Enzyme-mediated depletion of methylthioadenosine restores T cell function in MTAP-deficient tumors and reverses immunotherapy resistance

Chromosomal region 9p21 containing tumor suppressors CDKN2A/B and methylthioadenosine phosphorylase (MTAP) is one of the most frequent genetic deletions in cancer. 9p21 loss is correlated with reduced tumor-infiltrating lymphocytes (TILs) and resistance to immune checkpoint inhibitor (ICI) therapy. Previously thought to be caused by CDKN2A/B loss, we now show that it is loss of MTAP that leads to poor outcomes on ICI therapy and reduced TIL density. MTAP loss causes accumulation of methylthioadenosine (MTA) both intracellularly and extracellularly and profoundly impairs T cell function via the inhibition of protein arginine methyltransferase 5 (PRMT5) and by adenosine receptor agonism. Administration of MTA-depleting enzymes reverses this immunosuppressive effect, increasing TILs and drastically impairing tumor growth and importantly, synergizes well with ICI therapy. As several studies have shown ICI resistance in 9p21/MTAP null/low patients, we propose that MTA degrading therapeutics may have substantial therapeutic benefit in these patients by enhancing ICI effectiveness.

Dual CDKN2A/MTAP loss compared to CDKN2A loss alone and response to immune-checkpoint inhibitors (ICI) in advanced solid tumors

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Background: We previously showed that CDKN2A genomic alterations (GAs) are associated with resistance to ICI (Adib E, Clinical Cancer Research, 2021). The majority of such GAs are homozygous deletions, which commonly (̃50-80%) include MTAP, located 100kb telomeric of CDKN2A. MTAP loss leads to 5′-deoxy-5′-methylthioadenosine (MTA) accumulation and immunosuppressive effects in tumors. We examined combined CDKN2A/MTAP deletion vs. CDKN2A deletion/mutation alone as predictors of poor ICI response. Methods: We curated clinical data for cancer patients (pts) treated with ICI at Dana-Farber Cancer Institute through 6/2021, who had targeted panel sequencing. Inclusion criteria were: ICI in metastatic setting, ≥2 cycles, no concurrent systemic therapy, cancer type with > 50 pts treated. CDKN2A/ MTAP GAs were defined as a deep deletion affecting both genes; CDKN2A only GAs included both homozygous deletions and truncating mutations. Hazard ratios (HR) for overall survival (OS) and time-to-treatment failure (TTF) were derived using multivariable Cox regression, adjusted for prior lines of therapy, treatment type (single vs. combination ICI), tumor mutational burden and ECOG PS. We also used a machine learning approach to quantify the density of tumor-infiltrating lymphocytes (TILs) in digital whole-slide H&E images of 144 melanoma pts with available genomic data. Results: 921 pts with 6 cancer types were studied: non-small cell lung cancer (NSCLC, n = 366), melanoma (mel, n = 228), urothelial carcinoma (UC, n = 120), esophagogastric carcinoma (EGC,n = 90), head and neck squamous cell carcinoma (HNSCC, n = 58), and renal cell carcinoma (RCC, n = 59). UC pts with MTAP/ CDKN2A GAs had shorter OS and TTF than pts without GA in either gene (OS HR = 1.9[1.1-3.4], p = 0.005; TTF HR = 1.8[1.0-3.1], p = 0.0016) after adjusting for covariates. Similar results were seen for melanoma (OS HR = 2.5[1.4-2.6],p = 0.00065; TTF HR = 1.9[1.1-3.2],p = 0.018). There was no significant difference between pts with CDKN2A GA only and those without GA in either gene for OS or TTF in either UC or melanoma. CDKN2A/MTAP status was not associated with significantly shorter survival for NSCLC and EGC; while the analysis was confounded by HPV events for HNSCC, and underpowered for RCC. ML-based analysis of digital slides for melanoma, showed that tumors with CDKN2A GAs only (n = 42) had similar median density of TILs compared to tumors without GAs in either gene (n = 84; 920 vs. 943 TILs/mm2; p = 0.42). In contrast, tumors with co-occurring CDKN2A/ MTAP GAs had lower TIL density (529 TIL/mm2, n = 17 vs. 925 TIL/mm2, n = 126 (pooled); p = 0.018, Wilcoxon rank sum). Conclusions: In this study, we showed that co-occurrence of MTAP/CDKN2A GAs, but not CDKN2A GA only, was associated with worse outcomes in pts with UC and melanoma treated with ICI. Lower TIL density was also seen in melanoma tissue samples with combined MTAP/CDKN2A GA.

Susac Syndrome: Clinical characteristics, diagnostic findings and treatment in 19 cases

Susac's Syndrome (SS), which was first described in 1979, is a rare and presumably autoimmune disorder characterized by encephalopathy, hearing loss, and visual disturbance resulting from branch retinal artery occlusion (BRAO). This study reports 19 SS patients' clinical characteristics, MRI features, CSF analysis, treatment strategies and outcomes. At initial presentation, only three of 19 patients demonstrated the complete clinical triad. Clinic presentation varied from isolated hemiparesis to the full triad (encephalopathy, hearing loss and visual disturbances). Corpus callosum (CC) involvement was noted in the MRI of 18 patients (97%) and BRAO was detected in 17 (95%) patients. All patients were treated with intravenous methylprednisolone after the initial assessment. This case series is presented to emphasize the differences in clinical presentation of SS and the importance of MRI and FFA in diagnosis.

