Posterior median surgical approach to anterior sacral meningocele complicated by rectothecal fistula

In this case report, we aimed to describe the clinical presentation, surgical approach, and follow-up of a patient with rare anterior meningocele associated with rectothecal fistula. An 17-year-old female patient was admitted to the emergency department with meningitis. On further examinations, an anterior sacral meningocele accompanied by rectothecal fistula was detected. Appropriate antibiotic treatment was arranged and surgical plan was made with the pediatric surgery clinic. The patient underwent meningocele repair via posterior approach and colostomy operation. The patient did not experience any neurological issues after the surgery. The colostomy was reversed 3 months later, and third-month follow-up MRI showed complete regression of the meningocele sac with no neurological complications. Anterior meningocele accompanied by a rectothecal fistula is a rare and complicated case. Only seven cases of coexisting ASM and RTF have been reported in literature. Although both anterior and posterior approaches have been used for the treatment of ASM, the choice of treatment is essentially based on the patient's clinical and imaging findings.

Comparison of the results of open repair and laparoscopic repair with the PIRS method in the treatment of hydrocele in children

PURPOSE

Hydrocele is a result of intraperitoneal fluid filling into the scrotum through the patent processus vaginalis (PPV). While the traditional approach of pediatric hydrocele has been open repair (OR) for years, laparoscopic repair (LR) of hydrocele has been accepted worldwide after the proven efficacy of laparoscopy. The purpose is to compare the outcomes of both techniques in a single center.

METHODS

We retrospectively analyzed the clinical data of all the patients who underwent hydrocele repair from August 2016 to November 2022. In our center, the standard approach was OR in hydrocele until the November of 2021. Starting from this date, LR has begun to be preferred, as the experience has increased and its success has been observed. In the LR group, single-port percutaneous internal ring suturing technique was performed.

RESULTS

The data of 113 patients (OR 58.4% (n = 66), LR 41.6% (n = 47)) were collected. In preoperative examination, 12.4% (n = 14) patients were diagnosed as communicating and 87.6% (n = 99) non-communicating hydrocele. Intraoperatively, 65.5% (n = 74) patients were communicating and 34.5% (n = 39) were non-communicating. Total recurrence rate was 7% (n = 8). The OR group experienced a recurrence rate of 10.6% (n = 7), while the LR group experienced 2.12% (n = 1).

CONCLUSION

Laparoscopy may reveal intrabdominal connection of hydrocele better than open approach. It provides a high quality view of both inguinal rings and has the advantages of minimally invasive surgery.

Is Laryngeal Mask a Good Alternative in Children Undergoing Laparoscopic Inguinal Hernia Repair with Percutaneous Internal Ring Suturing Under and Over Two Years Old?

Objective

This study aimed to evaluate respiratory parameters during percutaneous internal ring suturing (PIRS) for inguinal hernia repair in two different-aged pediatric patients in whom the airway is provided with a laryngeal mask or endotracheal tube for general anaesthesia.

Methods

After local ethics committee and parental consent, 180 ASAI-II children were randomly allocated to 4 groups; according to their age (0-24 months / 25-144 months) and airway device laryngeal mask (LMA) / endotracheal tube (ETT) used for general anaesthesia (45 children each) for laparoscopic inguinal hernia repair. Standard anaesthesia induction was done with lidocaine, propofol, and fentanyl, and 0.6 mg kg^-1 rocuronium was added to the ETT groups. Sevoflurane is used for maintenance. Hemodynamic parameters, peak airway pressure, end-tidal carbon dioxide (EtCO₂), and peripheric oxygen saturation (SpO₂) values were recorded after induction, before, and during pneumoperitoneum. The duration of anaesthesia, surgery, recovery time, and surgical satisfaction was recorded. Airway complications (cough, laryngospasm, bronchospasm, desaturation, and aspiration) were recorded.

