Billur Demirogullari

Congenital Muscular Torticollis in Children

Aim: The aim of this study was to evaluate the data of our patients treated for congenital muscular torticollis (CMT) in the period between 1990 and 2004. Here we report our clinical experience with CMT and review the literature. Patients and Methods: We retrospectively evaluated the data of our patients in terms of age, sex, clinical presentation, additional deformities, localization of the lesion, history of previous treatment attempts, diagnostic tests, additional abnormalities, findings at operation and surgical procedures. Results: The mean age of the patients who were operated for CMT (25 females, 27 males) was 4.3 years (range: 5 months to 16 years). Most of the lesions were seen on the left aspect of the neck. There was only one case with bilateral CMT. Seventeen out of 52 patients with CMT (32%) were diagnosed in the newborn period. The most encountered complaint at application was restriction of neck motion (57%). Associated complaints such as head tilt (53%), fascial asymmetry (34%), deformity of the skull (9.6%) were seen. Sternocleidomastoid tumor accounted for only 11% of the patients’ complaints. All patients in this series were treated by surgical intervention. Apart from one recurrence no other postoperative complication was observed during the follow-up period. Conclusions: Patients whose pathology does not resolve after 12 months of physical therapy or who develop facial asymmetry or plagiocephaly during the follow-up period should be operated on in order to achieve the best cosmetic result. In delayed cases additional surgery may be needed for the best cosmetic and functional result.

Conservative Surgery for Treatment of Hydatid Cysts in Children

Human echinococcosis is endemic in Turkey and many other areas of the world. Fifteen years of surgical assessment related to involved structures, operative procedures, complications, and the recurrence rate is analyzed in pediatric patients with pulmonary and abdominal hydatid cysts. Between 1986 and 2001, the records of 42 pediatric patients (15 girls, 27 boys; ages 2–15 years) with pulmonary and abdominal hydatid cysts operated on in our clinic were analyzed retrospectively. The features of the disease, involved structures, operative procedures, complications, and recurrences were noted. A total of 26 patients presented with solitary cysts in the lung (9) and liver (17). Another 11 had multiple cysts in both lung and liver, and 5 had disseminated abdominal disease. Conservative surgical procedures were used for all lung and liver cysts: cystotomy (7) or cystotomy plus capitonnage (13) for lung cysts; partial pericystectomy with capitonnage (25), omentoplasty (28), tube drainage in the presence of bile leakage (5), or a combination of these procedures for liver cysts. Cyst excision was used for omental and peritoneal localizations when feasible. Radical procedures were never used (wedge or major liver and lung resections). Operative mortality was zero, and the morbidity rate was 14%. Three patients with disseminated disease (7%) showed recurrence. We suggest that no partial organ resections are necessary for hydatid disease, and highly successful results can be achieved using conservative surgical approaches, such as cystotomy plus capitonnage for lung cysts and partial pericystectomy with capitonnage, omentoplasty, or both for liver cysts.

Surgical treatment of cervicofacial cystic hygromas in children.

Aim: The aim of this study was to evaluate the results of surgical treatment of cervicofacial cystic hygromas in children. Patients and Methods: Medical records of 17 patients who were operated for cervicofacial cystic hygroma between 1985 and 2004 were evaluated in terms of age, gender, symptoms, diagnostic workups, outcomes and complications. Results: There was a slight male predominance – 10 (59%) boys and 7 (41%) girls. Nine (53%) out of 17 lesions were located on the left side of the neck, 7 (41%) lesions were located on the right side of the neck and 1 lesion (6%) was located in the middle of the neck. Eleven (65%) lesions were located in the infrahyoid region, 6 (35%) lesions in the suprahyoid region. Following surgical excision of the lesion, we encountered 4 postoperative complications: 1 recurrence (6%), 2 facial paralyses (12%) and 1 collection of fluid (6%) at the resection site. The patient who had a recurring lesion needed to be reoperated, other complications were treated conservatively. Conclusions: Cervicofacial cystic hygromas are easy to diagnose. There is no need for expensive and time-consuming imaging studies. Surgery seems the treatment of choice. However, nonsurgical treatment options may be considered for the lesions located over the parotid region in order to avoid complications of surgery.