Incarcerated Inguinal Hernia in Children

Introduction

The aim of this study was to document the data of incarceration in a group of children with inguinal hernia and to investigate whether incarceration could have been prevented.

Materials and methods

A retrospective study reviewed the records of 3100 children who underwent herniorrhaphy between 1989 and 2007 in one centre, with 113 patients having hernia incarceration. In 16 patients, manual reduction was not attempted because of signs of strangulation, and in the remaining ones, reduction following sedation was not successful. The patients were evaluated with respect to age, postoperative mortality, and morbidity and especially whether he or she had been scheduled for operation in a surgical department. The incidence of incarcerated inguinal hernia and risk factors were analysed.

Results

Of the 113 patients with incarcerated inguinal hernia, 105 were boys (92.9%), with a male to female ratio of 13:1. The majority of the patients were under one year of age (n=73); and 47 were 0-3 months old. Three laparotomies, 7 small intestinal resection and primary anastomoses, 2 oophorectomy, 7 partial omentectomy and 8 appendectomies were performed. During the 6 months to 18 years follow-up, testicular atrophy was seen in 4 boys. Two babies died. Scrotal oedema, testicular atrophy and mortality rate were significantly higher in incarcerated hernia patients compared with those without incarceration (all with p=0.001).

Conclusions

Apparently, incarceration may be a preventable problem. Priority should be given to the treatment of inguinal hernias in infants less than 1 year of age, especially those 1-3 months old, as their risk of incarceration is higher.

Electrophysiological and clinical correlates of corpus callosum atrophy in patients with multiple sclerosis

Multiple sclerosis (MS) is an idiopathic inflammatory demyelinating disorder of the central nervous system (CNS) characterized by demyelination and axonal degeneration. Corpus callosum (CC) is commonly involved during the disease process leading to atrophy (93%). Currently, there are no established markers of disease progression and the interplay of processes leading to brain atrophy in MS remains unknown. The primary aim of this study was to assess the frequency of CC atrophy in MS patients. Furthermore, the relationship between expanded disability status scale (EDSS) and transcranial magnetic stimulation (TMS) evoked motor potentials (MEP) were assessed to capture disease effects by independent parameters. Seventy-nine MS patients and 50 controls were included and their CC volumes were assessed. Out of 79 patients, 31 patients (39·2%) had CC atrophy. The distribution of EDSS scores among the group with CC atrophy [13 (32%) patients with EDSS 0-2; 11 (58%) patients with EDSS 2-4; 19 (24%) patients with EDSS ≥4] was not statistically significant (p>0·05). MEP latency was abnormal in 34 (43%) patients, 67 (85%) patients had abnormal MEP amplitude and CMCT was abnormal in 32 (41%) patients. The relation between EDSS and MEP was statistically significant among the patient population including the subgroup of patients with CC atrophy (p<0.05). Our results lacked to provide an association between disability and CC atrophy, but there was a correlation between CC atrophy and TMS evoked motor potentials. Early evolution of axonal degeneration and brain atrophy should be considered in terms of follow-up measures to provide long-term efficiency impacting disability, progression and brain atrophy.

INHIBIN B LEVELS IN PERIPHERAL VEIN DO NOT CORRELATE WITH INHIBIN B LEVELS IN THE SPERMATIC VEIN IN ADOLESCENTS WITH VARICOCELE

This study was conducted to evaluate the inhibin B with FSH and LH levels on spermatogenesis in varicocele patients. The study group consisted of 10 adolescent with left idiopathic varicocele of grade II and III. Blood specimens were obtained from dilated spermatic vein and peripheral vein simultaneously. Peripheral samples were also collected from 7 healthy children as controls. Inhibin B was measured with ELISA inhibin B kits. FSH and LH were analyzed by radioimmunoassay techniques. The results were analyzed using Mann-Whitney U and Spearman's rank tests. A value of p < 0.05 was considered significant. Peripheral FSH, LH and inhibin B levels were the same in the study and control group (p > 0.05). Mean inbibin B levels of spermatic vein were significantly higher than the control and peripheral blood of the study groups (p < 0.05). FSH, LH, and inhibin B levels correlated poorly each other (p > 0.05). Preoperative serum inhibin B concentration could not reliably predict a response to varicocelectomy, but the increase in inhibin B levels after treatment might suggest an improvement in testicular function.

Sequential cytokine levels in the diagnosis of appendicitis

OBJECTIVE

To determine the diagnostic value of sequential white blood cell count (WBC), tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in patients with abdominal pain.

MATERIAL AND METHODS

Tests were determined at hospital admission and 6 h later in 105 children. Patients who were non-operatively followed and had a normal histopathology were classified as the non-appendicitis (NA) group. Patients with symptoms consistent with appendicitis were classified as the appendicitis group (A). Data were analyzed as positive/negative predictive value, sensitivity, specificity and accuracy rate (AR). The global power of the variables in discriminating the patients between the two groups and advanced/simple appendicitis was assessed from the area under the receiver operating characteristic (ROC).

