Levent Elemen

LigaSure compared with ligatures and endoclips in experimental appendectomy: how safe is it?

PurposeThe present study aims to compare strength, healing, and inflammation of appendiceal stumps closed by LigaSure Precise™ (Valleylab, Boulder, CO, USA) device, ligatures using polyglactin 910 (Vicryl, Ethicon, Edinburgh, UK) and endoclips (Ligaclip ERCA, Ethicon, OH, USA), and operation time (OT) in experimental appendectomy.MethodsForty-eight Sprague–Dawley rats were divided into two (Group A and B). Each group was further subdivided into three subgroups (AS, AC, AL, BS, BC, BL) containing eight rats. Appendectomy was performed and stump was closed by ligatures in S, by endoclips in C and by LigaSure™ in L subgroups. OT was recorded. In Group A, cecum bursting pressures (BP) were determined instantly after the operation. In Group B, BP, histological evaluations, and measurements of collagen contents estimated by the tissue hydroxyproline (HPL) level were made on the seventh postoperative day. Statistical analyses were performed with Kruskal–Wallis test and Mann–Whitney U test. P value was considered significant at less than 0.05.ResultsBPs of subgroups were comparable on postoperative immediate period and day 7. HPLs and OTs were significantly better in L subgroups. BL had the least inflammation.ConclusionBetter healing, less inflammation, shorter OT, and equal strength achieved with LigaSure™ device comparing with polyglactin 910 ties and endoclips in experimental appendectomy is encouraging.

Is the use of cyanoacrylate in intestinal anastomosis a good and reliable alternative

PURPOSE The present study aims to compare strength, healing, and operation time of experimental intestinal anastomoses performed by polyglactin 910 (Vicryl; Ethicon, Edinburgh, United Kingdom) sutures with ethyl-2-cyanoacrylate glue (Pattex; Henkel, Dusseldorf, Germany). MATERIAL AND METHODS Ninety-six Sprague-Dawley rats were divided into 2 (groups E and L). Each group was further subdivided into 6 subgroups (EA1, EA2, EA3, EB1, EB2, EB3, LA1, LA2, LA3, LB1, LB2, LB3), each containing 8 rats. Intestinal anastomosis was performed by polyglactin 910 sutures in A subgroups and with ethyl-2-cyanoacrylate in B subgroups. The anastomosis was end to end in A1 and B1, side to side in A2 and B2, and end to side in A3 and B3. Time for anastomosis performance (AT) was recorded. In group E, bursting pressures and hydroxyproline levels were determined on the second postoperative day, whereas in group L, the same measurements were made on the sixth postoperative day. One-way analysis of variance was used for analyses of variance in the groups. Quantitative data were analyzed with Students t test. P value was considered significant at less than .05. RESULTS There was no significant difference between bursting pressures of subgroup pairs on both postoperative days 2 and 6. Hydroxyproline levels and AT were significantly better in B subgroups. CONCLUSION Better healing, shorter AT, and equal strength were achieved with ethyl-2-cyanoacrylate compared with polyglactin 910 sutures in intestinal anastomosis in the experimental setting.

Surgical Experience in a Baby With Congenital Broncho-Biliary Fistula

Congenital tracheobiliary and bronchobiliary fistulae are rare malformations in which patent communications exist between the respiratory system and biliary tract, respectively. We present a newborn who was admitted with respiratory distress and bilious tracheal discharge. Investigation revealed a bronchobiliary fistula originating from the left main bronchus, as well as biliary atresia. Excision of the bronchobiliary fistula was successful and the connection between biliary tract and gastrointestinal system was established by performance of a Roux-en-Y cholecysto-jejunostomy. Diagnostic tools, differential diagnosis, and surgical correction strategies are discussed.

