Mehmet Eliçevik

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.

Management of esophageal perforation secondary to caustic esophageal injury in children

PurposeTo review our management of esophageal perforation in children with caustic esophageal injury.MethodWe reviewed the medical records of 22 children treated for esophageal perforations that occurred secondary to caustic esophageal injury.ResultsThere were 18 boys and 4 girls (mean age, 5 years; range, 2–12 years). Three children were treated for perforation during diagnostic endoscopy and 19 were treated for a collective 21 episodes of perforation during balloon dilatation. One child died after undergoing emergency surgery for tracheoesophageal fistula and pneumoperitoneum. Another patient underwent esophagostomy and gastrostomy. Twenty patients were treated conservatively with a nasogastric tube, broad spectrum antibiotics, and tube thoracostomy, 16 of whom responded but 4 required esophagostomy and gastrostomy. Although the perforation healed in 21 patients, 20 were left with a stricture. Two children were lost to follow-up, 8 underwent colonic interposition, and 10 continued to receive periodic balloon dilatations. Two of these 10 patients underwent colonic interposition after a second perforation. The other 8 became resistant to dilatations: 4 were treated by colon interposition; 2, by resection and anastomosis; and 2, by an esophageal stent.ConclusionsEsophageal perforation can be managed conservatively. Because strictures tend to become resistant to balloon dilatation, resection and anastomosis is preferred if they are up to 1 cm in length, otherwise colonic interposition is indicated.

Timing of surgery in perineal ectopic testes : analysis of 16 cases

Abstract Between 1993 and 1998, 16 patients with perineal ectopic testes (PET) (1%) were diagnosed among the 1,576 patients operated upon for undescended testes (UDT) in two pediatric surgical centers. The mean age was 23 ± 22.5 months. The clinical presentation was an empty scrotum with an ipsilateral palpable perineal mass in 16 patients and an inguinal hernia in 5. In all except 1 patient whose atrophic testis was removed, orchiopexy into the dartos pouch was easily performed through a standard inguinal skin-crease incision. The length of the testicular vessels and vas deferens was adequate and retroperitoneal dissection was not required. Although the complications of UDT are the same as for PET, the timing of surgery should be different. It is generally accepted that children must not be below 6 months of age for surgical correction of UDT, but there is no need to delay surgery in PET, which can easily be diagnosed by physical examination in the neonatal period. Surgery is indicated even if there is no hernia present.

Persistent Cloaca A 10-Year Review of Prenatal Diagnosis

The purpose of this study was to review antenatal sonographic findings in children born with persistent cloaca.

Congenital Short Bowel Syndrome Associated With Appendiceal Agenesis and Functional Intestinal Obstruction

Congenital short bowel with functional intestinal obstruction and absence of appendix vermiformis is a very rare condition with poor prognosis. Seventeen cases of congenital short bowel have been reported previously in the literature. The etiology is unknown. In this report, a case of congenital short bowel, combined with functional intestinal obstruction, mal-rotation, and absence of the appendix vermiformis, is presented and the pathogenesis discussed.

CONTROL OF BLEEDING ASSOCIATED WITH HEMOPHAGOCYTIC SYNDROME IN CHILDREN: An Audit of the Clinical use of Recombinant Activated Factor VII

This paper presents 2 cases of hemophagocytic lymphohistiocytosis (HLH) in whom recombinant factor VIIa (rFVIIa) was used for the management of hemorrhage. Both patients were diagnosed as HLH and were bleeding from the gut, which could not be controlled. Patients received rFVIIa at total doses of between 90 and 180 μg/kg body weight. Hemostatic affect was achieved in both of the patients but lasted only a short time. The response was achieved after 1 h of administration of rFVIIa, lasting for 24 h. The use of rFVIIa was well tolerated. These 2 patients suggest that rFVIIa is a beneficial agent in the management of hemorrhage in patients with HLH, although for a permanent homeostasis the control of primary disease is essential.

Comparison of urodynamic investigations before and after posterior sagittal anorectoplasty for anorectal malformations

METHODS The authors evaluated 21 patients (10 boys, 11 girls) who had anorectal malformations (ARM). Ten of them had infralevator (low-group I) and 11 of them had supralevator (high-group II) type ARM. All of the patients underwent urodynamic investigation before and after posterior sagittal anorectoplasty (PSARP) operation. RESULTS Sacral and spinal anomalies were found in 54% (6 of 11) patients who had supralevator type ARM. None of the patients with infralevator type ARM had additional sacral or spinal anomalies. Before PSARP operation urodynamic investigations of all infralevator type ARM patients were within normal limits, whereas 82% (9 of 11) of patients with supralevator type ARM showed neurovesical dysfunction (NVD). There was no significant difference between the preoperative and postoperative urodynamic findings. The possibility of additional sacral or spinal anomalies and NVD in supralevator type ARM was high. After PSARP operation no additional lower urinary tract dysfunction was detected in the urodynamic evaluation of ARM patients.

Remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy: comparison of adjuvant propofol and ketamine

OBJECTIVE: Laryngoscopy and stimuli inside the trachea cause an intense sympatho-adrenal response. Remifentanil seems to be the optimal opioid for rigid bronchoscopy due to its potent and short-acting properties. The purpose of this study was to compare bolus propofol and ketamine as an adjuvant to remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy. MATERIALS AND METHODS: Forty children under 12 years of age who had been scheduled for a rigid bronchoscopy were included in this study. After midazolam premedication, a 1 µg/kg/min remifentanil infusion was started, and patients were randomly allocated to receive either propofol (Group P) or ketamine (Group K) as well as mivacurium for muscle relaxation. Anesthesia was maintained with a 1 µg/kg/min remifentanil infusion and bolus doses of propofol or ketamine. After the rigid bronchoscopy, 0.05 µg/kg/min of remifentanil was maintained until extubation. Hemodynamic parameters, emergence characteristics, and adverse events were evaluated. RESULTS: The demographic variables were comparable between the two groups. The decrease in mean arterial pressure from baseline values to the lowest values during rigid bronchoscopy was greater in Group P (p = 0.049), while the reduction in the other parameters and the incidence of adverse events were comparable between the two groups. The need for assisted or controlled mask ventilation after extubation was higher in Group K. CONCLUSION: Remifentanil-based total intravenous anesthesia with propofol or ketamine as an adjuvant drug along with controlled ventilation is a viable technique for pediatric rigid bronchoscopy. Ketamine does not provide a definite advantage over propofol with respect to hemodynamic stability during rigid bronchoscopy, while propofol seems more suitable during the recovery period.

Expression of Estrogen and Androgen Receptors in Children with Hypospadias: Preliminary Report

This investigation was conducted to evaluate the presence of estrogen and androgen receptors in penile tissues of patients with hypospadias. The biopsy specimens from prepuce, glans, and urethral plate were sampled during the hypospadias surgery in five patients and were analyzed immunohistochemically. Twelve specimens were investigated for the presence of estrogen or androgen receptors (n: 24); the result was negative in 9 (37%) and positive in 15 (63%). Estrogen receptors were present in 10 specimens (42%) (prepuce: 5, glans: 3, and urethral plate: 2). Androgen receptors were present in 5 specimens (21%) (prepuce: 3, glans: 1, and urethral plate: 1). There was expression of both estrogen and androgen receptors in 5 specimens and only estrogen receptors in the remaining 5. Dominant expression of estrogen receptors in penile tissues of children with hypospadias may be the postnatal finding of disrupted estrogen and androgen receptor interaction during the intrauterine development of external genitalia.

Penile erection during remifentanil anesthesia in children

oxidation of fatty acids (2). This disorder is often diagnosed because it can precipitate hypoglycemia, seizures and coma. Our patient was a 2-year-old male who was presented for dental rehabilitation surgery. His past medical history was positive for hypoglycemia and seizures which led to the diagnosis of MCAD. He was being treated with carnitine (Carnitor) with good control. His past surgical history included bilateral myringotomy tubes and tooth extractions of which there were no anesthetic complications. He had a recent history of croup syndrome 3 weeks prior to this admission and was being treated with amoxicillin. As he had been NPO for 8 h prior to arriving at the hospital, an intravenous line was placed and 5% dextrose in lactated Ringer’s was started in the day surgery unit. An accucheck done preoperatively revealed a blood glucose of 5.5 mmolÆl (100 mgÆdl). After premedication with 8 mg of oral midazolam, the patient was taken to the operating room where standard ASA monitors including electrocardiogram, noninvasive blood pressure, and pulse oximetry were placed. Anesthesia was induced with propofol and a nasotracheal tube was placed without difficulty and maintained with oxygen, air, and sevoflurane. Following an uneventful intraoperative course his trachea was extubated when he was fully awake. Postoperatively an accucheck revealed a blood glucose of 7.7 mmolÆl (140 mgÆdl). His postoperative course was uneventful and he was discharged home the same day. Clinical symptoms of MCAD often present in children 2–3 years of age and are often precipitated by periods of fasting greater than 12 h and/or viral infections. Vomiting and lethargy can progress to seizures, coma and in extreme cases, cardiorespiratory collapse (1). Liver enlargement may occur secondary to fatty deposition (1). Hypoglycemia is often present during acute episodes as well as low urinary ketone concentrations. A secondary carnitine deficiency may be seen when plasma and tissue concentrations of carnitine are reduced by 25–50% (1). Treatment of acute illnesses includes intravenous fluids containing dextrose. Chronic therapy includes prevention of prolonged fasting, restriction of dietary fat and carnitine (1). Review of the literature reveals no reports of anesthesia in children with MCAD deficiency. Although, treatment with carnitine is controversial and many times ineffective, with our patient carnitine therapy appeared to be therapeutic. MCAD is one of the many acyl-CoA dehydrogenases, which are mitochondrial enzymes that are required for beta-oxidation of fatty acids (2). The mechanism of hypoglycemia in these patients is evident during periods of starvation when fat becomes the body’s major fuel source (1). Although our experience is limited with MCAD patients, we offer the following recommendations for anesthesia management: (i) limit NPO status to 2–4 h; (ii) preoperative intravenous catheter placement; (iii) 5% dextrose in lactated Ringer’s solution preoperatively; and (iv) close perioperative blood glucose monitoring.