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Annals of Pediatric Surgery:
doi: 10.1097/01.XPS.0000405384.39294.f1
Abstracts

Abstracts presented at Joint Congress of TAPS, EPSA, PEDURO, and PSNA May 16–19, 2011, Istanbul, Turkey

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General Pediatric Surgery Oral Presentations

OP1: Evaluation of alterations due to antisperm antibody in contrlateral testis and protective effect of p/e selectin blockage in experimental orchitis

Ö Cesura, MK Aslana, Ş Ayvab, MF Şenyücela, T Soyera, Ü Kisac and M Çakmaka

Departments of aPediatric Surgery, bPathology and cBiochemistry, Kirikkale University Faculty of Medicine

Aim: An experimental study was performed to evaluate the efficacy of antimicrobial theraphy and preventive effect of p/e-selectin blockage (a cause of blood testicle damage due to neutrophyl infiltration) in contrlateral testis in experimental orchitis.

Materials and methods: The 6-group covering each group of 6 rats was created. When the control group (CG), the testes removed, 1 ml saline was injected in the sham group (SG). Orchitis model (OM) was obtained by injecting 0.1 ml 106 cfu/ml E. coli (0 : 6 strain) and 1 ml saline in the right testis. In antimicrobial treatment group (AG), the ciprofloxacin (50 mg/kg, Im) were given 24 h after orchitis. In P/E selectin blockade group (PESG), P/E-selectin antibody (100 microrg-mixture, IM) were given. In the last treatment group (TG), antibiotics were given as well as P/E-selectin antibody. In the groups which received antibiotic treatment, serum samples for antisperm antibody (ASA), P-selectin and E-selectin for in were taken on the 0. and 14. day, when the treatment were proceed for 14 days. The right and left testes were removed at the end of 14. day, to evaluate Johansen score and testicular damage.

Results: In OG, AG, PESG ve TG, ASA levels were significantly increased when compared to SG at day 14 (P<0.05). In groups which did not received P/E-selectin antibody (OG and AG) serum p/e-selectin levels were significantly increased at 14th day (P<0.05). In TG, ASA levels were decreased with respect to AG (P<0.05), however PESG did not cause similar decrease (P>0.05). Histopathologic evaluation showed no difference between AG and OG in right testicle (P>0.05). In TG and PESG, lymphocyte numbers were decreased and Johansen scores were decreased when compared to OG (P<0.05). When right and left testicles were compared only AG and OG had increased Johansen scores in contrlateral testis (P<0.05).

Conclusion: P/E-selectin blockage decreases ASA levels when used with antimicrobial treatment. In groups without P/E-selectin blockage contrlateral testis show increased histopathologic injury when compared to testis with orchitis.

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OP2: Quantitative analysis of ultrasonographic textures with software in experimental testicular torsion

MK Aslana, İ Küçükaslanb, B Mülazimoğluc, T Soyera, MF Şenyücela, M Çakmaka, J Scholbachd and S Aslanc

aDepartment of Pediatric Surgery, Kirikkale University Faculty of Medicine, bDepartment of Obstetrics and Gynecology, Dicle University Faculty of Veterinary Medicine, cDepartment of Obstetrics and Gynecology, Ankara University Faculty of Veterinary Medicine and dDepartment of Mathematics and Informatics, Münster Univerisity Institute of Mathematics

Aim: Although, the diagnostic value of ultrasonography (US) is high in testicular torsion, it is vulnerable to several errors especially in the early period. Echotexture (ETX) analysis softwares provide to numerical expression of B mode images and quantitative evaluation in blood flow due to ischemic damage by power doppler US (PDUS) analysis. Our aim is to determine the diagnostic value and effective parameters of EXT analysis softwares on early period of torsion by B-mode and PDUS images.

Materials and methods: Eight rats were used in the study. After anesthesia the right testis was rotated 108 degrees counter clockwise position while the left testis was left in place to have control group. B-mode and PDUS images of both sides were obtained and recorded with portable US device immediately (0 h) and 1and 2 h after torsion. B-mode images analyzed in terms of gradient, homogenity and contrast with BS200pro software (BAB Digital Imaging System 2007, Ankara, Turkey). I-red (intensityand A-red (area) values were measured by Pixelflux (Version 1.0, Chameleon-Software, Leipzig, Germany) on PDUS images. The data were evaluated by Mann-Whitney U and Wilcoxon test.

Results: Data from B-mode US imageanalysis show that there was no significant difference between right and left testis in 0–2 h (P>0.05). The values obtained from PDUS analysis (I-red, A-red) significantly decreased at side of testicular torsion at the end of 2nd hour (P<0.05). I-red and A-red values at 0–1 h of torsion have similar blood flow alterations (P>0.05) whereas they have been found significantly decreasedbetween 0–2 h (P<0.05).

Conclusion: In experimental testicular torsion, ischemic changes can be obtained by PDUS angio mod by using blood flow alterations as early as second hour. Tissue damage cannot be evaluated within the first 2 h of torsion with B-mode ETX analysis.

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OP3: Extracellular matrix members and fetal wound healing: elastin is not a triggering factor in scar formation

E Temeltaşa, AO Heperb and T Aktuğa

Departments of aPediatric Surgery and bPathology, Ankara University, Faculty of Medicine

Aim: The aim is to find out the distribution of extracellular matrix members and their relation on scar formation by using fetal skin and trachea tissues which heal without scar and fetal stomach, diaphragm and similar adult tissues which heal with scar tissue.

Materials and methods: Tissue samples of 1 cm3 were taken from skin, trachea, stomach and diaphragm of three fetuses of a 20-day pregnant New Zeland type rabbit. Tissue samples were also taken from similar tissues of adult rabbit. Cross-sections of the tissues were stained with hemotoxylen-eosin, immunohistochemical and histochemical stains. Tissues were numerically classified according to elastin and hyaluronic acid quantity of the tissues. Mann-Whitney U test was used for statistical analysis.

Results: There was no statistically significant difference in elastin between fetal tissues which heal with scar and fetal tissues which heal withour scar (P>0.05). Elastin which was absent in fetal tissues was present in adult tissues (P<0.05). The presence of elastin in similar tissues wasn't significantly different (P>0.05). Hyaluronic acid was present in all fetal tissues. While tissues which heal with scar tissue had (+) staining, tissues which heal scarless had (+++) staining. There was statistically significant difference in hyaluronic acid between tissues healing with scar and without scar tissue (P<0.05). Hyaluronic acid was absent in all adult tissues except trachea. Trachea was stained as (±).

Outcome: Elastin which is present in all adult tissues is absent in all fetal tissues regardless of scar. The amount of hyaluronic acid in scarless tissues was found to be much more relevant than those in fetal tissues which heal with scar and in adult tissues.

Conclusion: Fetal wounds which heal with scar tissue in the absence of elastin prove that there are other triggering factors than elastin in scar formation. The presence of elastin in ECM of adult tissues is not only factor in tissue healing with scar. The presence of excess amount of hyaluronic acid in ECM shows that hyaluronic acid is one of the important components of scarless healing.

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OP4: The effect of degree of inflammation on the oxidative stress parameters in the rat appendicitis model

M Tana, L Elemena, K Yanarc, Y Gürbüzb and S Aydinc

Departments of aPediatric Surgery, bPathology, Kocaeli University Medical Faculty and cDepartment of Biochemistry, İstanbul University Cerrahpaşa Medical Faculty

Aim: To evaluate the oxidative stres parameters in the rat appendicites model related to the degree of the inflammation.

Materials and methods: Forty-two rats, that had previously created appendicitis by simple ligation of the appendix while preserving the mesenteric vessels, were randomly located in seven groups. In Group 1 appendectomy was carried out simultaneously. In rest of the groups re-laparotomy was performed on the 6th, 12th, 24th, 48th, 72nd and 96th post-operative hours respectively and appendectomy was performed. Excised appendices were cleared with serum physiologic and divided into two equal pieces for tissue biochemical analzes and histopathological evaluations. The samples kept for tissue biochemical analyzes were preserved in a deep fridge at −70 degrees Celsius while the samples for histopathological examination were kept in 10% formalin. Following homogenization the tissues were centrifuged (Jouan G412) at +4 degrees Celsius and tissue preotein carbonyl (PCO), total thiol (T-SH), protein thiol (P-SH) and advanced oxidation protein products (AOPP) levels were measured by a UV–visible spectrophotometer (Heraeus 400, Kendro Laboratory Product, Osterode, Germany). Total protein assay was performed by Bradford method. Inflammation was evaluated with modified Biert-Verhofstad classification. Necrosis, polimorphonuclear leukocyte count, macrophage count, peritonitisi, perforation, hemorhage and edema were evaluated and total scores were determined. The values were presented as mean±Standard deviation and the statistical analyzes were performed with One-Way ANOVA and Tukey tests. P was significant at <0.05.

Results: The AOPP levels were similar between the groups (P>0.05), evaluation of but P-SH (P<0.05), PCO (P<0.05), T-SH (P<0.05), P-SH (P<005) and total protein levels (P<0.05) revealed significant differences. Tissue T-SH, P-SH and PCO values were found to increase while total protein and AOPP levels were decreasing with respect to the duration of the inflammation. Total histological scores in Group 1 (0.51±0.33), Group 2 (7.83±2.22), Group 3 (9.16±2.92), Group 4 (8.16±1.47), Group 5 (11.33±1.86), Grup 6 (8.66±2.16) and Group 7 (10.83±1.47)(P<0.05) were significantly different (P<0.05).

Discussion: The role of oxidative stres is well documented in the inflamattory processes. Tissue PCO content is a valuable index in protein oxidation. Similarly, tissue T-SH, P-SH and AOPP levels demonstrate the oxidative stress. The progressive decrease found in the total protein levels was due to the progressive damage of the tissues. The relative decrease in AOPP levels was probably due to the decrease in the protein content of the tissues. On the other hand, increased T-SH and P-SH values indicate the increase in thiol-containing enzymes in the mitochondria as a protective measure against the tissue damage. Of course, measurement of tissue oxidative stress parameters is of no value in the clinical practice, but we may speculate that the evaluation of plasma oxidative stress parameters may be beneficial in the medical follow-up of the appendicitis patients.

