Yüksel Yeker

Systemic stress response during operations for acute abdominal pain performed via laparoscopy or laparotomy in children

We compared the endocrine and metabolic changes during acute emergency abdominal surgery performed using either laparoscopy or laparotomy in children. Twenty‐nine children aged 1.5–14 years were assigned to undergo laparoscopy (n = 15) or laparotomy (n = 14) with a standard anaesthesia technique. Arterial blood gases and blood prolactin, cortisol, interleukin‐6, glucose, insulin, lactic acid and epinephrine levels were determined 5 min after the induction of anaesthesia, 30 min into surgery and at the end of surgery. Intra‐operative heart rate and mean arterial pressure were stable in both groups. In the laparoscopy group, slight respiratory acidosis occurred during surgery (p < 0.01) but there were no changes in the laparotomy group. Insulin, cortisol, prolactin, epinephrine, lactate and blood glucose levels increased in both groups (p < 0.05) although there was no difference between the groups. The surgical stress and trauma imposed by laparoscopy seems similar to that caused by laparotomy in children undergoing emergency abdominal surgery.

The cardiorespiratory effects of laparoscopic procedures in infants

We assessed the cardiorespiratory effects of laparoscopic procedures in 27 infants aged between 36 and 365 days. Infants were monitored and anaesthetised in a standardised manner. Heart rate, mean arterial pressure, end‐tidal carbon dioxide and oxygen saturation were recorded, and blood gases were measured at 5 min after intubation, 15 and 30 min after carbon dioxide pneumoperitoneum, 5 min after desufflation and after extubation. The pH, Pao2, base excess, Sao2 and Spo2 decreased, and Pco2 increased by insufflation of carbon dioxide intraperitoneally, and improved following deflation. Changes in pH and Pao2 during the study were statistically significant (p < 0.0001). The increase in Paco2 30 min after pneumoperitoneum was statistically significant when compared with initial values. Transient arrhythmias were observed in 10 infants 1 min after pneumoperitoneum. There were no statistically significant alterations in heart rate and systolic blood pressure.

Single-injection lumbar epidural morphine for postoperative analgesia in children: A report of 175 cases

Background and Objectives. Since the first report of epidural opioid administration to pediatric patients, several studies have described the quality of analgesia, doses, pharmacokinetics, and side effects of this procedure. A pediatric series using an easy and cheap single‐injection technique of epidural morphine administration for postoperative analgesia is presented. Methods. Postoperative analgesia was achieved with a single lumbar epidural morphine injection (0.1 mg/kg in 0.2 mL/kg saline), which was given via a 22‐gauge intramuscular needle to 153 pediatric patients (aged 4 months‐17 years) following 175 lower abdominal or urologic operations. Injections were given by 43 anesthesiology residents under the supervision of pediatric anesthesiologists, after termination of surgery performed under general anesthesia. Results. The success rate of epidural puncture on the first attempt was 92%. Pain control was considered excellent in 76% of patients for 24 hours. The remaining patients had analgesia lasting 10.9 ± 5.5 hours after epidural morphine administration. No alterations in hemodynamic parameters were observed. Two patients (1.1%) developed respiratory depression during early postoperative care and one, with a history of apneic spells, had an episode of apnea 5 hours after morphine administration. The incidences of minor side effects were: nausea, 33.9%; vomiting, 42.9%; pruritis 9%; and urinary retention 12.5%. Conclusions. This technique is easy to perform, even for trainees in anesthesiology. With appropriate patient selection and avoidance of the concomitant use of narcotics and sedatives, epidural morphine provides prompt, effective, safe, and prolonged analgesia in children.

Effects of systemic and epidural morphine on antidiuretic hormone levels in children.

Background: Although the use of opioids during general anaesthesia suppresses stress response to surgery and pain, the effects on antidiuretic hormone (ADH) are controversial. The aim of this study was to find the effects of morphine with either intravenous infusion or epidural route on ADH and other stress hormones.

