Nebil Büyükpamukçu

Bronchoscopy for evaluation of foreign body aspiration in children

PURPOSE The aim of this study was to present the entire spectrum of pediatric bronchoscopy performed for foreign body aspiration (FBA), with emphasis on accuracy of diagnostic tools, technical aspects, and predictors of complications. METHODS Records of patients who underwent bronchoscopy for evaluation of FBA in our unit from 1991 to 2000, inclusive, were reviewed retrospectively. Age, sex, history of FBA, symptoms, results of radiologic studies, bronchoscopy findings, complications, and outcome were recorded and statistically analyzed to find out the most accurate diagnostic tool. RESULTS A total of 740 bronchoscopies were done in 663 children (402 boys, 261 girls) presenting with a mean age of 3.1 +/- 0.1 years. FBA was confirmed in 563 (85%) patients, whereas normal bronchoscopic findings, signs of pulmonary infection, and endobronchial mass were noted in 43 (6%), 54 (8%), and 3 (0.4%) patients, respectively. There was significant difference between patients with and without FBA with regard to presence of definite history (91% v 54%), normal physical examination findings (14% v 46%), and normal radiologic findings (13% v 31%). However, none of these parameters or their associations were found to be reliable to predict the presence of FBA or clinical complications. Presence of history was the most sensitive (91%), accurate (84%), and specific (46 %) diagnostic tool. Bronchoscopic removal of-foreign bodies was succeeded in 558 (99%) children. Worsening of respiratory tract infection (n = 13), cardiac arrest (n = 6), laryngeal edema (n = 5), pneumothorax (n = 5), pneumomediastinum (n = 2), tracheal laceration (n = 2), and bronchospasm (n = 2) were the life-threatening complications observed in 21 (4%) patients with FBA and 14 (14%) patients without FBA (P <.05). There were 5 (0.8%) deaths. Of these, 2 patients presented with cardiopulmonary arrest immediately after FBA. Although foreign bodies were removed as quickly as possible, cardiac arrest was irreversible. The remaining 3 patients died of complications of bronchoscopy as irreversible cardiac arrest during bronchoscopy (n = 1) and worsening of respiratory tract infection after bronchoscopy (n = 2). CONCLUSIONS The third year of the life carries the highest risk for FBA. There are no specific symptoms and signs to make a clear-cut differential diagnosis between FBA and respiratory tract infection. Bronchoscopy is invariably indicated on the basis of reliable history alone even when symptoms are minimal, and imaging studies are negative. Secondary bronchoscopy should be done in patients with persistent signs and symptoms to rule out overlooked organic foreign body particles or to remove persistent granulation tissue to avoid long-term complications necessitating lobectomy. The long duration of the procedure, presence of dense granulation tissue, and type of foreign body are important predictors of complications. Bronchoscopy should be regarded as an expert procedure and done with great care to avoid lethal complications. Differential diagnosis of respiratory tract infection by various diagnostic tools is of utmost important to avoid morbidity and mortality related to needless bronchoscopy.

CT virtual bronchoscopy in the evaluation of children with suspected foreign body aspiration

OBJECTIVE Computed tomography (CT) virtual bronchoscopy is a noninvasive technique that provides an internal view of trachea and major bronchi by three-dimensional reconstruction. The aim of this study was to investigate the usefulness of virtual bronchoscopy in the evaluation of suspected foreign body aspiration in children. MATERIALS AND METHODS Twenty-three children (12 girls, 11 boys) with a mean age of 2.4 years (8 months-14 years) who were admitted to emergency room with a suspicion of foreign body aspiration were included in this study. Chest radiograms, spiral computed tomography scans and virtual bronchoscopy images were obtained. Then, rigid bronchoscopy was performed within 24 h. RESULTS CT virtual bronchoscopy and conventional bronchoscopy revealed the location of the foreign body in seven patients. It was in the right main bronchus in four patients, in the right lower lobe bronchus in one patient, and in the left main bronchus in two patients. There was no discordance between two modalities. CT examination revealed hyperaeration of the ipsilateral lung in four patients, hyperaeration of the ipsilateral lung and mediastinal shift in one patient and bronchiectatic changes in one patient. CT detected no additional finding in one patient with a foreign body in the right main bronchus. In 10 of 16 patients without foreign body, CT examination demonstrated atelectasis, infiltration, peribronchial thickening, and paratracheal lymphadenpoathy. CONCLUSION Helical CT scanning with virtual bronchoscopy should be performed in only selected cases with suspected foreign body aspiration. When the chest radiograph is normal and the clinical diagnosis suggests aspirated foreign body, helical CT and virtual bronchoscopy can be considered in order to avoid needless rigid bronchoscopy.