Results

Hundred and eighty patients (45 in each group) were analyzed. Duration of surgery and surgical satisfaction were similar in all groups. Duration of anaesthesia and recovery times were significantly shorter in the LMA groups. Peak airway pressure and EtCO2 levels were significantly lower in the LMA groups. Rare airway complications were observed without significance.

Conclusion

In laparoscopic inguinal hernia repair with the PIRS technique, LMA offered comparable operating conditions and surgical satisfaction.

Effects of intraperitoneal bupivacaine injection in laparoscopic appendectomy in children on post-operative pain: A controlled randomized double-blinded study

BACKGROUND

The aim of this study is to determine the effects of local anesthetics administered intraperitoneally in laparoscopic appendectomy.

METHODS

Patients who underwent laparoscopic appendectomy due to acute appendicitis were enrolled in the study. The children were divided into two groups. Intraperitoneal bupivacaine injection to appendectomy site and subdiaphragmatic area was performed after resection of appendix and aspirastion of intraperitoneal reactive fluid in Group 1 while Group 2 did not receive this therapy. The children were questioned by a nurse at postoperative 1st, 6th, 12th, and 24th h. Pain scores (PS) (abdominal), abdominal wall incisional pain (IP), shoulder pain (SP), and first need for analgesics were recorded.

RESULTS

One hundred and twenty children were enrolled to the study. There was no significant difference in PS values and IP values between the two groups (p>0.05). SP values at 12th and 24th h were significantly lower in Group 1 (p<0.05). There was a statistically significant reduce in analgesic need in Group 1 (p=0.007).

CONCLUSION

Intraperitoneal bupivacaine instillation to surgery site and subdiaphragmatic area seems to reduce the SP post-opera-tive and also reduce post-operative analgesic need. More meaningful results can be obtained with an increase in the number of patients.

Acute Abdomen—A Clinical Presentation of MIS-C in Children

Objective Multisystemic inflammatory syndrome in children (MIS-C) is characterized by persistent fever, systemic hyperinflammation, and multiple-organ dysfunction. There are a few reports about MIS-C presenting with acute abdomen. The aim of this study was to demonstrate the clinical characteristics and treatment options for MIS-C-related acute abdomen and appendicitis.

Methods This was a retrospective study conducted between April 2020 and October 2020 in our pediatric intensive care unit in Turkey. Patients between the ages of 1 month and 18 years who presented with acute abdomen and were ultimately diagnosed with MIS-C were included.

Results Seven patients with a median age of 12.5 (interquartile range 10.5–13) years were enrolled. Four were females. The most frequent symptoms were fever, abdominal pain, and vomiting. Three patients had involvement of the appendix that required surgical intervention. All pathology reports were compatible with appendicitis. The other patients also had an acute abdomen. One patient had malignant hyperthermia during induction of anesthesia, so surgery was postponed and medical management was commenced. The clinical picture regressed with immunomodulation. All patients were treated with intravenous immunoglobulin and steroids. Four patients with acute abdomens improved with immunomodulation, and surgery was not needed.

Conclusion MIS-C may present with an acute abdomen. Immunomodulation should be considered instead of surgery if the clinical course is not complicated.

An indirect effect of COVID-19 pandemic: Increased pediatric perforated appendicitis rate due to delayed admission

Objectives

Appendicitis is a common surgical emergency among children. The coronavirus pandemic affected the system of hospitals more than any other field, and great amount of people were concerned about visiting the hospitals for any reason. In this study, it was aimed to evaluate the profile of appendicitis by emphasizing perforated and acute appendicitis in the pandemic period and to compare the rates with previous three years.

Material and Methods

Charts of the children who underwent laparoscopic appendectomy due to appendicitis between March 11-September 30 between 2017-2020 were retrospectively analyzed in terms of demographic data, duration of symptoms, duration between hospital admission and surgery, radiologic imaging and perioperative outcomes.