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OP5: Protective effect of intraperitoneal ozone application in experimental ovarian ischemia/reperfusion injury

MK Aslana, MF Şenyücela, Ş Ayvab, Ü Kisac, N Aksoyc, T Soyera, Ö Cesura and M Çakmaka

Departments of aPediatric Surgery, bPathology and cBiochemistry and cKirikkale University Faculty of Medicine

Aim: Ovary saving surgery is an accepted approach in ovarian torsion (OT). Ozone therapy is used to reduce ischemia/reperfusion injury. An experimental study was performed to evaluate the effect of intraperitoneal ozone treatment in ischemia/reperfusion injury due to OT.

Materials and methods: Eighteen rats in 3 groups (n:6) were included. After anesthesia, right ovary was fixed to abdominal wall and removed at the end of 2 h in sham group (SG). In torsion group (TG), right ovary was torsioned 720 degrees at counterclockwise direction. Two hour after torsion reperfusion was performed and overies were removed 2 h after reperfusion. In ozone group (OG), mixture of %95 oxygene +%5 ozone was given intraperitoneally (25 µg/ml, 0.5 mg/kg) 10 min before reperfusion. Two hour after reperfusion, ovaries were removed. Histopathologically ovarian and periovarian sections were examined for the presence of congestion (C), hemorrhage (H), intersititial edema (IE), polymorphonuclear neutrophilic (PMN) infiltrations. Tissue samples were analysed for malondialdehyde (MDA), nitric oxide (NO) and sulphidryl (SH) levels. Results were compared between three groups.

Results: Histopathologic examination revealed ovarian C, PMN infiltration and periovarian IE were increased in TG with respect to SG (P<0.05). In OG, ovarian C and periovarian IE were decreased when comapred to TG, whereas only ovarian C was increased incomparison with SG (P<0.05). Oxidative stress markers showed no difference between SG and TG (P>0.05). OG had increasedMDAlevels and decreased NO and SH levels when compared to TG (P<0.05). MDA levels were decreased in OG with respect to SG (P<0.05) and there was no difference between these groups in NO and SH levels (P>0.05).

Conclusion: Intraperitonealapplication of ozone has a positive impact on histological and biochemical markers on I/R injury due to OT. The ozone application can be optimized in order to support the other efforts to protect the ovary in OT.

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OP6: Heat dispersion comparison of bipolar electro-surgical devices-II: histopathological study

L Elemena, Y Yazirb and A Akaya

Departments of aPediatric Surgery and bHistology, Kocaeli University Medical Faculty

Aim: To examine the heat dispersion of bipolar electro-surgical devices by histopathological evaluation of the rat tissues.

Materials and methods: Twelve Wistar-Albino rats were randomly allocated into two Groups (B, L). Following midline vertical laparotomy, bipolar electrocautery in Group B and LigaSure vessel sealing system in Group L were applied on esophagus, liver and small intestine for 5 s. The tissues were excised containing the damaged region in the middle and kept for histopathological examination. After fixation and dehydration, the tissues were embedded in paraffin wax and sections with 5 micrometer thickness were collected on slides. The tissues were examined by Olympus BX-50 microscope, and the tissue damage as mm was evaluated in 4×10 magnification with ocular micrometer. Olympus DP-20 camera was used for tissue photographs. The values were presented as mean±standard deviation and Mann Whithney U test was used statistical analyses. P was significant at <0.05.

Results: Tissue damage in liver (1.2±0.09 vs. 2.37±0.09 mm), small intestine (1.26±0.1 vs. 2.62±0.1 mm) and esophagus (0.8±0.2 vs. 2.47±0.1) were significantly lower in Group L (P<0.001, P<0.001, P<0.001).

Discussion: Electrosurgical devices are routinely used in dissection and hemostasis. We compared two bipolar devices with respect to their heat damage on the tissues. Our results indicate that utilization of LigaSure vessel sealing device on liver, small intestine and esophagus is more secure than the bipolar electrocautery on the experimental setting.

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OP7: Non-reversed appendicostomy for antegrade continent enema in the treatment of encopresis

Kamal Abdel-Elah Aly, Basem Saied, Adham Elsaied and Sabry Mahmouda

aPediatric Surgery Unit, General Surgery Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Background/purpose: Constipation in children is considered when stool frequency is less than 3 thimes per week. Encopresis represents 80–90% of children with fecal incontinence. Operative strategy for management of encopresis ranges from resectional surgry to myotomy. The objective of the study was to evaluate the efficacy of non reversed appendicostomy without antireflux mechanism for management of encopresis in children.

Materials and methods: The study included 35 patients with sever idiopathic constipation and encopresis with failure of conservative measures. Theirmedian age at the time of operation was 5 years (2.5–9) years with the male prepondrance 60% of the series (21 cases). Diagnostic evaluation included contrast enema and rectal bunch biopsy. They were subjected to non-reversed appendicostomy without anti-reflux procedures.

Results: Encopresis and constipation resolved within one-three months of ACE washouts. The mean follow up period was 23 months (11 to 34 months), during which there was no fecal impaction or episodes of soiling. The mean follow up period was 23 months (11 to 34 months), during which there was no fecal impaction or episodes of soiling. The incidence of complication was 22.8% and included stomal leak, stricture, retraction and granulation tissue formation. False passage during dilatation occurred in one case. Antegrad continent enema effectively controlled constipation and encopresis.

Conclusion: Non-reversed appendicostomy without antireflux mechanism is safe and rapid with minimal incidence of leakage. Constipation and encopresis was effectively controlled with this simple procedure.

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OP8: Inflammatory bowel disease among children in Egypt: observational increase in incidence in the last decade

Sherif Mohamed Shehata

Section of Pediatric Surgery, Tanta University, Tanta, Egypt

Introduction and aim: There is limited information about inflammatory bowel disease (IBD) in Arab children. IBD was believed to be infrequent in our area; however, unofficial reports have confessed the continuing rise in IBD in our country. The aim of this study was to highlight the problem of IBD in our community.

Methods: Along a period of 5 years (2005–2009), 21 cases of IBD were diagnosed among children in TUH and other hospitals. Clinical features, extension of disease and complications of 16 patients with ulcerative colitis (UC) and 5 with Crohn's disease (CD) in age below 15 years were assessed prospectively.

Results: Median pediatric UC age was 8 years (range 4–14). Seven of the 16 UC had proctitis, while 6 had left colitis and 3 had extensive pancolitis. 3 presented with bleeding per rectum and anemia that necessitate ICU admission and blood transfusion. Only one has extra intestinal manifestation. In CD, age ranged between 8 and 15 years with a median of 13 years. 2 presented at laparotomy for complication and one with peril anal manifestations. 2 out of 5 had involvement of terminal ileum and colon, while inflammation was limited to the colon in 3 cases. All improved under conservative treatment. All confirmed by histopathology examination.

Conclusion: Among Inflammatory bowel diseases, UC and CD are important diseases in our society among children. Although the true epidemiologic profile of IBD in Egypt is still unknown, it is not as rare as previously thought, and it seems as if gradual adoption of a Western lifestyle and junk meals may be associated with the continuing rise in IBD. We recommend a broad based epidemiological study, simultaneously involving clinicians, and pathologists, to document the characteristics of this disease in Egypt.

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OP9: A prospective, randomized, double blind, compared of efficacy diltiazem, glyceryl trinitrate and lidokain for the treatment of anal fissure in childhood

M Çevika, ME Bolekena, ÇA Karadağc, I Korukb, S Öcala, E Balcioğlua and A Aydinoğlua

Departments of aPediatric Surgery, bPublic Health, Harran University Medical Faculty and cDepartment of Pediatric Surgery, Sisli Etfal Education and Research Hospital

Background: Anal fissure (AF) is a well-known perianal condition with painful defecation and bloodstain stools which has been treated with various ointments such as glyceryl-trinitrate (GTN), botulinum toxin and lidokain in the therapy of anal fissure childhood. Although adult patients with anal fissures have been treated successfully with diltiazem ointment, it has not yet been studied in the children who suffer from anal fissure. The present study randomized, prospective and double-blind study, it was aimed to compare of response, side effects and recurrens.

Materials and methods: Ninety-three children with anal fissures were divided randomly into 3 groups. Each group, received double-blinded a topical ointment. Group GTN (n=30) received 0.2% GTN, group L (n=32) 10% lidocaine, and group D (n=31) 2% diltiazem ointment twice daily to the distal anal canal for a median duration of 7.5 (2–16) weeks was performed. Patients were periodically reviewed and the study was ended after 12 months.

Results: Eighty-two patients completed the study at end of 12 monthsbut 84 patientscompleted treatment. Completed healing of the fissure occured in (48.8%) 41 of 84 patients. Patients treated with lidokain 25%, GTN 39.3% and diltiazem 82.1% completed healing end of 8th week. Who did not respond to treatment for first 8- weeks course, they treated with same ointment further 8 weeks. Completed healing of the fissure ocured in (79.8%) 67 of 84 patients. Patients treated with lidokain 64.3%, GTN 82.1% and diltiazem 92.9% completed healing end of 16-week. Two patients experienced perianal dermatitis one of them when treated with GTN other one with diltiazem. No other side-effects were recorded. Reccurent of the fissure ocured in twenty-five of eighty-two patient, group L 57.1%, Group GTN 37% and group ditiazem 11.1%. The difference between the study group D significantly difference others groups P<0.002, X2=12.79. Between group GTN better than group L.

Conclusion: Treatment with diltiazem is a promosing quick effective, safe, and low rate of reccurences of treatment in anal fissure in children. The characteristic pharmacokinetics of diltiazem leads to a better effect than GTN in healing and also the high rate absorption than GTN. Diltiazem leading to a smoother dose concentration curve, therefore itmay be cause side-effect less than GTN.

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OP10: Is there a need of open surgical experience for laparoscopic appendectomy training?

H Akpinar, G Küçük, C Köse, U Ateş, G Göllü, M Bingol Kologlu, H Dindar and A Yagmurlu

Department of Pediatric Surgery, Ankara University School of Medicine

Background: Resident experience in open appendectomy (OA) has diminished since laparoscopic appendectomy (LA) became gold standard in childhood appendicitis. For the last 6 years no OAs were performed in our department. With the concern of whether OA experience was needed for LA and general pediatric surgical training, the factors influencing operative time, outcome in LA and the safety of LA performed by residents and attending surgeons were investigated.