Conservative treatment for small intestinal intussusception associated with Henoch-Schönlein's purpura

Abstract.Purpose: Emergency laparotomy is generally considered the appropriate course of action for small bowel intussusception associated with Henoch-Schönleins purpura (HSP). In this paper, we define a conservative approach after witnessing spontaneous reduction of ileoileal invagination at laparotomy in a patient with HSP who had been on steroid therapy for renal involvement. Methods: HSP was diagnosed by the appearance of a purpuric rash without thrombocytopenia. Intussusception was diagnosed by ultrasonography (USG) and plain abdominographs, which showed signs of obstruction, and clinical examination. Barium enema was used to treat ileocolic intussusceptions, and conservative therapy, consisting of nasogastric drainage, steroids, and intravenous fluid administration, was used to treat ileoileal intussusceptions. Emergency laparotomy was performed for the patients unresponsive to therapy within 24 h, those with peritonitis, and those with ileocolic invagination not able to be reduced by barium enema. Results: Six children with an ileoileal intussusception and one with an ileocecal intussusception were studied. The average age was 6 years old. Apart from the initial patient in whom spontaneous reduction was seen at laparotomy, three others required emergency laparotomy; for ileocolic intussusception unable to be reduced by barium enema in one, for ileoileal invagination with peritonitis on admission in one, and for ileoileal intussusception unresponsive to conservative therapy in one. The other three patients were successfully treated by conservative therapy. Conclusion: Conservative therapy is feasible for HSP patients with small bowel intussusception as long as the time of onset is known, an ultrasonographic and X-ray diagnosis is confirmed, emergency operating facilities are available, and an experienced pediatric surgical team follows up the patients.

STOBADINE PROTECTS RAT KIDNEY AGAINST ISCHAEMIA/REPERFUSION INJURY

1 Ischaemia–reperfusion (I/R) injury, one of the main causes of acute renal failure, still needs satisfactory treatment for routine clinical application. Stobadine, a novel synthetic pyridoindole anti‐oxidant, has the ability to reduce tissue injury induced by mechanisms involving reactive oxygen species during I/R. The aim of the present study was to determine the effects of stobadine on renal I/R injury. 2 Forty male Wistar rats were randomly divided into four groups as follows: sham, I/R, stobadine treated and I/R + stobadine treated. Stobadine (2 mg/kg, i.v.) was given intravenously to two groups of rats. The stobadine‐treated group was treated with stobadine following sham operation before the abdominal wall was closed, whereas the I/R + stobadine group received stobadine at the beginning of reperfusion. Renal I/R was achieved by occluding the renal arteries bilaterally for 40 min, followed by 6 h reperfusion. Immediately thereafter, blood was drawn and tissue samples were harvested to assess: (i) serum levels of blood urea nitrogen and creatinine; (ii) serum and/or tissue levels of malondialdehyde (MDA), glutathione (GSH), glucose 6‐phosphate dehydrogenase (G‐6PD), 6‐phosphogluconate dehydrogenase (6‐PGD), glutathione reductase (GR) and glutathione peroxidase (GPx); (iii) renal morphology; and (iv) immunohistochemical staining for P‐selectin. 3 Stobadine was able to significantly attenuate the renal dysfunction as a result of renal I/R injury. Iscahemia–reperfusion resulted in a significant increase in serum and kidney MDA levels and a decrease in serum and kidney GSH. Stobadine treatment at the beginning of reperfusion attenuated both the increased MDA levels and decreased GSH secondary to I/R injury. In addition, the decreased G‐6PD activity observed after I/R was significantly attenuated by stobadine treatment. Stobadine did not alter 6‐PGD activity after I/R. Neither GR nor GPx activity was significantly changed in the I/R alone or the I/R + stobadine groups compared with the sham group. In addition, stobadine decreased the morphological deterioration and high P‐selectin immunoreactivity secondary to renal I/R injury. 4 A pyridoindole anti‐oxidant, stobadine exerts a renal protective effect in renal I/R injury, which is probably due to its radical‐scavenging and anti‐oxidant activities.

