Ali Avanoglu

Safer circumcision in patients with haemophilia: the use of fibrin glue for local haemostasis

To evaluate the efficacy and the reduced costs of factor concentrates in circumcision by using fibrin glue in patients with haemophilia.

Unilateral inguinal hernia in girls : is routine contralateral exploration justified ?

To determine the incidence of contralateral hernia development after unilateral inguinal hernia repair in girls, collected case series from two large hospitals were analyzed retrospectively. Among the 294 girls who had analyzed repair of a unilateral inguinal hernia (during a 15-year period), 245 could be traced; the mean follow-up period was 8.4 years. In 25 (10.2%) of the patients, contralateral hernia developed, mostly within one year (4 months to 6.5 years). The incidence of contralateral hernia development with respect to the original side of the inguinal hernia was significantly higher (19%) for the originally left-sided hernias than for the right-sided ones (6%) (P < .01). Although the incidence of contralateral hernia development for girls with a left inguinal hernia decreased as age increased, it was still 14.9% for the girls age 3 and up. Contralateral exploration should not be routine for girls who have a right-sided hernia, at any age. For left-sided hernias, it may be performed routinely for girls up to 2 years of age, and selectively for older patients.

Bladder Dynamics and Vesicoureteral Reflux: Factors Associated With Idiopathic Lower Urinary Tract Dysfunction in Children

PURPOSE The objective of this study was to determine the clinical, demographic, urodynamic and prognostic characteristics related to vesicoureteral reflux among patients with idiopathic lower urinary tract dysfunction. MATERIALS AND METHODS We retrospectively reviewed the records of 348 children with idiopathic detrusor overactivity or dysfunctional voiding who had been examined for vesicoureteral reflux between 1995 and 2005 at a university hospital. Demographic, clinical and urodynamic parameters were compared between groups according to the presence, grade, laterality and resolution of vesicoureteral reflux. RESULTS Among the 348 patients 8 infants were excluded from statistical analysis and are discussed separately. Among the 340 remaining patients 1 year and older vesicoureteral reflux was documented in 155 (46%), of whom 32% had bilateral reflux. Of the overall cases 60% were grade III or higher. Mean age in the refluxing group (6.5 +/- 2.8 years) was significantly lower than in the nonrefluxing group (7.6 +/- 2.5 years, p <0.001). Continent children presented with a significantly higher rate of vesicoureteral reflux compared to incontinent children (74% vs 42%, p <0.001). Among the patients who had urinary tract infection the presence of reflux increased the rate of renal cortical abnormalities (45% vs 17%, p <0.001). However, among patients who were free of urinary tract infection the presence of reflux was not associated with cortical abnormalities (25% vs 24%, p >0.05). Median maximum filling pressure was higher in the refluxing group compared to the nonrefluxing group (40.0 vs 34.0 cm H(2)O, p <0.001). Detrusor overactivity and dysfunctional voiding showed similar rates for development of vesicoureteral reflux. Reflux was resolved with medical treatment in 40% of the patients. The resolution rate was significantly higher in children with nondilating reflux and initial lower median cystometric bladder capacity. CONCLUSIONS Vesicoureteral reflux is associated with daytime incontinence, urinary tract infection, younger age and renal cortical abnormalities among patients with idiopathic lower urinary tract dysfunction. Increased intravesical pressures seem to be the primary factor for inducing reflux in idiopathic lower urinary tract dysfunction. Initial bladder capacity predicts the resolution of reflux.

Gastrointestinal Perforations in Children: A Continuing Challenge to Nonoperative Treatment of Blunt Abdominal Trauma

The present trend towards conservative management of hemodynamically stable pediatric trauma patients may be increasing the risk of delay in the diagnosis of traumatic hollow viscus perforations (HVP). The purpose of this study is to determine whether there is a delay in the diagnosis of HVP because of expectant management. A survey of factors leading to diagnostic delay was also made and the value of current diagnostic tools were reevaluated. In 1,283 trauma admissions between 1980-1994, 34 patients were operated for HVP caused by blunt abdominal trauma. Sites of perforation were; stomach (four), duodenum (five), jejunum (12), ileum (nine), and jejunum/ileum (four). Signs of peritoneal irritation were positive in 32 of 34 patients. There was free air in only six of 24 abdominal roentgenograms. Free peritoneal fluid without solid organ injury was detected in only four out of 13 patients with ultrasound. Peritoneal lavage was diagnostic in eight of nine patients. Time from admission to operating room averaged 24 +/- 4.1 (mean +/- standard deviation) hours. Eleven patients died after the operation mostly because of accompanying head injury. Only two of the deaths were the result of sepsis originating from the perforated bowel. There is an apparent delay in the diagnosis of traumatic HVP in this series. Signs of peritoneal irritation are the most consistent findings of HVP after blunt abdominal trauma in children. Persistence of abdominal signs indicates peritoneal lavage, which has a high diagnostic sensitivity for HVP compared to other diagnostic modalities.

