Senocak Me

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.

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.

Rare congenital abnormalities of the anterior urethra

Congenital abnormalities of the anterior urethra other than hypospadias (valve, diverticulum, and megalourethra) are rare conditions and can be difficult to diagnose. Based on five recent cases of these urethral abnormalities, we review the embryology and the English literature, and have found reports of about 100 cases of valve and diverticulum and 50 cases of megalourethra. For all these abnormalities, the clinical presentation depends on age and the diagnosis depends essentially on voiding cystourethrography, which must show the entire urethra, and careful urethroscopic examination.

Urinary obstruction caused by factitious urethral stones: an amazing manifestation of Munchausen syndrome by proxy.

The diagnosis of Munchausen syndrome by proxy is frequently difficult to document and often delayed. A unique presentation of a case of Munchausen syndrome by proxy involving insertion of factitious stones in the lower urinary tract is reported.

Ureteropelvic junction obstruction causes histologic alterations in contralateral kidney.

BACKGROUND/PURPOSE Ureteropelvic junction (UPJ) obstruction causes histologic alterations both in ipsilateral and contralateral kidney. Because these alterations directly affect the fate of renal damage, definition of these alterations is of utmost importance from the clinical point of view. Thus, an experimental study is designed to determine the alterations of renal histology in response to partial and complete UPJ obstruction. METHODS Fifteen adult female New Zealand rabbits were assigned randomly into 3 groups (each containing 5 rabbits) according to the degree of unilateral UPJ obstruction as group I, sham operation was performed and served as the control group; group II, partial UPJ obstruction was made; group III, complete UPJ obstruction was made. The animals in group I and II were killed after 3 weeks, and animals in group III were killed after 2 weeks. Tissue samples were prepared and processed according to routine light microscopic tissue processing. RESULTS UPJ obstruction led to glomerulosclerosis, dilatation of proximal and distal tubules of loops of Henle, and dilatation of collecting tubes consistent with necrotic and apoptotic changes in ipsilateral kidneys. Severity of these degenerative changes depended on degree of obstruction. UPJ obstruction also led to histologic alterations on the contralateral kidneys such as glomerular edema, congested blood vessels, dilated tubuli, and necrotic and apoptotic changes in epithelia, which were more prominent in group III than group II. CONCLUSIONS It is well known that compensating changes including increased blood flow and parenchymal hypertrophy occurs in contralateral kidney as a response to unilateral UPJ obstruction. However histologic findings of this study confirmed progression of parenchymal damage and presence of apoptosis in contralateral kidney for the first time.

Endoscopic Treatment of Vesicoureteral Reflux in Children: Our Experience and Analysis of Factors Affecting Success Rate

Aim: To clarify the factors affecting the success rate of endoscopic subureteral injection (ESI) treatment of vesicoureteral reflux (VUR). Method: All patients who had ESI treatment for VUR at our unit between 1999 and 2002 were retrospectively reviewed with regard to age, gender, causes of VUR, reflux grade, type of injected materials, number of injections, results of cystourethrograms (VCUG), and outcome. The injected implants were gluteraldehyde cross-linked bovine collagen (GclBC), dextranomers in sodium hyaluronan (DiSH) and calcium hydroxylapatite (CH). A successful result was defined as absence of VUR confirmed by VCUG performed 3 months after the ESI procedure. Basic descriptive statistics were performed along with the χ2 test (p < 0.05 was significant). Results: 50 children (81 ureters) consisting of 27 girls (43 ureters) and 23 boys (38 ureters) with a mean age of 7.4 ± 4.6 years constituted the study group. Grade III VUR was the most prominent grade (42%, 34 ureters) noted in all age groups. There was no significant difference between boys and girls with regard to the number of each grade of VUR. The success rate of first ESI procedure was 55.6% and was similar in each grade of VUR varying from 50 to 66%. Repeated injections have resulted in an overall success rate of 84%. No significant difference was noted between the age groups with regard to the success rate of ESI. Repeated ESI procedures were found to be unsuccessful in grade V VUR when compared to other grades (p < 0.05).There was a significant difference between primary reflux (76.5%, 62 ureters) and exstrophic (21%, 17 ureters) patients with regard to the grade of VUR and success rate of ESI. Exstrophic patients presented with a higher incidence of grade V VUR (41%) and with a lower success rate of ESI (64.7%). DiSH was the most commonly used agent (47 ureters) followed by CH (22 ureters) and GclBC (12 ureters). The success rates of the ESI procedure by each material were 91.5, 81.8, and 58.3%, respectively. No significant difference was noted between DiSH and CH. Low success rates by GclBCwere attributed to less usage of the material. 82% of the ESI procedures were done by surgeon A (49 ureters) and B (18 ureters) with a success rate of 96 and 72%, respectively. No significant difference was noted between A and B with regard to the success rate and type of injected material and the success rate in each grade of VUR (p > 0.05). No untoward effects were noted in short- and long-term follow-up (mean 4 ± 1.2 years) of any patient. Conclusion: The ESI procedure provides a high success rate for the treatment of VUR which decreases in grade V VUR and presence of exstrophia vesica. Single injection of various materials has been found to be successful in most of the patients with grade II VUR, whereas grade IV and III patients have required repeated injections which have resulted in 100 and 94% success rates, respectively. Grade I VUR can be managed by close follow-up and appropriate antibiotic therapy without any surgical and/or endoscopic intervention. Patients presenting with grade V VUR should undergo open surgery if the first trial of ESI procedure results in failure as repeated injections have proved to be unsuccessful in this grade. The success rate of the ESI procedure does not seem to be affected by the type of injected material and different surgeons performing the procedure after achieving the learning curve.

Multilocular Endocervical Polyp in a Five-Year-Old Girl

In childhood, benign tumon of the cervix and corpus uteri are very rare. Clinical and pathological findings of a benign multilocular cystic polyp of the cervix uteri in a 5-year-old girl are presented and the origin of the polyp is discussed.

Inguinal hernia as a rare manifestation of meconium peritonitis: report of a case.

Abstract.The usual manifestations of meconium peritonitis confined to the inguinoscrotal region are soft hydroceles, hard nodules in the scrotum, and, occasionally, calcified nodules in the wall of a hernia sac, with or without calcification on abdominal X-ray. Inguinal hernia is an extremely rare manifestation of healed meconium peritonitis. An unusual presentation of meconium peritonitis encountered during hernia repair is described herein to alert the pediatric surgeon of this possibility to avoid unnecessary abdominal exploration.

Is BCG vaccine innocent

Four patients admitted to the Hacettepe University Department of Pediatric Surgery between 1987 and 1995, two with Bacille Calmette-Guérin (BCG) lymphadenitis and two with multisystem postvaccination tuberculosis (MPT), are presented. The hospital records and records of the Ministery of Health Tuberculosis Control Department were evaluated to determine the complications of BCG vaccine. The most common complication was lymphadenitis with or without suppuration (0.3‰–3‰). Surgical intervention was required in two BCG lymphadenitis cases and two cases of MPT. Involved lymph nodes were excised in two lymphadenitis cases. Colostomy and percutaneous nephrostomy was performed in the first case of MPT in addition to triple antituberculous drug therapy. Although BCG lymphadenitis is self limited, chronically discharging nodes and tumor-like lymphadenopathy masses need to be excised. On the other hand, MPT has a silent nature with resistance to antituberculous drug therapy. Surgical intervention may be required, directed to the involved systems.