The effect of taurine on renal ischemia/reperfusion injury

Summary.Ischemia-reperfusion (I/R) injury is one of the most common causes of renal dysfunction. Taurine is an endogenous antioxidant and a membrane-stabilizing, intracellular, free beta-amino acid. It has been demonstrated to have protective effects against I/R injuries to tissues other than kidney. The aim of this study was to determine whether taurine has a beneficial role in renal I/R injury. Forty Wistar-Albino rats were allocated into four groups as follows: sham, taurine, I/R, and I/R + taurine. Taurine 7.5 mg/kg was given intra-peritoneally to rats in the groups taurine and I/R + taurine. Renal I/R was achieved by occluding the renal arteries bilaterally for 40 min, followed by 6 h of reperfusion. Immediately thereafter, blood was drawn and tissue samples were harvested to measure 1) serum levels of BUN and creatinine; 2) serum and/or tissue levels of malondialdehyde (MDA), glutathione (GSH), glucose 6-phosphate dehydrogenase (G-6PD), 6-phosphogluconate dehydrogenase (6-PGD) and glutathione reductase (GSH-red); 3) renal morphology; and 4) immunohistochemical staining for P-selectin. Taurine administration reduced I/R-induced increases in serum BUN and creatinine, and serum and tissue MDA levels (p < 0.05). Additionally, taurine lessened the reductions in serum and tissue glutathione levels secondary to I/R (p < 0.05). Taurine also attenuated histopathologic evidence of renal injury, and reduced I/R-induced P-selectin immunoreactivity (p < 0.05). Overall, then, taurine administration appears to reduce the injurious effects of I/R on kidney.

A Comparative Study of the Effects of Hemin and Bilirubin on Bilateral Renal Ischemia Reperfusion Injury

Background/Aims: The aim of this study was to determine the effects of hemin, a heme oxygenase-1 inducer, and bilirubin on renal ischemia-reperfusion (I-R) injury. Methods: 40 Wistar-Albino rats were allocated into six groups as follows: sham (S), bilirubin (B), hemin (H), ischemia/reperfusion (IR), IR + bilirubin (IRB) and IR + hemin (IRH). Conjugated bilirubin (20 mg·kg–1 i.v.) was given to rats in groups B and IRB, and hemin (50 mg·kg–1 i.p.) was given to rats in groups H and IRH just prior to reperfusion. Renal I-R was achieved by occluding the renal arteries bilaterally for 50 min. Following 6 h of reperfusion, blood was drawn to study BUN, creatinine and bilirubin, and tissue samples were harvested to determine the renal malonyldialdehyde and heme oxygenase-1 levels, and for histopathologic grading. Results: BUN, creatinine and malonyldialdehyde levels in group IRH were similar to controls whereas the results of groups IR and IRB were significantly higher (p < 0.01). There was a grade 2 damage in all I-R groups. Conclusion: This study showed the preventive effect of hemin on renal ischemia reperfusion injury. Administration of exogenous bilirubin did not prevent the I-R injury.

Establishment of interdisciplinary child protection teams in Turkey 2002–2006: Identifying the strongest link can make a difference!

