the SC area, ovary, paraovarian structures, and medastinum. The distribution of EEPs localization differs with age. Local recurrence rate of EEPs after coccyx excision is zero, however, it increases to 71% when the coccyx was left behind.

CONCLUSION

The identical clinical characteristics of the SC teratomas and EEPs imply that the SC EEPs may be monophasic teratomas as their ovarian counterparts are named. Coccyx excision is an important part of the surgical treatment of these tumors, with an apparent decrease in the recurrence rate.

The effects of intraamniotic human neonatal urine and meconium on the intestines of the chick embryo with gastroschisis

BACKGROUND/PURPOSE

Urinary waste products in the amniotic fluid has been implicated as a cause of intestinal damage (ID) in gastroschisis based on the fact that fetus urinates physiologically into the amniotic cavity. However, experimental and clinical data suggest that intrauterine defecation is a physiological event, thus gastrointestinal waste products also may be responsible for ID in gastroschisis. An experimental study was performed to investigate the effects of intraamniotic human neonatal urine and diluted meconium on the intestines of chick embryo with gastroschisis.

METHODS

Five-day-old fertilized chick eggs (Gallus domesticus) were used. Gastroschisis was created through amniotic cavity without opening the allantoic cavity. Sterile urine and meconium were obtained from newborn humans, and 1% meconium suspension was prepared. The eggs were divided in to 3 groups. In the first group, gastroschisis was created, and amniotic fluid was reinstilled without changing its composition (control group). Equal amounts of amniotic fluid and urine mixture was instilled into the amniotic cavity in second group (urine group) and 1% meconium suspension was instilled in similar fashion in the third group after creation of gastroschisis (meconium group).

RESULTS

Histopathologic features of the intestines of the urine group did not differ from the intestines of the control group. The meconium group's bowel showed serosal thickening, inflammation, focal fibrin, and collagen deposits. Histopathologic changes of intestines induced by intraamniotic diluted meconium are consistent with the ones described for human gastroschisis specimens.

CONCLUSION

Gastrointestinal waste products seem responsible for the ID in gastroschisis rather than urinary waste products.

Kinetics of P-selectin expression in regional vascular beds after resuscitation of hemorrhagic shock: a clue to the mechanism of multiple system organ failure

Leukocyte-endothelial cell interactions play an important role in mediating organ dysfunctions observed after hemorrhagic shock. P-selectin is the first endothelial cell adhesion molecule to be upregulated after an ischemic insult. The objective of this study was to define kinetics of P-selectin expression in different regional vascular beds of mice exposed to hemorrhagic shock. In-vivo P-selectin expressions were determined using dual radiolabeled monoclonal antibody technique in lungs, heart, liver, kidneys, intestinal mesentery, stomach, small bowel, and colon 0.5, 1, 2, 5, 10, and 24 h after resuscitation of 40 mmHg hemorrhagic shock. In another group, P-selectin expression was determined in same organs 5 h after resuscitation of 30 mmHg hemorrhagic shock. Hemorrhagic shock of 40 mmHg caused significant upregulation of P-selectin in lungs and liver at 30 min after resuscitation (P < 0.001). There was a second and more pronounced upregulation of P-selectin in lungs and liver at 5 h after resuscitation (P < 0.001). In heart, intestinal mesentery, stomach, small bowel, and colon, P-selectin was not upregulated until 5 h after resuscitation from 40 mmHg hemorrhagic shock (P < 0.001). While hemorrhagic shock of 40 mmHg did not cause P-selectin upregulation in kidneys, hemorrhage to 30 mmHg did elicit a significant increase at 5 h after resuscitation (P < 0.001). We conclude that P-selectin is upregulated after resuscitation of hemorrhagic shock in lungs, liver, heart, stomach, and intestines. P-selectin upregulation in kidneys only takes place after more severe hemorrhagic shock.

