Ozok G

Enzymatic debridement of burn wound with collagenase in children with partial-thickness burns

Seventy-eight pediatric burn patients treated by enzymatic debridement with collagenase clostridiopeptidase A (CCA), were compared to 41 patients those burn wounds were excised surgically. Patients whose burn wounds were initially assessed as partial-thickness at admission were enrolled in the study. Total removal of eschar was achieved in 49 of 78 (62.8%) patients by CCA only (group D). In 29 patients (37.2%), therapy with CCA was ceased because of the development of burn wound infection or a manifest need for grafting of the wound, therefore, these patients underwent tangential wound excision (group DS). The records of 41 patients, treated by early tangential excision, having similar burn wounds by extent and depth with groups D and DS were used as controls (group S). There was no significant difference between the time to achieve a clean wound bed in groups D, DS and S (mean 7.8, 8, and 7 days, respectively, P>0.05). In group D, none of the patients required blood transfusion, except one. Patients in group DS were found to have fewer excisions (mean 1.1) when compared to those in group S (mean 1.5, P<0.05). The shortest hospital stay was found in group D (12.5 days, P<0.01). In conclusion, the use of CCA, provided a short hospital stay, reduced the overall need for surgery and blood transfusions in patients with partial-thickness burns. Thus, CCA should be considered as an initial treatment of choice for removal of eschar in children, having a partial-thickness burn wound without infection.

Aluminum in total parenteral nutrition solutions produces portal inflammation in rats

BACKGROUND Aluminum contaminates parenteral nutrition solutions and accumulates in bone and liver of patients receiving total parenteral nutrition therapy. Although previous reports have shown that parenteral administration of aluminum in pharmacologic doses to rats results in the production of elevated total serum bile acid concentrations alone or in combination with decreased bile flow, they have failed to demonstrate any abnormalities in the histologic appearance of liver tissue. The effects of aluminum in total parenteral nutrition and of aluminum chloride on total serum bile acid concentrations, aluminum contents of the liver, and histopathologic changes in the liver were studied in rats. METHODS The aluminum concentrations in the aluminum chloride solution and total parenteral nutrition formula were equal (300 microg/l). They were given intraperitoneally as follows: control group, 0.9% saline for 14 days; T7 group, total parenteral nutrition for 7 days; A7 group, aluminum chloride for 7 days; A14 group, aluminum chloride for 14 days; T7A7 group, total parenteral nutrition for 7 days and aluminum chloride for the next 7 days; and T7O7 group, total parenteral nutrition for 7 days and 0.9% saline for the next 7 days. Volumes of 0.9% saline, aluminum chloride, and total parenteral nutrition given to rats were equal. During the experiment, rats were maintained on rat chow and water ad libitum. Serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, alkaline phosphatase, and bile acid concentrations and aluminum content of the liver were measured. The liver was evaluated histopathologically by light microscope, and a morphologic portal inflammation index was calculated. RESULTS Portal inflammation was present in all groups except the control group. The morphologic portal inflammation correlated with hepatic aluminum accumulation in all groups and was the highest in the T7A7 group. Levels of serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, and alkaline phosphatase did not correlate with the histopathologic findings, but serum bile acid concentrations correlated with morphologic portal inflammation and hepatic aluminum accumulation in all groups. Hepatic aluminum accumulation also correlated with the duration of exposure to total parenteral nutrition and aluminum chloride concentration. CONCLUSION Aluminum in contaminating doses, not in pharmacologic doses, accumulates in the liver and can produce hepatobiliary dysfunction characterized by portal inflammation detectable in histologic examination of liver tissue.

Unilateral inguinal hernia in girls : is routine contralateral exploration justified ?

To determine the incidence of contralateral hernia development after unilateral inguinal hernia repair in girls, collected case series from two large hospitals were analyzed retrospectively. Among the 294 girls who had analyzed repair of a unilateral inguinal hernia (during a 15-year period), 245 could be traced; the mean follow-up period was 8.4 years. In 25 (10.2%) of the patients, contralateral hernia developed, mostly within one year (4 months to 6.5 years). The incidence of contralateral hernia development with respect to the original side of the inguinal hernia was significantly higher (19%) for the originally left-sided hernias than for the right-sided ones (6%) (P < .01). Although the incidence of contralateral hernia development for girls with a left inguinal hernia decreased as age increased, it was still 14.9% for the girls age 3 and up. Contralateral exploration should not be routine for girls who have a right-sided hernia, at any age. For left-sided hernias, it may be performed routinely for girls up to 2 years of age, and selectively for older patients.