RESULTS

Initial measurements showed WBC to be a valuable diagnostic tool in acute appendicitis (AR = 74 %), whereas IL-6 and TNF-alpha were found not to be valuable. The second measurements revealed higher values, and IL-6 reached its highest AR (89 %). When initial values were evaluated in combination, the highest AR of 73 % was observed with TNF-alpha + WBC. The highest AR (90 %) was seen with IL-6 + TNF-alpha in the second measurements. ROC analysis showed WBC to be the most valuable parameter of the three. The area under the curve (AUC) was 0.750 for the initial measurement and 0.779 for the repeat measurement of WBC (p = 0.001). The most useful diagnostic parameter in discriminating between the simple and the advanced cases was IL-6 as assessed with the ROC curve (p<0.01).

CONCLUSIONS

WBC elevation in patients with suspected acute appendicitis is an important parameter supporting the diagnosis at initial admission, whereas IL-6 is a more valuable tool in diagnosing advanced appendicitis.

Cefoperazone induced gastro-intestinal haemorrhage. A case report

Cefoperazone is a parenteral third generation cephalosporin which is active against many Gram positive and Gram negative organisms. Cefaperazone, like other cephalosporins which contain methyltiotetrazole side chain, can cause hypoprotrombinaemia and bleeding problems. Here we report a nine-year old child with Meckel's diverticulum who had cefoperazone induced massive gastrointestinal bleeding on the fifth day following the operation.

Association of tumor necrosis factor, interleukin-6 and cyclooxygenase pathway with lipopolysaccharide-induced intussusception

INTRODUCTION

Many factors and mechanisms have been proposed as causes for intussusception (IN); however, the etiology remains unclear. Inflammatory mediators such as tumor necrosis factor (TNF) and interleukin-6 (IL-6), which are elevated during infectious diseases, can significantly affect gastrointestinal motility. Motility changes caused by these agents might contribute to the development of IN. The aim of this experimental study was to determine the preventive effects of indomethacin on lipopolysaccharide (LPS)-induced IN in mice and to investigate the role of TNF and IL-6 on intussusception.

MATERIALS AND METHODS

Seventy-eight mice were divided into five groups. In the Control group (n=6), no procedure was done. In the Sham group (n=6), 1 ml saline, in the Indomethacin group (n=6), 10 mg/kg of indomethacin, in the LPS group (n=30), 12 mg/kg of LPS was administered intraperitoneally (IP). In the Treatment group (n=30), 10 mg/kg of indomethacin was administered IP following 12 mg/kg of LPS. All animals were laparotomized 6 hours following IP injections. The existence of IN was noted and blood specimens were obtained. TNFalpha and IL-6 plasma level measurements were performed by standard ELISA for mice. The results were compared using the Mann-Whitney U test and one-way ANOVA test. A value of p<0.05 was considered significant.

RESULTS

Five mice (1 in the control, 2 in the LPS, 2 in the Treatment group) were excluded from the study. IN was observed in 6 (20%) mice in the LPS group, whereas it was not found in any mice in the Treatment group. Mean TNFalpha and IL-6 levels were statistically higher in the LPS group (394.72+/-403.79; 195.18+/-218.37 pg/ml, respectively) compared to all other groups, including the Treatment group (p<0.05 for each comparison). Within the LPS group of mice, the levels were higher in animals with IN compared to the mice without IN.

CONCLUSION

Increased TNFalpha and IL-6 levels induced by LPS correlated well with the occurrence of IN, and a decrease in these levels via cyclooxygenase (COX) inhibition by indomethacin prevented IN from forming in this experimental model.

Ankyloglossia and effects on breast-feeding, speech problems and mechanical/social issues in children

BACKGROUND

This aim of this study was to define the characteristics of the patients who underwent surgery for ankyloglossia.

PATIENTS AND METHODS

The patients (n = 127) with ankyloglossia underwent surgery between 1987 and 2005. The patients were evaluated for age, gender, complaints, grade, and operative procedures. This study did not cover postoperative evaluation of the procedure.

RESULTS

The ages of the children ranged from 20 days to 7 years, and 84% of them were under 1 year of age. Seventy-two percent were boys; 28% were girls. The most common complaint of the parents of infants under one year of age was breast-feeding (35/84). When the tongue movements of the patients were examined, 57 patients (of whom 18 were over one year of age) had limited tongue mobility. The mean frenulum length of the patients was grade 1 in 72 patients and grade 2 in 55 patients. Ankyloglossia was corrected by frenotomy. Three patients had bleeding from their frenotomy site which resolved with local pressure. General anaesthesia was preferred for 77 patients, and there was a need for suturing in 20 patients.

CONCLUSION

The correction of ankyloglossia at an early age reduces the risk of latent complications. In addition, the early correction will mitigate the feeding- and speech-related concerns of parents and doctors alike.

A child with a giant omental cyst

A case of giant omental cyst diagnosed preoperatively is described. A 4-year old girl presenting with abdominal distension and misdiagnosed as having ascites, was subsequently proved to have a giant omental cyst. This is a rather difficult diagnosis to reach and results in wrong treatment methods. A high index of suspicion is therefore required early in the course of the disorder to decrease the complication rate. This report describes the diagnostic modalities and our approach to the patient who was cured by total excision of the cyst and free of disease in the fourth year of follow-up.