Results

This study includes 467 children who underwent laparoscopic appendectomy. There were 97 procedures in 2020, 111 in 2019, 146 in 2018 and 113 in 2017. Multiple comparison tests revealed that age did not show difference; but onset of symptoms in admission (p= 0.004), hospitalization time before surgery (p <0.001), total hospitalization time (p <0.001) showed statistically significant difference between years. Pairwise comparisons showed that these parameters were increased in 2020 compared to other years. Perforated appendicitis rate was significantly increased in 2020 when compared to previous years.

Conclusion

Although there is no direct relation between appendicitis and COVID-19 infection in the current knowledge, perforated appendicitis was found to be increased in children during the COVID pandemic. Reason of the higher rate of perforated appendicitis may be multifactorial; however, the pandemic appears to have a role in increased morbidity in children with appendicitis indirectly due to delay of hospital admissions.

Comparison of laparoscopic percutaneous internal ring suturing method and open inguinal hernia repair in children under 3 months of age

Objective: Laparoscopic inguinal hernia repair in younger infants has not been completely accepted worldwide. The aim of this study was to evaluate the safety and feasiblity of laparoscopic percutaneous internal ring suturing method in children aged younger than 3 months and compare the recurrence and complication rates with open repair; which may still be mentioned as the gold standard procedure.

Material and Methods: A total of 387 children underwent inguinal hernia repair in the clinic between 2016 and 2019. One hundred and forty of them were under 3 months old and divided into two groups; children who underwent laparoscopic percutaneous internal ring suturing (Group 1) and open surgery (Group 2). Selection of the surgical method was regardless of weight, sex or any patient characteristics other than surgeon’s choice. Operation durations, complications and recurrences were compared between the two groups.

Results: A total of 140 patients underwent surgery due to inguinal hernia. Group 1 included 85 and Group 2 included 55 children. There were two recurrences in each group (p> 0.05). Operative durations were shorter in Group 1 for both; unilateral and bilateral repairs (< 0.0001). There were no intraoperative complications in any group. There was one major postoperative complication in Group 2: iatrogenic undescended testis, and none was observed in Group 1. In the laparoscopic group, 47% of the children who were diagnosed to have unilateral hernia were revealed to have bilateral inguinal hernias (n= 31).

Conclusion: Laparoscopic percutaneous internal ring suturing method seems favourable in terms of operative time. It also has the advantage of detecting contralateral patent processus vaginalis or asymptomatic contralateral inguinal hernia.

Management of sacrococcygeal pilonidal sinus disease in children: A survey study in Turkey

Objective: Sacrococcygeal pilonidal sinus disease is common in children. The disease reduces the quality of life of patients with symptoms such as pain and chronic discharge. Variable surgical techniques have been described for the treatment of pilonidal sinus disease. This study aims to evaluate clinical approach of Turkish pediatric surgeons to children with pilonidal sinus disease.

Material and Methods: Survey questions were prepared through a literature review for controversial issues. The participants were asked pre-selected and checkbox questions. The survey was sent to 450 pediatric surgeons, members of the Association of Turkey Pediatric Surgery via a link to Google Forms.

Results: Nineteen percent (88) of the members responded. Seventy five (85.2%) of the pediatric surgeons stated that they did not perform additional preoperative imaging. Surgical excision methods were preferred more than minimally invasive procedures (102 to 46). Sixty (68.2%) of the participants preferred preoperative prophylactic single dose intravenous antibiotics and postoperative oral antibiotics. Regarding the participants’ practices, poor local hygiene, overweight, wide or deep sinus pit were stated as the most common causes of recurrence. Vast majority of the pediatric surgeons recommended laser epilation (%85.2) and slimming (59.1%) to patients.

Conclusion: Various studies have been published from Turkey for pilonidal sinus disease. As seen in the current study, Turkish pediatric surgeons do not have a common opinion in pilonidal sinus disease and prefer surgical excision methods more frequently. Prospective randomized studies with bigger number of patients are required to establish common guidelines in disease management.

