Sule Yalcin

The evaluation of deglutition with videofluoroscopy after repair of esophageal atresia and/or tracheoesophageal fistula.

AIM A retrospective study was performed to evaluate the functional disorders of deglutition with videofluoroscopy (VFS), in children operated for esophageal atresia (EA) and/or tracheoesophageal fistula (TEF). METHODS Patients with the repair of EA-TEF were evaluated in respect to the type of malformation, operative procedure, postoperative complications, deglutitive and respiratory symptoms, and gastroesophageal reflux disease (GERD). The dysphagia score, VFS findings of oral, pharyngeal and esophageal phases, and penetration-aspiration scale (PAS) score were recorded in the evaluation of the deglutitive functions. RESULTS Thirty-two cases with a median age of 48months (2-120months), and male to female ratio of 14:18 were included in the study. Most of the cases had Gross type C anomaly (n=26, 81.3%), and the others were type A (n=3), D (n=2) and E (n=1). The incidence of associated anomalies was 71.8%. The patients underwent primary (n=26, 81.3%) or delayed (n=6, 18.7%) anastomosis. Postoperative complications including anastomotic stricture (n=12), leak (n=2) and recurrent fistula (n=2) were managed by dilatation, conservative approach and repair of the fistula, respectively. Recurrent pneumonia (n=13), cough with liquid intake (n=10) and food impaction (n=7) were recorded in the history. Management of GERD included medical (n=11) and surgical (n=7) treatment. The median dysphagia score was 3.5 (min: 0-max: 27). The oral phase of VFS was normal in most of the cases (n=29, 90.6%). Only three had mild or moderate impairment, and none had severe. The pharyngeal phase showed no impairment in 23 of the cases (71.8%), and severe impairment was observed only in 3 of all, for the parameters of hyolaryngeal elevation and airway closure. Opposite to the first two phases of the deglutition, the esophageal phase was normal in only 2 of the cases (6.3%). Among the other 30 cases with impairment, only two had mild, and the rest had moderate to severe problems. Esophageal backflow, motility and residue were the most severely impaired parameters of this phase. The PAS evaluation revealed no penetration and aspiration in 26 of the cases (81.3%), while 1 had penetration and five had aspiration. CONCLUSION The patients with repaired EA-TEF may reveal deglutitive and respiratory symptoms in follow-up, necessitating certain investigations. The deglutition is functionally evaluated with VFS. While the disorders of oral and pharyngeal phases are less frequent and prominent, the esophageal phase reveals disorders with higher incidence and severity.

Childhood pneumonectomies: two decades' experience of a referral center.

PURPOSE We aimed to review the pre- and postoperative characteristics of children undergoing pneumonectomy, with special emphasis on the management of surgical complications, in comparison with the current literature findings. PATIENTS AND METHODS A total of 20 patients who underwent pneumonectomy for various etiologies from 1988 to 2011 were investigated retrospectively with respect to the presenting findings, preoperative evaluation, surgical information, postoperative follow-up, and outcome. RESULTS A total of 11 girls and 9 boys with a median age of 8 years (0.5-17 years) presented with symptoms of productive cough (n = 9), recurrent chest infections (n = 9), nonproductive cough (n = 1), respiratory distress (n = 1) with a median duration of 2 years (0.16 to 12 years). Medical histories revealed chest infection (n = 11), foreign body aspiration (n = 3), aspiration pneumonia (n = 2), tuberculosis (n = 2), caustic aspiration (n = 1), and congenital lung pathology (n = 1). Clinical evaluation provided diagnoses of bronchiectasis (n = 16), total atelectasis (n = 2), bronchopleural fistula (BPF) (n = 1), and cystic lung disease (n = 1). Pneumonectomy was performed on the right in 6 and left in 14 of the cases. Pericardial (n = 1) and esophageal (n = 1) laceration were the perioperative (11.1%), massive hemorrhage (n = 1) and chylothorax (n = 1) the postoperative (11.1%), and scoliosis (n = 1) and BPF (n = 1) the long-term (11.1%) complications. Pathological evaluation revealed bronchiectasis (n = 14), consisting of three cases with additional sign of foreign body, chronic inflammation (n = 4), atelectasis with fibrous pleural thickening (n = 1), and congenital pulmonary lymphangiectasia (n = 1). A total of 14 cases were free of symptoms and 5 had significant improvement in general condition during the follow-up, for a median duration of 2 years (1 to 10). The one with the diagnosis of Becker muscular dystrophy died 2 years after pneumonectomy because of respiratory failure. CONCLUSIONS Correct selection of indications, careful preoperative preparation with eradication of infection, meticulous performance of surgical and anesthetic techniques, early detection and management of complications, and long-term follow-up including pulmonary rehabilitation are essential parameters to reduce morbidity and mortality rates in childhood pneumonectomy. Better compensatory lung growth and improvement in development after the operation will facilitate better health and improved life quality in children.