Treatment of Morgagni hernias by transabdominal approach

BACKGROUND

Recently, the thoracic approach has been suggested in the surgical treatment of Morgagni hernias with some reported advantages over abdominal surgery. This manuscript reports the authors' experience with childhood Morgagni hernias repaired via laparotomy.

SUBJECTS AND METHODS

Records of five cases of Morgagni hernias were evaluated with respect to age, presentation, operative data, complications, and outcome.

RESULTS

The average age of four male and one female patients was 34 months (range 6 months to 8 years). Predominant presenting symptoms were related to the respiratory system. The diagnoses were made by posterior-anterior and lateral chest X-rays and confirmed by barium enema contrast radiographs. Associated anomalies were detected in three cases. All cases were managed by abdominal approach through upper midline incisions reducing the herniated viscera (transverse colon in all and including omentum in one patient) and excising the hernia sac which was present in all patients. The postoperative period was uneventful in this series and no recurrence was detected in an average of four years of follow-up.

CONCLUSION

The transabdominal approach is appropriate in the surgical correction of paediatric Morgagni hernias.

Surgical breast lesions in adolescent patients and a review of the literature

BACKGROUND/PURPOSE

Breast disease in adolescence is uncommon, with most presenting lesions being benign. Breast lesions in adolescent patients are discussed in this article with a review of world literature.

PATIENTS AND METHODS

The clinical records of 30 patients operated upon for breast lesions in our hospital during 18 years were reviewed.

RESULTS

There were 25 female and five male patients, ranging in age from 16 years. Twenty-five female patients were operated on for breast mass and/or discharge, and five male adolescents were operated on for gynaecomastia. The most frequent (n = 27) complaint was palpation of mass in the breast. The most common histologies were fibro-adenoma (n = 14) and gynaecomastia (n = 5). The average duration of pre-operative symptoms was 2.9 months for fibro-adenoma, 1.6 years for gynaecomastia (extremes 2 days to 1 year). Nipple discharge was observed in three patients. Average diameters of palpable masses were 2.9 cm for fibro-adenomas and 5 cm for gynaecomastia. Lesions were excised surgically in all patients. Masses diagnosed as fibro-adenomas in the pre-operative period were reported upon pathological examination to be precancerous lesions such as cystosarcoma phylloiedes, juvenile fibro-adenoma, solitary intraductal papilloma, tubular adenoma and juvenile papilloma. One postoperative wound infection and one recurrence of fibro-adenoma was seen.

CONCLUSION

The most frequently encountered breast masses were fibro-adenomas. These lesions are mostly benign in nature and can be treated conservatively but the possibility of precancerous lesion should be considered during follow-up.

Unusual localization of hydatid cyst

We report a case of a single large echinococcal cyst that originated from the retroperitoneal space. Diagnosis was confirmed with serologic test and radiological examinations. Especially in the endemic areas hydatid cyst should be considered when evaluating cystic masses and it can be treated by extraperitoneal operation.

Omentum prevents intestinal adhesions to mesh graft in abdominal infections and serosal defects

BACKGROUND

Many studies have evaluated the use of grafts in the reconstruction of abdominal wall defects. In this study, the effects resulting from the presence or absence of the omentum were evaluated in the setting of infection or serosal defects in the formation of adhesions in abdominal closures using mesh grafts.

METHODS

For this study, 60 Wistar albino rats were divided into six groups. A circular 3.79-cm(2) fascioperitoneal defect was created. After group-specific procedures, defects were reconstructed using polypropylene mesh grafts. In group C (control group), only a mesh graft recontruction was performed, whereas group O (O for omentectomy) underwent an omentectomy plus mesh closure. In group SD (serosal defect group), the cecum was abrased with a brush before mesh closure. Group SDO underwent cecal abrasion plus an omentectomy. In group I (infection group), the intraabdominal space was filled with 1 ml of solution containing 100,000 colony-forming units (CFUs) of Escherichia coli per milliliter. Group IO received the same same amount of E. coli solution plus an omentectomy before mesh closure. After 28 days, the groups were evaluated by intraabdominal and blood cultures, grading of intraabdominal adhesions, graft-organ adhesions, proportion of adhesions to graft size, and histopathologic studies. The results were statistically evaluated using one-way variant analysis and Scheffe's and Fisher's definite chi-square tests.

RESULTS

For the groups in which the greater omentum was preserved, intestinal adhesions to the graft surface were less frequently observed, especially in cases with intraabdominal infections and serosal defects (p < 0.05).

CONCLUSIONS

Preservation of the greater omentum reduces the formation of intestinal adhesions, especially in cases with underlying infections and serosal defects in abdominal closures using mesh grafts. This could be beneficial in related clinical situations in lowering the rate of intestinal fistulas, erosions, and obstructions that can be attributed to the formation of adhesions.

Effect of melatonin on healing of colonic anastomosis in a rat model of peritonitis

BACKGROUND

The aim of this study is to determine the effect of melatonin on intestinal anastomosis in the presence of peritonitis.