Sclerotherapy for lymphangioma in children

Although surgical excision has been considered to be the treatment of choice by most of the surgeons, sclerotherapy of lymphangioma has gained popularity during recent years. A prospective clinical trial was conducted to evaluate the efficacy of bleomycin and OK-432 sclerotherapies for treating lymphangioma in children. Fifteen patients were enrolled in the study conducted between 1998 and 2002. All patients were hospitalized. Bleomycin or OK-432 was injected into the lesion. Patients were observed in the hospital for 1 day. The response was considered as excellent in cases with total disappearance of the lesion. If the lesion was regressed more than 50% of the original size, the response was considered as good. Little or no change in the size of lesion was considered to be a poor response. Ten girls and five boys with ages ranging from 4 days to 12 years were treated. Five patients had been operated previously for lymphangioma. Most of the lesions were located only in the cervical region (n=13). Other cases revealed extensions into the mediastinum (n=1) or axilla (n=1). Bleomycin (n=8, 2.87+/-2.03 inj.), OK-432 (n=5, 2+/-1 inj.) or both in order (n=2, 6 and 16 injs.) were injected. No allergic reaction, scar formation or pulmonary complication was encountered. Fever (11%), local reactions (4%) and vomiting (2%) were encountered following a total of 55 injections. After a follow-up period of 6-36 months, the responses were excellent in 53.4%, good in 26.7% and poor in 6.6%. Macrocysts disappeared in the remaining 13.3% of patients who had mixed cervicofascial lymphangioma. Lower success rates were encountered among patients who had undergone prior surgery. Sclerotherapy with bleomycin and OK-432 is effective in the treatment of lymphangioma in children. Adverse effects are minor and rarely encountered. However, the surgeon should be alert for the possible serious complications. Sclerotherapy can be also used as an adjunctive therapy in the treatment plan of widespread or mixed forms of lymphangiomas. In the light of our results, sclerotherapy should be preferred as the primary mode of treatment in childhood lymphangiomas.

Congenital Lobar Emphysema: Diagnostic and Therapeutic Considerations

BACKGROUND/PURPOSE Congenital lobar emphysema (CLE) is characterized by overinflation of a pulmonary lobe and may present as a diagnostic and therapeutic dilemma. The authors have reviewed their experience to clarify the controversies about the diagnosis and management of CLE in children. METHODS Children who had CLE and were treated at our department between 1991 and 1998, inclusive, were reviewed. RESULTS Fourteen children consisting of 8 boys and 6 girls (age range, 25 days to 2.5 years) had CLE. Eight children (57%) were symptomatic at birth. Major presenting symptoms were dyspnea (n = 8, 57%), cyanosis (n = 6, 43%) and recurrent respiratory tract infection (n = 4, 28.5%). Chest x-rays and computerized tomography scans showed hyperaeration of the affected lobes in 14 and 12 patients, respectively. Pulmonary perfusion scan was performed in 8 patients and showed loss of perfusion in the affected lobe in 7 cases. The affected sites were left upper lobe (n = 8, 57%), right middle lobe (n = 4, 28.5%) and right upper lobe (n = 2, 14.5%). Congenital cardiac anomalies were encountered in 2 patients (14.5%). Ten children underwent lobectomy, and postoperative course was uneventful. Nonoperative management was performed in 4 cases (28.5%) presenting at older age with milder symptoms. In the latter, although symptoms subsided, radiological abnormalities persisted during the follow-up period of 3 months to 4 years. No mortality was encountered in the series. CONCLUSIONS The diagnosis of CLE is established by combined radiological and scintigraphic imaging methods. Surgical excision of the affected lobe is the appropriate treatment in all infants under 2 months of age and in infants older than 2 months presenting with severe respiratory symptoms. Infants older than 2 months presenting with mild to moderate respiratory symptoms associated with normal bronchoscopic findings can be treated conservatively. In conservative management, the children should be under close follow-up, and the family should be alarmed about the disease. Further studies are required to determine the long-term outcome of conservative management.