Gastrointestinal Perforations in Children: A Continuing Challenge to Nonoperative Treatment of Blunt Abdominal Trauma

The present trend towards conservative management of hemodynamically stable pediatric trauma patients may be increasing the risk of delay in the diagnosis of traumatic hollow viscus perforations (HVP). The purpose of this study is to determine whether there is a delay in the diagnosis of HVP because of expectant management. A survey of factors leading to diagnostic delay was also made and the value of current diagnostic tools were reevaluated. In 1,283 trauma admissions between 1980-1994, 34 patients were operated for HVP caused by blunt abdominal trauma. Sites of perforation were; stomach (four), duodenum (five), jejunum (12), ileum (nine), and jejunum/ileum (four). Signs of peritoneal irritation were positive in 32 of 34 patients. There was free air in only six of 24 abdominal roentgenograms. Free peritoneal fluid without solid organ injury was detected in only four out of 13 patients with ultrasound. Peritoneal lavage was diagnostic in eight of nine patients. Time from admission to operating room averaged 24 +/- 4.1 (mean +/- standard deviation) hours. Eleven patients died after the operation mostly because of accompanying head injury. Only two of the deaths were the result of sepsis originating from the perforated bowel. There is an apparent delay in the diagnosis of traumatic HVP in this series. Signs of peritoneal irritation are the most consistent findings of HVP after blunt abdominal trauma in children. Persistence of abdominal signs indicates peritoneal lavage, which has a high diagnostic sensitivity for HVP compared to other diagnostic modalities.

Determination of serum bile acids routinely may prevent delay in diagnosis of total parenteral nutrition-induced cholestasis

BACKGROUND/PURPOSE Early diagnosis of development of cholestasis is a current major problem for patients receiving total parenteral nutrition (TPN). Conventional tests for hepatic function such as serum transaminases and alkaline phosphatase do not often reflect simultaneously histopathologic changes of the liver. The aim of this study is to find out the relationships between conventional hepatic function tests, total serum bile acid concentrations (TSBA), and the histopathologic changes in the liver during TPN administration in rats. METHODS Forty Albino rats were divided into four experimental groups, each consisting of 10 rats, as follows: control group (C), 0.9% saline for 14 days; T7 group, TPN for 7 days; T14 group, TPN for 14 days; T7O7 group, TPN for 7 days and then 0.9% saline for the next 7 days. All solutions were administered by infusion through intraperitoneal catheter in two equal doses. During the experiment, rats also maintained on rat chow and water ad libitum. Levels of serum glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, alkaline phosphatase, and TSBA were measured. Liver was evaluated histopathologically by light microscope and then Morphological Cholestasis Index (MCI) was calculated. RESULTS Cholestasis was present in all experimental groups except control. Levels of transaminases and alkaline phosphatase were not correlated with the histopathologic changes (P > .05), but TSBA concentrations were correlated with MCI in all groups (P< .01). TSBA concentrations and MCI in all groups also were correlated with the duration of exposure with TPN (P< .01). CONCLUSIONS Measurement of TSBA seems to be more sensitive in early diagnosis of TPN-induced cholestasis. Therefore, periodical determination of TSBA during TPN administration can be done routinely.