Materials and methods: 572 LA procedures consecutively performed by three attending surgeons, 5 senior and 3 junior residents were collected retrospectively in a computer database and analyzed prospectively. The number of LA procedures needed to decrease operating time under 40 min was determined by ROC curve analysis. Univariate analyses and multivariate analyses with logistic regression were performed to identify factors influencing operating time. The investigated parameters were general surgical experience, laparoscopic surgical experience, OA experience and LA experience, institutional experience in LA, as well as the presence of complicated appendicitis. The strength of the correlation was determined by Pearson correlation analysis. The complications of LA were also analyzed according to the surgeons. The results of attending surgeons experienced in OA and residents unexperienced in OA were compared.

Results: There were only 9 complications including wound infection in the umblicus (n:6), stump leakage with intraabdominal abcess (n:2), and bleeding from trocar site (n:1). These complications occured during the first 70 cases performed by attending surgeons and was associated with lack of experience in laparoscopic surgery. Residents started to perform LA after the initial 73 cases and there were no complications recorded since then. Mean operating time decreased with increased institutional experience (61±36 in initial 100 cases, 44.2±26 in 101–200, 39±21 in 201–272 cases, 35±21 in 272–450 cases, 30±21 in 450–572 cases). According to ROC curve analysis, the number of procedures needed to decrease operating time under 40 min was 19. Residents needed less procedures than attendings to decrease operating time under 40 min. The univariate analysis demonstrated that laparoscopic surgical experience, LA experience, institutional LA experience and presence of complicated appendicitis effected operating time (P<0.05). The multivariate analysis showed that the factors independently associated with operating time were the surgeons' LA experience, institutional LA experience and presence of complicated appendicitis. OA experience and general surgical experience did not correlate with operating time or experience in LA.

Conclusion: Our findings certainly demonstrate that LA is a safe procedure in hands of both junior and senior residents and there is no need for OA experience prior to LA training as laparoscopic procedures require their own specific skills independent from open surgical experience. The decrease in the number of OA is not a drawback for resident training and it is possible to acquire an adequate knowledge of anatomy and surgery from LA training.

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OP11: Are intra-abdominal abscesses more common after laparoscopic or open appendicectomies?

RM Nataraja, W Teague, BS Ashwath, AT Mitra, L Moore, T Tsang, S Khurana, MJ Haddad and SA Clarke

Chelsea & Westminster Hospital

Aim of the study: Whilst laparoscopic appendicectomy (LA) is an accepted alternative to the open approach, it has been suggested that there is a higher incidence of intra-abdominal abscesses (IAA) following LA when compared to the open approach (OA). Our aim was to determine the incidence of IAA in three paediatric surgical centres routinely practicing both techniques.

Methods: Data were collected retrospectively for paediatric patients (<18 years) undergoing LA or OA in three centres over an 8-year period. Patients were analysed for IAA formation, complexity of appendicitis, radiological and histological investigations, grade of surgeon, and wound infection. Complicated appendicitis was defined by gangrene or perforation on histology with correlation of intra-operative findings. Data were analysed using Fisher's exact test; P-value of <0.05 was considered significant.

Main results: 1267 appendicectomies were performed: 514 LA and 753 OA. 62 patients were excluded as they underwent interval or incidental procedures. There was no significant difference between the incidence of IAAs following LA (3.5%, 17/491) and OA (3.6%, 26/714), P=1.0. This finding was consistent in all 3 centres (P=1.0, 1.0, 0.6). Patients with complicated appendicitis developed more IAAs: 33/375 (8.8%) versus 10/830 (1.2%). This was regardless of technique: 15/182 versus 2/309 (LA, P=0.0001) and 18/193 versus 8/521 (OA, P=0.0001), and despite more complicated appendicitis in the LA group: 182/491 versus 193/714 (P=0.0002). A surgical trainee was the primary surgeon in 58.7% (LA) versus 83.8% (OA), P=0.0001, but IAA incidence did not correlate with grade of surgeon (5/245 versus 8/149, P=0.09). 4.6% LA (8/174) versus 2.5% OA (18/378) developed a wound infection (P=1.0). Postoperative IAAs were treated with intravenous antibiotics and if necessary radiological or surgical drainage.

Conclusion: These data show technique of appendicectomy does not affect the incidence of IAAs, contradicting widely stated dogma. Rather, patients with complicated appendicitis are more likely to develop an IAA regardless of technique.

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OP12: The method of trans-axillary subcutaneous endoscopic approach in neck surgery of children: endoscopic surgery for torticollis

B Tokar, MS Arda, H Ilhan, D Demet Dereli and Y Aydoğan

Department of Pediatric Surgery, Eskişehir Osmangazi University, School of Medicine, Eskisehir, Turkey

Aim: Benign subcutaneous lesions of the neck are typically excised through an incision on the skin overlying the lesion. Incisions are placed in skin creases to camouflage the scar, but scarring is unpredictable, and theaesthetic results can be displeasing to the patient and the family. In this study, we describe our method of trans-axillary subcutaneous endoscopic approach (TASEA)without a neck incision by the technique we used in patients with torticollis. The lesions such as torticollis, cervical lymph nodes, thyroglossal duct cysts, dermoid cysts, and parathyroid adenomas could be excised by TASEA.

Methods and results: Seven patients were operated for torticollis by TASEA. Five of them were on the left side. All the patients were girl except one boy and the age range was between 6 and 15 years old. All patients had torticollis with significant facial asymmetry and head and neck postural abnormality. In supine position, keeping lateral of pectoralis major muscle, the both clavicular and sternal legs of SCM muscle were divided endoscopically by transaxillary 2 ports. A 4 or 5 mm 300 optic guide and 3 or 5 mm unipolar hook and bipolar cauterization were used following a 5 mm mid-axillary incision and a cavern formation by a 8 FG Foley catheter balloon; Hegar dilator and esophageal balloon dilator in last 3 cases. Postoperative early and late result was very satisfactory for the surgeon, the patients and the families.

Conclusion: In young children, following a neck surgery incision, a visible neck scarringcan have long-term psychological consequences. Removing these lesions through a neck incision essentially replaces one deformity for another. Many surgical subspecialties have used subcutaneous endoscopic techniques, typically through hidden incisions on the scalp, for management of a variety of lesions. Depending on the characteristic of the lesion and the experience of surgeon, TASEA could be preferred with its cosmetic outcome in pathologies placed in neck.

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OP13: Role of laparoscopy in mangement of patients with disorders of sexual differentiation

N Dessouky

Pediatric Surgical Division, Cairo University Specialized Pediatric Hospital, Cairo University Faculty of Medicine, Egypt

Background: In recent years, laparoscopy has gained acceptance as a useful method in management of intersex states. The indications for laparoscopy in such conditions are still evolving.

Materials and methods: Laparoscopic operations were performed for 97 patients with disorders of sexual differentiation (DSD) conditions. Their ages ranged between 3 weeks and 46 years (Mean=5.8). Cases of gonadal dysgenesis (GD) included 42 patients; twelve of them were true hermaphrodites (TH). Patients with female pseudohermaphroditism (FPH) included 26 cases while those with male pseudohermaphroditism (MSH) were 29. Two trocars were used for diagnostic procedures and a third was added if further surgical management was needed

Results: Simple diagnostic laparoscopy was performed for 43 cases; 25 of these were FPH reared as males having congenital adrenal hyperplasia (CAH) with severely masculinized external genitalia. They reversed their sex after surgery. All cases of gonadal dysgenesis required laparoscopy for their accurate diagnosis as well as for their further management. Hysterectomy was performed for 22 patients: 8 cases had gonadal dysgenesis (MGD); 7 cases were TH reared as males, 5 cases of dysgenetic male pseudohermaphroditism, a case of persistent Mullerian duct syndrome and an adult male with lately diagnosed CAH. Forty-eight gonadectomies were performed for 35 patients: streak gonads (26), ovaries (7), dysgenetic testes (7) and ovotestes (8). Bilateral gonadectomy for gonadoblastoma was performed for three patients: a pure gonadal dysgenesis, an androgen insensitivity syndrome and a patient with 5-alpha reductase deficiency. Laparoscopic orchiopexy was performed for 19 patients. Staged Fowler Stephen's technique was adopted in 13 of these cases. Laparoscopic repair of associated hernial sacs was performed in 5 cases.

Conclusion: Although the initial diagnosis can be reached in most cases of DSD by the clinical presentation, cytogenetic, biochemical and hormonal studies; yet in certain cases, laparoscopy provides a minimally invasive technique for their accurate diagnosis especially for cases with abnormal gonadal differentiation. It also serves as an efficient method for completion of their surgical reconstruction and removing structures contradictory to the assigned gender. It is associated with low morbidity allowing a short postoperative recovery with minimal scars, an aspect which is important for patients with ambiguous genitalia who seek for reaffirmation of their body image and self- esteem.

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OP14: Laparoscopic approach in paediatric hernia repair

S Çelebi, A Yildiz, A Üçgül, ÇA Karadağ, N Sever and Aİ Dokucu

Paediatric Surgery Department, Şişli Etfal Training and Research Hospital

Aim: The aim of this study was to assses whether laparoscopic repair techniques reduce the testicular circulation more than conventional open technique.

Materials and methods: Two different laparoscopic hernia repair techniques were compared with the hernia repair using conventional techniques. The advantages and disadvantages of laparoscopic hernia repair were evaluated prospectively. This study was performed of the collected datas of seventy inguinal hernia repairs in 57 male children between 2 and 14 years of age (median age was 5.65) in our instituon from between January 2009–March 2010. The hernia was unilateral in 51 patients (32 on the right side, 19 on the left side), and bilateral in 6 patients. Measurements of testicular resistive index (RI) by colour Doppler ultrasonography were conducted before and after surgery, one week and one month later. Any change on testicular resistance was evaluated. Eighteen patients were subjected to conventional open technique, twenty patients underwent laparoscopic hernia repair with the technique that Schier described and the last nineteen patients with Montupet's laparoscopic technique. In total, 49 cases were subjected into laparoscopic repairs.

Results: Open surgery group showed significant statistically increase of capsular testicular V-max but decrease inRIin the early postoperative period and remains low. Same decrease in RI in laparoscopic hernia repair groups was also observed but significant difference was not found. A metachronous hernia developed in one patient in open surgery group and one patient had to be operated for the secondary undescended testes during a follow-up time of 4 months to 15 months (average 9 months). No post operative complication has been reported in laparoscopic hernia groups.

Conclusion: In contrast to studies in literature, we found no difference in RI and V-Max values when we compare with all groups. Laparoscopic or open technique have no significant effect on testicular perfusion although each technique has its own advantage and disadvantage.