Bronchogenic cyst of the right hemidiaphragm mimicking a hydatid cyst of the liver: report of the first pediatric case

Bronchogenic cyst (BC), which develops from abnormal budding of the tracheal diverticulum or ventral foregut, is a congenital bronchopulmonary malformation. Localization of the BC varies depending on the level of the abnormal budding. Thoracic or abdominal-sited diaphragmatic lesions are the rarest presentations of the BC. We present a case of BC that originated from the diaphragm and mimicking hydatid cyst of the liver in a 19-month-old girl. Diagnosis of a diaphragmatic lesion was confirmed during laparotomy and complete resection was successful.

Heterotopic gastric mucosa leading to recurrent intussusceptions: Report of a case

Although most cases of intussusception during childhood are caused by viral enlargement of the Peyer’s patches, the remainder of the cases may be due to congenital anomalies, such as heterotopic gastric mucosa (HGM). This report presents a case of HGM in a 4-year-old boy. The patient presented with acute abdominal signs with a right lower quadrant mass. His medical history indicated three episodes of recurrent intussusceptions. The abdominal ultrasound examination detected an intussusception. A laparotomy revealed an ileocolic intussusception and reduction was accomplished. During exploration, an intraluminal mass in the ileum, which was the lead point, was discovered by palpation. An enterotomy showed a 2-cm-diameter crater-shaped mucosal thickening. An ileal resection and anastomosis was performed. The histopathological examination revealed HGM. Heterotopic gastric mucosa is supposed to be of vitellointestinal tract origin and may cause intussusception as being a lead point in the ileum. Despite its rarity, HGM should be considered in cases of recurrent intussusceptions and diagnostic studies should be performed. A laparotomy is required for the diagnosis and treatment in complicated cases. Surgical management should include reduction of the intussusception and careful manual examination of the ileum which may expose such pathology. An intestinal resection and anastomosis is sufficient to prevent complications.

Segmental dilatation of the ileum accompanying hypoproteinemia

PURPOSE Segmental intestinal dilatation (SID) is a rare pathologic finding, which causes intestinal obstruction in newborn period and gastrointestinal bleeding, anemia, abdominal pain, malabsorption, and growth failure in older children. We present a case of SID causing hypoproteinemia. PATIENT A 10-year-old girl presented with recurrent abdominal distension since she was 8.5 months old. She was diagnosed to have protein-losing intestinal lymphangiectasia. Result of physical examination was normal except moderate growth retardation. Her blood workup showed depletion in total protein, albumin, and globulin levels. Gastrointestinal series revealed a dilated segment of small intestine, and Tc(99m)-pertechnetate scintigraphy detected ectopic activity in abdomen. The patient was taken to operation with the presumptive diagnosis of intestinal duplication. A dilated segment of ileum was encountered, and segmental resection and anastomosis were performed. RESULTS Patient was discharged on the postoperative fourth day and remains well. Histopathologic examination of the specimen revealed SID. DISCUSSION Segmental intestinal dilatation is an uncommon congenital anomaly. Most of the cases were operated on in newborn period because of intestinal obstruction, and their diagnoses were made perioperatively; the others were diagnosed in older ages during the investigation of nonspecific symptoms. The index patient is the second case of SID having hypoproteinemia in the literature. Gastrointestinal series suggested the diagnosis, and segmental resection and anastomosis were the adequate treatments.

Comparison of bipolar electrosurgical devices with ligatures and endoclips in the rat appendicitis model