Management of tracheoesophageal fistula as a complication of esophageal dilatations in caustic esophageal burns

The authors report on eight patients with caustic esophageal burns in whom tracheoesophageal fistula (TEF) developed during dilatation programs. This study covered a period of 17 years between 1975 and 1992. The age of the patients ranged from 1.5 to 8 years (mean age, 3.4 years). TEF developed after 5 to 43 months after injury (mean, 20.05 months). In each case, after documentation of the fistula by esophagography, esophagoscopy, and/or bronchoscopy, the fistula was blocked by an intraluminal esophageal stent, a polytetrafluoroethylene (PTFE) tube with a large lumen (10-mm diameter maximum). In this period, patients were fed via a jejunostomy tube and by total parenteral nutrition (TPN) if indicated, while the existing pneumonia was being treated. In one patient, fistula closed spontaneously during the stent application program, which ended with a patent esophagus. In two patients primary closure of TEF was attempted. In one of them fistula recurred and in the other it was technically impossible to separate the esophagus from trachea safely because of the very tight adhesions. In five patients a two-stage coloesophagoplasty was performed to bypass the fistulated esophagus. In the first stage, retrosternal pull-through of the colon and coloesophagogastric anastomosis was performed. In the second stage, closure of the distal esophagus and cervical coloesophagostomy was carried out. The patient with the primary closure attempt and one patient with stage 1 coloesophagoplasty died 3 and 4 months, respectively, after the operations. The cause of death was uncontrollable pneumonia in both cases. Follow-up of the four patients showed no complications. Another fistula patient is currently on stent treatment program with pneumonia under control.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric trauma score: Is it reliable in predicting mortality?

The Pediatric Trauma Score (PTS) is rapidly gaining acceptance for use in prehospital triage. This study examines its reliability in predicting mortality. The charts of the 533 trauma patients hospitalized between 1984–1989 were reviewed and the PTS was calculated for each. There were 3 deaths in 370 patients with PTS >8, while 24 of 163 children with PTS ⩽8 died. Size categorization was found to be overemphasized because of the low mortality (7.7%) in children smaller than 10 kg, although their mean PTS (6.4 ± 2.1) was significantly lower than the mean PTS (9.0 ± 2.2) of children over 10 kg. Forty-nine of 71 surgically treated patients having intra-abdominal organ injuries had a PTS >8. The existing parameters of PTS did not have equal relationships to mortality, and may even all be inadequate in the correct triage of children with blunt abdominal trauma.

Clostridial collagenase aggravates the systemic inflammatory response in rats with partial-thickness burns

AIM Clostridial collagenase A (CCA) has been shown effective in degrading collagen in eschar tissue and promoting healing in partial-thickness burns. As there are also reports of fever, leukocytosis, increased C-reactive protein (CRP) levels and septic complications during treatment with CCA, we aimed to determine in rats whether CCA aggravates the systemic inflammatory response. METHODS Rats with partial-thickness burns were randomly divided into groups with either no dressing (ND), povidone-iodine dressing (PID) or CCA dressing (CCAD). Body weights and temperatures, blood leukocyte counts, and serum levels of CRP, interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-alpha), were measured at 0, 3, and 24h and days 3 and 7 from burn. Wounds were cultured on days 1, 3 and 7 and burn depth was evaluated on day 1. RESULTS Body weights for all groups were significantly lower after burn, with highest loss (25.5%) in the CCAD group. At 3h a significant drop in rectal temperature was noted in all groups. The CCAD group had higher rectal temperature levels than the PID group on days 3 and 7 (p<0.05). Changes in serum levels of CRP, IL-1 beta, IL-6 and TNF-alpha were not significant in the ND and PID groups; the CCAD group showed a significant rise in serum levels of CRP on day 1, of IL-6 on day 3 and of TNF-alpha on day 7. Wound infection was more common in CCAD group and increased on days 3 and 7, but this was insignificant. CONCLUSION CCA aggravated the systemic inflammatory response in rats with partial-thickness burns, which is accompanied by a higher risk of infection.

High-pressure oxygen insufflation to facilitate submucosal dissection in Soave's operation

The aim of the present study is to demonstrate a new, simple method of facilitating the submucosal dissetion that is the most difficult and timeconsuming part of Soaves operation. For rectal submucosal dissection, oxygen under high pressure is insufflated via a needle inserted into the submucosal space at a level just above the peritoneal reflection of the rectum down to the anal canal. The technique has been successfully used in 35 cases of Hirschsprungs disease. A considerable reduction in the operating time and the incidence of iatrogenic mucosal perforations could be achieved. We conclude that the method is time-saving and provides safety during a period of the operation where scrupulous care is needed.

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.