Emre Divarcı

Incidence and prognosis of intraabdominal hypertension and abdominal compartment syndrome in children

PURPOSE Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are associated with high mortality rates in children (40-60%). However, literature lacks comprehensive series in childhood. In this study, we aimed to determine the incidences of IAH and ACS, to identify high risk disorders for the development of IAH/ACS and to decrease ACS-associated mortality by early diagnosis and timely intervention. METHODS A prospective study was performed between December 2009 and October 2010 in our institution. IAH was defined by a sustained or repeated pathological elevation in IAP≥12mmHg without a new organ failure. ACS was identified as a sustained IAP>15mmHg with a new organ dysfunction/failure. After recognition of IAH or ACS, patients underwent prompt decompressive interventions as medical or surgical procedures. RESULTS 150 patients were enrolled to the study (86 M, 64 F). The incidences of IAH and ACS were 9% and 4%, respectively. High risk disorders were trauma, ileus, necrotizing enterocolitis, abdominal wall defects, diaphragmatic hernia and septic shock with massive fluid resuscitation. 14 patients with IAH were treated and mean IAP was decreased from 13.9±1.9mmHg to 9.2±2.1mmHg (p<0.001). None of them progressed to ACS. Six patients with ACS underwent decompressive laparotomy. Mean IAP decreased significantly from 20±3mmHg to 9±1.4mmHg (p=0.001). Vital signs like mean urine output, abdominal perfusion pressure (APP) and respiratory rate were significantly improved after surgery (p<0.05). ACS-associated mortality rate was determined as 16%. CONCLUSIONS IAH or ACS was occurred in nearly one tenth of patients admitted to neonatal and pediatric intensive care units. High clinical suspect must be drawn on to recognize and treat these clinical complications more efficiently. Regular and frequent IAP measurement in high risk disorders is essential for early diagnosis. Lower mortality rates can be achieved by early recognition and timely intervention in children.

Retroperitoneoscopic laparoscopic treatment of renal hydatid cyst in a child

A 17-year-old girl with the diagnosis of right renal hydatid disease was treated by retroperitoneoscopic technique. No complications occurred at peroperative and postoperative periods. There were no clinical symptoms and radiologic pathologic causes to show recurrence at postoperative second year. This is the first case that is reported via retroperitoneoscopic laparoscopic approach at the treatment of renal hydatidosis in children. We prefer retroperitoneoscopic approach to avoid intraperitoneal contamination. Retroperitoneoscopic laparoscopic treatment can be an alternative treatment technique at renal hydatidosis therapy because of its advantages to conventional surgery, Although further reports of its long-term outcomes and additional experiences are necessary.

Necrotizing Liver Granuloma/Abscess and Constrictive Aspergillosis Pericarditis with Central Nervous System Involvement: Different Remarkable Phenotypes in Different Chronic Granulomatous Disease Genotypes

Chronic granulomatous disease (CGD) is a primary immune deficiency causing predisposition to infections with specific microorganisms, Aspergillus species and Staphylococcus aureus being the most common ones. A 16-year-old boy with a mutation in CYBB gene coding gp91phox protein (X-linked disease) developed a liver abscess due to Staphylococcus aureus. In addition to medical therapy, surgical treatment was necessary for the management of the disease. A 30-month-old girl with an autosomal recessive form of chronic granulomatous disease (CYBA gene mutation affecting p22phox protein) had invasive aspergillosis causing pericarditis, pulmonary abscess, and central nervous system involvement. The devastating course of disease regardless of the mutation emphasizes the importance of early diagnosis and intervention of hematopoietic stem cell transplantation as soon as possible in children with CGD.

The Efficacy of Intralesional Steroid Injection in the Treatment of Corrosive Esophageal Strictures in Children.

