Feza M. Akgür

REPERFUSION INJURY AFTER DETORSION OF UNILATERAL TESTICULAR TORSION

SummaryReperfusion injury has been well documented in organs other than testis. An experimental study was conducted to investigate reperfusion injury in testes via the biochemical changes after unilateral testicular torsion and detorsion. As unilateral testicular torsion and varicocele have been shown to affect contralateral testicular blood flow, reperfusion injury was studied in both testes. Given that testicular blood flow does not return after 720° testicular torsion lasting more than 3 h, the present study was conducted after 1 and 2 h of 720° torsion. Adult male albino rats were divided into seven groups each containing ten rats. One group served to determine the basal values of biochemical parameters, two groups were subjected to 1 and 2 h of unilateral testicular torsion respectively, two groups were subjected to detorsion following 1 and 2 h of torison respectively, and two groups underwent sham operations as a control. Levels of lactic acid, hypoxanthine and lipid peroxidation products were determined in testicular tissues. Values of these three parameters obtained from the sham operation control groups did not differ significantly from basal values (P>0.05). All three parameters were increased significantly in both ipsilateral and contralateral testes after unilateral testicular torsion when compared with basal values (P<0.01 and P<0.05, respectively). Detorsion caused significant changes in lipid peroxidation products levels in ipsilateral but not in contralateral testes when compared with values obtained after torsion (P<0.01 and P>0.05, respectively). It is concluded that ipsilateral testicular torsion causes a decrease in perfusion not only in the ipsilateral but also in the contralateral testis. Additionally, detorsion following up to 2 h of 720° torsion causes reperfusion injury in ipsilateral but not in contralateral testis.

Prospective Study Investigating Routine Usage of Ultrasonography as the Initial Diagnostic Modality for the Evaluation of Children Sustaining Blunt Abdominal Trauma

In this prospective study, 217 children sustaining blunt abdominal trauma were initially evaluated with ultrasonography (US) and those with any abnormal ultrasonographic findings were further evaluated with computed tomography. Results of ultrasonographic examination were normal in 157 children and showed abnormalities such as free intraperitoneal fluid (FIF), intra-abdominal organ injury, and intrapleural fluid in 60 children. Computed tomographic examination of the 42 children with organ injury, the seven children with minimal FIF of no definite source, and the three children with intrapleural fluid revealed findings consistent with ultrasonographic findings. Computed tomographic examination of the eight children with more than minimal FIF of no definite source detected by US showed the source as liver injury in one and spleen injuries in two patients. The source of FIF could not be identified with computed tomography in five patients. After clinic follow-up examination, one of these five patients was operated on for abdominal tenderness, fever, and air-fluid levels detected on plain abdominal radiographs, and duodenal perforation was encountered. Clinical courses of the patients with normal ultrasonographic findings were uneventful. We conclude that US, aside from being a screening tool, is alone sufficient in the evaluation of the majority of the children sustaining blunt abdominal trauma. Although this is a preliminary study with further work needed to be done, we propose that further evaluation with computed tomography should be performed on those children in whom more than minimal FIF of no definite source is detected with US.

The effects of intraamniotic human neonatal urine and meconium on the intestines of the chick embryo with gastroschisis

BACKGROUND/PURPOSE Urinary waste products in the amniotic fluid has been implicated as a cause of intestinal damage (ID) in gastroschisis based on the fact that fetus urinates physiologically into the amniotic cavity. However, experimental and clinical data suggest that intrauterine defecation is a physiological event, thus gastrointestinal waste products also may be responsible for ID in gastroschisis. An experimental study was performed to investigate the effects of intraamniotic human neonatal urine and diluted meconium on the intestines of chick embryo with gastroschisis. METHODS Five-day-old fertilized chick eggs (Gallus domesticus) were used. Gastroschisis was created through amniotic cavity without opening the allantoic cavity. Sterile urine and meconium were obtained from newborn humans, and 1% meconium suspension was prepared. The eggs were divided in to 3 groups. In the first group, gastroschisis was created, and amniotic fluid was reinstilled without changing its composition (control group). Equal amounts of amniotic fluid and urine mixture was instilled into the amniotic cavity in second group (urine group) and 1% meconium suspension was instilled in similar fashion in the third group after creation of gastroschisis (meconium group). RESULTS Histopathologic features of the intestines of the urine group did not differ from the intestines of the control group. The meconium groups bowel showed serosal thickening, inflammation, focal fibrin, and collagen deposits. Histopathologic changes of intestines induced by intraamniotic diluted meconium are consistent with the ones described for human gastroschisis specimens. CONCLUSION Gastrointestinal waste products seem responsible for the ID in gastroschisis rather than urinary waste products.