Effects of dextran and pentoxifylline on hemorrhagic shock-induced P-selectin expression

BACKGROUND

Dextran and pentoxifylline have been shown to prevent leukocyte-endothelium adherence encountered after hemorrhagic shock. P-Selectin is the first endothelial cell adhesion molecule to be upregulated after an ischemic insult. We investigated the effects of resuscitation with dextran 70 and administration of pentoxifylline during resuscitation on hemorrhagic shock-induced P-selectin expression.

MATERIAL AND METHODS

Hemorrhagic shock was induced in C57BL/6 mice by withdrawing blood to reduce mean arterial blood pressure to 30 mm Hg for 45 min. Animals were resuscitated by infusing one of the following solutions (each n:5): (1) Ringer's lactate, (2) 6% dextran 70, (3) Ringer's lactate plus 50 mg/kg pentoxifylline, (4) 5% human albumin. Afterward shed blood was infused. In vivo P-selectin expression was determined using dual-radiolabeled monoclonal antibody technique in lung, heart, liver, kidney, mesentery, stomach, small bowel, and colon 5 h after resuscitation.

RESULTS

P-Selectin was significantly upregulated in all of the organs studied in the Ringer's lactate resuscitation group (P < 0.001). Resuscitation with dextran 70 and administration of pentoxifylline during resuscitation prevented P-selectin upregulation. Resuscitation with human albumin caused significant attenuation but could not prevent P-selectin upregulation (p < 0.01).

CONCLUSION

Our study implies that the prevention of hemorrhagic shock-induced leukocyte-endothelium adherence by dextran 70 and pentoxifylline observed in other studies may be mediated by prevention of P-selectin expression by these agents.

An experimental study investigating the effects of intraperitoneal human neonatal urine and meconium on rat intestines

Urinary waste products (UWP) in the amniotic fluid have been held responsible for the intestinal damage (ID) in gastroschisis, based on the fact that the fetus urinates physiologically into the amniotic cavity. However, experimental and clinical evidence suggests that intrauterine defecation is a physiological event; thus gastrointestinal waste products (GWP) may also be responsible for ID in gastroschisis. An experimental study was performed to investigate the effects of intraperitoneal human neonatal urine and diluted meconium on rat intestines. Adult Wistar albino rats were used. Sterile urine and meconium were obtained from newborn humans and 5% meconium suspension was prepared. Histopathological features of the intestines of the rats injected with urine did not differ from the intestines of the untreated rats. The bowel in rats injected with a meconium suspension showed serosal thickening, inflammation, focal fibrin and collagen deposits. Histopathological changes in intestines induced by intraperitoneal diluted meconium were consistent with those described for human gastroschisis specimens. We conclude that GWP, rather than UWP, seems to be responsible for the ID in gastroschisis.

Colonic atresia associated with Hirschsprung's disease: it is not a diagnostic challenge

Colonic atresia Hirschsprung's disease association (CAHDA) is usually diagnosed after several failures of intestinal anastomoses. Having previously reported one of the cases of CAHDA, we established the diagnosis in a patient before attempting intestinal anastomosis for stoma closure. We herein report the first patient with CAHDA in the literature diagnosed before a therapeutic challenge. We recommend a biopsy of the distal colonic segment either during initial laparotomy or before attempting intestinal anastomosis for closure of colostomy to prevent therapeutic challenge in the patients with colonic atresia.

Amnio-allantoic fluid exchange for the prevention of intestinal damage in gastroschisis. III: Determination of the waste products removed by exchange

Experimental amnio-allantoic fluid (AAF) exchange has been shown to prevent intestinal damage in the chicken embryo gastroschisis model. AAF contains both urinary and gastrointestinal waste products (UWP and GIWP). An experimental study was performed to find the waste products responsible for this intestinal damage. Gastroschisis was created in 20 chick embryos. Half were treated with AAF exchange, the other half were not treated. AAF samples were obtained for biochemical determination of urea nitrogen and creatinine as UWP, bile acids and bilirubin as GIWP at the end of the incubation. Intestines were evaluated by light microscopy. While GIWP (Bile salts and bilirubin) were significantly removed from AAF by exchange, the levels of UWP (urea nitrogen and creatinine) were unaffected. Intestinal wall thickness was less in the exchange group compared to the untreated group. The unchanged levels of UWP after AAF exchange may be attributed to their relatively rapid production compared to GIWP. Dilution of GIWPs by AAF exchange results in prevention of the intestinal damage in gastroschisis.