Successful Mesenchymal Stem Cell Application in Supraventricular Tachycardia-Related Necrotizing Enterocolitis: A Case Report

Necrotizing enterocolitis (NEC) is one of the most important life- threatening diseases in neonates. Recurrent episodes of supraventricular tachycardia (SVT) can lead to gut ischemia, with subsequent reperfusion injury resulting in NEC. Mesenchymal stem cells (MSCs) are multi-potential cells which can differentiate into multiple cell types. Case report: A 22-day old male baby delivered to 34 yr old mother at 37-weeks' gestation via cesarean section, birth weight 3550 g, developed NEC 14 hours after being treated with cardioversion for SVT. At laparotomy, there was pan-NEC, and 60 cm of necrotic and perforated bowel was resected. 1 × 10⁷ umbilical cord origin allogeneic MSCs were given intravenously, with subsequent improvement of the remaining bowel. Conclusion: MSC may be a promising treatment for adjacent ischemic bowel in NEC helping prevent short bowel syndrome.

Which morphological abnormalities better define the elongation of transverse aortic arch: a magnetic resonance angiography study

BACKGROUND

The aim of the study is to investigate the relation between morphological abnormalities that might indicate elongation of transverse aortic arch (ETA) and various aortic and thoracic measurements, and to determine which morphological criteria define the elongated transverse arch better.

MATERIALS AND METHODS

Patients under 40 years of age who underwent contrast enhanced thoracic magnetic resonance angiography were included in the study. Images were evaluated for the presence of morphological arch abnormalities such as late take off (LTO) of left subclavian artery (LSA), flattening of the arch, and kinking at the posterior or anterior contour of the lesser curvature. Various aortic and thoracic measurements, including the distance between the orifices of the left common carotid artery (LCCA) and LSA, were made. Statistical relation between morphological abnormalities and these measurements was analysed. The effect of morphological abnormalities and their combinations on the distance between LCCA and LSA orifices was evaluated by linear regression analysis.

RESULTS

Ninety three cases were included in the study. All morphological abnormalities and most of their combinations show statistically significant relation with longer LCCA to LSA distance. The parameters that most affected this distance were combination of flattening with LTO of LSA, anterior kinking and combination of anterior kinking with both flattening and LTO, respectively.

CONCLUSIONS

Our study showed that the finding which best defines ETA is the combination of LTO and arch flattening. Therefore, we recommend using this combination in the diagnosis of ETA instead of the classical diagnostic criteria including combination of LTO and posterior kinking.

Stuck tunneled central venous catheters in children: Four cases removed by angiography assistance

Ateş U, Taştekin NY, Mammadov F, Ergün E, Göllü G, Can ÖS, Uçar T, Bingöl-Koloğlu M, Yağmurlu A, Aktuğ T. Stuck tunneled central venous catheters in children: Four cases removed by angiography assistance. Turk J Pediatr 2018; 60: 221-224. Adherent tunneled catheters can usually be removed by a surgical cut down, but in some cases the line can become stuck to the wall of the central veins. In such cases, forceful traction can cause vascular injury, or fracture of the catheter. We present four cases of fixated cuffed tunneled catheters. Three children had acute lymphoblastic leukemia and one had an immunodeficiency syndrome. All catheters were made from polyurethane. Indwelling times were 12-24 months. All patients` catheters were removed with great difficulty by trans-femoral access. The angiography-assisted technique is safe and easily-applied for the removal of stuck catheters in pediatric patients. These cases raise important questions concerning the maximum indwelling time and the choice of catheter material when implanting permanent central venous catheters (CVCs) in children.

Elongated transverse aortic arch in subjects without turner syndrome: A preliminary computed tomography study

