Cenk Büyükünal

Bronchoscopic removal of tracheobroncheal foreign bodies: value of patient history and timing.

Abstract Between 1990 and 1999, 741 bronchoscopic procedures were performed in 698 children, 594 of whom were evaluated for foreign-body aspiration (FBA) (mean age 3.9 years, male:female 287/307). Based on the presenting symptoms, clinical outcome, and complications, two major groups were identified. Group 1 consisted of 438 patients with a definitive history of FBA. Most were admitted soon after the aspiration with sudden onset of symptoms such as coughing, choking, wheezing, and respiratory distress. Group 2 comprised 156 patients with chronic pulmonary infections and/or atelectasis without a definitive history of FBA. The most common radiographic finding was emphysema of one lung in group 1 (61.1%) and pneumonia in group 2 (70%). Among the patients in whom a FB was removed, the percentage of normal radiography was 17%. The FB was identified and removed in 83% of cases in group 1. The complication rate in this group was 9.8%, and all the complications were treated medically. Only 2 patients required intercostal drainage. In group 2, a FB was identified in 25% of bronchoscopic examinations and 17% of the patients developed complications. One of these patients underwent an urgent thoracotomy due to bilateral tension pneumothoraces and 2 required tracheostomies. Patients with a definitive history of FBA, even with a normal physical examination and radiographic findings, must undergo bronchoscopic investigation. Cases with late presentation and chronic pulmonary infection are at high risk. In this group care should be take in determining the indication and timing of bronchoscopy in order to prevent life-threatening complications.

Splenic artery ligation: A ten-year experience in the treatment of selected cases of splenic injuries in children

Splenic artery ligation (SAL) combined with either splenorrhaphy or partial splenectomy has been used as a spleen saving procedure in the management of massively bleeding splenic injuries. During the last 10 years, 37 children have been submitted to SAL following a selective management schedule. This study was jointly undertaken by two separate Pediatric Surgical Units in two different countries, in order to evaluate some preliminary observations published previously, with regard to; 1) the percentage of splenic injuries requiring ligation of the splenic artery; 2) the effect of this procedure on the arrest of bleeding; 3) the postoperative complications related to dearterialization of the spleen; 4) the immunological status after the operation and; 5) the postoperative imaging of the spleen using radioscintigrams and ultrasonograms. The mean age of the patients was 6.9 years and the follow up period ranged from 1 to 10 years. Thus, SAL was concluded to be an effective mode of treatment for rare cases of splenic injury unable to be treated nonoperatively or by splenorrhaphy alone. No postoperative complications were recorded in this series, while the immunological status remained undisturbed postoperatively and imaging of the spleen revealed intact and functional tissue with adequate healing.

Extensive intestinal aganglionosis

Extensive aganglionosis very close to the ligament of Treitz and total intestinal aganglionosis are rare forms of Hirschsprungs disease. In these cases, nutrition, fluid, and electrolyte balance are a problem. Although the myectomy-myotomy technique of Ziegler appears hopeful, no effective surgical method has been put into the practice for the treatment of these rare forms of Hirschsprungs disease. We report four cases with extensive intestinal aganglionosis, one of which was total intestinal aganglionosis with involvement of the stomach.

TREATMENT OF WILMS TUMOR: A Report from the Turkish Pediatric Oncology Group (TPOG)

Aim: To standardize diagnosis and treatment of childhood Wilms tumor (WT) in Turkey. Methods and patients: Between 1998 and 2006, WT patients were registered from 19 centers. Patients <16 years with unilateral WT whose treatment started in first postoperative 3 weeks were included. Treatments were stage I favorable (FH) and unfavorable histology (UH) patients, VCR + Act-D; stage IIA FH, VCR + Act-D; stage IIB FH, VCR + Act-D + radiotherapy (RT); stage III–IV FH, VCR + Act-D + adriamycin (ADR) + RT; stages II–IV UH tumors, VCR + Act-D + ADR + etoposide + RT. Results: 165/254 registered cases were eligible (bilateral, 5.9%) [median age 3.0 years; M/F: 0.99; 50/165 cases ≤2 years]. 9.7% cases had UH tumors. Disease stages were stage I 23.6%; IIA 36.4%; IIB 5.5%; III 22.4%; IV 12.1%. Cases >2 years had significantly more advanced disease. 1/11 cases with recurrent disease died; 2/165 had progressive disease, 2/165 had secondary cancers, and all 4 died. In all cases 4-year OS and EFS were 92.8 and 86.5%, respectively. Both OS and EFS were significantly worse in stage IV. Conclusions: Despite problems in patient management and follow-up, treatment results were encouraging in this first national experience with a multicentric study in pediatric oncology. Revisions and modifications are planned to further improve results and minimize short- and long-term side effects.

Maternal cocaine abuse resulting in necrotizing enterocolitis. An experimental study in a rat model. II. Results of perfusion studies.