Purpose of the Study: Esophageal dilatation can be insufficient in the treatment of severe corrosive esophageal strictures. In this study, we aimed to present the efficacy of intralesional steroid injection as an adjunct to dilatation therapy. Materials and Methods: Retrospective analysis of children who underwent intralesional steroid injection between 2004 and 2014 was performed. Patients’ age, type of corrosive substance, length of stricture, number of injection and dilatation sessions and complications were reviewed. The success was evaluated by the comparison of number, frequency, and requirement of dilatation therapy before and after injection. Results: Intralesional steroid injection was performed to 32 children with a mean age of 3.6±2.5 years. The types of corrosive agents were alkali (24) or acid (8). Mean number of injection sessions was 2.5±1.1(1 to 6). Mean number of dilatation sessions was decreased from 10±8.8 to 5.4±4.6 after injection (P=0.003). Mean frequency of dilatations was extended from 3.6±0.9 weeks to 8.7±3.9 weeks (P=0.000). Dilatation treatment was successfully terminated in 25 of 27 children with short-segment strictures after injection (92%). Whereas all of the children with long-segment strictures could not resolved and finally required esophageal replacement (5 patients). One patient had transient cushingoid phenotype as a complication. There was not seen any major complication-like perforation. The mean follow-up period was 6±3 years. Conclusions: Intralesional steroid injection is an effective adjunct to dilatation in most of the children with short-segment strictures. It should be performed as a safe and efficient treatment option in patients with short-segment corrosive esophageal strictures resistant to dilatation therapy.

Intraoperative parathyroid hormone monitoring corroborates the success of parathyroidectomy in children.

Objective: To assess the efficacy of intraoperative parathyroid hormone (PTH) monitoring in evaluating the outcome of parathyroidectomy in pediatric patients. Methods: Intraoperative PTH monitoring during parathyroidectomy was performed in five children (3M, 2F); three had parathyroid adenomas (single gland disease) and two had primary hyperplasia. One patient had undergone two previous surgical interventions to remove the parathyroid glands, but the PTH levels had remained high with persistence of symptoms. Immunoradiometric analysis was used for PTH measurements. Preoperative PTH values were obtained to monitor the baseline levels. Serum samples were collected 20 minutes after removal of the adenoma/parathyroid gland(s) and PTH levels were compared with preoperative values. Specimens were also confirmed by frozen sectional examination. Results: Mean age of the patients was 11 years (range: 3 months-16 years). Mean preoperative PTH values were 633.3±579 pg/mL (range: 143-1300 pg/mL). Intraoperative values decreased to 18.7±5.5 pg/mL (range: 8-27 pg/mL) following removal of the gland(s). Normal calcium levels were achieved with adequate management following surgery. One patient (with multiple surgeries and found to have an ectopic parathyroid gland) had hungry bone syndrome after the operation and was treated successfully. There were no major complications. All patients maintained normal calcium/phosphorus levels in the follow-up period, ranging from 2 to 5 years. Conclusion: An ectopic parathyroid gland or another undetected adenoma can be overlooked during surgery. Owing to the short life of the hormone, intraoperative PTH monitoring to determine PTH clearance proved to be a feasible marker for adequacy and safety of surgery and “cure”.

Topical Mitomycin C Application Is Effective Even in Esophageal Strictures Resistant to Dilatation Therapy in Children

Purpose: Several treatment techniques may be used in the treatment of esophageal strictures. The purpose of this study was to present the effects of topical mitomycin C (TMC) as an useful adjunct to dilatation therapy in esophageal strictures. Materials and Methods: A retrospective analysis of patients who underwent TMC between February 2015 and July 2016 was performed. Dysphagia score, periodic dilatation index, and number of dilatations were compared before and after intervention to investigate the efficacy of TMC. Results: TMC was performed on 20 patients with a median age of 3.5 years (2 to 17 y). The diagnosis was corrosive esophageal strictures in 14 patients, anastomotic strictures in 5 patients, and congenital esophageal stricture in 1 patient. The length of the stricture was long in 10 patients (50%). The median dysphagia score decreased from 2 (1 to 3) to 0 (0 to 2) after application (P<0.001). The median number of dilatation sessions decreased from 5 (1 to 41) to 1 (0 to 11) after intervention (P<0.001). The median periodic dilatation index decreased from 1 (0.66 to 1.34) to 0 (0 to 1.33) after TMC (P<0.001). Regular esophageal dilatation was not necessary in 16 patients after application (80%). The length of the stricture did not affect the efficacy of TMC. The success of treatment was lower in patients with a long treatment period before TMC (>3 y) (50%). No complications were seen in a median follow-up period of 16 months (7 to 22 mo). Conclusions: TMC application has a significant positive effect as an adjunct to dilatation therapy in most of the patients with different types of esophageal strictures. It should be performed as a safe and efficient treatment option even in patients who were resistant to dilatation therapy.