The purpose of the present study was to investigate the presence of an elongated transverse aortic arch (ETA), which has been reported to be specific for Turner syndrome, in a population without Turner syndrome. A set of 1,012 patients (713 men, 299 women) under 40 years old, who underwent thoracic CT examination in our radiology department between July 2016 and December 2016, were included in the study. CT scans were performed by 16-slice scanners. CT images were retrieved from the picture archiving and communication system and retrospectively re-assessed by two radiologists. Diagnostic criteria for ETA, which are late take-off of the left subclavian artery (LSA), convex kinking of the inferior aortic arch along the lesser curvature and flattening of the transverse aortic arch, were searched in each case. The mean age of the study population was 25.5 ± 10.0 years. Late take-off of the LSA was detected in 17 (1.7%) subjects (10 men, 7 women). In six of these, the other criteria for ETA were not met. However, in the other 11 (1.1% of the study population) cases, in addition to late take-off of the LSA, aortic morphology was compatible with ETA. The dimensions of the aortic root and the ascending and descending aorta were within normal limits in all 17 cases. Our results supported the presence of ETA in subjects without Turner syndrome with ∼1.1% frequency. This is the first preliminary report regarding the frequency of ETA in non-Turner subjects. Clin. Anat. 31:887-890, 2018. © 2018 Wiley Periodicals, Inc.

Laparoscopic proctocolectomy with ileal j-pouch anal anastomosis in children

BACKGROUND/AIMS

We aimed to evaluate postoperative fecal incontinence scales of children who underwent laparoscopic proctocolectomy and ileal J-pouch anastomosis for familial adenomateous polyposis (FAP) and inflammatory bowel disease (IBD).

MATERIALS AND METHODS

Fecal incontinence scores were collected at 3 months post-surgery. A retrospective chart review was also performed to obtain the demographic data and operative technical details.

RESULTS

The postoperative Wexner Fecal Incontinence Score was 0 in 9 of 11 patients and satisfactory in the remaining two. None of the children had a major complication.

CONCLUSION

Even though the presented study does not have any comparable data, it seems that laparoscopic total proctocolectomy with ileal J-pouch anal anastomosis (TP IPAA) might be the best choice of surgery because it provides good continence with low complication rates.

Histomorphology of the Harderian gland in the Angora rabbit

This study was aimed to demonstrate the morphological and histochemical properties of the Harderian gland in the Angora rabbit. Ten healthy adult Angora rabbits obtained from private breeders constituted the material of the study. The Harderian gland, which is composed of the pink and white lobes, consists of cells that produce a secretion of lipid character. The pink lobe contained type I cells with large lipid vacuoles. Cells with small lipid vacuoles (type II) were found in the white lobe. Type III cells containing both large and small lipid vacuoles were not observed. While type I cells reacted strongly to staining with Oil red O, type II cells reacted weakly to this stain. The number of plasma cells was greater in the white lobe when compared to the pink lobe. The apical granules within the epithelial cells lining the intralobular and inter-lobular excretory ducts of the gland were positive for periodic acid-Schiff (PAS), periodic acid-Schiff/alcian blue (PAS/AB), alcian blue (AB) and performic acid/alcian blue (PA/AB). Electron microscopic examination revealed that type I cells contain large electron-light lipid vacuoles and an eccentric heterochromatic nucleus, due to the presence of these vacuoles. The cells, which were connected by tight junctions, possessed apically located microfolds. The nucleus of type II cells was situated basally and had an oval shape. Type II cells had apical microvilli-like cytoplasmic protrusions, longer than those of type I cells. Oval shaped myoepithelial cells were observed between the glandular epithelial cells and their basal lamina. The epithelium lining the excretory ducts of the gland contained two types of granules, which were dark and lightly coloured. Histochemical and ultrastructural examinations revealed no difference in the structure of the Harderian gland between female and male Angora rabbits.

Ultrastructure of pancreatic alpha and beta cells in young quails (Coturnix coturnix japonica) fed aflatoxin