MATERIAL AND METHODS

32 Wistar albino rats were randomized into four groups (n = 8): A (sham), B (control), C (melatonin 5 mg/kg), and D (melatonin 10 mg/kg). In group A, only cecal dissection was carried out. In the other groups, cecal ligation and puncture (CLP) followed cecal dissection in order to induce bacterial peritonitis. 24 h after the previous operation, cecal resection and ileocolic anastomosis were performed in the rats of all groups. In group C (5 mg/kg) and group D (10 mg/kg), melatonin was injected for 5 consecutive days starting after CLP. At the 48th hour of the CLP procedure, blood was drawn via the tail vein for tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) analysis, and on the 4th day of the experiment relaparotomy was carried out for bursting pressure (BP) measurements. The intestinal tissue containing the anastomotic line was then snap-frozen in liquid nitrogen and stored at -80 degrees C for determination of tissue levels of malondialdehyde (MDA) and glutathione (GSH).

RESULTS

The tissue MDA level, blood TNF-alpha and IL-6 levels of group B were significantly higher than in the other groups, whereas the BP results and GSH levels of group B were found to be significantly lower than in the other groups. The results of groups C and D are statistically different from those of group B. When we compared the results of groups C and D, we found significantly higher results in terms of BP and GSH levels in group D and also significantly lower results in terms of MDA, blood TNF-alpha and IL-6 levels in group D.

CONCLUSION

The findings of this experiment suggest that melatonin has a dose-independent positive effect on wound healing of colonic anastomosis.

Pancreas pseudocyst associated with L-asparaginase treatment: a case report

A major complication of L-asparaginase used in the treatment of paediatric malignancies in children is pancreatitis (2%-16%). However, only seven paediatric cases of pancreatic pseudocyst caused by the utilization of the agent have been reported in literature. We present the case of a 5-year old girl who had abdominal pain and epigastric dullness after the third course of BMF-95 protocol with a diagnosis of ALL. A pancreatic pseudocyst of 10 x 10 cm size was found by abdominal tomography. The cyst was treated by percutaneous external drainage, total parenteral nutrition (TPN), administration of octreotide and antibiotherapy for one month. Percutaneous external drainage has proven to be an effective, noninvasive method in this special case with a systemic disorder and the high risk of mortality should a surgical intervention have been performed.

Postoperative intussusception in children

Postoperative intussusception (POI) is an uncommon cause of postoperative mechanical bowel obstruction in children. Four cases of POI during a period of 15 years (1987-2001) were analysed retrospectively. Symptoms developed after a median period of 2.5 days following the operation. All cases were succesfully treated with operative manual reduction. POI occurs after a wide variety of surgical procedures and is often difficult to diagnose because the symptoms are often obscure. As a conclusion, we state that reaching a diagnose requires a high index of suspicion.

Massive ovarian oedema in adolescents

Massive ovarian oedema is an unusual clinical entity occurring in teenage girls. It is a rare tumour-like condition of the ovary characterized by marked enlargement of one or both ovaries due to marked accumulation of oedema fluid in the ovarian stroma. Massive ovarian oedema may result from partial or intermittent torsion of the mesovary, interfering with venous and lymphatic drainage, but not with arterial blood flow. The patients most commonly present with lower abdominal pain and enlargement. This entity can clinically mimic a neoplasia. We report three cases with massive ovarian oedema.

Effects of hyperosmolar agents--lactulose, lactitol, sodium phosphate and polyethylene glycol--on cecal coliform bacteria during traditional bowel cleansing: an experimental study in rats

Mechanical bowel cleansing is considered to be necessary prior to colorectal surgery, some radiological or endoscopic procedures, and for fecal disimpaction. Traditional bowel cleansing (TBC) with cathartics and enemas is a method of mechanical bowel cleansing for patients who have restrictive factors for whole-bowel irrigation (WBI), such as excessive fecal impaction, cardiac, hepatic or renal disorders. In this experimental study, TBC with hyperosmolar agents was evaluated in terms of their effects on colonic flora and bacterial translocation (BT). Sprague-Dawley rats were divided into 6 groups. The animals, except controls, were not fed for 72 h but received tap water ad libitum. During this period, lactulose, lactitol, sodium phosphate (NaP), polyethylene glycol 3350 (PEG3350) and physiological saline gavages were administered to the rats in groups 1-5, respectively, once a day. All animals except controls (group 6) received enemas with 15 ml of warm saline twice a day. The cecum, mesenteric lymph nodes (MLNs) and portal vein blood were sampled for microbiological and histopathological analysis. The highest level of coliform bacterial overgrowth and BT to MLNs were observed in the lactulose group, although the others, except the saline and control groups, also caused some degree of BT. Portal vein cultures were negative for all groups. Histopathological damage was not associated with cecal bacterial count and BT. As a result of this study, PEG3350 seems to be safer and more effective than lactulose, lactitol and NaP during TBC.

Diagnostic value of plain abdominal radiographs in acute appendicitis in children

OBJECTIVE

The plain film of the abdomen (PAX) is still utilised in the diagnosis of acute appendicitis (Aap). Aim of this study was to evaluate the value of PAX in the diagnosis of Aap in children, since it continues to be a controversial subject.

DESIGN

A retrospective study.

SETTING

Department of Paediatric Surgery, Gazi University Medical School.