Laparoscopic treatment of median arcuate ligament syndrome: A rare cause of chronic severe abdominal pain

Median arcuate ligament syndrome is a rare disorder characterized by chronic postprandial abdominal pain and weight loss caused by compression on celiac artery. A 17-year-old girl with chronic severe abdominal pain and weight loss was referred to our clinic. Other causes of chronic abdominal pain were investigated and excluded. The compression on celiac artery was detected on Doppler ultrasound and diagnosis was confirmed by computed tomography angiography. The patient underwent laparoscopic release of median arcuate ligament. There were no intraoperative complications; however, partial pain response was observed postoperatively that necessitated para-spinal ganglion blockage. The patient is symptom-free in 1-year follow-up period.

Management of Childhood Thyroid Nodules: Surgical and Endocrinological Findings in a Large Group of Cases

Objective: The management of childhood thyroid nodules is still a big challenge for clinicians. In this study, we aimed to present our surgical and endocrinological experience in more than one hundred pediatric cases. Methods: A retrospective analysis of patients admitted with a thyroid nodule between 2006 and 2014 was performed. Detailed ultrasonography and fine-needle aspiration biopsy (FNAB) were the cornerstones of the diagnostic approach. Results: One hundred-three children (72 female, 31 male) with a mean age of 13.1±3.6 years (3-18 years) were admitted to our center. Management strategy was surgery in 58 patients and follow-up in 45 patients. Mean nodule size was 17±12.7 mm (2-45 mm). The diagnoses were listed as benign solitary nodule (48 patients), thyroid carcinoma (26 patients), multinodular goiter (23 patients), Hashimoto thyroiditis (4 patients), and Graves’ disease (2 patients). Surgical procedures were nodulectomy/lobectomy (32 patients), total thyroidectomy (TT) (13 patients), or TT+ neck dissection (13 patients). The rate of malignancy was 25% in the total group and 44% in the surgery group. The malignancy rate was higher in patients younger than 12 years compared to older children (41% vs. 17%, p=0.040). Metastasis was seen in 38% of the malignant nodules. Postoperative complications were transient hypocalcemia (8%), permanent hypocalcemia (1.7%), and unilateral vocal cord paralysis (1.7%). Recurrence or mortality was not encountered in the 5.4±1.2-year follow-up period. Conclusion: Thyroid nodule in a child requires an aggressive diagnostic approach due to increased risk of malignancy and metastasis. Intraoperative frozen section examination must be done as a useful adjunct to determine the surgical strategy. Incidence of complications is small in thyroid surgery when performed by experienced surgeons.

Acquired right diaphragmatic hernia following pediatric living donor orthotopic liver transplantation

ADH following OLT is a rare entity. Herein, we report a case of Alagille syndrome who developed ADH secondary to OLT, and possible etiological causes are discussed in light of the literature.

Can high risk diseases for increasing intraabdominal pressure be treated more efficiently under intravesical pressure measurement

BACKGROUND Increased intra-abdominal pressure (IAP) can result in multiorgan failure. Trauma, mechanical bowel obstruction (MBO), abdominal wall defects (AWD) and fluid resuscitation in septic shock are conditions associated with a high risk of increased IAP in children. It may be possible to treat these conditions more effectively using intravesical pressure measurement. METHODS This prospective study was performed between December 2009 and October 2010. Intravesical pressure (IVP) measurement was used to determine IAP. The presence of Intra-abdominal hypertension (IAP >12 mmHg) and abdominal compartment syndrome (IAP >15 mmHg + new organ dysfunction) was evaluated in all clinical decisions. RESULTS IVP monitoring was applied in all patients with abdominal trauma (14), AWD (8), fluid resuscitation for septic shock (7), and MBO (6). A diagnosis of ACS was determined in 14% of trauma patients and required surgery. IAH/ACS occurred in 38% of AWD cases, which required closure. IAH occurred in 43% of patients undergoing fluid resuscitation for septic shock, requiring decompressive intervention. IAH/ACS occurred in 50 % of MBO patients, all of whom required surgery. DISCUSSION IVP measurement is a useful method to identify candidates for surgical treatment in cases of trauma and MBO. Similarly, IVP monitoring can facilitate the closure of abdominal wall defects and the application of fluid resuscitation in septic shock.