The place of ultrasonographic examination in the initial evaluation of children sustaning blunt abdominal trauma

Physical examination is stated to be inaccurate in detecting organ injury after blunt abdominal trauma (BAT) in children and the use of diagnostic peritoneal lavage (DPL) and computed tomography (CT) are suggested. However, assessments for the need of such diagnostic aids are quite subjective. The records of 109 patients initially evaluated by ultrasonography (US) for BAT were reviewed to determine whether an easily performed, quick method such as US could be used for selection. US showed free intraperitoneal fluid (FIF) in 30 patients (27.5%) and retroperitoneal injury in 5 patients (4.5%). Of the 30 patients with FIF, 23 patients (76.7%) were treated conservatively but 7 (23.3%) required laparotomy. The correlation between the amount of FIF and the requirement for operative treatment was statistically significant (P < .01). Of the 74 patients (68%) without FIF, clinical outcome was uneventful in 72 (97.3%) while 2 patients (2.7%) required laparotomy for peritonitis and ileal perforations were encountered. The present study has showed that US is inaccurate in detecting solid intraabdominal injuries; however, it is reliable in detecting FIF produced as a result of intraabdominal organ injuries and retroperitoneal organ injuries. We suggest the use of US as the objective initial evaluation method of choice on a routine basis.

Extrahepatic portal hypertension treated by anastomosing inferior mesenteric vein to left portal vein at rex recessus

For the treatment of recurrent bleeding despite sclerotherapy or clinically significant hypersplenism, portosystemic shunt procedures should be performed in cases of extrahepatic portal hypertension caused by extrahepatic portal vein thrombosis. A novel alternative to portosystemic shunt procedures in extrahepatic portal hypertension is mesenterico-left portal bypass. Portal vein thrombosis is bypassed by an autologous vein graft (usually left internal jugular vein) interposed between superior mesenteric vein and left portal vein. In the presence of an enlarged right gastroepiploic vein, the distal end of this vein can be anastomosed to left portal vein without disturbing its proximal end. Herein, the authors report a case of extrahepatic portal hypertension treated by anastomosing enlarged inferior mesenteric vein to left portal vein to bypass portal vein thrombosis.

Amniotic fluid exchange for the prevention of neural tissue damage in myelomeningocele: an alternative minimally invasive method to open in utero surgery.

Objective: Experimental studies have shown that neural tissue damage in myelomeningocele (MMC) is acquired, resulting from exposure of neural tissue to amniotic fluid (AF). Similar to neural tissue damage in MMC, in gastroschisis, intestines exposed to AF are damaged. In gastroschisis, intestinal damage can be prevented by changing the composition of the AF with partial AF exchanges. An experimental study was performed to investigate whether the neural tissue damage in MMC can be prevented by AF exchange. Methods: Thirteen-day-old fertilized chick eggs were used. In group 1, the amnio-allantoic membrane was opened to create a common cavity, and MMC was created (MMC-only group). In group 2, after creation of MMC, amnio-allantoic fluid exchange was performed (MMC-plus-exchange group). Chicks were extirpated for histopathologic examination 5 days later. Results: While edema, focal calcification, fibrosis, capillary cell proliferation and scattered mononuclear cells were observed in the MMC-only group, histopathologic changes were mild in the exchange group. The number of neuron-specific enolase stainings (+) neural cell count was significantly higher in the exchange group compared to the MMC-only group (p < 0.01). Conclusion: Exposure of MMC to AF causes structural neural tissue damage that can be prevented by AF exchange. AF exchange is minimally invasive compared to open in utero surgery for the closure of MMC. By AF exchange, neural tissue damage that occurs during the gestational period may be prevented.

Short-term intestinal ischemia-reperfusion alters intestinal motility that can be preserved by xanthine oxidase inhibition.

While the effects of transient intestinal ischemia on mucosa have been well investigated, less is known about its effect on motor function. An experimental study was designed to investigate the effects of ischemia–reperfusion (I/R) on intestinal motility and intestinal muscular microcirculation. Wistar albino rats were divided into four groups: (1) baseline, (2) sham operation, (3) I/R, and (4) I/R with allopurinol pretreatment. Ischemia was induced by clamping the superior mesenteric artery (SMA) for 10 min. Gastroanal transit time (GATT) was measured with serial x-rays after instillation of barium sulfate to the stomach. Intestinal muscular microcirculation was evaluated by determining the number of carbon-perfused intestinal muscular microvessels (CPIMM). I/R prolonged GATT and decreased CPIMM significantly (P < 0.01). Pretreatment with allopurinol prevented prolongation of GATT and returned the number of CPIMM to the level of sham treatment (P < 0.01). In conclusion, reperfusion after 10 min of SMA ischemia alters intestinal motility. The no-reflow phenomenon plays an important role in this alteration of motility. Administration of allopurinol before reperfusion preserves intestinal motility by preventing the occurrence of no-reflow phenomenon.