Ureterovesical junction obstruction causes increment in smooth muscle contractility, and cholinergic and adrenergic activity in distal ureter of rabbits.

BACKGROUND/PURPOSE The controversy in management of primary obstructed megaureter necessitates further elucidation of the underlying pathophysiology. We evaluated smooth muscle contractility, and cholinergic, adrenergic and serotonergic activity of rabbit distal ureters after ureterovesical junction (UVJ) obstruction. METHODS Sham (SH) operation, partial obstruction (PO) and complete obstruction (CO) of the right UVJ were performed in rabbits. Three weeks later, distal ureters were isolated; spontaneous contractions (SC), contractile responses to electrical field stimulation (EFS), high KCl, carbachol, phenylephrine and serotonin were recorded. RESULTS SC amplitudes increased in CO compared to PO and SH (p<0.001). SC frequency was higher in CO (p<0.05). EFS-induced contraction amplitudes were greater in CO than other groups (p<0.05). High KCl-induced contractions were greater in CO (p<0.001) and PO (p<0.01). Carbachol-induced contractility was enhanced in CO and PO (p<0.05). Contractile response to phenylephrine was greater in CO than other groups (p<0.05). Serotonin induced contractile responses in CO and PO, greater in CO (p<0.05). UVJ obstruction also increased spontaneous contractility in contralateral PO and CO ureters. CONCLUSIONS UVJ obstruction increased spontaneous and neurotransmitter-induced contractions in an obstruction grade-dependent manner. Obstruction also altered contractility of the contralateral ureters. Our findings may serve to provide further understanding of the pathophysiology of megaureter.

Presenting clinical features and outcome in intussusception

ObjectiveTo evaluate if a correlation exists between the clinical and radiologic characteristics at presentation; and the success of conservative management, morbidity and outcome of patients with intussusception.MethodsAll patients (total 179) treated for intussusception in our unit between 1993 and 2003, were retrospectively reviewed to find out the effects of physical examination (general appearence, consciousness, body temperature, abdominal distention and tenderness, blood on rectal examination), laborat (leukocyte count) and radiologic (air-fluid level on X-ray, free abdominal fluid on ultrasonography) findings on selection of first step therapeutic modality, conservative management (reduction with barium or air) success rate and surgical complication (serosal defect, intestinal perforation) rate. Additionally, the patients were subdivided into three subgroups as group A (patients for whom surgical management was performed primarily), group B (the ones who were operated after failure of reduction attempt with barium or air), group C (patients who had successful conservative reduction). These groups were compared within each other with regard to duration of nasogastric suction, antibiotic therapy; onset of oral feeding and duration of hospitalization. The chi-square, Kruskal-Wallis and ANOVA tests were used for the statistical analysis and p value less than 0.05 was considered to be significant.ResultsIncidence of selecting conservative treatment primarily was lower in patients with toxic appearence (p=0.02) and with free fluid on ultrasonography (p=0.007). Success rate of conservative treatment was lower in patients with moderate general appearence (p=0.000), lethargy (p=0.011), blood on rectal examination (p=0.004), air-fluid level on X-ray (p=0.039), free fluid on ultrasonography (p=0.001). Surgical complication rate was higher in patients with moderate general appearence (p=0.000), lethargy (p=0.007), air-fluid level on radiograph (p=0.009). In group A; the duration of N/G suction, antibiotic therapy and hospitalization was longer; the onset of oral feeding was later than the other two groups (p=0.000). In group B; the duration of N/G suction, antibiotic therapy and hospitalization was longer; the onset of oral feeding was later than group C (p=0.000).ConclusionToxic appearence, lethargy and air-fluid level on radiograph not only decrease the success rate of conservative management, but increase the surgical complication rate as well. Thus, these parameters deserve more importance in the management scheme. Reduction with conservative management is the most important factor which decreases the morbidity. Morbidity is lower in cases who are operated after failure of conservative management than the ones for whom surgery is performed primarily. Thus, conservative management should be tried for all patients unless there is a clear cut contraindication such as peritonitis and/or pneumoperitoneum.