Amnio-allantoic fluid exchange for prevention of intestinal damage in gastroschisis II: Effects of exchange performed by using two different solutions

The prevention of intestinal damage in gastroschisis was reported after amnio-allantoic fluid (AAF) exchange using serum saline. However it is not clear why AAF exchange prevents intestinal damage. Are some harmful chemicals withdrawn from AAF by exchange or sodium content of AAF is merely increased? A study was planned to find the end results of AAF exchange performed by using two different solutions in the chicken embryo gastroschisis model. After creation of gastroschisis, three groups were studied. In the first group AAF exchange was not performed. In the second group AAF exchange was performed using 0.075% NaCl solution (physiologic saline for chicken). In the third group AAF exchange was performed using 0.054% NaCl plus 1% dextrose solution. Exchange with two different solutions prevented cellular infiltration and fibrous peel formation in intestines which are observed in the non-treatment group. In the third group, intestinal edema was an additional pathologic finding. This study shows that in gastroschisis, the intestines outside the abdominal cavity are very sensitive to the quality of the fluid in which they are bathed. The intestinal damage resembling that encountered in human gastroschisis can be prevented by removing the harmful chemicals from AAF by exchange.

Laparoscopic appendectomy in children performed using single endoscopic GIA stapler for both mesoappendix and base of appendix

BACKGROUND/PURPOSE

Similar to open appendectomy (OA), most of the methods described for laparoscopic appendectomy (LA) require two steps: (1) dissection and division of mesoappendix and (2) excision of appendix. Dissection of mesoappendix requires more skill and experience during LA. In single endoscopic GIA stapler laparoscopic appendectomy technique (SESLAT), both mesoappendix and base of appendix may be divided in one step with the application of a single endoscopic GIA stapler.

METHODS

LA was attempted in 18 patients who had acute appendicitis and was successfully performed in 16 patients.

RESULTS

In two patients, the operation was converted to OA. The authors did not need conversion to OA because of complication resulting from the use of the stapler.

CONCLUSIONS

SESLAT is a quick, easy, and versatile method for LA in children that obviates dissection of mesoappendix and related complications. Thus, it enables LA to be performed by inexperienced beginners.

A case of split notochord syndrome: presence of dorsal enteric diverticulum adjacent to the dorsal enteric fistula

Like umblical enteric remnants (eg, umblical sinus and omphalomesenteric fistula), enteric remnants can be seen on the dorsal aspect of the body (dorsal enteric sinus, dorsal enteric fistula IDEF], dorsal enteric diverticulum) in conjunction with complete cleft of the vertebral column. Complete cleft of the vertebral column associated with gastrointestinal tract and central nervous system anomalies is known as "split notochord syndrome" (SNS). The authors present an unreported variant of SNS having dorsal enteric diverticulum adjacent to the DEF. The patient died 17 days after surgical repair.

A new ancient irrigation therapy for childhood renal candidiasis

Methylene blue (MB) alone, MB metabolites in the urine and the effect of MB plus alkalization on Candida species were determined. MB was used for the treatment of childhood renal candidiasis (CRC) in 3 patients as an irrigating solution. Besides irrigation, fluconazole 3 mg/kg/day intravenously and MB 0.2 mg/kg/day were administered perorally. Urine cultures were cleared of Candida. DMSA scans obtained after 6 months showed no evidence of scarring. MB can be used for irrigation of the urinary tract, with fewer side effects than amphotericin B (AB). Additionally we advocate the use of ureteral catheters instead of nephrostomy in the treatment of CRC.

Pretreatment of gastroschisis with transabdominal amniotic fluid exchange

BACKGROUND

Intestinal thickening in gastroschisis results from prolonged exposure to amniotic fluid (AF). Experimental AF exchange has been shown to prevent intestinal thickening in gastroschisis.