Ipsilateral and contralateral testicular biochemical acute changes after unilateral testicular torsion and detorsion

OBJECTIVES An experimental study has been conducted to investigate testicular blood flow alterations through acute biochemical changes during unilateral testicular torsion and detorsion. METHODS One hundred twenty male albino rats were divided into 12 groups, each containing 10 rats. One group served to determine basal values of biochemical parameters, 4 groups were subjected to varying periods of unilateral testicular torsion (3, 6, 12, and 24 hours, respectively), 3 groups were subjected to detorsion following varying periods of torsion (6, 12, and 24 hours, respectively), and 4 groups underwent sham operations as controls. Levels of lactic acid, hypoxanthine, and lipid peroxidation products were determined in testicular tissues. RESULTS Values of these 3 parameters obtained from sham operation control groups did not differ significantly from basal values (p > 0.05). All 3 parameters were increased significantly in both ipsilateral torted and contralateral nontorted testes after unilateral testicular torsion when compared with basal values (p < 0.05). Detorsion did not cause significant changes in levels of lipid peroxidation products in both ipsilateral torted and contralateral nontorted testes when compared with values obtained after torsion (p > 0.05). CONCLUSIONS Ipsilateral testicular torsion causes a decrease not only in the ipsilateral torted but also in the contralateral nontorted testicular perfusion. The clues of reperfusion injury do not become evident following detorsion of testicular torsion lasting more than 6 hours.

Colorectal carcinoma in children

BACKGROUND/PURPOSE Colorecta I carcinoma is extremely rare in children and presents with a poor prognosis. Surgical management and long-term follow-up of this entity are still obscure because of lack of data. Therefore, a retrospective clinical trial was performed to evaluate the clinical characteristics of childhood colorectal carcinoma and to determine the predictors of poor outcome. METHODS Records of children who had colorectal carcinoma and were treated at our unit between 1972 and 1997, inclusive, were reviewed retrospectively. Information recorded for each patient included age, sex, clinical characteristics, diagnostic procedures, extent of disease, treatment methods, histological types, and outcome. A modified Dukes staging scheme was used. RESULTS There were 12 boys and 8 girls who were treated for colorectal carcinoma (range, 7 to 16 years). Predisposing conditions were encountered in 2 patients (10%), one with Blooms syndrome and another with familial occurrence of colonic carcinomas. Predominant symptoms were abdominal pain, vomiting, and rectal bleeding. Barium enema, ultrasonography, computerized tomography, and endoscopic procedures were used for the diagnosis. Rectosigmoid region was the most common site for the primary tumor (65%). All patients presented with advanced stages of disease (stage C, 7; stage D, 13). Surgical procedures were incisional biopsy (n = 4), palliative permanent colostomy (n = 4), segmental resection (n = 5), complete resection (n = 6), and rectal biopsy (n = 1). Peritoneum was the most common site of extensive intraabdominal disease followed by omentum majus and liver. The lung also was involved in 2 patients. Predominant histological type was mucinous adenocarcinoma (80%). All patients but one received adjuvant chemotherapy, and 2 received palliative radiotherapy. Thirteen patients died of disease in a period ranging from 1 day to 1 year after initial surgery. The fate of 4 patients who were discharged in a very ill status was unknown. Three patients were alive for 2 years to 4 years postoperatively, and one of them presented with end stage disease. CONCLUSIONS Delayed diagnosis, advanced stages of disease at presentation, and, most importantly, mucinous type of histology are the major determinants of poor outcome in childhood colorectal carcinoma. We emphasize that possibility of a malignant colorectal tumor should be considered for any childhood case with signs and symptoms of intestinal obstruction, intractable abdominal pain, alteration in bowel habits and gastrointestinal bleeding. Colorectal malignancy should not be excluded only on the basis of the patients age. Because of the steadily increasing incidence of precancerous bowel diseases and poor prognosis of colorectal carcinoma, childhood cases of bowel disorders should receive the same detailed and vigorous diagnostic evaluation and appropriate treatment as given to adult cases. Contrast studies, ultrasonography, computed tomography, and endoscopy are essential procedures for both confirming the diagnosis and detecting the extent of the disease.

The diagnosis and treatment of H-type tracheoesophageal fistula

BACKGROUND H-type tracheoesophageal fistula (TEF) was diagnosed in 12 patients during the 25 years from 1971 to 1996. Although all patients were symptomatic since birth, in 58% of the cases, there was a diagnostic delay ranging from 26 days to 4 years. METHODS Esophagography and/or cineesophagography, or bronchoscopy and simultaneous methylene blue administration confirmed the diagnosis of H-type TEF. Although cineesophagography is highly effective in demonstrating H-type TEF today, bronchoscopy must be used in every patient suspected of having fistula, especially when the radiological methods fail. Bronchoscopy is helpful in diagnosis, in evaluation of associated respiratory tract anomalies, and in treatment. RESULTS Two newborn patients could not have been operated on because of pulmonary insufficiency resulting from delayed recognition of fistula. Ten patients underwent fistula repair, nine through cervical approach, and one through thoracotomy, with seven survivors. CONCLUSIONS The results suggest that early diagnosis is essential in the newborn period. Oversight in identification of H-type TEF, unsatisfactory radiological method, masquerading symptoms related to associated anomalies, and minute symptoms in some patients may cause delay in diagnosis. Radiological and endoscopic procedures are complementary in both diagnosis and treatment of H-type TEF.

