Ramazan Karabulut

Congenital Muscular Torticollis in Children

Aim: The aim of this study was to evaluate the data of our patients treated for congenital muscular torticollis (CMT) in the period between 1990 and 2004. Here we report our clinical experience with CMT and review the literature. Patients and Methods: We retrospectively evaluated the data of our patients in terms of age, sex, clinical presentation, additional deformities, localization of the lesion, history of previous treatment attempts, diagnostic tests, additional abnormalities, findings at operation and surgical procedures. Results: The mean age of the patients who were operated for CMT (25 females, 27 males) was 4.3 years (range: 5 months to 16 years). Most of the lesions were seen on the left aspect of the neck. There was only one case with bilateral CMT. Seventeen out of 52 patients with CMT (32%) were diagnosed in the newborn period. The most encountered complaint at application was restriction of neck motion (57%). Associated complaints such as head tilt (53%), fascial asymmetry (34%), deformity of the skull (9.6%) were seen. Sternocleidomastoid tumor accounted for only 11% of the patients’ complaints. All patients in this series were treated by surgical intervention. Apart from one recurrence no other postoperative complication was observed during the follow-up period. Conclusions: Patients whose pathology does not resolve after 12 months of physical therapy or who develop facial asymmetry or plagiocephaly during the follow-up period should be operated on in order to achieve the best cosmetic result. In delayed cases additional surgery may be needed for the best cosmetic and functional result.

Conservative Surgery for Treatment of Hydatid Cysts in Children

Human echinococcosis is endemic in Turkey and many other areas of the world. Fifteen years of surgical assessment related to involved structures, operative procedures, complications, and the recurrence rate is analyzed in pediatric patients with pulmonary and abdominal hydatid cysts. Between 1986 and 2001, the records of 42 pediatric patients (15 girls, 27 boys; ages 2–15 years) with pulmonary and abdominal hydatid cysts operated on in our clinic were analyzed retrospectively. The features of the disease, involved structures, operative procedures, complications, and recurrences were noted. A total of 26 patients presented with solitary cysts in the lung (9) and liver (17). Another 11 had multiple cysts in both lung and liver, and 5 had disseminated abdominal disease. Conservative surgical procedures were used for all lung and liver cysts: cystotomy (7) or cystotomy plus capitonnage (13) for lung cysts; partial pericystectomy with capitonnage (25), omentoplasty (28), tube drainage in the presence of bile leakage (5), or a combination of these procedures for liver cysts. Cyst excision was used for omental and peritoneal localizations when feasible. Radical procedures were never used (wedge or major liver and lung resections). Operative mortality was zero, and the morbidity rate was 14%. Three patients with disseminated disease (7%) showed recurrence. We suggest that no partial organ resections are necessary for hydatid disease, and highly successful results can be achieved using conservative surgical approaches, such as cystotomy plus capitonnage for lung cysts and partial pericystectomy with capitonnage, omentoplasty, or both for liver cysts.

Surgical treatment of cervicofacial cystic hygromas in children.

Aim: The aim of this study was to evaluate the results of surgical treatment of cervicofacial cystic hygromas in children. Patients and Methods: Medical records of 17 patients who were operated for cervicofacial cystic hygroma between 1985 and 2004 were evaluated in terms of age, gender, symptoms, diagnostic workups, outcomes and complications. Results: There was a slight male predominance – 10 (59%) boys and 7 (41%) girls. Nine (53%) out of 17 lesions were located on the left side of the neck, 7 (41%) lesions were located on the right side of the neck and 1 lesion (6%) was located in the middle of the neck. Eleven (65%) lesions were located in the infrahyoid region, 6 (35%) lesions in the suprahyoid region. Following surgical excision of the lesion, we encountered 4 postoperative complications: 1 recurrence (6%), 2 facial paralyses (12%) and 1 collection of fluid (6%) at the resection site. The patient who had a recurring lesion needed to be reoperated, other complications were treated conservatively. Conclusions: Cervicofacial cystic hygromas are easy to diagnose. There is no need for expensive and time-consuming imaging studies. Surgery seems the treatment of choice. However, nonsurgical treatment options may be considered for the lesions located over the parotid region in order to avoid complications of surgery.

Conservative treatment for small intestinal intussusception associated with Henoch-Schönlein's purpura

Abstract.Purpose: Emergency laparotomy is generally considered the appropriate course of action for small bowel intussusception associated with Henoch-Schönleins purpura (HSP). In this paper, we define a conservative approach after witnessing spontaneous reduction of ileoileal invagination at laparotomy in a patient with HSP who had been on steroid therapy for renal involvement. Methods: HSP was diagnosed by the appearance of a purpuric rash without thrombocytopenia. Intussusception was diagnosed by ultrasonography (USG) and plain abdominographs, which showed signs of obstruction, and clinical examination. Barium enema was used to treat ileocolic intussusceptions, and conservative therapy, consisting of nasogastric drainage, steroids, and intravenous fluid administration, was used to treat ileoileal intussusceptions. Emergency laparotomy was performed for the patients unresponsive to therapy within 24 h, those with peritonitis, and those with ileocolic invagination not able to be reduced by barium enema. Results: Six children with an ileoileal intussusception and one with an ileocecal intussusception were studied. The average age was 6 years old. Apart from the initial patient in whom spontaneous reduction was seen at laparotomy, three others required emergency laparotomy; for ileocolic intussusception unable to be reduced by barium enema in one, for ileoileal invagination with peritonitis on admission in one, and for ileoileal intussusception unresponsive to conservative therapy in one. The other three patients were successfully treated by conservative therapy. Conclusion: Conservative therapy is feasible for HSP patients with small bowel intussusception as long as the time of onset is known, an ultrasonographic and X-ray diagnosis is confirmed, emergency operating facilities are available, and an experienced pediatric surgical team follows up the patients.