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OP15: Internal inguinal ring may give a clue about the intracanaliculer testis during diagnostic laparoscopy for nonpalpable testis

T Özdemir, A Arikan, Ö Atacan, A Sayan and Y Arpaz

Tepecik Training and Research Hospital, Department of Pediatric Surgery, Izmir

Aim: Patients who undergone diagnostic laparoscopies because of nonpalpable testis were reviewed and relation between internal inguinal ring and intracanaliculer testis was evaluated.

Materials and methods: Between 2007 and 2011, 57 patients were undergone diagnostic laparoscopy because of nonpalpable testis. Demographics, unilaterality or bilaterality of the nonpalpable testis, intraoperative findings, subsequent inguinal operation and type of inguinal operation were recorded.

Findings: Mean age of the patients was 1.5 years (6 months–9 years). In 7 patients nonpalpable testis was bilateral. In 12 patients one testis was undescended and contralateral was nonpalpable. In 38 patients unilateral nonpalpable testis was present. During laparoscopy, 17 of 64 testis units were intraabdominal. Six of these 17 testes were atrophic and removed. In 11 testes, laparoscopy assisted inguinal orchiopexy was performed. Four of these testes remained high scrotal, and other 7 could be placed into scrotum. Among other 47 testis units, in 6 units, vas deferens and vessels were ending blindly close to the internal inguinal ring. In remaining 41 units, vas and vessels were entering into the internal inguinal ring. 32 of these inguinal rings were open and 9 were closed. These 41 testis units were explored via inguinal access. During inguinal exploration, all testes with open internal ring were normal in terms of volume and density (100%). Standard inguinal orchiopexy were performed. 7 of 9 testes with closed internal ring were atrophic and removed (77%). Other two testes were normal and orhiopexy was possible.

Conclusion: Diagnostic laparoscopy is a standard and safe procedure in nonpalpable testis. Presence of a patent processus vaginalis during laparoscopy appears a good indication of a presence of a normal testis in inguinal canal. A closed inguinal ring with a inserting vas and vessels seems an indication of an atrophic intracanaliculer testis.

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OP16: Laparoscopic gastrostomy

G Küçük, G Göllü and A Yağmurlu

Department of Pediatric Surgery, Ankara University School of Medicine

Aim: The aim is to review the results of children who were undergone laparoscopic Nissen fundoplication together with gastrostomy because of gastroesophageal reflux disease and malnutrition.

Materials and methods: A retrospective chart review of 52 patients who were undergone laparoscopic gastrostomy was performed were reviewed. Demographic data of the patients, associated diseases, operation time, duration of feeding postoperatively, duration of hospital stay, presence of intraoperative and postoperative complications and recurrence rates were evaluated.

Results: Twenty-seven of cases were boy and 25 were girl. The median age of patients was 3 years (20 days–16 years). The median body weight was determined as 11 kg (2–35 kg). Ninety-four percent of patients had neurological problem (cerebral palsy (n=19), hypoxic ischemic encephalopathy (n=8), hydrocephalus (n=5), arthrogryposis multiplex (n=2), other (n=15)). U-stitch technique was used for gastrostomy in twenty patients and trocar site technique in the rest thirty-two patients. Mean operative time together with fundoplication was 65 min (29–150 min). Mean feeding time postoperatively was 1day (1–3 day). Mean length of hospital stay was 5 days (2–19 days). In the first week postoperatively peritonitis occurred in two patients because of dislocation of gastrostomy and they were undergone laparotomy and revision of gastrostomy.

Conclusion: Laparoscopic gastrostomy and simultaneous fundoplication is the gold standard treatment especially in neurologically impaired patients who have malnutrition and need enteral feeding for a long period since the recovery is fast and feeding is early postoperatively. Laparoscopic gastrostomy is a safe procedure that can be preferred in patients when laparoscopic fundoplication is simultaneously required and percutaneous endoscopic gastrostomy cannot be performed. Trocar site gastrostomy is accepted as a safer method than U-stitch technique although their difference is statistically insignificant.

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OP17: The molecular basis of pathophysiology of pulmonary hypertension in infants with congenital diaphragmatic hernia

Sherif M. K. Shehataa,b, Wolter Mooib,c and Dick Tibboelb

Departments of aPediatric Surgery-Tanta University Hospital, Tanta, Egypt, bPediatric Surgery-Sophia Children's Hospital and cPathology, Erasmus University Medical Center, Rotterdam, The Netherlands

The most important factors determining survival in congenital diaphragmatic hernia (CDH) infants is the degree of pulmonary hypertension (PH). For improvement in the management and care of CDH patients, we need to understand in-detail the development of the pulmonary vasculature. Studies in human CDH and age matched controls are essential with regards to the pulmonary vasculature in the hypoplastic lungs to understand the pathology of PH in CDH.

Aim: In order to unravel some of these involved mechanisms with the evolution of molecular vascular biology techniques we conducted a group of investigations with the following aims:

To evaluate the expression pattern of various angiogenic growth factors such as VEGF, PDGF-BB.

To evaluate the expression pattern of nitric oxide synthase enzymes (NOS), which generate the vasodilator NO.?

To evaluate some stress molecules at pulmonary vascular bed as heat shock proteins (HSPs: 27 and 70).

Materials: In our studies we used archival autopsy lung specimens of 33 term neonates who died of CDH. All cases belonged to the high-risk group and presented with respiratory insufficiency within the first 6 h after birth and PH. Eleven age-matched neonates, who died from acute placental insufficiency that served as controls. Controls were subjected to similar ventilator therapy up to 16 h. These controls showed no lung abnormalities or hypoplasia on histological examination and had no clinical features of PH as revealed by repeated cardiac ultrasounds.

Results: Significantly elevated levels of VEGF immunoreactivity were observed in CDH lungs as compared to the controls. Data on PDGF-BB expression revealed to be lower in CDH cases as compared to controls. No significant differences in eNOS immunolocalization were found. Endothelial expression of iNOS in small pulmonary arteries was reduced in CDH cases as compared to controls. There is enhanced expression of HSP-70 and HSP-27 inthe pulmonary vasculature as compared to controls.

Conclusion: We concluded that the role of PDGF-BB in the VEGF-stimulated angiogenesis pathway in human CDH cases is minimal, in contrast to the results observed in rat lung development. Our data of iNOS confer the observations of Hecker's et al, supporting the notion of abnormal reactivity or non-responsiveness to the released NO without involvement of eNOS. This leads to altered pulmonary vascular response with development and/or persistence of PH in CDH cases. We summarized that our studies regarding the molecular basis of pulmonary vasculature in CDH cases will provide some clues to the pathologic molecular mechanisms involved in the production of PH in human CDH. This understanding will have therapeutic implication by molecular alteration in the perinatal period.

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OP18: Thoracoscopic treatment of pulmonary hydatid cyst in children

M Küçükaydin, AB Doğan, S Arslan, KC Sulubulut, A Aslan and Ö Yandim

Department of Pediatric Surgery, Erciyes University, School of Medicine, Kayseri

Background and aim: Surgical treatment has remained the standard option in the management of hydatid disease. Fourteen pediatric cases of pulmonary hydatid cyst, treated successfully using the thoracoscopic approach, were retrospectively reviewed in this study.

Materials and methods: From April 1999 to December 2010, 10 boys (71%) and 4 girls (29%) aged between 6 and 16 years (average 9 years) old have been operated on for hydatid cyst of the lung by a thoracoscopic procedure. All of the patiens receive oral albendazole 10–12 mg/kg/day soon after diagnosis. The patients were put in a full lateral decubitus position. Two 5-mm and one 10 mm cannulas were placed in a triangular fashion. A 5 mm 30o telescope was introduce through middle port. For noncomplicated cysts the hypertonic saline was injected, and then the endocysts were extracted using a 10 mm endobag. Irrigations, partial decortications and partial excision of the exocyst were performed and the cyst in using suture ligation for air leak. Infected endocysts and partial exocyst were extracted as the same manner. A chest tube was placed through the lower port site.

Results: It was a vomited cyst in 1 case, a pyopneumocyst in 7 cases, and a noncomplicated and univesicular cyst in 6 cases. The patients had uneventful postoperative courses. Median follow up period was 5 years (range 6 months to 10 years). In follow-up period, they were free of symptoms with no recurrence on chest x-ray.

Conclusion: All stages of the surgical treatment of hydatid cyst of the lung in children can be accomplished by thoracoscopy. Thoracoscopic management of pulmonary hydatid cyst is safe, offers the advantages of less pain, rapid recovery, less short and long term morbidity and good cosmesis.

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OP19: Thoracoscopic versus open repair of Esophageal Atresia and Tracheoesophageal Fistula (EA-TEF)

C Özcan, K Polatdemir and HA Erdener

Department of Pediatric Surgery, Ege University Faculty of Medicine

Aim: This study aimed to evaluate the efficacy and safety of the thoracoscopic versus open techniques in rapair of EA-TEF.

Materials and methods: Fourteen patients underwent traditional repair through thoracotomy while thoracoscopic approach was used in 22 patients. The operative parameters and the complications of surgery were compared between 2 groups.

Results: The mean time to extubation was 8 days (range, 0–28), versus 8 days (range, 0–22); tube thoracostomy duration was 10 days (range, 6–30) versus 11 days(5–13), anastomotic leak rate was %14 versus %19, the stricture rate was %85 versus %57, gastroesophageal reflux rate was %50 versus %19, need for antireflux procedure was %28 versus % 0, whereas recurrent TEF rate was %19 versus % 14 for the open and closed techniques, respectively. Statistically significant difference was found only for the need of an antireflux procedure between 2 groups.

Conclusion: Our results suggest that the outcomes of the thoracoscopic technique are comparable to that of the open technique.

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OP20: Thoracoscopic repair of esophageal atresia and tracheaesophageal fistula

M Küçükaydin, A Aslan, AB Doğan, KC Sulubulut, S Arslan and Ö Yandim

Department of Pediatric Surgery, Erciyes University, School of Medicine Kayseri

Aim: Thoracoscopic repair of esophageal atresia and tracheaesophageal fistula (EA-TEF) in children were retrospectively reviewed in this study.