Anomalous congenital bands causing intestinal obstruction in children

The records of eight patients treated for intestinal obstruction resulting from bands that have no identifiable embryologic or acquired basis were reviewed retrospectively. All patients presented with symptoms and signs indicative of intestinal obstruction. Patients older than 2 years of age additionally had a history of chronic abdominal pain. One thick anomalous congenital band with blood vessels in it was found to be the cause of obstruction in each patient. Bands were located between ascending colon and terminal ileum in four patients (50%), ligament of Treitz and terminal ileum in two patients (25%), right lobe of liver and terminal ileum in one patient (12.5%), and right lobe of liver and ascending colon in one patient (12.5%). The obstructive mechanisms were compression of bowel by band in five patients (62.5%) and entrappment of an intestinal loop between the band and mesenterium in three patients (37.5%). These bands are suggested to be the anomalies of mesenterium that may cause intestinal obstruction and chronic abdominal pain in children.

Gastric outlet obstruction due to corrosive ingestion: incidence and outcome.

Abstract A retrospective clinical study was performed to determine the incidence, management, and outcome of gastric outlet obstruction (GOO) caused by caustic ingestion in children. Of 220 patients who sustained caustic substance ingestion and were treated at our unit between 1976 and 1996, 168 ingested alkaline substances; of these, 9 children (5.3%) developed GOO in addition to esophageal strictures. The remaining 52 patients ingested acid agents, and 2 of them (3.8%) presented with GOO without esophageal strictures. The overall incidence of corrosive GOO was 5% (n = 11). The mean age of the patients with GOO was 5.7 ± 2.8 years (range 2–14) with a female:male ratio of 6:5. Sodium hydroxide (n = 6), potassium hydroxide (n = 3), and hydrochloric acid (n = 2) were the ingested caustic agents. The patients were subdivided into two groups according to serial endoscopic and radiologic findings: group I: moderate (dense superficial and spotty ulcerations with intact mucosa) mucosal injury with partial pyloric obstruction; and group II: severe (deep ulcerations, extreme hemorrhagic erosions, eschar formation with white plaques) mucosal injury with complete pyloric obstruction. Group I consisted of 5 patients who ingested alkali agents while group II included 6 who presented with ingestion of alkaline (n = 4) and acid (n = 2) agents. Surgical treatment included Billroth I (n = 6) operations performed in group II and Finney (n = 3) and Heineke-Mikulicz (n = 2) pyloroplasty procedures done in group I. All patients are alive without any complaints. Fiberoptic endoscopy should be the preferred method of evaluating a patient with ingestion of a corrosive agent. It determines the presence of injury and assesses the extent of damage, establishing the diagnosis and allowing therapy to be instituted immediately. Our experience revealed that substantial damage has occurred early after ingestion, and early surgical intervention has decreased the morbidity and mortality. The extent of the mucosal injury and status of the pylorus and antrum determined the type of surgical treatment. A Billroth I procedure recommended for severely injured mucosa with complete pyloric obstruction, and pyloroplasty for moderate mucosal injury associated with partially obstructed but still viable pylorus. In contrast to the current belief, alkali ingestion also has a high risk of corrosive gastric injury causing GOO, which should be considered during assessment of the injury. We emphasize that a detailed evaluation of radiologic and especially endoscopic findings is very important for determining the timing, necessity, and type of appropriate surgical treatment.

Bilateral Poland anomaly

Bilateral absence of the pectoralis major muscle with accompanying abnormalities of shoulder muscles has been reported in patients without Poland anomaly (PA). However, symmetric absence of pectoralis major muscles, hypoplasia of breasts and nipples with symmetric chest wall deformity and bilateral hand anomaly has not previously been reported. A 6-year-old girl with bilateral absence of pectoralis major muscles and hand involvement and symmetric chest wall deformity is, to our knowledge, the first known case of bilateral Poland anomaly.