OBJECTIVES The University of Iowa Child Protection Program collaborated with Turkish professionals to develop a training program on child abuse and neglect during 2002-2006 with the goals of increasing professional awareness and number of multidisciplinary teams (MDT), regional collaborations, and assessed cases. This paper summarizes the 5-year outcome. METHODS A team of instructors evaluated needs and held training activities in Turkey annually, and provided consultation when needed. Descriptive analysis was done via Excel and SPSS software. RESULTS Eighteen training activities were held with 3,570 attendees. Over the study period, the number of MDTs increased from 4 to 14. The MDTs got involved in organizing training activities in their institutions and communities. The number of medical curriculum lectures taught by MDTs to medical students/residents, conferences organized by the MDTs, and lectures to non-medical professional audiences increased significantly (R(2)=91.4%, 83.8%, and 69.2%, respectively). The number of abuse cases assessed by the MDTs increased by five times compared to pre-training period. CONCLUSIONS A culturally competent training program had a positive impact on professional attitudes and behaviors toward recognition and management of child abuse and neglect in Turkey. The need to partner with policy makers to revise current law in favor of a greater human services orientation became clear. PRACTICE IMPLICATIONS Pioneers in developing countries may benefit from collaborating with culturally competent instructors from countries with more developed child protection systems to develop training programs so that professional development can improve recognition and management of child abuse and neglect.

Clinical approach to graft hepatic artery thrombosis following living related liver transplantation

Abstract: Hepatic artery thrombosis (HAT) has an occurrence rate of 1.7–26% following living donor liver transplantation (LDLT) and is one of the most common reasons for graft loss and mortality in this population. There is a higher incidence of HAT in pediatric recipients. The aim of this case report is to discuss clinical approaches for the treatment of HAT occurring in the early post‐operative period after LDLT. An 11‐month‐old, 7.8‐kg female with cirrhosis secondary to biliary atresia underwent LDLT at Gazi University Hospital in Ankara. The graft was a left lateral segment from her father with a left hepatic artery (HA) of 2 mm diameter and a graft weight/recipient body weight ratio of 2.0%. After an uneventful early post‐operative period, HAT was diagnosed by Doppler ultrasonography (USG) on the fifth post‐operative day. Following angiographic evaluation, immediate exploration and reanastomosis was performed using an operation microscope. Post‐operatively, the HA was patented by Doppler USG and graft function returned to normal. Now, 42 months later, the patient continues to do well with normal graft function, using a regimen of tacrolimus monotherapy for immunosuppression. In countries which have very limited resources for urgent re‐transplantation, given their serious donor shortage, graft salvage may be the only option for patient survival when HAT occurs. In these circumstances, early diagnosis and immediate revascularization may be the only method for graft salvage. A daily routine of Doppler USG examination in the early post‐operative period may provide a method for the early diagnosis of HAT, before liver enzymes are elevated and hepatic necrosis has begun.

The effects of iloprost, a prostacyclin analogue, in experimental ischaemia/reperfusion injury in rat ovaries

Ovarian torsion is a surgical emergency affecting not only the ipsilateral ovary but also contralateral ovary. Although the conventional treatment is salpingo-oophorectomy, recent studies advocate detorsion. We hypothesized that iloprost, an analogue of prostacyclin with cytoprotective properties, may prevent the harmful effects of ischaemia-reperfusion injury in bilateral ovaries after unilateral ovarian torsion-detorsion in rat. In this study, 24 female Wistar-albino female rats were divided into four groups. Ovarian torsion was produced by applying vascular clamps to right ovaries. In Group I, bilateral oophorectomy was performed. In group II, bilateral oophorectomy was performed after a unilateral torsion period of 4h. In group III, bilateral ovaries were removed, following unilateral torsion-detorsion periods each lasted for 4h. Saline was injected i.p. 30 min before detorsion. In group IV, same experimental protocol, which was conducted in group III, was repeated. Iloprost was injected i.p. 30 min before detorsion instead of saline in group IV. Tissue levels of malondialdehyde (MDA) and nitric oxide (NO), which are the indicators for oxidative stress were determined and histopathological evaluation was performed in bilateral ovaries in all groups. The MDA and NO levels for ipsilateral ovaries of four groups were compared and no significant difference was found (p>0.05). The same comparison were done for the contralateral sides and no difference was seen either (p>0.05). In histological examination, iloprost produced improvement in I/R-induced alterations in ipsilateral and contralateral ovaries. In conclusion, these results showed that iloprost has beneficial effect on the histological appearances in both the ipsilateral and contralateral rat ovaries after unilateral torsion-detorsion.