CASE

A 25-year-old primigravida was referred at 24 weeks' gestation with a prenatal diagnosis of gastroschisis. Transabdominal AF exchange was performed at 29 weeks. This pretreatment did not cause any complications and prevented intestinal thickening in our patient. Thus, we were able to perform primary fascial closure with an intra-abdominal pressure less than 5 mmHg. We began feeding the infant on the 5th day and discharged her on the 8th day.

CONCLUSION

Evidence obtained from this initial case seems promising for the further application of the AF exchange for prevention of intestinal thickening in gastroschisis.

A case of mediastinal cystic hygroma whose only symptom was hoarseness

Hoarseness caused by mediastinal cystic hygroma has not been reported before. The authors report a case of mediastinal cystic hygroma in which the patient's only symptom was hoarseness. A 6-year-old girl had hoarseness. Physical examination findings were normal except for indirect laryngoscopy, which showed unilateral vocal cord paralysis. The chest radiograph showed an opacification 3 cm wide in the left side of the superior mediastinum. Through a median sternotomy, a large multicystic mass was resected. During resection, left laryngeal recurrent nerve was seen to be intact, and its integrity was preserved. Six months later the left vocal cord was moving to a limited extent. A chest radiograph should be considered in a case of hoarseness caused by a peripheral nerve lesion to detect a mediastinal mass without any cervical component.

Testis sparing surgery for epidermoid cyst of the testis: a case report

A rare tumour of a prepubertal child, an epidermoid cyst, was excised with testicular preservation. Childhood testicular tumours are usually benign. Although epidermoid cysts of the testis may have teratomatous component, testicular teratomas are generally benign in the prepubertal child. For these reasons testis sparing surgery seems applicable in childhood epidermoid cysts.

Congenital esophageal stenosis owing to tracheobronchial remnants: a case report

A 3.5-year-old girl who had congenital esophageal stenosis caused by tracheobronchial remnants without esophageal atresia or tracheoesophageal fistula is presented. The diagnostic difficulties are discussed.

Experimental study investigating the feasibility of a new method for laparoscopic indirect inguinal hernia repair

With the progress in laparoscopic techniques in recent years, there is an increased interest in laparoscopic hernia repair. The laparoscopic indirect inguinal hernia repair with simple closure of the internal ring seems feasible in childhood inguinal hernia repair; however, this technique carries the risk of postoperative patent processus vaginalis. In this-study we investigated the possibility of avoidance of this complication by chemical obliteration of processus vaginalis with 6% iodine solution in rats. The study population was comprised of three groups: simple suture of the internal ring, iodine application plus simple suture of the internal ring, and iodine application alone. While processus vaginalis was anatomically closed in 75% of the rats in the iodine plus simple suture of the internal ring group, it was closed in 10% of the iodine application alone group and was not closed in the simple suture of the internal ring alone group. No histopathologic injuries to the testis or cord were detected attributable to iodine. Our study showed that simple suture of the internal ring is not sufficient for hernia repair. Laparoscopic chemical agent application in addition to simple suture of the internal ring may be beneficial for successful laparoscopic indirect inguinal hernia repair in children.

Prospective study investigating routine usage of ultrasonography as the initial diagnostic modality for the evaluation of children sustaining blunt abdominal trauma

In this prospective study, 217 children sustaining blunt abdominal trauma were initially evaluated with ultrasonography (US) and those with any abnormal ultrasonographic findings were further evaluated with computed tomography. Results of ultrasonographic examination were normal in 157 children and showed abnormalities such as free intraperitoneal fluid (FIF), intra-abdominal organ injury, and intrapleural fluid in 60 children. Computed tomographic examination of the 42 children with organ injury, the seven children with minimal FIF of no definite source, and the three children with intrapleural fluid revealed findings consistent with ultrasonographic findings. Computed tomographic examination of the eight children with more than minimal FIF of no definite source detected by US showed the source as liver injury in one and spleen injuries in two patients. The source of FIF could not be identified with computed tomography in five patients. After clinic follow-up examination, one of these five patients was operated on for abdominal tenderness, fever, and air-fluid levels detected on plain abdominal radiographs, and duodenal perforation was encountered. Clinical courses of the patients with normal ultrasonographic findings were uneventful. We conclude that US, aside from being a screening tool, is alone sufficient in the evaluation of the majority of the children sustaining blunt abdominal trauma. Although this is a preliminary study with further work needed to be done, we propose that further evaluation with computed tomography should be performed on those children in whom more than minimal FIF of no definite source is detected with US.