PATIENTS

The histopathological diagnoses and PAX of 213 children (mean age 9-6 years) operated for acute right-lower quadrant pain were evaluated retrospectively. There were 181 patients with Aap and 32 with normal appendix.

METHODS

The rate of detection of overall thirteen roentgenographic criteria defined in various reports in medical literature as indicating appendicitis were noted and compared with histopathological diagnoses. The PAX which revealed one or more of these signs in combination was considered to be positive for Aap. Data was analysed statistically and sensitivity, specificity and positive and negative predictive values of PAX in the diagnosis of Aap were determined.

RESULTS

Roentgenographic sign(s) were detected in 170 (79%) cases, 18 without Aap. The most frequent were lumbar scoliosis with left-sided convexity (50%) and small intestinal air-fluid levels (32%). In 39 cases, 25 with Aap, no sign(s) was detected. In all of the perforated cases, at least one of the determined criteria was seen. The percentage of roentgenographic signs found in cases with and without appendicitis was different significantly (p<0.01). The negative predictive value of PAX in the diagnosis of acute appendicitis was 32.5% and positive predictive value was 89%.

CONCLUSION

PAX could he helpful in diagnosis in children with suspected acute appendicitis.

Effects of amrinone on bilateral renal ischemia/reperfusion injury

Renal ischemia/reperfusion injury could arise as a consequence of clinical conditions such as renal transplantation, shock, cardiac arrest, hemorrhage and renal artery surgery. In this experimental study, we aimed to determine the preventive effects of amrinone on bilateral renal ischemia/reperfusion injury in rats. A total of 60 Wistar-albino rats were divided into six groups ( n=10). Midline laparotomies were made under ketamine anesthesia. In the sham, amrinone1 and amrinone2 without ischemia (AWI1 and AWI2) groups saline, 5 and 10 mg/kg of amrinone was infused, respectively. In the ischemia, ischemia plus amrinone1 (IPA1) and ischemia plus amrinone2 (IPA2) groups, saline and 5 and 10 mg/kg of amrinone was infused, respectively, at the beginning of reperfusion, subsequent to 45 min of bilateral renal artery occlusion. Following 6 h of reperfusion, blood was drawn to study serum BUN and creatinine and a bilateral nephrectomy was done to determine tissue malonyldialdehyde ( MDA) and myeloperoxidase (MPO) levels. The results were analysed by Mann-Whitney U-test. The parameters studied were statistically higher in the ischemia group compared with the other groups ( P<0.05 for each comparison), indicating renal I/R injury. These parameters were lower in the amrinone without ischemia groups (AWI1 and AWI2) than in the sham group, however there were no significant differences between the groups ( P>0.05, for each comparison). The treatment groups IPA1 and IPA2 had statistically similar results compared with the sham group, showing the preventive effect of amrinone on renal I/R injury at the given doses. We conclude that amrinone prevented experimental renal ischemia/reperfusion injury in rats, independently of the administered doses. This preventive effect of the agent could depend on its effect of regulating the microcirculation, in decreasing intracellular calcium and in preventing neutrophil activation. We propose that this preventive effect of amrinone - which has gained clinical application especially in cases of cardiac insufficiency - could also be exploited in clinical conditions related with renal ischemia/reperfusion.

Colon interposition for esophageal stenosis in a patient with epidermolysis bullosa

Epidermolysis bullosa (EB) is a disease with 3 forms, most hereditary, characterized by spontaneous blistering lesions. The autosomally inherited form, epidermolysis bullosa dystrophica recessive (EBDR), is responsible for esophageal lesions consisting of web or stenosis. The authors could find only 9 cases treated by various esophageal replacement procedures in the literature, and the experience with 1 case treated by colon interposition is presented. J Pediatr Surg 36:1861-1863.

Effect of bilirubin in ischemia/reperfusion injury on rat small intestine

PURPOSE

The aim of this study was to determine the effects of bilirubin in experimental small intestinal ischemia/reperfusion (I/R) injury in rats.

METHODS

Thirty rats were divided into 5 groups (n = 6). In group S, saline and in group B, bilirubin, 20 mg/kg were infused via the jugular vein without an additional procedure. In groups S-IR, saline, B(1)-IR and B(2)-IR, 10 and 20 mg/kg/h of bilirubin were infused for 2 hours, respectively. In these groups, an I/R procedure was done after infusions by occluding the superior mesenteric artery for 45 minutes followed by 1 hour of reperfusion. After reperfusion, the small intestines were resected for histopathologic and malondialdehyde (MDA) assessments. Mucosal lesions were scored between 0 and 5. Malondialdehyde levels and histopathologic grades were analyzed statistically.

RESULTS

Mucosal injury was severe in S-IR (grade 4 to 5), mild in B(1)-IR (grade 0 to 3) and none in B(2)-IR group (grade 0). Grades of group S-IR were higher than those of B(1)-IR and B(2)-IR statistically (P <.05). Tissue MDA levels of the S-IR group were significantly higher than those of B(1)-IR and B(2)-IR groups (U = 36, P <.05). Bilirubin levels correlated inversely with MDA levels (r = -0.94).

CONCLUSIONS

Bilirubin effectively prevents intestinal I/R injury in rat. This observation is consistent with the hypotheses regarding bilirubin as an antioxidant, having a role in the body defense. J Pediatr Surg 36:1764-1767.