Materials and methods: Between March 2009 and December 2010, 11 patients (8 male, 3 female) who underwent thoracoscopic repair. The mean age at operation was 7.7 days (2–18 days) and the mean weight was 2650 g (2100–3100 g). There were no severe associated anomalies in this group. A 4-mm camera and two 3-mm working ports were used and during the procedure right lung was collapsed by CO2 insufflations at a pressure level of 3–4 mmHg. After the dissection, the fistula was ligated with a 5/0 polidioksanon sutureand divided. Proximal and distal parts of the esophagus were prepared and anastomosed with interrupted 5/0 polidioksanonsutures. A 6 Fr NG tube was passed through the stomach and achest tube was inserted. The mean operation time was 100 min (90–120 min).

Results: All the intended cases, the repair of EA-TEF could be completed withthoracoscopicaly. Feeding was started in 3rd postoperative day with NG tube. No anastomotic leak was developed in the patients. The mean mechanical ventilation times were 3.8 days (2–7 days). Follow up periods were uneventful in these patients.

Conclusion: Thoracoscopic repair of EA-TEF is good option if surgeon has enough experience.

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OP21: Thoracoscopic repair of congenital diaphragmatic hernia

C Özcan, S Tiryaki and G Bulut

Department of Pediatric Surgery, Ege university

Aim: The aim of this study was to determine the efficiency and outcomes of thoracoscopic repair in congenital diaphragmatic hernia.

Materials and methods: Hospital records of children who had undergone thoracoscopic repair of Bochdalek type congenital diaphragmatic hernia (CDH) between years 2006–2009 were reviewed.

Results: This study included 15 children who had undergone thoracoscopic repair. Twelve patients had left, 3 of the patients had right sided haernias. Nine patients were antenatally diagnosed (mean operation time: 4 days), three patients were lately diagnosed (operation time: 2.6 and 12 months). Thoracoscopic CDH repair was performed using 3 trocars (one 3 and two 5 mm) and a 30 degrees telescope; the diaphragm was repaired primarily using interrupted 2/0 silk sutures. Diaphragmatic stitches were passed around the ribs and tied extracorporeally when there was no identifiable rim. No nmesh was used. Nine patients required mechanical ventilation, 2 patients needed additional high frequency oscillation ventilation and NO application. Only one patient died, because of pulmonary hypertension. Mean follow-up was 29 (5–55 m) months and 5 recurrences occurred in 4 patients. Recurrences were repaired by thoracotomy in 3and first thoracotomy than laparotomy in one patient. To determine the possible causes of recurrence, patients were divided into two groups as recurrence and no recurrence. Demographic, anatomical and clinical data were assessed and no significant difference was identified.

Conclusion: Thoracoscopic repair can safely be used for CDH however there is a risk of recurrence. No prognostic factor for recurrence in this study between teo gropus was detected. Further investigation shall be carried out to approve thoracoscopic repair as a standard technique for congenital diaphragmatic hernia.

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OP22: Mitomycin-C is effective in treatment of refractory caustic esophageal strictures

S İskit, Z Özçelik, C Parlakgümüş, S Türker, M Alkan, R Tuncer and Ü Zorludemir

Department of Pediatrc Surgery, Çukurova University Medical Faculty, Adana, Turkey

Aim: To evaluate the efficacy of mitomycin C in the management of refractory caustic esophageal strictures after failure of conventional dilatation program.

Methods: Retrospective review of patients treated by mitomycin-C application for persistent caustic esophageal strictures was performed to determine the efficacy and safety of the procedure. Before the mitomycin-C application a standard protocol was used in the treatment of all patients, including dilatation and local steroid injection. Mitomycin-C was applied in a concentration of 1 mg/ml for 3 min.

Results: There were 9 patients with a median age of 8 (5–16) years. Mitomycin-C was applied after repeated dilatations varying from 8 to 51 (median 22). The intervals between dilatations significantly increased and oral intake was improved with mitomycin-C application. Major success in 7 and partial success in 2 patients occured after a median period of 4 (2–17) months. Median follow-up period was 22 (9–33) months.

Conclusion: Our findings suggest that mitomycin-C application is a safe and effective treatment alternative for refractory caustic esophageal strictures in children.

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OP23: Comparison of thoracic and abdominal repair of congenital diaphragmatic hernia in neonates

S Arslan, AB Doğan, KC Sulubulut, Ö Yandim, A Aslan, M Küçükaydin and C Turan

Departments of Pediatric Surgery, Erciyes University, School of Medicine

Aim: Comparison of the results of the patients with posterolateral congenital diaphragmatic hernia (CDH) who underwent CDH repair with transabdominal and transtoracic ways.

Materials and methods: Between March 2008 and December 2010, 15 patients (8 male, 7 female) who underwent repair of CDH were investigated. The patients were divided in two groups according to surgical approach. Group I: CDH were repaired with transabdominal approach, group II: CDH were repaired with transtoracic approach. The results of patients were compared according to sex, gestational age, birth weight, operation time, hernia side, herniation of liver in thorax, ventilation time, starting to feed, the time in charge and mortality.

Results: There was no difference between two groups according to sex (F/M: 8/7), gestational age (37.5/39.3 week), birth weight ağirliği (2631/2846 g), operation time (1.3/2.3 day), hernia side (left 15), herniation of liver in thorax (2), the time in charge(19.5/20.6 day) and mortality (1/1). In group II, ventilation time (7.1/11.6 day) and starting to feed (7.5/12.3 day) was longer than group I.

Conclusion: The study shows that, there is no superiority between the transtoracal and the transabdominal methods for the repair of CDH.

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OP24: Comparison of one-session surgery with two- session surgery in colonic interposition

K Polatdemir, C Özcan and HA Erdener

Department of Pediatric Surgery, Ege University Faculty of Medicine

Aim: Colonic interpositioning surgery procedures are commonly used for eosophagus replacement at pediatric age. In this study we compared one-session surgery with two-session surgery which is applied in colonic interpositioning.

Materials and methods: A total of 18 patients underwent colooesophagoplasty surgery. 9 were operated by one; the other 9 were operated by two sessions. The patients are analyzed by age, weight, cervical drainage time, leakage, stenosis, reflux, and necrosis.

Results: The mean age was 6 years (range 1–10), mean weight was 17 kgs (range 6–18), mean drainage time was11 days (range 9–15) in the one-sessioned-surgery group. The mean age was 9 years (range 4–18), median weight was 26 kgs (range 12–55), median drainage time was 9 days (range 5–12) in the two-sessioned surgery group. There were no necrosis reported in both groups. Stenosis was encountered only in 2 patients who underwent two-sessioned surgery. One of them was recovered after oesophageal dilatation. The leakage ratio was %33 in one- sessioned, %44 in two- sessioned surgery group. There was no remarkable difference between two groups considering drainage time and leakage (P>0.05).

Discussion: According to this study we think that colooeosophagoplasty procedures can be applied in one session in case of well perfusioned colonic segment.

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OP25: The prognostic factors of congenital diaphragmatic hernia patients and the evaluation of the effects of lung development with ventilation-perfusion scintigraphy

OD Özbaya, İ Ötgüna, P Oğuzkurta, EA Gençoğlub and A Hiçsönmeza

aDepartment of Pediatric Surgery, Baskent University Faculty of Medicine and bDepartment of Nuclear Medicine, Ankara, Türkiye

Aim: Congenital posterolateral diaphragmatic hernias are the anomalies that the mortality rates are changing between 10–35% with the latest improvements. The aim of our study is to determine the prognostic factors of survival of congenital diaphragmatic hernia patients and to evaluate the effects of lung development with ventilation-perfusion scintigraphy.

Materials and methods: There are 55 patients who were operated with the diagnosis of congenital posterolateral diapragmatic hernia between January 2000 and April 2010 in pediatric surgery clinic were evaluated retrospectively with their demographic findings, probable prognostic factors, surgery results and the results of 19 patients' ventilation-perfusion scintigraphy in the infancy period.

Findings: The mortality rate of our congenital diapragmatic hernia patients is 20%. The prognosis was influenced bad with postterms (P=0.013), the right sided congenital diapragmatic hernia patients (P=0.042), patients with diameter of the defect were 4 and more than 4 (P=0.015), the apgar score was less than 5 in the fifth minute (P=0.001), the left sided congenital diapragmatic hernia patients with liver herniation (P=0.018), the patients who had cardiac anomalies (P=0.048), the patients who had pulmonary hypertension (P=0.001), the patients who had low pH values in the first, pre and post operation blood gases (P=0.024, 0.001, 0.000) and the high PaCO2 values in the first, pre and post operation (P=0.014, 0.001, 0.000). The perfusion and ventilation were decreased in ipsilateral lung and elevated in contalateral lung. The ipsilateral lung ventilation was badly ifluenced in boy patients (P=0.042). The use of pathches of ipsilaterallung badly influenced the perfusion (P=0.039) and ventilation (P=0.039). The patients who had left sided hernias with gastric herniation had ipsilateral low lung perfusion (P=0.014) and contralateral high lung perfusion (P=0.014) and the patients who had liver herniation had contralateral high lung ventilation (P=0.013) were also demonstrated with the evalution of ventilation-perfusion scintigraphy.

Discussion: The ventilation-perfusion scintigraphy could be done infants very easly. Boy gender, using patchs, left sided hernias with gastric and liver herniation were contributed pulmonary hypoplasia in living patients.

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OP26: The new treatment method in pectus excavatum deformity: vacuum therapy

S Şiyve, O Ateş, G Hakgüder, M Olguner and FM Akgür

Department of Pediatric Surgery, Dokuz Eylul University, School of Medicine, İzmir

Introduction: Minimal invasive repair of pectus excavatum (MIRPE) technique is usually preferred in pectus excavatum (PE) deformity. Nonsurgical alternative treatment techniques are used in PE deformity. Chest wall lifting with the help of a vacuum is the one of these treatments. Successful results of vacuum therapy have been reported in patients with symmetrical and asymmetrical PE deformity. Vacuum method has been used during MIRPE to facilitate the transition between sternum and heart out of PE primary treatment. The vacuum method has become interesting in the treatment of PE deformity. We have presented preliminary results in cases with asymmetric PE.

Materials and method: Vacuum therapy was applied three patients (1 female, 2 male) with asymmetric PE deformities. Appropriate vacuum according to patient's body and deformity (16 cm, 19 and 26 cm diameter) was chosen. First, we trained patients and parents for vacuum therapy applying, after vacuum cup was (Klobe, Germany) applied by patient and/or family as vacuum pressure up to %15 below atmospheric pressure. Initially, the vacuum was applied twice daily each practice at least 30 min. Daily practice time was increased. Patients were followed before and after vacuum applying in terms of possible complications and effectiveness.