A striking and frequent cause of premature thelarche in children: Foeniculum vulgare

Isolated premature thelarche is a common disorder characterized by breast development, usually younger than 2 years, with no other signs of puberty. Although it is usually associated with adrenal or ovarian disorders, hypothyroidism, and use of exogenous hormones or drugs, it may also be associated with long-term use of herbal medicine. Thus, long-term use of preparations such as Foeniculum vulgare, which is used to eliminate gas and regulate intestinal function in children, may cause premature thelarche, and thus, the use of such preparations should be limited.

Mitomycin C decreases the rate of stricture formation in caustic esophageal burns in rats

BACKGROUND Although the incidence of caustic ingestion is declining, the management of caustic esophageal strictures remains a challenge. Although many agents have been tried experimentally to treat strictures, few have gained clinical application. The aim of this study was to investigate the influence of mitomycin C (MMC), which inhibits fibroblastic proliferation in treating delayed caustic esophageal strictures. METHODS Forty-two rats were allocated into 3 groups. Caustic esophageal burns were created as described by Gehanno. Group A was instilled only with saline. Group B was injured with 10% NaOH and left untreated. Group C was injured and received topical MMC at 0.04% concentration in the fourth week. At 56 days, stenosis index (SI), collagen deposition, and hydroxyproline content (HP) were determined in distal esophageal segments. Statistical analyses were performed. RESULTS The mean SI in group B was significantly higher than others (SI: 1.15 +/- 0.37 d/lum, P < .05). Collagen accumulation was highest in group B, followed by groups C and A, respectively. Collagen deposition in group C was statistically lower than group B (P < .018). The mean HP in group B was statistically higher than others (5.07 +/- 1.30 microg/mg tissue, P < .05), and similar between groups A and C (1.20 +/- 0.20, 1.91+/- 0.79, respectively, P = .73). CONCLUSION In the current study, MMC treatment ameliorated caustic esophageal stricture as reflected in the significantly lower SI. We conclude that MMC application is effective in the treatment of caustic esophageal strictures.

Sequential cytokine levels in the diagnosis of appendicitis

Objective. To determine the diagnostic value of sequential white blood cell count (WBC), tumor necrosis factor‐alpha (TNF‐α) and interleukin‐6 (IL‐6) in patients with abdominal pain. Material and methods. Tests were determined at hospital admission and 6 h later in 105 children. Patients who were non‐operatively followed and had a normal histopathology were classified as the non‐appendicitis (NA) group. Patients with symptoms consistent with appendicitis were classified as the appendicitis group (A). Data were analyzed as positive/negative predictive value, sensitivity, specificity and accuracy rate (AR). The global power of the variables in discriminating the patients between the two groups and advanced/simple appendicitis was assessed from the area under the receiver operating characteristic (ROC). Results. Initial measurements showed WBC to be a valuable diagnostic tool in acute appendicitis (AR = 74 %), whereas IL‐6 and TNF‐α were found not to be valuable. The second measurements revealed higher values, and IL‐6 reached its highest AR (89 %). When initial values were evaluated in combination, the highest AR of 73 % was observed with TNF‐α + WBC. The highest AR (90 %) was seen with IL‐6 + TNF‐α in the second measurements. ROC analysis showed WBC to be the most valuable parameter of the three. The area under the curve (AUC) was 0.750 for the initial measurement and 0.779 for the repeat measurement of WBC (p = 0.001). The most useful diagnostic parameter in discriminating between the simple and the advanced cases was IL‐6 as assessed with the ROC curve (p<0.01). Conclusions. WBC elevation in patients with suspected acute appendicitis is an important parameter supporting the diagnosis at initial admission, whereas IL‐6 is a more valuable tool in diagnosing advanced appendicitis.