Abstract During the last decade, several publications have appeared associating the maternal use of cocaine and subsequent development of necrotizing enterocolitis (NEC). In 1994, the effects of cocaine in pregnant rats had been reported by this group: a significant decrease in the number of live births, mean birth weight and mean placental weight. In addition, histopathologic examinations revealed severe inflammation and degenerative vascular changes in the uterus and placenta. Severe histopathologic changes resembling NEC such as focal necrosis, necrobiosis, and hemorrhagic inflammatory changes in the gastrointestinal tract of the embryos were also reported. The aim of the second part of this study was to assess the hemodynamic effects of cocaine HCl in pregnant rats and the results of perfusion studies in the uterus, placenta, and fetuses to determine a relation between the dose of drug, hemodynamic changes, and degree of histopathologic findings. Forty-seven Wistar albino rats and 91 rat fetuses were studied: group A (pregnant rats), 16 rats and 91 rat fetuses, group B (non-pregnant rats), 31 rats. Each group was divided into subgroups of cocaine-abused and non-cocaine-abused rats. In each group 2–3 mCi technetium Tc-99m methoxyisobutyl-isonitryl (Sesta MIBI) was injected into the tail vein. Radioactivity counts per g tissue (cps/g) in the uterus, placenta, and fetus were assessed by gamma counter. Cocaine 75 mg/kg per day severely decreased the perfusion of the uterus, placenta, and fetuses. These impairments were statistically significant. In lower doses (30–50 mg/kg per day) no statistically significant changes were observed in the perfusion of the uterus and placenta, but a significant decrease in fetal perfusion was seen. In group B, no significant changes in the perfusion of the uterus due to cocaine were seen. Thus, maternal cocaine abuse results in a reduction in perfusion of the uterus, placenta, and fetus. There was a dose-dependent correlation between the perfusion changes and the development of NEC-like histopathologic changes: the higher the cocaine dose received by the mother, the higher the level of placental and fetal injury. We suggest that perinatal cocaine exposure should be considered a high risk for development of NEC in rat fetuses and embryos. For this reason, infants with a history of possible maternal cocaine abuse or positive urinary cocaine metabolites have to be followed very carefully for NEC.

Radionuclide imaging of Meckel's diverticulum: cimetidine versus pentagastrin plus glucagon

The aim of this study was to investigate the effects of prior administration of cimetidine in radionuclide imaging of Meckels diverticulum. In three groups of seven rats with artificial Meckels diverticulum, containing ectopic gastric mucosa, the effects of pentagastrin + glucagon plus 99mTc-pertechnetate, as well as cimetidine premedication plus 99mTc-pertechnetate, and 99mTc-pertechnetate alone were compared to attain improved radionuclide imaging of Meckels diverticulum. This experimental model suggests that the use of cimetidine seemed to have some advantages: (a) nontarget (intestinal) radioactivity was diminished by cimetidine, (b) the target to nontarget (Meckels diverticulum to intestinal activity) ratio increased with cimetidine pretreatment. This resulted in an enhanced accumulation of pertechnetate in the ectopic gastric mucosa, and reduced excretion of the radionuclide into the lumen. Consequently, better scintiphotograms and a low rate of false results added to the validity of this method.

Congenital epulis of the tongue: A case report and review of the literature

We report a case on a neonate with congenital epulis rarely detected on the anterior ventral surface of the tongue.

A therapeutic method for failed bladder augmentation in children : re-augmentation

To investigate the causes leading to the deterioration of previously successful bladder augmentation and to evaluate the efficacy of re‐augmentation.

Experience with Laparoscopy in Nonpalpable Testis

Aim: The aim of this study was to investigate the feasibility and benefits of diagnosis and interventional laparoscopy in those paediatric patients with nonpalpable testes (NPT). Patients and Method: Between 1992 and 1999, 75 patients with NPT (mean age 3 years, range 6 months to 14 years) were treated. 86 testes were evaluated. Results: According to the laparoscopic findings, 4 groups of testes were identified: Vanishing testis (n = 32), low abdominal testis (!2 cm to the internal ring) (n = 26), high abdominal testis (12 cm to the internal ring) (n = 24) group and intersex patients (n = 4). Of the first group, 19 testes (one bilateral) had blind ending spermatic cord and vessels and if an atrophic testicular tissue was identified, it was removed laparoscopically. For those with spermatic cord and vessels beyond the internal ring (13 testes), atrophic testes were removed through a high scrotal incision. 19 testes of the second group had a laparoscopy-assisted orchiopexy. In the same group a laparoscopic orchiopexy was performed on 7 testes. 24 testes in the 3rd group had a Fowler Stephens (FS) stage I and 18 testes had a laparotomy performed for FS stage II procedure (laparotomy and orchiopexy) after 6 months. At laparotomy there was no evidence of testicular atrophy in all but one testis which was removed and the FS stage II procedure was completed in 17 testes. The follow-up period is between 6 months and 4 years, and two more testicular atrophies were noted after FS stage II. The results were satisfactory in 15 testes among 18 (83%). In the intersex group, the patient with testicular feminization had laparoscopic orchiectomy. The other patient with bilateral nonpalpable testis was identified to have a uterus and two intra-abdominally located gonads on laparoscopy and gonadal biopsies were obtained for diagnosis. Histology demonstrated bilateral ovotestes confirming the diagnosis of a true hermaphrodite. Conclusion: We think that laparoscopy decreases the number of laparotomies in NPT, allows a single stage procedure in low abdominal testis and facilitates clip ligation of the testicular artery in high abdominal testis. Also laparoscopy provides diagnostic and therapeutic options in vanishing testis and intersex patients.

Congenital lobar emphysema ― A report of 5 cases

Five infants with congenital lobar emphysema whose main symptoms included dyspnea, cyanosis and recurrent respiratory infections, are presented herein. The most reliable diagnostic tool was plain chest X-ray films with antero-posterior and lateral views, while radio-isotopic investigation of the lung perfusion state took second place in the diagnosis of this disease. The affected lobes were the left upper lobe in four patients and the right middle lobe in one. Lobectomy was performed with good results in 4 patients, however, 1 infant was lost following an emergency thoracotomy.