Management of instrumental perforations of the esophagus occurring during treatment of corrosive strictures

BACKGROUND The initial symptoms of esophageal perforations (EP) may be subtle, but the progression is very rapid, and the outcome may be disastrous unless the diagnosis is made early and proper treatment is started immediately. METHODS Between 1976 and 1996, 1,249 patients with caustic esophageal burns were treated at Ege University. The study group is composed of 52 patients with instrumental ER Perforations occured during dilatation attempts of esophageal strictures. Twelve patients were referred from other institutions after the occurrence of EP. RESULTS In two patients, emergency surgical repair of the perforation was possible. Seventeen patients with unilateral and two patients with bilateral empyema were treated by pleural drainages. Anterior retrosternal mediastinal drainage was needed in one patient, and 11 patients required posterior mediastinal drainages. Three patients were treated by both anterior and posterior mediastinal drainage. Tracheoesophageal fistulas (TEF) developed in eight patients immediately after a dilatation attempt. Seven of these patients required esophageal replacement with colon to bypass the fistulas, and one patient in this group healed spontaneously. EP healed in 42.5 +/- 49.4 days. Twelve (23%) patients died of mediastinitis and sepsis. CONCLUSION When EP is diagnosed and treated with these methods, the mortality rate should approach zero.

Factors Affecting Renal Scar Development in Children with Spina Bifida

Background/Aims: Prevention of renal scarring is the main therapeutic goal in children with spina bifida. We aimed to determine factors affecting renal scar development in these patients. Materials and Methods: Records of 312 children admitted between 1994 and 2005 with spina bifida were reviewed. Age on admission, gender, presence of previous febrile urinary tract infections (UTIs), vesicoureteral reflux (VUR), and initial urodynamic findings were noted. Patients were grouped regarding presence/absence of renal scars on DMSA scans. χ2 and Student’s t tests were used for statistical evaluation. Results: Seventy-two patients had renal scars on admission. Mean age was 4.62 ± 4.59 years for patients without renal scars and 6.35 ± 4.9 years for patients with scars. Male/female ratio was 1:1 in the scarless group and 1:2 in the group with scars. Previous febrile UTI was present in 11 of 240 scarless patients in contrast to 7 out of 72 patients in the scar group (p > 0.05). VUR was present in only 16.3% of cases without scars, whereas 36.1% of patients in the scar group had VUR. Detrusor overactivity and detrusor sphincter dyssynergia were observed in 67.1% of scarred patients, whereas this figure was 42.4% in the scarless group. The comparison of age on admission, gender, detrusor overactivity, and detrusor sphincter dyssynergia revealed significant differences between patients with and without renal scars. Conclusions: Late referral, female gender, overactive detrusor, and detrusor sphincter dyssynergia have detrimental effects on renal parenchymal function in spina bifida patients. Patient selection for aggressive treatment using these features may prevent renal parenchymal deterioration.

Botulinum injection is useless on fibrotic neuropathic bladders.

OBJECTIVE Studies on the use of intradetrusor botulinum toxin A injection for children with neuropathic bladders are insufficient and the results are controversial. The aim of the present study was to evaluate the effect of intradetrusor botulinum toxin A injection for children with neuropathic bladders that are resistant to anticholinergic treatment, and to reveal any criteria indicating treatment success. PATIENTS/METHODS Hospital records were reviewed of 16 children with neuropathic bladders due to myelomeningocele, and who had botulinum toxin A injections between 2007 and 2010. Botulinum toxin A (10 units/kg) was injected endoscopically into various sites of the detrusor, except the trigone. The success was defined as complete dryness between clean intermittent catheterizations. Urodynamic studies before and after the application were evaluated and parameters, including bladder capacity (measured/expected) and compliance, were also analyzed. Reviewing the results, patients were then classified into two groups: as having fibrotic bladders (noncompliant, acontractile bladders with high pressures) or overactive bladders. Urodynamic findings and therapy success were then compared between the groups. RESULTS A total of 19 injections, including repeat injections in three patients, were performed. Results of the 16 initial injections were evaluated. Nine patients had detrusor overactivity, and five out of nine (56%) applications in this group resulted in complete dryness between clean intermittent catheterizations. In bladders with typical detrusor overactivity, there was a significant increase in both the capacity (from 0.53 to 0.74) and compliance (from 4.7 to 8.6 ml/cm H2O). Looking at the seven patients that displayed fibrotic bladders with very low compliance and no contraction at all, none of them presented with notable clinical improvement from injections. Comparing the urodynamic findings, there was no significant difference in compliance (3.1 ml/cm H2O before and 3.5 ml/cm H2O after) and bladder capacity (0.58 before and 0.52 after the treatment) in the fibrotic bladders. DISCUSSION Despite its worldwide usage and FDA approval, studies on the effectiveness of botulinumtoxin A on neuropathic bladders in children are controversial. There are now numerous studies attesting to the good results of BoNTA in neuropathic detrusor overactivity; however, only scarce reports comment on the specific features of the disease process among patients and reasons for failure in some. In our study, reviewing the urodynamic findings carefully, it was observed that the patients who did not respond to injections were the ones with no contractions, despite high pressures and low compliance. Therefore, describing the indications of BoNTA as neuropathic detrusor overactivity and urinary incontinence despite anticholinergic medications may lead to mistreatment of patients in the decompensated phase of a hyper-reflexive detrusor. Pretreatment urodynamic evaluation might be a good indicator, without biopsies, of estimating the degree of fibrosis and the patients who will benefit from the injection. CONCLUSION Botulinum toxin A injection in the neuropathic bladder of myelomeningocele patients was found to be ineffective if the detrusor was fibrotic, of low compliance and had lost contractility. Urodynamic findings should be carefully analyzed in order to select appropriate patients that may benefit from Botulinum injection.