Results: In three patient, vacuum treatment is still in progress. In one patient, we have seen visually noticeable improvement in levels of PE deformity after 5 months application. No complications were observed. Initially, moderate sternal pain and pressure sensation regressed later.

Conclusion: Vacuum therapy is an alternative method to surgical treatment in patients with asymmetric PE deformity.

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OP27: Conservative management in congenital lobar emphysema

G Kiyana, SY Turana, B Karadağb, R Ersub and T Dağlia

Departments of aPediatric Surgery and bPediatrics Division of Pediatric Pulmonology, Marmara University School of Medicine

Congenital lobar emphysema can be managed conservatively unless there are clinical and radiological findings of a severe disease. In this study we evaluated eight cases of congenital lobar emphysema, who were managed conservatively.

There were one girl and seven boys. Mean age of onset of symptoms was 3.3 months in six patients (8 days–6 months). One patient with a diagnosis of left upper and right middle lobar emphysema, a left upper lobectomy was performed and the right middle lobe was managed conservatively. One patient had a prenatal diagnosis. Symptoms were respiratory distress in all patients, while infection accompanied the distress in two cases. Emphysema was detected in the left upper lobe in four patients, in the right upper lobe in two patients and in the right middle lobe in the remaining two patients.

The patients were followed for 31 months (2–72 months) after the diagnosis. During this time, child had an attack of pneumonia in the emphysematous lobe. Other children did not experienced any problems. Radiological follow-up chest radiography revealed improvement in two cases. Radiological findings remained unchanged in the other six patients.

As a result, congenital lobar emphysema patients without severe clinical problems can be managed conservatively. These children do not experience any serious lung problem during conservative management period.

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OP28: Foreign bodies aspiration in children

A Şengün, M Kaçar, A Gürpinar and H Doğruyol

Department of Pediatric Surgery, The Medical Faculty of Uludag University

Aim: The young children have a tendency to place objects in their mouths. Therefore foreign bodies aspiration (FBA) is common in young children. The aim of this studyis to evaluate the results and complications of patients who underwent rigid bronchoscopy in the diagnosis of FBA.

Patients and methods: 462 children (269 male, 193 female) underwent rigid bronchoscopy for FBA between 1992–2011 in our department. Age and gender of the patients, medical history, symptoms, physical examination, radiological and bronchoscopic findings were evaluated retrospectively. FBs were extracted using a rigid bronchoscope and suitable coaxiel forceps.

Results: The mean age of the patients is 3.1 years (1 months–16 years). Patients had symptoms like cough, wheezing, choking attacks, respiratory distress. The duration of symptoms from the time of aspiration until bronchoscopy ranged from 1 h to 2 years. The history in 349 patients (89.2%), physical examination in 246 (62.9%), radiological findings in 286 (73.1%) were consistent with FBA. 84.6% (n:391) of patients were foreign bodies. FBs were removed of 214 right, 147 left, 6 both mainstem bronchus and 24 trachea. Despite a history of aspiration, bronchoscopy was negative in 53 (% 11.4) of the cases. Most of FBs were non-radio opaque and sunflower seeds and hazelnuts topped the list. Patients were evaluated with chest X-ray postoperative 3 h and the patients were discharged the same day. Tracheostomy and thoracotomy were performed in 2 and 4 patients respectively. Cardio respiratory arrest observed in 8 patients (2%) and 3 patients (0.7%) was died.

Conclusion: Diagnosis of foreign body aspiration in children is sometimes difficult. Therefore, bronchoscopy should be performed in children with apparent suspicion of FBA for the differential diagnosis and treatment. Family education is the best preventive measure for decreasing the incidence of FBA.

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OP29: Laparoscopically assisted anorectal pull-through for high imperforate anus

M Küçükaydin, Ö Yandim, KC Sulubulut, S Arslan, AB Doğan and A Aslan

Department of Pediatric Surgery, Erciyes University, School of Medicine Kayseri

Aim: In this study, thechildren who underwentlaparoscopically assisted anorectal pull-through for high imperforate anus were retrospectively reviewed.

Materials and methods: From March 2000 to December 2010, 27 patients (24 male, 3 female)with diagnosis of high imperforate anus underwent LAARP. The patients aged from 2.5 months 2.5 years (mean age, 7.5 months). Twenty patients (74%) had rectourethral fistulae and rectovesical fistulae in four patients (4%). The associated malformations were sacral and cardiac malformations, esophageal atresia, duodenal atresia, gall bladder malformation, proximal type hypospadias, PUJ obstruction and renal agenesis. All patients were treated with a colostomy in the neonatal period by a delayed LAARP.

Results: Laparoscopic mobilization has been possible on all the cases attempted. All of the patients have a brisk and symmetric anal contraction with perineal electrostimulation. Followed up period was 4 months to 10 years. Three patients died because of following the heart surgery. Rectal prolapsus developed in two patient with sacral anomalies underwent revision. In 11 patients, older than five years, anorectal functions were good in 6 patients (22%), fair in 5 (18.5%) and incontinent in 4 (18.1%). In 10 patients with smaller than 5 years, anorectal functions could not be evaluated.

Conclusion: In this study, results of anal functions in patients older than 5 years and early results in patients smaller than 5 years showed that LAARP one of the good option for treatment of high imperforate anus.

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OP30: Investigation of the effectiveness of honey and sugar on prevention of fibrosis in corrosive esophagitis induced rats

AF Aydin, ÇA Karadağ, N Sever, A Yildiz and Aİ Dokucu

Paediatric Surgery Department, Şişli Etfal Training and Research Hospital

Aim: The aim of this study is to investigate the efficacy of honey and sugar on the prevention of fibrosis and stricture development after esophageal caustic injuries in rat.

Materials and methods: Twenty-four rats were divided into four groups; sham-operated, untreatment, honey, sugar groups. A standart caustic esophageal burn was created by applying 1 ml of %25 NaOH for a period of 60 s followed by water rinse. Honey group recieved (0.1–0.2 g) pure honey twice a day and diluted honey (9 g/100 cc, 28 kcal/100 cc) in rat's drinking water. Sugar group recieved table sugar (7 g/100 cc, 28 kcal/100 cc) in rat's drinking water. All rats were sacrificed at 21 days. Efficacy of the treatment was assessed by measuring macroscopic stenosis formation, stenosis index, histopathologically connective tissue score and weight changes.

Results: At the end of the study, the stenosis index, connective tissue score and mean body weight loss in the honey and sugar-treated groups was significantly lower than untreated group and smilarly in the sham laparatomy group. Effectiveness of honey is relatively more than sugar. The rate of macroscopic stenosis was 83% in untreated group but 16% in honey group, and 16% in sugar group. No stenosis has been observed in sham group.

Conclusion: The conclusion of this study is that honey and sugar reduces similarly the degree of fibrosis and can prevent development of stenosis of esophagus occurred after alkali esophagus burn in rat model.

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OP31: Assesment of the effectiveness of N-acetylcysteine with histopathological and biochemical parameters at the early and late periods of oesophageal corrosive burns

Ö Katia, İ Ötgüna, E Demiralayb, T Çandarc and A Hiçsönmeza

Departments of aPediatric Surgery, bPathology and cBiochemistry, Baskent University Faculty of Medicine

Aim: In this study, our aim was to show the earlier and late histopathological changes, effects on glutathione (GSH) level and oxidative stress of N- acetylcysteine (NAC) – which is an antioxidant- on the rats who had corroded esophagus.

Materials and methods: 49 female Wistar Albino rats were used. Modified Gehanno and Guedon models were used to make corroded esophagus. Rats were divided into 3 main groups. Group 1: SHAM, group 2: esophagitis with no treatment, group 3: esophagitis with the therapy of NAC. Each group was divided into 2 subgroups (a) and (b). In the group with therapy, NAC was given after 2 h of corrosion and the treatment was given to both subgroups for 10 days. Group (a) were sacrificed on day 11, group (b) were sacrificed on day 21. Esophageal specimen and blood samples which were collected from those rats, were studied histopathologically and biochemically. MDA, which is an outcome of lipid peroxidation, was studied on tissue samples and plasma. GSH, which is an antioxidant molecule, was studied on tissue and blood samples.

Findings: Histopathological studies show that the rats, which were sacrificed on the 11th day of the caustic damage, the damage was milder in those treated with NAC than those with esophagitis. In those rats which NAC was given metabolite levels were lower than those without treatment but glutathione levels were higher. The levels were not divergent in those collected on the 21st day.

Discussion: In this experimental study, significant effects of NAC treatment were shown histopathologically. Studies with different dosages and the time of NAC treatment are necessary. NAC can be a promising treatment in corroded esophagus cases.

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OP32: Corrosive substance ingestion: what have changed in last decade?

E Aydin, R Özcan, Ş Emre, M Eliçevik, S Kuruoğlu, N Sarimurat, D Yeker, G Topuzlu Tekant and E Erdoğan

Departments of Pediatric Surgery, Istanbul University, Cerrahpaşa Medical Faculty, Istanbul Turkey

Purpose: We analysed the patients that have admitted to our clinic due to caustics.

Materials and methods: In years 2000–2010, 537 patients (Male:345, F:192) that have been admitted to our clinic due to caustics retrospectively analysed. The mean age was 3.9. In 470 of the cases the caustic was acidic but base 67 of the cases.

Results: The patients was analysed in two groups. 356 patients that admitted to our clinic in 48 h after ingestion corrosive subtance were stoped feeding and endoscopy was performed. 164 patients (Grade 1: 42, grade 2: 109, grade 3: 13) of all have some degree of caustic oesophagus burn in the first endoscopy. All the patients those were diagnosed as grade 2 or 3 caustic oesophagus burn medically treated by iv antibiotic, steroid and H2 receptor antogonist and fed by the way of nasogastric tube. Patients were fed by orally on findings in control endoscopy that performed 15 days after the first one. 55 patients (%33) have been admitted to dilatation programme due to stricture. The mean dilatation number was 6.2. Colon interposition was performed in 9 of those patients. Tracheostomy, gastrostomy and oesephagostomy was performed in one patient, resection-anostomosis was performed in one patient and antrectomy was performed in one patient due to gastric outlet obstruction. 181 patient were admitted to our clinic 48 h after ingestion the caustics. 98 of them (%54) stricture was developed. The mean dilatation number was 6.4 for this group. Colon interposition was performed in 13, resection and anastomosis in 2 patients of all. Five piloroplasty, 2 antrektomi, 1 pyloromyotomy and 1 antrektomy was performed in 9 patients those result at gastric outlet obstruction. One patient died due to severe burn after performing gastrectomy, oesephagectomy and duedenostomy.