End-results of experimental gastroschisis created by abdominal wall versus umbilical cord defect

An experimental study was conducted to determine the end-results of two different defects on the anterior abdominal wall: an abdominal wall defect (AWD) versus an umbilical cord defect (UCD) using chick embryos. The AWD was created by leaving an intact skin bridge between the defect and the umbilical cord in group 1; the UCD was created on the umbilical cord near the junction of the skin in group 2. At the end of incubation, the intestines appeared hemorrhagic in the AWD group, but not in the UCD group. During microscopic examination, hemorrhagic areas were observed in the bowel wall and mucosal villi in the AWD group but not in the UCD group. The end-result of the defect causing the physiological umbilical hernia resulted in bowel damage resembling the classic picture of gastroschisis (GS). We conclude that the site of the defect in GS is not the abdominal wall itself, but the physiological umbilical hernia.

The effect of allopurinol pretreatment on intestinal hypoperfusion encountered after correction of intestinal volvulus

After reversal of blood flow following a prolonged period of ischemia, blood flow returns for a few seconds and is reduced afterward. This is called "no-reflow phenomenon." Antioxidants such as allopurinol have been shown to prevent the occurrence of this phenomenon in organs other than the intestine. An experimental study was conducted to investigate the effect of allopurinol pretreatment on intestinal blood flow after correction of intestinal volvulus in rabbits. In group 1, baseline intestinal blood flow (IBF) was evaluated using radiolabeled red blood cells. In group 2, 720 degrees intestinal volvulus was created and IBF was evaluated 6 hours later. In group 3, intestinal volvulus was created and devolvulus was performed 6 hours later. Intraperitoneal isotonic saline was injected 60 minutes before correction of the volvulus. IBF was evaluated after correction of the volvulus. Group 4 had the same procedures as group 3, but allopurinol (200 mg/kg) was injected in place of the isotonic saline. IBF stopped 6 hours after volvulus. Compared with the baseline group, IBF was significantly lower in the group with volvulus + devolvulus (P < .01). The IBF of the allopurinol-treated group was significantly higher than that of the isotonic saline group (P < .01) and it did not differ significantly from that of the baseline group. Histopathological examination showed that intestinal volvulus leads to histological injury. The histological injury was more pronounced in the devolvulus group and was less severe in the allopurinol group in comparison to the isotonic saline pretreatment group (P < .01). It is concluded that allopurinol pretreatment prevents the intestinal hypoperfusion (no-reflow phenomenon) and histological injury encountered after correction of intestinal volvulus of 6 hours' duration.

Testis sparing surgery for epidermoid cyst of the testis: a case report

A rare tumour of the prepubertal child, an epidermoid cyst was excised with testicular preservation. Childhood testis tumours are usually benign. Although epidermoid cysts of the testis may have teratomatous component, testicular teratomas are generally benign in the prepubertal child. For these reasons testis sparing surgery seems applicable in childhood epidermoid cysts.

A case of gastric cicatrization caused by ingestion of sulfuric acid, treated with Hunt-Lawrence jejunal pouch substitution for the stomach

To the authors' knowledge, there had been no reported pediatric case of total cicatrization of the stomach owing to acid ingestion. The authors report a case caused by sulfuric acid ingestion. When admitted, the child did not have any oral intake and was fed through a jejunostomy, which had been placed in an other center. An upper gastrointestinal barium study showed a small gastric fundal pouch and no passage to the duodenum, but with passage to the jejunum through two fistulas. The modified Hunt-Lawrence pouch was created using the fistulous jejunal segment. After 6 months the patient is well.