Effectiveness of morphine via thoracic epidural vs intravenous infusion on postthoracotomy pain and stress response in children

Background : Thoracotomy causes severe pain in the postoperative period. The aim was to evaluate effectiveness of two pain treatment methods with morphine on postthoracotomy pain and stress response.

Arterial carbon dioxide markedly increases during diagnostic laparoscopy in portal hypertensive children.

Several factors are responsible for hypercarbia during laparoscopic procedures. This study was undertaken because we observed a sudden increase in Paco2 in children with portal hypertension (PHT), which was unusual in healthy children undergoing laparoscopic procedures. Fifty-seven children underwent laparoscopic procedures under general anesthesia and were mechanically ventilated. Arterial blood samples were obtained 5 min after intubation (T0), 15 min and 30 min after CO2 pneumoperitoneum (T15 and T30), 5 min after desufflation (Tend), and 10 min after extubation (Text) for blood gas analysis. The changes in Paco2, pH, and ETco2 were statistically significant during the study periods in both groups (P < 0.05). The percentage of Paco2 increase between T0 and T15 was 11.5% and 20.1%, respectively, in the control group and the PHT group (P < 0.05). This increase reached 36.8% at T30 in the PHT group, whereas the control group had a 17.2% increase (P < 0.05). ETco2 presented similar changes. The variability in base excess, bicarbonate, Pao2, arterial oxygen saturation, and Spo2 was not significant in either group (P > 0.05). The Paco2 increased remarkably in children with PHT undergoing laparoscopy, with no difference in intrahepatic or extrahepatic origin. Limiting the duration of CO2 pneumoperitoneum and intraabdominal pressure and adjusting ventilatory variables to accommodate hypercarbia are of the utmost importance for such cases.

Esophageal Variceal Bleeding Secondary to Portal Hypertension: Endoscopic Sclerotherapy as the First-Step Treatment

BACKGROUND Variceal bleeding from the esophagus is an important cause of mortality and morbidity in children with portal hypertension (PHT). PATIENTS AND METHODS A series of 69 PHT cases (41 intrahepatic, 28 extrahepatic) have been evaluated in our department since 1990. According to the Child-Pugh classification, 49 cases were in class A, 16 cases were in class B, and 4 cases were in class C at admission. In our protocol, endoscopic sclerotherapy is performed in all patients, and the diagnosis is achieved directly by diagnostic laparoscopy and fine-needle liver biopsy. The procedure is applied under general anesthesia, and 1% aethoxysclerol (polidocanol) is injected paravariceally and intravariceally with the use of a flexible endoscope. RESULTS The Sugiura procedure was performed in nine patients who presented with recurrent bleeding episodes despite the strict sclerotherapy protocol. Liver transplantation was performed in two patients who were in Child class C. The total mortality rate in this series was 7% (5/69). CONCLUSION Endoscopic sclerotherapy, as presented herein, decreases the need for additional surgical interventions in children with PHT.

Extrathoracic Liver Hamartoma

Mesenchymal hamartoma is a benign tumor of the liver that often presents because of a palpable abdominal mass or respiratory distress. An unusual protrusion of this tumor through the chest wall of a neonate with Poland’s syndrome is reported.

A case of wandering spleen causing urinary symptoms after correction of a posterolateral diaphragmatic hernia.

Abstract A 12-year-old girl who had had an operation for a posterolateral diaphragmatic hernia was admitted to the hospital because of enuresis. Physical examination and radiologic studies revealed the spleen behind the urinary bladder, left-sided hydronephrosis, and a high volume of residual urine. The hydronephrosis and residual urine resolved immediately following splenectomy.

Caroli's disease in children: Is it commonly misdiagnosed?

Aim: Carolis disease is a simple form of intrahepatic bile duct ectasia. It can be complicated with the involvement of liver parenchyma and portal hypertension. Herein, the difficult management of delayed presentation of Carolis disease is reported. Methods and results: We report on four different forms of clinical presentation of Carolis disease: an infant with fulminant liver failure, a teenager with persistent biliary fistula, a boy with hypersplenism in the face of portal hypertension and a girl with variceal bleeding.