The effects of acute tension increase on rat esophageal muscle contractions: An in vitro study

In long-gap esophageal atresia surgeries, anastomoses can be tensioned by several traction methods in order to establish esophageal continuity. It is unclear whether the etiology of esophageal dysmotility after traction is related with esophageal atresia itself or tensioned esophagus. Therefore, we evaluated the effects of acute in vitro esophageal tension application on esophageal muscle contractility in rats. 26 Wistar rats weighing 250-300 g were included to the study. After diethyl ether anesthesia, proximal segment (PS) and distal segment (DS) of esophagus were removed and suspended in an isolated organ bath kept at 37°C, Krebs-Henseleit solution. Rats were enrolled into four groups including control group (CG, n=14) without tension, 5 g (5G, n=4), 15 g (15G, n=4) and 25 g (25G, n=4) tension groups. In all groups, contractile responses to electrical field stimulation (EFS), carbachol and KCl, and relaxation responses to serotonin were obtained. In CG, higher contractile responses were obtained in PS than DS after EFS. Both PS and DS showed higher contractile amplitudes in 5G with respect to that of CG, 15G and 25G (p<0.05). In 5G, contractile responses to carbachol were significantly increased in both PS and DS with respect to CG (p<0.05). However, contractile amplitudes in response to carbachol were decreased in PS when tension was increased to 15 g and 25 g. In DS, contractile responses in 15G and 25G were lower than 5G, and still higher than CG. Serotonin relaxation responses in PS were decreased when compared to CG at tension levels of 5 g, 15 g and 25 g (p<0.05). In DS, responses to serotonin were also decreased in tension groups. PS had higher contraction amplitudes than DS when contractile responses were obtained by high K(+) (p<0.05). Tension groups of both PS and DS showed increased contractions to high K(+) compared to CG (p<0.05). Increased esophageal tension led to increase in cholinergic responses of smooth muscles as well as in EFS-induced skeletal muscle responses. On the other hand, relaxation responses induced by serotonin decreased. These data indicate that esophageal tension increase impairs esophageal motility in both segments.

Clinical Presentation and Management of Gastroesophageal Reflux Disease in a Referral Center in Turkey

PURPOSE The aim of this study was to analyze the characteristics of the pathway from the onset of clinical findings related to gastroesophageal reflux disease (GERD) until the surgical therapy to achieve a better organization of the multiple disciplines and create the best management scheme in a referral center in Turkey. PATIENTS AND METHODS All patients who underwent anti-reflux surgery for GERD in our unit between 2000 - 2006 were retrospectively reviewed. Information on their past medical follow-up, the clinical findings, diagnostic evaluation and the therapeutic approach was recorded. RESULTS There were 24 girls and 40 boys with a median age of 36 months (3 - 192 months). Of the 64 cases, 36 (56.3 %) had a history of past medical follow-up. Of these 36 patients, 20 had received medical and/or surgical therapy for GERD without any standardization. The remaining 16 were treated supportively for neurological, respiratory and metabolic problems without having had a diagnosis of GERD. The median duration of symptoms in 28 patients without a past medical history was shorter than that in the remaining 36 patients (p = 0.03). Of the 64 patients at presentation, 35 had neurological, 4 had metabolic, and 3 had a respiratory pathology; the other 4 had a history of esophageal atresia and tracheoesophageal fistula operation; 5 had been operated in another center for GERD and only 13 cases had isolated GERD. The most commonly used diagnostic methods were contrast study (n = 52) and pH monitoring (n = 36). Forty-one of the 64 had anti-reflux surgery primarily after presentation, in addition to selection of medical therapies and/or other surgical interventions as a first step in the remaining 23. Reevaluation of those 23 patients after a median period of 7 months (1 - 36) finally led to anti-reflux surgery (ARS). Patients presenting with a stricture due to GERD (n = 13) underwent ARS, either as a primary procedure (n = 3) or after a course of dilatations (median period of time: 8.5 months) (n = 10). CONCLUSIONS Extended nonresponsive medical therapy is as harmful as needless surgical therapy performed prior to appropriate medical management. Our experience emphasizes that guidelines on the use of a multidisciplinary approach is the first step for successful GERD treatment. ARS in early infancy should only be justified in the presence of severe neurological and/or respiratory pathologies. If there is any doubt about the diagnosis of GERD with preliminary methods, endoscopic and pathological confirmation of the disease is mandatory for a correct management.