Conclusion: Burn in oesephagus and gastric due to caustics still has severe morbidity and mortality ratios.

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OP33: Comparison of collis and uncut collis antireflux procedures in the treatment of gastroesophageal reflux

S İskit, R Tuncer, Z Özçelik, G Güler, M Alkan and H Okur

Department of Pediatric Surgery, Çukurova University Medical Faculty, Adana, Turkey

Aim: To review the results of Collis (CA) and ‘uncut Collis’ (UCA) antireflux prosedures in our series.

Materials and methods: We evaluated the clinical data of children undergoing CA and UCA in our department and age, sex, diagnosis, duration of symptoms, indication, preop and postop endoscopic findings of the patients were noted.

Results: Fourteen cases with the median age of 8 (8–18) underwent CA (7) and UCA(7). Indications for surgery were gastroesophageal reflux in 12 patients (esophageal atresia, diaphragmatic hernia, stricture) and shortness of intraabdominal esophagus secondary to distal resection in the remaining ones. The median time to start feeding was 6 days and median length of hospital stay was 10 days after the operation. Three of the patients was out of clinical follow up and median duration of follow up fort he remaining ones was 10 (5–108) months. Gastroesophageal reflux could be controlled in all of the CA patients. However, there was a recurrence of gastroesophageal reflux in all of the followed UCA patients.

Conclusion: Collis antireflux prosedure has found to be more effective than ‘Uncut Collis’ antireflux procedure.

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OP34: Our surgical management on achalasia

B Kiliç, T Günendi, AO Kaya, F Gün, T Salman and A Çelik

Department of Pediatric Surgery, Istanbul University Istanbul Medical faculty

Aim: Achalasia is a disorder of esophageal motility and is rare in children. In this study, our aim is to review children who were treated for achalasia by symptoms, diagnosis, treatment, type and complications. Retrospectively.

Materials and methods: 21 patient (13 male, 8 female) ages ranging between 7 months–15 years through 1988–2011 who treated for achalasia. Symptoms were vomiting (%62), dyphagia (%33), weight-loss (%14.2), coughing (%14.2), wheezing (%9.5). Symptoms period ranged from 1 month–6 years. Diagnosis was established by barium meal enema all patients however 8 patients neeed additional oesophaegeal manometry. 3 patients were diagnosed for Triple A syndrome on follow-up. Baloon dilatation was perfomed in 5 patients whose ages between 14 month–11 years. Heller kardiomyotomy and Thal fundoplication were performed of all patients. 1 patient had an additional myotomy operation secondary to insufficient prior myotomy. 2 patient had GER on follow up responsive to medical therapy.

Results: We believe that Heller myotomy conducted with thal funduplication is an effective method with minimal complication rates in achalasia treatment.

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OP35: Laparoscopy-assisted endorectal pull-through for Hirschsprung's disease

M Küçükaydin, S Arslan, AB Doğan, A Aslan, KC Sulubulut and Ö Yandim

Department of Pediatric Surgery, Erciyes University, School of Medicine, Kayseri

Background and aim: There has been a recent trend in the use of laparoscopic-assisted one-stage endorektal pull-through in the management of Hirschsprung's disease (HD). We want to present our experience with laparoscopic assisted endorektal pull-through (LAERPT) for HD in the small infants.

Materials and methods: From January 2005 to August 2010, 30 patients (18 boys, 12 girls)underwent LAERPT for biopsy-proven HD in our clinical. The patients' ages at operation ranged from 10 days to 2 months (mean age 20 days). The procedure was done through one 4 mm camera and two 3 mm working ports. The transition zone was identified by seromuscular biopsies obtained laparoscopically. The colon and proximal rectum were mobilized laparoscopically. A transanal endorectal mucosal dissection and a coloanal anastomosis were done, using an absorbable monofilament 4/0 polyglyconate suture. Anal dilatation program was started in 14 th day of operations.

Results: The entire mobilization of the bowel as well as biopsy confirmation of the transition zone was done laparoscopically in all the cases. The median operative time was 120 min (range, 90–150 min). All children tolerated full enteral feeds after 48 h and the median hospital stay was 5 days (range, 4–7 days). There were no early postoperative major complications. Two cases developed the mild enterocolitis that resolved with conservative management. The average followed up period was 3.5 years. The overall functional outcome was good in all cases with no soiling, stool incontinence or constipation.

Conclusion: LAERPT, apart from being cosmetically superior, permits obtaining biopsies as well as an adequate mobilization of the bowel and a minimal dissection which causes less damage to the internal sphincter and pelvic nerves.

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OP36: ‘To cut or not to cut the cuff’ in transanal endorectal pull-through procedure in Hirschsprung's disease

Ç Akyildiz, S Tiryaki, A Çelik and O Ergün

Department of Pediatric Surgey, Ege University

Aim: Transanal endorectal pull-through (TERPT) has become the most popular procedure in the treatment of Hirschsprung's disease (HD) in recent years. Whether to cut the rectal muscular cuff is a matter of debate to impact the long term functional outcome after surgery. The aim of this study was to examine the functional and manometric outcome in patients with cut or uncut rectal muscular cuffs in TERPT procedure.

Patients and methods: Thirty four patients had undergone TERPT procedure between years 2001–2010. Families of all patients were thoroughly inquired for their anorectal function including postoperative enterocolitis, constipation, fecal soiling and incontinence. Sixteen (cuff cut: 6, cuff uncut: 10 patients) agreed to be further evaluated by anorectal and vector volume manometry.

Results: Mean age of patients was 18 months (1 month–12 years) and mean postoperative follow-up was 18 months (2–66 m). All 34 patients were continent in the series. There was no postoperative enterocolitis; however, constipation was noted in 2 in the ‘cut’ and 4 in the ‘uncut’ group. Four patients in the ‘cut’ and 6 in the ‘uncut’ group mentioned soiling.

Mean age of patients who underwent manometric evaluation was 4.1 years for uncut and 5.2 years for cut group; mean postoperative follow-up was 5.6 and 6.4 years respectively. Manometric values for ‘cut’ and ‘uncut’ groups respectively were: Mean resting anal canal pressures 28.1±12 cmH2O versus 28.6±12 cmH2O (P=0.947); maximum squeeze pressures 72.8±30 cmH2O versus 67.8±29.5 cmH2O (P=0.916); length of anal canal 25±5.9 mm versus 22.4±5.1 mm (P=0.343); high pressure zone 13±4.5 mm versus 11.9±3.8 mm (P=0.611). Radial asymmetry index was for the ‘cut’ 17.3 versus 18% for the ‘uncut’ group (P=0.88).

Conclusion: There were no clinical or manometric data to justify the necessity to cut the rectal muscular cuff in TERPT procedure in HD. Larger series are required.

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OP37: Transanal endorektal pull-through versus soave-boley procedure in Hirschsprung disease: a comparision study

Ç Akyildiz, S Tiryaki, A Çelik and O Ergün

Department of Pediatric Surgery, Ege University

Aim: Although numerous operative techniques have been described in the management of Hirschsprung's disease, management strategies have evolved into less invasive and cosmetically more acceptable surgical techniques over the years. The aim of this study was to compare the functional outcomes of transanal endorectal pull-through (TERPT) and Soave-Boley (SB).

Materials and methods: Hospital records of 34 patients who had undergone TERPT and 55 patients who had undergone SB operations in the last 20 years were reviewed retrospectively. Data regarding mean hospital stay, resumption of enteral feedings, stool frequency, continence status and postoperative complications were assessed.

Results: Mean hospital stay was 18.3±9.3 days for SB and 5.6±1.7 days for TERPT (P=0.000). Enteral feedings were resumed on day 3 for SB and day 2 for TERPT (P=0.000). Stool frequency was similar (1–3/day) for both procedures. Constipation was noted in 14% of SB and 9% of TERPT group (P=0.421). Incontinence rates for SB and TERPT was 12% versus none respectively (P=0.04); however, soiling was found to be higher in TERPT group (32.3% for TERPT and 7.2% for SB, P=0.003). Postoperative enterocolitis was significantly more frequent in SB patients (n; 29%) and (n; 11%) in TERPT procedure (P=0.041). Five patients developed stercoral fistula following SB procedure. There were no statistically significant differences between the two procedures in terms of complications including anastomotic stricture, pelvic abscess and perianal dermatitis.

Conclusion: TERPT seems to be associated with less postoperative complications, better continence level, earlier resumption of enteral feedings, shorter recovery and hospital stay, perfect cosmetic outcome when compared to SB procedure; however, soiling is a significant problem for patients who had undergone TERPT.

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OP38: Comparison of the results of transanal endorectal pull-through and martin modified duhamel operations in Hirschprung's disease

Y Dere Günala, A Karamanb, D Erdoğanb, MK Aslanc, MN Azilid, H Çavuşoğlub and İ Karamanb

aDepartment of Pediatric Surgery, Samsun Women-Child Health Hospital, bDepartment of Pediatric Surgery, Dr. Sami Ulus Women-Child Health Education and Research Hospital, cDepartment of Pediatric Surgery, Kirikkale University Medical School and dDepartment of Pediatric Surgery, Ankara Child Health Hematology-Oncology Education and Research Hospital

Purpose: The availability of neonatal diagnosis of Hirschsprung's disease (HD) and developments in the neonatal anesthetic procedures have directed the surgical treatment of HD to primary pull-through operations which are preferred during the neonatal period. Transanal endorectal pull-through (TEPT) is the latest development in surgical treatment of HD. The aim of the study is to determine the effectiveness and safety of TEPT tecnique in surgical treatment of HH.

Materials and methods: Between October 2002 and May 2007 we evaluated 53 patients with HD treated with Martin Modified Duhamel (n=17), transanal endorectal pull-through (n=24) and endorectal pull-through with a laparotomy requirement after an initiated transanal approach(n=12). Age, gender, length of aganglionic segment, intraoperative details, postoperative functional results and compliations are evaluated and compared among these patient groups.