PURPOSE The aim of this study is to compare bipolar radiofrequency-driven vessel sealer, bipolar electrocautery, polyglactin 910 sutures, and endoclips in appendiceal stump closure with respect to operative time, appendiceal stump strength, and inflammation in a rat appendiceal model. METHODS Forty-eight Wistar-Albino rats, which had previously created appendicitis, were divided into 2 (groups A and B). Each group was further subdivided into 4 subgroups (AL, ABPC, AC, AS, BL, BBPC, BC, and BS) each containing 6 rats. An appendectomy was performed, and the stump was closed by bipolar radiofrequency-driven vessel sealer in the L, bipolar electrocautery in the BPC, endoclips in the C, and ligatures in the S subgroups. Cecum bursting pressures were determined instantly after the operation in group A and on the seventh postoperative day in group B. All operative times were measured. Appendices and appendiceal stumps underwent histopathologic examination. Statistical analyses were performed with Kruskal-Wallis and Mann-Whitney U tests. P < .05 was considered significant. RESULTS Bursting pressures of the subgroups were comparable on postoperative immediate period and day 7. Operative times were significantly shorter in the L and BPC subgroups in A and B. Histopathologic examination showed that the inflammation scores were similar in group A. In group B, inflammation parameters were also similar except the necrosis status, which was found to be decreased in BL compared with BC and BS. Necrosis status was significantly lower, and lymphocyte quantity was significantly higher in BL and BBPC compared with AL and ABPC. CONCLUSIONS Bipolar radiofrequency-driven vessel sealer and bipolar electrocautery achieve safe stump closure with satisfactory bursting pressure values in an experimental rat appendicitis model. Decreased operative time and unimpaired healing are encouraging.

Acquired ileal atresia because of adhesive small bowel obstruction.

Michaelis et al [1] had reported a unique case of an ileal atresia in a 19-month-old child, which was further identified as the acquired intestinal atresia (AIA). Only 3 articles in English language literature and 1 article in the German literature were published regarding AIA [1-4]. We report an unusual case of AIA caused because of adhesive small bowel obstruction. A 2-year-old girl was admitted with abdominal distension and bilious vomiting that were ongoing for a week. Before these symptoms had begun, she had constipation for 2 months. Her medical history was significant for a left-sided Bochdalek hernia repair in the newborn period. Physical examination revealed a left subcostal incisional scar and a moderately distended abdomen without rebound tenderness. The laboratory studies including complete blood count, serum electrolytes, and liver function tests were normal except for a mildly elevated C-reactive protein level (3.12 mg/dL). Abdominal plain radiography and ultrasonography revealed dilated bowel loops with multiple air-fluid levels suggestive of adhesive small bowel obstruction. The patient was hospitalized, antibiotics were administered, and a conservative trial with nasogastric tube drainage was started because of lack of fever and acute abdominal signs. During a conservative trial of 33 hours, no improvement was achieved and the patient was taken to the operating room. Exploratory laparotomy revealed dense adhesions. After lysis of the adhesions, an adhesive band was found obstructing an ileal segment 15 cm proximal to the ileocecal valve. Resection of the band exposed blindended proximal and distal segments with a V-shaped mesentery defect resembling a type III-a congenital ileal atresia (Fig. 1). Ileal resection and end-to-end anastomosis were performed. Histopathologic examination revealed chronic inflammation consistent with an AIA. No necrosis was detected. Normal gastrointestinal motility was achieved in 4 days. The patient had an uneventful course and was discharged on the seventh postoperative day. She remains well without any complications for follow-up of 18 months. Although a substantial number of the necrotizing enterocolitis survivors develop intestinal strictures, and rarely an atresia, as a consequence of cicatricial healing of a segment of the intestine injured by ischemia, AIA in non–necrotizing enterocolitis–related patients is uncommon [5-11]. This entity was first described by Michaelis et al [1] in a 19-month-old boy in whom ileal atresia developed after drainage of a large intraabdominal abscess. The authors proposed that ileal strangulation with resorption of the devitalized segment led to an AIA, conceptually similar to instances of congenital jejunoileal atresia. In 2 additional cases reported by Ratan et al [4], the underlying cause was postulated to be intestinal inflammation leading to thromboembolism. In all these cases, AIA was because of interruption of the blood supply of the bowel confirming the intrauterine vascular injury theory of Louw and Barnard [12] in cases of congenital jejunoileal atresia. Less frequently, mechanical factors such as congenital bands and premature closure of an omphalic ring were described as causes of congenital jejunoileal atresia by trapping an intestinal segment [13-15]. Concluding that these accidents may potentially create intestinal atresia beyond the fetal period, Vassy et al [16] presented 2 patients in whom www.elsevier.com/locate/jpedsurg