Effect of Swallowing Rehabilitation Protocol on Swallowing Function in Patients with Esophageal Atresia and/or Tracheoesophageal Fistula

Aim The aim of this study was to evaluate the results of Swallowing Rehabilitation Protocol (SRP) on swallowing function (SF) of esophageal atresia and tracheoesophageal fistula (EA‐TEF) patients with pharyngeal swallowing disorder. Materials and Methods In this study, 24 children with EA‐TEF who had deglutitive and respiratory problems were grouped into either study (n = 12) or control group (n = 12) by basic randomization. Study group received the SRP including neuromuscular electrical stimulation, thermal tactile stimulation, and hyolaryngeal mobilization. The control group received nonnutritive stimulations. SF was evaluated with 3 mL liquid and pudding barium by videofluoroscopic swallowing study (VFSS) before and after 20 sessions of interventions. Results No statistical differences were found between groups in terms of descriptive characteristics including age, sex, weight, height, type of atresia, repair type, repair time, and start time of oral intake (p > 0.05). There were no statistical differences between groups in term of swallowing parameters (p > 0.05), except reflux (p = 0.004) according to VFSS findings. After 20 sessions of interventions, the study group showed improvement in penetration‐aspiration scale scores, oral phase dysfunction, delay in swallowing reflex, and residue in valleculae and pyriform sinuses after pudding swallow. The control group showed improvement only in oral phase dysfunction. Conclusion SRP can be recommended to improve SF in patients with EA/TEF who have pharyngeal swallowing disorders.

P-37: The Evaluation of Deglutition and Dysphagia After Repair of Esophageal Atresia and Tracheoesophageal Fistula

Results: Of 52 patients evaluated (mean follow-up 6.5 y; range 1.5–10), 6 (12%) had an endoscopy suspected BE with GM confi rmed at histology. No patients developed intestinal metaplasia. There was no difference in atresia type nor associated malformations between patients with GM with those without GM (NM). The anastomotic leak rate was similar (28% vs 33%, NM vs GM). 41% of NM patients developed anastomotic strictures requiring a mean (range) of 3.3 (1–8) dilatations, vs 66% of GM patients (7 (3–17) dilatations). No patients with GM tolerated discontinuation of PPI therapy versus 53% of NM patients (p < 0.01, χ 2 test). Higher rates of esophagitis were observed on endoscopy or histology in patients with GM (83% vs 37%; p < 0.01). Conclusion: 12% of EA-TEF patients < 10 years followed in a single center EA-TEF clinic developed esophageal GM. These patients had more severe gastroesophageal refl ux. This underscores the need of a close endoscopic follow-up of these children.

Malignant sacrococcygeal germ cell tumors in children: a 30-year experience from a single institution.

BACKGROUND Our aim was to analyze treatment results and survival characteristics of our patients with malignant sacrococcygeal germ cell tumors. PROCEDURE Patient files of children with malignant sacrococcygeal germ cell tumors, treated at our institution between 1979 and 2009, were searched. Patient characteristics, histopathological subtypes, extension of disease, alpha-fetoprotein (AFP) level at the time of diagnosis and relapse, extent of surgical resection, chemotherapy protocols, details of radiotherapy and survival characteristics were recorded. RESULTS A total of 58 patients (M/F = 20/38) with malignant sacrococcygeal germ cell tumor was included in analysis. With a mean follow-up of 156 months (range, 26 days to 288.8 months) overall and event-free survival rates of the 58 patients were 50.9% and 43.8%, respectively. AFP status of the patients (37% in patients with <10,000 ng/ml, 68.9% in patients with ≥ 10,000 ng/ml), type of resection (total vs others), coccygeal resection, chemotherapy protocol (PEB vs others) and number of chemotherapy courses had an impact on event-free survival in univariate analysis. In multivariate analysis, AFP status had the greatest effect on prognosis. CONCLUSIONS Our treatment results are worse than those reported in the literature. Elevated AFP level at the time of diagnosis had a beneficial effect on prognosis, but year of diagnosis, tumor stage, presence of metastasis, tumor size and histopathological subtype had no impact on survival in patients with malignant sacrococcygeal germ cell tumors.