Amnio-allantoic fluid exchange for the prevention of intestinal damage in gastroschisis: an experimental study on chick embryos

In gastroschisis, the protruding intestine is usually shortened, thickened, and covered with a fibrous peel. Urine components, which are increased in the amniotic fluid with the onset of renal function, are responsible for these changes. In the chick embryo model of gastroschisis, the authors performed amnio-allantoic fluid exchange to reduce the effect of urinary products. There were three study groups: control, gastroschisis only, and gastroschisis plus exchange. There was a significant decrease in creatinine (P < .05) and a slight decrease in urea concentrations in the gastroschisis-plus-exchange group compared with the gastroschisis-only group. Whereas macroscopic and microscopic studies showed severe fibrosis and bowel-wall thickening in the latter group, the bowel was normal or slightly oedematous in the former. On the basis of this study, the authors suggest that antenatal amniotic fluid exchange might reduce the bowel damage in human foetuses.

Is ipsilateral testis mandatory for the occurrence of contralateral intratesticular biochemical changes indicative of hypoxia after unilateral spermatic cord torsion?

Experimental unilateral spermatic cord torsion has been shown to induce both ipsilateral and contralateral intratesticular biochemical changes indicative of hypoxia. An experimental study was conducted to see whether the presence of the ipsilateral testicular tissue is necessary for the occurrence of the biochemical changes in the contralateral testis. Male, adult, albino rats were divided into four groups each containing 10 rats. One group served to determine basal values of biochemical parameters indicative of tissue hypoxia, another group was subjected to unilateral spermatic cord torsion in the presence of ipsilateral testis; a further group was subjected to unilateral spermatic cord torsion after ipsilateral subepididymal orchiectomy, and the last group underwent unilateral subepididymal orchiectomy alone as control. Lactic acid, hypoxanthine and lipid peroxidation product levels which are biochemical indicators of tissue hypoxia were determined in testicular tissues and kidneys. All three parameters increased significantly in contralateral testes but not in kidneys after unilateral spermatic cord torsion both when the ipsilateral testis was present and absent (p < 0.05). It is concluded that the ipsilateral testis does not play a role in transmitting these contralateral changes after unilateral spermatic cord torsion. Impulse-triggering contralateral changes may arise from spermatic vessels or nerves.

Ipsilateral and contralateral testicular biochemical acute changes after unilateral testicular torsion and detorsion

OBJECTIVES

An experimental study has been conducted to investigate testicular blood flow alterations through acute biochemical changes during unilateral testicular torsion and detorsion.

METHODS

One hundred twenty male albino rats were divided into 12 groups, each containing 10 rats. One group served to determine basal values of biochemical parameters, 4 groups were subjected to varying periods of unilateral testicular torsion (3, 6, 12, and 24 hours, respectively), 3 groups were subjected to detorsion following varying periods of torsion (6, 12, and 24 hours, respectively), and 4 groups underwent sham operations as controls. Levels of lactic acid, hypoxanthine, and lipid peroxidation products were determined in testicular tissues.

RESULTS

Values of these 3 parameters obtained from sham operation control groups did not differ significantly from basal values (p > 0.05). All 3 parameters were increased significantly in both ipsilateral torted and contralateral nontorted testes after unilateral testicular torsion when compared with basal values (p < 0.05). Detorsion did not cause significant changes in levels of lipid peroxidation products in both ipsilateral torted and contralateral nontorted testes when compared with values obtained after torsion (p > 0.05).

CONCLUSIONS

Ipsilateral testicular torsion causes a decrease not only in the ipsilateral torted but also in the contralateral nontorted testicular perfusion. The clues of reperfusion injury do not become evident following detorsion of testicular torsion lasting more than 6 hours.