Sacrococcygeal extraspinal ependymomas: the role of coccygectomy.

BACKGROUND Ependymomas, the common glial tumors of the spinal cord, occur occasionally outside the central nervous system and are called exstraspinal ependymomas (EEP). EEPs are found primarily in sacrococcygeal region during childhood. The pathogenesis and the treatment of the sacrococcygeal (SC) ependymomas are still controversial. Therefore, we present our case with metaanalysis of other case reports to determine the optimal treatment modality for SC EEPs. METHODS A metaanalysis of case reports of SC EEPs, including the current case, was conducted. Also all available case reports of EEPs, without age limit, were analyzed to determine the distribution of EEPs localization. RESULTS EEPs usually are found in teratoma localizations such as the SC area, ovary, paraovarian structures, and medastinum. The distribution of EEPs localization differs with age. Local recurrence rate of EEPs after coccyx excision is zero, however, it increases to 71% when the coccyx was left behind. CONCLUSION The identical clinical characteristics of the SC teratomas and EEPs imply that the SC EEPs may be monophasic teratomas as their ovarian counterparts are named. Coccyx excision is an important part of the surgical treatment of these tumors, with an apparent decrease in the recurrence rate.

Laparoscopic appendectomy in children performed using single endoscopic GIA stapler for both mesoappendix and base of appendix

BACKGROUND/PURPOSE Similar to open appendectomy (OA), most of the methods described for laparoscopic appendectomy (LA) require two steps: (1) dissection and division of mesoappendix and (2) excision of appendix. Dissection of mesoappendix requires more skill and experience during LA. In single endoscopic GIA stapler laparoscopic appendectomy technique (SESLAT), both mesoappendix and base of appendix may be divided in one step with the application of a single endoscopic GIA stapler. METHODS LA was attempted in 18 patients who had acute appendicitis and was successfully performed in 16 patients. RESULTS In two patients, the operation was converted to OA. The authors did not need conversion to OA because of complication resulting from the use of the stapler. CONCLUSIONS SESLAT is a quick, easy, and versatile method for LA in children that obviates dissection of mesoappendix and related complications. Thus, it enables LA to be performed by inexperienced beginners.

Percutaneous Treatment of Hydatid Liver Cysts in Children as a Primary Treatment: Long-term Results

PURPOSE To evaluate the effectiveness and long-term results of percutaneous treatment for hydatid liver cysts in pediatric patients. MATERIALS AND METHODS Thirty-four pediatric patients (15 male, 19 female; ages 4-17 years; mean age, 9.4 years) with 51 hydatid liver cysts underwent ultrasound (US)-guided percutaneous treatment with albendazole prophylaxis. There were 15 type II lesions with membrane detachment and 36 type I lesions resembling simple hepatic cysts with pure anechogenic content or small echogenic reflections and a regular well-delineated wall. The method of US-guided puncture, aspiration, injection of hypertonic saline solution, and reaspiration was preferred for 21 lesions. For the remaining 30 larger cysts, the intervention was performed with the same percutaneous technique but followed by catheterization, drainage, control cystography, and sclerotherapy with ethanol. During follow-up, US examinations were performed at 1, 3, 6, and 12 months for the first year and yearly thereafter. RESULTS Percutaneous treatment of hepatic hydatid disease was successful in 33 patients (97.1%). During follow-up, US findings in the lesions changed significantly; at year 1, the inner content of the lesions became heterogeneous with a semisolid appearance, and the mean reduction in volume was 81.4%. At 2-year follow-up, most hydatid cysts had become solid in nature and the reduction in volume reached 65%-99% (mean, 85.1%). There were no recurrences or additional lesions after the follow-up of 1-6 years (mean, 3.1 years). Average hospital stay for the whole group in this study was 3.5 days. CONCLUSIONS The long-term results of percutaneous liver hydatid cyst treatment in children are in accordance with the results in adults. Percutaneous treatment of uncomplicated type I and type II liver hydatid cysts in pediatric patients is an efficient and safe treatment with short hospitalization.