The present investigation was undertaken to assess the effects of aflatoxin (AF) containing diets on alpha and beta cells of the endocrine pancreas in young quails by means of light and electron microscopy. A total of thirty quails were divided into 3 groups, each comprising 10 animals. Total AF was incorporated into the diet of these groups, at dosages of 0 (control, group 1), 2.5 (group 2), and 5.0 (group 3) mg AF/kg feed. The chicks were housed in electrically heated battery cages and exposed to light for 24 h from hatching to 3 weeks of age. Quails consumed the diets and water ad libitum. Electron microscopic examinations demonstrated degranulation of alpha cells, decrease in the size and number of secreting granules, and increase in the number of free ribosomes and polisomes in the animals of group 2 and 3. In beta cells, the numbers of free ribosomes and polisomes decreased, whereas the number of mature granules increased in the animals of group 3. Mononuclear cell infiltrates were observed in the periphery of capillaries and around endocrine islets in the experimental groups. Furthermore, capillaries of the animals in group 2 and 3 were dilated at all sides of both alpha and beta islets. According to the results of this study, the addition of aflatoxin to the diets of quails at dosage of 2.5 and 5 mg AF/kg leads to significant changes in pancreatic alpha and beta cells. These changes may exhibit adverse effect on the metabolism of carbohydrates in poultry.

Hydrated sodium calcium aluminosilicate for reduction of aflatoxin in quails (Coturnix coturnix japonica)

The purpose of the present study was to evaluate the toxic effects of aflatoxin (AF) on growth performance and various processing parameters of quails and to determine the preventive efficacy of hydrated sodium calcium aluminosilicate (HSCAS). One hundred and eighty 1-d-old quails of both sexes were randomly divided into 4 experimental groups with 5 replicates and 45 birds following weighing. The experimental design consisted of four dietary treatments: 1) control with 0 mg AF/kg of diet and 0% HSCAS; 2) 0.5% HSCAS; 3) 2.5 mg AF/kg of diet; 4) 2.5 mg AF/kg of diet plus 0.5% HSCAS. The chicks were housed in electrically heated battery cages and exposed to light for 24 h from hatching to 3 weeks of age. Quails consumed the diets and water ad libitum. Body weight (BW) was significantly (p < 0.001) increased by addition of HSCAS to AF diet. The lowest BW gains in groups received AF alone was observed at all periods. The reduction in BW gain caused by 2.5 mg AF/kg of diet was significantly (p < 0.001) diminished by the addition of 0.5% HSCAS to the diet. The addition of HSCAS to the AF diet significantly (p < 0.001) protected against decrease of feed intake at all periods with exception of the first period. None of the treatments altered significantly the feed conversion ratio (FCR). The relative weights of the liver, kidney and spleen were increased in the chickens consuming the AF alone diet. However, light microscopic examination demonstrated the addition of HSCAS to quail feed to partially decrease fat deposition caused by the toxin, and besides, electron microscopic examination of indicated a reorganization in the endoplasmic reticulum and increase in the number of ribosomes and polisomes. Furthermore, the decrease in the antibody titre induced by Newcastle vaccine, due to aflatoxins, was relatively prevented. No significant differences were observed for serum total protein, total cholesterol and glucose levels. The results of indicate that HSCAS is effective in preventing the deleterious effects of AF.

Light and electron microscopic studies on liver histology in chicks fed aflatoxin

This study was carried out under both light and electron microscopy to investigate the effects on liver carbohydrate and lipid metabolism caused by aflatoxin (AF) fed to chicks. Twenty broiler chicks were used. The birds were housed in electrically heated battery cages and exposed to light for 24 h. Feed and water were provided ad libitum. The animals were allocated to two groups each made up of 10 broilers. Total aflatoxin levels of zero (0) and 5 mg of AF/kg feed (81.05% AFB1, 8.79% AFG1, 6.06% AFB2, and 4.10% AFG2) added to a commercial diet, were fed to chicks from hatching up to 3 weeks of age, when the experiment was terminated. The chicks were executed by cervical dislocation and liver samples were obtained for light and electron microscopy. Oil red 'O', Sudan Black B, periodic acid Schiff (PAS) and Best's carmine stains were used to reveal fat and glycogen in the liver. Histological changes in hepatocytes included increased lipid droplets, high glycogen content, and mild mononuclear cell infiltration in the portal areas. Ultrastructural findings were destruction of rough endoplasmic reticulum (rER), reduction in mitochondrial size, enlargement of bile canaliculi, and cisternal dilatation of the smooth endoplasmic reticulum (sER).