Management of tracheoesophageal fistula as a complication of esophageal dilatations in caustic esophageal burns

The authors report on eight patients with caustic esophageal burns in whom tracheoesophageal fistula (TEF) developed during dilatation programs. This study covered a period of 17 years between 1975 and 1992. The age of the patients ranged from 1.5 to 8 years (mean age, 3.4 years). TEF developed after 5 to 43 months after injury (mean, 20.05 months). In each case, after documentation of the fistula by esophagography, esophagoscopy, and/or bronchoscopy, the fistula was blocked by an intraluminal esophageal stent, a polytetrafluoroethylene (PTFE) tube with a large lumen (10-mm diameter maximum). In this period, patients were fed via a jejunostomy tube and by total parenteral nutrition (TPN) if indicated, while the existing pneumonia was being treated. In one patient, fistula closed spontaneously during the stent application program, which ended with a patent esophagus. In two patients primary closure of TEF was attempted. In one of them fistula recurred and in the other it was technically impossible to separate the esophagus from trachea safely because of the very tight adhesions. In five patients a two-stage coloesophagoplasty was performed to bypass the fistulated esophagus. In the first stage, retrosternal pull-through of the colon and coloesophagogastric anastomosis was performed. In the second stage, closure of the distal esophagus and cervical coloesophagostomy was carried out. The patient with the primary closure attempt and one patient with stage 1 coloesophagoplasty died 3 and 4 months, respectively, after the operations. The cause of death was uncontrollable pneumonia in both cases. Follow-up of the four patients showed no complications. Another fistula patient is currently on stent treatment program with pneumonia under control.(ABSTRACT TRUNCATED AT 250 WORDS)

Safer and much cheaper circumcision using fibrin glue in severe haemophilia.

Summary. Circumcision is a traditional ceremony for Muslims and Jewish people. In order to reduce the high cost of factor concentrates, we administered locally manufactured heat‐treated fibrin glue during operation. Circumcision can be performed safely and is much cheaper using fibrin glue plus a small amount of factor concentrates.

Multicenter Survey of Endoscopic Treatment of Vesicoureteral Reflux Using Polyacrylate-Polyalcohol Bulking Copolymer (Vantris)

OBJECTIVE To evaluate an outcome of endoscopic correction of vesicoureteral reflux (VUR) using Vantris (Promedon, Cordoba, Argentina) in terms of its effectiveness and morbidity in a multicenter study. MATERIALS AND METHODS From 2009 to 2013, 611 patients (210 boys and 401 girls) with a mean age of 3.56 years (range, 1 month-18 years) were treated at 7 centers worldwide endoscopically with Vantris injection. VUR was unilateral in 413 and bilateral in 198 patients comprising 809 renal refluxing units (RRUs). Of these, primary VUR was present in 674 RRUs (83.3%) and 135 (16.7%) were complex cases. Reflux was grades I-V in 24 (2.96%), 123 (15.2%), 451 (55.8%), 158 (19.5%), and 53 (6.6%) RRUs respectively. The follow-up continued from 6 to 54 months. RESULTS Reflux resolved in 759 RRUs (93.8%) after first Vantris injection, in 26 (3.1%) after second, and in 6 (0.7%) after third injection, respectively. VUR improved to grade I after 1 or 2 injections in 5 ureters (0.6%), which needed no further treatment. Thirteen ureters (1.6%) failed endoscopic correction and required ureteral reimplantation. Vesicoureteral junction obstruction requiring ureteral reimplantation developed in 6 ureters (0.7%) and in 4 (0.5%) required stent insertion. Twenty-three patients (3.8%) suffered afebrile urinary tract infection. Seven (1.2%) developed febrile urinary tract infection. None of the studied patients demonstrated VUR recurrence on voiding cystourethrography. CONCLUSION The results of this multicenter survey confirm that endoscopic subureteral Vantris injection is a simple, safe, and effective outpatient procedure for treating all grades of VUR.