The effect of allopurinol pretreatment before detorting testicular torsion

The resumption of blood flow to organs following ischemia may cause a further increase in tissue damage through an increase in peroxidation of lipids in cell membranes. An experimental study was conducted to investigate the prevention of reperfusion injury after testicular torsion through changes in the lipid peroxide content of the testis. Adult male albino rats were divided into 11 groups, each containing 10 rats. One group served to determine base values of the lipid peroxide content of the testis and kidney; 3 groups were subjected to unilateral testicular torsion lasting 1, 3 and 5 hours; 3 groups were subjected to detorsion following torsion lasting 1, 3 and 5 hours; 3 groups were treated with allopurinol before detorsion following torsion lasting 1, 3 and 5 hours; and 1 group underwent sham operation as a control. Thiobarbituric acid reactive products of lipid peroxidation (TBAR) were assessed in testicular and renal tissues. Testicular torsion caused a significant increase in TBAR in the testis (p < 0.01), but not in the kidneys. Detorsion caused a further significant increase in testicular TBAR (p < 0.01). Pretreatment with allopurinol prevented this further increase (p < 0.01). It is concluded that, biochemically, reperfusion injury occurs in the testis following detorsion after testicular torsion of 720 degrees lasting as long as 5 hours. Pretreatment with allopurinol before detorsion prevents such reperfusion injury.

Reperfusion injury after detorsion of unilateral testicular torsion

Reperfusion injury has been well documented in organs other than testis. An experimental study was conducted to investigate reperfusion injury in testes via the biochemical changes after unilateral testicular torsion and detorsion. As unilateral testicular torsion and varicocele have been shown to affect contralateral testicular blood flow, reperfusion injury was studied in both testes. Given that testicular blood flow does not return after 720 degrees testicular torsion lasting more than 3 h, the present study was conducted after 1 and 2 h of 720 degrees torsion. Adult male albino rats were divided into seven groups each containing ten rats. One group served to determine the basal values of biochemical parameters, two groups were subjected to 1 and 2 h of unilateral testicular torsion respectively, two groups were subjected to detorsion following 1 and 2 h of torsion respectively, and two groups underwent sham operations as a control. Levels of lactic acid, hypoxanthine and lipid peroxidation products were determined in testicular tissues. Values of these three parameters obtained from the sham operation control groups did not differ significantly from basal values (P > 0.05). All three parameters were increased significantly in both ipsilateral and contralateral testes after unilateral testicular torsion when compared with basal values (P < 0.01 and P < 0.05, respectively). Detorsion caused significant changes in lipid peroxidation products levels in ipsilateral but not in contralateral testes when compared with values obtained after torsion (P < 0.01 and P > 0.05, respectively). It is concluded that ipsilateral testicular torsion causes a decrease in perfusion not only in the ipsilateral but also in the contralateral testis.(ABSTRACT TRUNCATED AT 250 WORDS)

Initial evaluation of children sustaining blunt abdominal trauma: ultrasonography vs. diagnostic peritoneal lavage

A prospective clinical study was performed to compare ultrasonography (US) with a modality having 96-99% accuracy like diagnostic peritoneal lavage (DPL) to find the accuracy of US in the initial evaluation of children sustaining blunt abdominal trauma (BAT). Sixty-eight children with BAT were initially evaluated by US, then DPL. All patients with pathologic US findings underwent computerized tomographic examination before DPL to confirm the pathologies. Through US examination free intraperitoneal fluid (FIF) was present in eleven, absent in 57 patients. DPL was positive in ten, negative in 58 patients. Sensitivity, specificity, negative predictive value, positive predictive value and efficiency of US were 100, 98.3, 100, 91 and 98.5 respectively. US detected intraperitoneal solid organ injuries in eleven patients, but DPL was positive in only ten of these patients. While US detected renal injuries in six patients and intrapleural fluid in two patients, DPL was positive in only two of these patients as a result of concomitant intraperitoneal solid organ injuries with FIF. The present study has shown that US can detect FIF with a high rate of accuracy comparable to DPL in children. In addition, US has advantages over DPL in the detection of intraperitoneal organ injuries with or without concomitant FIF, retroperitoneal injuries and intrathoracic injuries. Thus US is thought to be superior to DPL and recommended as a routine first choice screening tool in the initial evaluation of children sustaining BAT.