Postoperative necrotizing enterocolitis following incarcerated inguinal hernia repair: report of a case

The postoperative development of necrotizing enterocolitis (NEC) following major surgery in neonates has often been described. We report herein the case of an older infant in whom postoperative NEC developed following emergency repair of an incarcerated inguinal hernia.

Diffuse fibrous proliferation of tunica vaginalis associated with testicular infarction: a case report

Fibrous pseudotumor of the tunica vaginalis testis is an uncommon lesion of unknown pathogenesis. Although this reactive process of testicular tunics is benign, this usually is diagnosed after radical orchiectomy. The authors describe a case of fibrous pseudotumor of the tunica vaginalis testis associated with testicular infarction. To our knowledge, this is the first case presented with similar association, second case consisting predominantly of myofibroblasts and the fourth reported case encountered in childhood.

Effects of polyethyleneglycol-superoxide dismutase (PEG-SOD) and pentoxifylline on small intestinal anastomoses established in the 24th hour of reperfusion: an experimental study in rats

In a previous study, we had shown that anastomoses established in the 24th hour of reperfusion healed less than the ones established in earlier periods. In this study, we aimed to assess the impacts of polyethyleneglycol-superoxide dismutase (PEG-SOD), a free oxygen radical scavenger and of pentoxyfilline, a methyl-xanthine derivative on anastomotic healing at 24th hour of reperfusion. 18 Wistar-albino rats were divided into 3 groups (n = 6). In all groups superior mesenteric artery was occluded for 40 minutes and the intestine was reperfused for 24 hours. Rats were relaparotomized in the 24th hour and small intestinal anastomoses were established. In Sham group, saline (0.5ml); in Group PTX, pentoxyfilline (25mg/kg); and in Group PGS, PEG-SOD (1,500U/kg) was administered intravenously 20 minutes before anastomoses. In the 5th day, anastomotic healing was evaluated by bursting pressures and hydroxyproline contents. Results were analized by Mann-Whitney U test, p < 0.05 was considered significant. Both of average bursting pressures and average hydroxyproline contents were highest in Group PGS (240 mmHg +/- 23.9; 7.71 +/- 0.68 micromol/g-tissue), followed by sham group (168.3 +/- 18.3 mmHg; 5.94 +/- 0.62 micromol/g-tissue) and Group PTX (83.8 +/- 9.2 mmHg, 5.94 +/- 0.62 micromol/g-tissue). Differences of these two parameters between all groups were statistically significant (p < 0.05). Best anastomotic healing in the 24th hour of reperfusion was achieved by PEG-SOD administration, whereas pentoxyfilline did not favor the healing.

Hydatid cysts of the lung in childhood: is capitonnage advantageous?

In the treatment of thoracal hydatid cysts, there is not an agreement whether the cyst cavity to be capitonnaged or not. In this retrospective study, it was aimed to compare the cases of capitonnaged and not capitonnaged thoracal hydatid cysts with regard to hospital stay and post-operative chest tube removal day. Documents of 15 patients operated for pulmonary hydatid cysts in our clinic were reviewed. In 7 cases pericystectomy and removal of germinative membrane was performed whereas in 8 patients capitonnage was added to the procedure. In all cases open airways were suture controlled and pleural cavity was drained with chest tube connected to waterseal system. Average hospital stay of capitonnaged cases was 8 days and of uncapitonnaged ones was 12 days. Thoracal drainage tubes were removed in an average of 4 post-operative days in capitonnaged cases and of 7 days in the others. Statistical analysis were made by Mann-Whitney U test. Difference between the hospital stays of the 2 groups were not significant, whereas it was significant statistically between chest tube removal days (p<0.05). Capitonnage shortens postoperative chest tube drainage period in pulmonary hydatid cysts, resulting in lower morbidity compared with the uncapitonnaged cases.

Comparison of consequent small bowel anastomoses after transient ischemia: an experimental study in rats

BACKGROUND/PURPOSE

The role of ischemia/reperfusion (I/R) damage on intestinal anastomotic healing remains to be precisely determined. The objective of this study was to investigate healing of small bowel anastomoses performed at different times after transient ischemia.

METHODS

Thirty male Wistar-Albino rats were investigated in five groups (four study and one control). Under general anesthesia, the superior mesenteric artery (SMA) was occluded for 40 minutes in the study rats. Biopsy specimens, to document I/R histopathology, were obtained before small intestinal anastomoses at 20 minutes (group 1), 90 minutes (group 2), 6 hours (group 3), and 24 hours (group 4) after reperfusion. In a control group, biopsy and intestinal anastomoses were performed after SMA dissection without occlusion. The rats were relaparotomized on the fifth day to determine in situ bursting pressures and to obtain specimens for hydroxyproline content and histopathologic evaluation.

RESULTS

Hydroxyproline content and bursting pressures were compared statistically with Mann-Whitney U test. Although there was no statistical difference between the control group and group 1, there were significant differences (P < .05) between groups 2, 3, and 4, with both parameters decreasing as the duration after reperfusion increased.

CONCLUSION

Anastomosis are less likely to leak when performed sooner rather than later after an ischemia/reperfusion event.