An In Vitro and In Vivo Evaluation of Tensile Strength and Durability of Seven Suture Materials in Various pH and Different Conditions: An Experimental Study in Rats

Development in material engineering provide many kinds of suture materials to medical fields. The choice of utilization depends on the surgeons decision, the durability, absorbtion times, tensile strength of the suture, and operation site in means of organ and tissue. In this study we aimed to investigate 7 different suture materials in vivo and in vitro conditions to evaluate the properties and durability. Basal tensile strength (TS) values of all sutures were measured and 168 Wistar albino rats were utilised in vivo groups. The sutures were placed in the bladder, stomach, intestine and bile duct (after obstructive jaundice). Urine and bile of rat, pH 1 and pH 10 were used as in vitro conditions. Seven different suture materials (Maxon, Vicryl, Plain Catgut, Surgical Silk, Polypropylene, Caprosyn and Biosyn) were investigated in 9 different in vitro and in vivo conditions. All sutures were chosen to be in size 5/0. In the following 5th day the sutures were tested related to durability and stability. Results were compared stastically using the Mann-Whitney U test and p < 0.05 was considered as stastically significant. Among all the suture materials only polypropylene proved to preserve its stability in vivo and in vitro surveys. Cat-gut and caprosyn lost its TS in all medias. Silk and biosyn lost its TS in all conditions except the stomach and intestines. Maxon also lost its TS in all condition except urine. Utilisation of caprosyn and biosyn in urinary procedures reduces stone formation and infections. The suture of choice in biliary tract should be vicryl, maxon or biosyn since polypropylene preserves its stability that could result in stone formation. In intestinal operations polypropylene, vicryl, and silk could be preferred.

Surgical Breast Lesions in Adolescent Patients and a Review of the Literature

Abstract Background/purpose: Breast disease in adolescence is uncommon, with most presenting lesions being benign. Breast lesions in adolescent patients are discussed in this article with a review of world literature. Patients and methods: The clinical records of 30 patients operated upon for breast lesions in our hospital during 18 years were reviewed. Results: There were 25 female and five male patients, ranging in age from 16 years. Twenty-five female patients were operated on for breast mass and/or discharge, and five male adolescents were operated on for gynaecomastia. The most frequent (n = 27) complaint was palpation of mass in the breast. The most common histologies were fibro-adenoma (n = 14) and gynaecomastia (n = 5). The average duration of pre-operative symptoms was 2.9 months for fibro-adeno-ma, 1. 6 years for gynaecomastia (extremes 2 days to 1 year). Nipple discharge was observed in three patients. Average diameters of palpable masses were 2.9 cm for fibro-adenomas and 5 cm for gynaecomastia. Lesions were excised surgically in all patients. Masses diagnosed as fibro-adenomas in the pre-operative period were reported upon pathological examination to be precancerous lesions such as cystosarcoma phylloiedes, juvenile fibro-adenoma, solitary intra-ductal papilloma, tubular adenoma and juvenile papilloma. One postoperative wound infection and one recurrence of fibro-adenoma was seen. Conclusion: The most frequently encountered breast masses were fibro-adenomas. These lesions are mostly benign in nature and can be treated conservatively but the possibility of precancerous lesion should be considered during follow-up.

Colonic motility and functional assessment of the patients with anorectal malformations according to Krickenbeck consensus

BACKGROUND/PURPOSE In this study, the patients operated on for anorectal malformations (ARM) were evaluated in terms of segmental (SCTT) and total colonic transit times (TCTT) and clinical status according to Krickenbeck consensus before and after treatments. METHODS Forty-one patients with ARM (28 males/13 females) older than 3 years (median age, 7.7 years; range, 3-25) who had no therapy before were assessed for voluntary bowel movements (VBM), soiling (from 1 to 3), and constipation (from 1 to 3), retrospectively. Distribution of the patients were rectourethral fistula (17), perineal fistula (PF; 8), vestibular fistula (VF; 8), cloaca (3), rectovesical fistula (1), rectovaginal fistula (1), pouch colon with colovestibular fistula (1), no fistula (1), and unknown (1). The patients ingested daily 20 radiopaque markers for 3 days, followed by a single abdominal x-ray on days 4 and 7 if needed. The results were compared with the reference values in the literature. RESULTS Mean follow-up period was 36 months (range, 1-108.5 months). All patients but 1 had soiling in different degrees. Twenty-one patients who had VBM were divided into group 1, with constipation (n = 9), and group 2, without constipation (n = 12). The other 19 patients who had no VBM were divided into group 3, with constipation (n = 14), and group 4, without constipation (n = 5). The longest TCTT and rectosigmoid SCTT were found in group 3 (69.5 and 35.2 hours, respectively). Group 1 had long SCTT in rectosigmoid but normal TCTT (27.8 and 47.4 hours, respectively). Groups 2 and 4 had normal SCTT and TCTT, and there was no significant difference between them. After the appropriate treatment, of the patients, 45% (18/40) had no soiling, and the soiling score decreased to grade 1 in 27.5% (11/40) and to grade 2 in 10% (4/40). Four had unchanged soiling score, and 3 were excluded from the study because of follow-up problems. Half of the patients in group 3 (4 VF, 2 rectourethral fistula, PF) gained VBM without soiling after laxative treatment. Only four of 23 patients had decreased constipation score (2 cloaca, PF, VF). CONCLUSIONS In this study, ARM patients complaining of constipation with or without VBM had prolonged SCTT in the rectosigmoid region. Percentage of the improvement in soiling scores was more conspicuous than that of constipation scores. The dismal figure observed at the first examination in the assessment of VBM was not associated with an unfavorable improvement with laxative treatment. So, it is suggested that assessment of VBM initially may be deceptive for clinical status.