Assessment of anastomotic reliability with pulse oximetry in graded intestinal ischemia: an experimental study in dogs

BACKGROUND/PURPOSE

Pulse oximetry has been proposed as an appropriate and feasible technique in the assessment of intestinal ischemia in recent years. In this study the authors aimed to assess the reliability of anastomoses in the dog small intestine in which there is graded irreversible ischemia as measured by pulse oxymeter.

METHODS

In a control group of four dogs, without any devascularization, three small bowel anastomoses were formed in each dog. The study group consisted of 12 dogs. In each animal three intestinal segments with different levels of ischemia were created by ligating the marginal vessels proximally and distally in sequence beginning from the midpoint of the segmental vascular arcade. Preanastomotic pulse oximeter readings between 80% and 90% were assigned to mild ischemia, 70% and 80% to moderate, and 60% and 70% to severe ischemia group. Pulse oximetry measurements were obtained from probes applied to the antimesenteric serosal surfaces at the midpoint of small intestinal segments. A total of 48 intestinal segments (12 nonischemic in the control group and 36 with three different levels of ischemia in the study group) were transected in the midpoint and anastomosed in double layers. Postanastomotic SaO2 values were also noted. The anastomoses were evaluated 48 hours later macroscopically if there was any leakage, and biopsy specimens were obtained for histopathologic ischemic gradings. All results were studied statistically.

RESULTS

Histopathologic grades between each group were statistically different (P < .01 for each comparison) except for control and mild ischemia groups (P > .05), worsening as the level of ischemia increased. Pre- and postanastomotic pulse oximetry measurements correlated very well with the histological gradings (r = -0.90, P < .001 and r = -0.93, P < 0.001 respectively). Number of anastomotic leakages were none in control, one in mild, nine in moderate, and 12 (all of the anastomoses) in severe ischemia groups. In the moderate ischemia group with an average preanastomotic pulse reading of 76.75%, each of the leaking anastomoses had a postanastomotic pulse measurement of lower than 70%. The finding that the difference between histopathologic grades of control and mild ischemia groups with average preanastomotic pulse measurements of 96% and 85%, respectively is not statistically significant enables us to suggest that a saturation of at least 85% is necessary for a reliable anastomosis.

CONCLUSION

These results suggest clearly that anastomotic reliability can be predicted objectively with pulse oximetry.

Neovascularization of the testicle through spermatic vessels by omental pedicle flap: a new experimental model

The aim of this experimental study in rats was to consider the supplementary role of an omental pedicle flap on the neovascularization of the testicle through the spermatic vessels, for which a Fowler-Stephens procedure had been planned. To compare results, 12 animals had only the spermatic vessels ligated, without an additional procedure (Fowler-Stephens procedure [FS group]), and 12 others had omentopexy of the spermatic vessels of the left testes, with ligation of the vessels 4 weeks later (Fowler-Stephens procedure plus omentopexy [FSO group]). In the sham group (n = 8), only omentopexy of the left spermatic vessels was performed. Six rats served as controls. In each rat, both testes were evaluated by color Doppler ultrasonography to assess capsular and intratesticular blood flow, followed by orchiectomy to determine testicular weights, testicular biopsy scores, and mean seminiferous tubule diameters. Data were analyzed statistically. According to the color Doppler ultrasonography, the testicular blood flow in the FSO group was better than that of the FS group, but was less sufficient than that of the sham and control groups. The testicular weights and biopsy scores for the FSO group were statistically greater than those of the FS group, and less than those of the sham and control groups. There was no significant difference in the mean seminiferous tubule diameters of the FSO and FS groups. The contralateral tests of the four groups did not differ significantly for any parameter. In light of the data available, it is suggested that the omental pedicle flap neovascularizes the testicle through spermatic vessels. Given the high incidence of testicular atrophy associated with Fowler-Stephens orchiopexies, it might be beneficial to perform laparoscopic orchiopexy of testicles neovascularized with omental pedicle flaps as the first-stage procedure.

Hungry bone syndrome in a child following parathyroid surgery

The rare hungry bone syndrome was encountered in a 15-year-old child after the removal of a parathyroid adenoma. Contrary to the hypocalcemias caused by the removal of all parathyroid glands or transient ischemia after parathyroid surgery, in which the serum inorganic phosphorus level is usually normal, both serum calcium and inorganic phosphorus levels are decreased in hungry bone syndrome in the early postoperative period. Vigorous calcium supplementation and vitamin D are required for prolonged periods.

Polyorchidism

Polyorchidism, defined as the presence of more than two histologically proven testes, is a rare entity. A review of the literature has yielded 46 cases of true polyorchidism suitable for consideration in this review, and we add two more, one of them being the 12th case of complete duplication of the testis reported in the literature.

Experience with childhood urolithiasis. Report of 196 cases

A total of 196 children with urinary calculi were treated surgically. Their ages ranged from 1 to 14 years. The male:female ratio was 3:1. Stones were located in the kidney in 96 patients, in the bladder in 52 and in the ureters in 32. Multiple organ involvement was present in 16 patients and associated urinary tract anomalies were found in 11. Stone analysis revealed calcium oxalate and phosphate stones in 121 patients, struvite stones in 60 and uric acid stones in 15.