Results: In this study age at the time of operation, duration of the operation, time to first oral feeding, time to first stool and hospital stay in the patients treated with TEPT were significantlyless or shorter than those ones treated with Martin Modified Duhamel or endorectal pull-through that required laparotomy (P<0.001). Blood transfusion requirement during operation in patients treated with TEPT was less than the patients treated with other procedures, but this difference didn't reach statistical significance (P=0.109). Postoperative enterocolitis had a higher incidence in patients treated with Martin Modified Duhamel procedure, but there was also no significiant difference (P=0.338). There was no difference in the long-term functional results (continance, soiling, constipation) of all three procedures (P=0.504, 0.656, 0.584).

Conclusions: TEPT is both feasible and safe tecnique. It is a preferable choice particularly in early diagnosed rectosigmoid HD patients without enterocolitis or bowel dilatation.

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OP39: The importance of resecting the dilated ganglionic segment in Hirschsrprung's disease; experience with 203 cases of transanal pull through

Sameh Shehata

Head of Pediatric Surgery Department, Alexandria University, Egypt Middle East Reprst. of the WOFAPS

Background: The aim of this study was to evaluate the functional outcome after a one-stage transanal pull-through operation for Hirschsprung's disease in children, with specific emphasis on the importance of the dilated segment above the cone of transition.

Methods: Two hundred and three patients who underwent a one-stage transanal pull-through operation for Hirschsprung's disease were followed up for 6–24 months. The children (156 boys and 47 girls) were from 1 month to 7 years of age (mean age, 1.2 years). All patients had an aganglionic segment confined to the rectosigmoid area (confirmed by preoperative barium enema and postoperative histology). long segment disease was excluded from the study. In all cases, the dilated ecstatic segment above the area of aganglionosis was resected clinical outcome was assessed by interviews and questionnaires, Contrast barium enema was performed on all children postoperatively.

Results: The stooling patterns were considered satisfactory in 82% children. Of all the children, the mean stool times were 1 to 2 per day 6 months postoperatively, and transient postoperative soiling was found in 7%. Constipation was observed in 11%, and Hirschsprung's-associated enterocolitis in 23%. There was no cases of frank incontinence, cuff infection, or mortality noted. One case in the early series had anastomotic leak, one had fecal umbilical fistula secondary to untreated enterocolitis. Barium enema showed that the dilated and spastic colonic segment disappeared in all children. The dilated sigmoid loops disappeared in all cases on postoperative barium enema.

Conclusions: Patients with Hirschsprung's disease have normal anal sphincter mechanism, and it should be expected that the majority of patients have perfect continence after operation. The Transanal pull through for classical rectosigmoid Hirschsprung's disease has proved excellent functional results in the short and medium term follow up. Attention to certain technical details, specifically using minimal anal dilatation during the procedure, will help improve the results and avoid incontinence. The removal of the dilated segment above the area of aganglionosis is of paramount importance to achieve best functional results.

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OP40: Evaluation of quality of life perception in children following completion of treatment for Hirschsprung's disease: preliminary findings

YH Çavuşoğlua, A Karamana, ÖŞ Ünerib, B Yağiza, İF Özgünera, D Erdoğana and İ Karamana

Departments of aPediatric Surgery and bPediatric and Adolescent Psychiatry, Dr. Sami Ulus Maternity and Children's Hospital, Altindağ, Ankara, Turkey

Introduction/purpose: Quality of Life (QL) is defined as an individual's perception of his own status within a system of culture and values. Our aim in this study was to evaluate the QL in children between 2–18 years of age, whose treatment were completed for Hirschsprung's Disease (HD) according to period after corrective surgery, surgical technique and level of aganglionosis.

Materials and methods: The work was conducted in our hospital's Pediatric Surgery Clinic. The cohort included children with HD, between the ages of 2–18, with a minimum of 24 months following the completion of corrective surgery. The children that had fulfilled the inclusion criteria of the study and their parents were scored using PedsQL Pediatric Quality of Life Scale and parents were scored with Gastrointestinal Symptom Scale. Simultaneously, the sociodemographic information forms prepared by the researchers were completed.

Results: The cohort included 17 children and their parents. The parent Physical Health Summary Scores (PHSS) and Total Scale Scores (TSS) of children operated with Duhamel technique were significantly higher than operated with transanal endorectal pull trough technique (P<0.05). All scores of children with 4 and more years passed after their last operation were significantly lower than with 2–3 years passed (P<0.05). The Psychosocial Health Summary Score (PsHSS) of children with long segment HD was significantly higher than children with short segment HD (P<0.05). There were no significant differences with other scores. There was a good correlation between the parent ve child for PsHSS but no correlation for PHSS and TSS.

Conclusion: QL is a new tool assessing the results of chronic pediatric patients besides following short and long term complications. The results obtained from these studies will give us valuable clues when consulting the families of patients with HD, and to know which functions were defective will help us to direct our efforts to fix that function. It was an unexpected finding that all scores of children with 4 and more years passed after their last operation were significantly lower than with 2–3 years passed, but the results of our study cannot be generalized due to the limited sample size. This abstract qualifies as a preliminary evaluation of our ongoing study.

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OP41: Transanal endorectal pull-through for Hirschsprung's disease: experience with 44 patients

Ü Adigüzel, İ Kiriştioğlu, M Kaçar and H Doğruyol

Department of Pediatric Surgery, The Medical Faculty of Uludag University, Bursa, Turkey

Aim: Transanal endorectal pull-through (TEPT) is the latest development in treatment of Hirschsprung's disease (HD). The aim of this study was to evaluate the outcome of TEPT in HD for demographic, clinical finding, diagnosis and results and follow-up after TEPT.

Materials and methods: A retrospective study of 44 patients who underwent TEPT between June 2001 and December 2010 was conducted. These patients were evaluated with regard to age, sex, preoperative investigations, length of the aganglionic segment, intraoperative and postoperative complications and result of follow-up.

Results: Thirty-eight patients were boys and 6 were girls. The patients' ages ranged from 14 days to 8 years (mean, 8 months). Sixteen patients were operated in first 2 months of their life. The most common symptoms were abdominal distention and vomiting. Delayed meconium passage (>24 h) was found in 32 (72%) patients. The primer diagnosis in 35 patients was barium enema and anorectal manometry finding. Rectal biopsy was performed in only 9 (20%) patients before the TEPT. Preoperative barium enema and anorectal manometry performed in 43 patients. Barium enema showed transitional zone in 38 (88%) patients. Barium retansiyon, more than 24 h, was found 39 patients. An anorectal manometry revealed lack of rectoanal inhibitory reflex in 37 (86%) patients. Hirschsprung's-associated enterocolitis (HAEC) was seen preoperatively in 11 patients. Seven of the patients had a history of previous laparotomy. The average length of resected bowel was 25.5 cm (range, 10 to 50 cm). Two patients required laparotomy because of achieve ganglionic segment. The mean time of start feeding was 1.8 days. Average follow-up was 26 months. Postoperative complications included transient perianal excoriation in 12 patients, HAEC in 10, anastomotic stricture in 3, encopresis in 3, recurrent constipation in 2, rectal prolapse in 1 and rectovestibuler fistula in 1. Medication was needed more than 2 weeks in 8 patients.

Conclusion: The transanal endorectal pull- through is a feasible and safe procedure in children with rectosigmoid HD. The clinical outcome is satisfactory. The hazards and morbidities associated with laparotomy and colostomy may be avoided with a TEPT technique in HD confined to the recto-sigmoid region. The outcome has been favorable, but long-term follow-up is necessary for full assessment of those patients.

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OP42: Transanal pullthrough for hirschsprung disease; functional evaluation for postoperative incontinence

MS El-Debeiky, HA Safan, IA Shafei, AF Hamza and SA Hay

Department of Paediatric Surgery, Ain Shams University, Cairo, Egypt

Background: There is a growing acceptance of one-stage primary transanal pullthrough procedure for treatment of children with Hirschsprung Disease specially neonates to reduce the risk of abdominal surgery and its postoperative morbidity. The purpose of this study was to evaluate the anatomical and physiological status of the ano-rectum and the related neuromuscular complex in children with postoperative incontinence.

Materials and methods: 31 patients with incontinence after at least six months postoperative were subjected to evaluation by anorectal manometery, endoanal ultrasound, needle EMG and barium enema. Informed consent from parents of each child and acceptance of the ethical committee for medical research in the institute was obtained.

Results: Anorectal manometery showed weak resting pressure in 11 patients, weak squeezing pressure in 17 and failure to maintain squeezing in 7 of the 14 with good squeeze. Sensation was absent in 18, induced by volume higher than normal in 7 and within normal references in 6 patients. The Rectoanal inhibitory reflex was absent in 26 and weak in the remaining patients. Endoanal ultrasound revealed injury to either internal or external sphincters in all cases. Deficient sensation and nerve conduction were encountered by EMG in 15 children. Colonic dilatation was only present in 2 cases.

Discussion: Despite the safety and short learning curve, transanal pullthrough seems to present a considerable risk to the state of continence and needs to be revised to decide upon the chances of improving the outcome.

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OP43: Transanal endorectal pull-through for Hirschsprung's disease during the first month of life

Kamal Abd El-Elah Aly

Department of Surgery, Pediatric Surgery Unit, Faculty of Medicine, Mansoura university, Egypt

Background/purpose: Hirschsprung's disease (HD) is a common cause of bowel obstruction in the newborn period. One-stage surgery for HD is well established and the results are comparable or better than multistage surgery. The aim of this study was to test the feasibility and safety of transanal endorectal pull-through (TEPT) for management of HD during the neonatal period.

Patients and methods: 28 neonates having HD were treated with TEPT at pediatric surgery unit, Mansoura University Children's Hospital (MUCH) during the period from May 2007 to Jun 2009. Six cases were in need for concomitant laparotomy due to long segment disease. Endorectal mucosectomy was started one cm. above dentate line and continued till the peritoneal reflection. The affected bowel was resected and colo-anal anastomosis was performed with 4/0 absorbable sutures.

Results: The mean operative time was 90±18 min. Blood transfusion was not needed. Oral feeding started 24–48 h postoperatively and the mean hospital stay was 3–5 days. The commonest postoperative complication was perianal excoriations (64.3%), anastomotic leak occurred in one case. Two cases were in need for repeated dilatations while 4 cases presented with postoperative enterocolitis (EC).

Conclusion: TEPT during the neonatal period is easy, bloodless, without visible scar and with short intraoperative time and postoperative hospital stay.

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OP44: Intra vesical pressure measurement can be used as a guide at the management strategy of high risk childhood diseases

E Divarcia, A Çelika, B Karapinarb, M Yalazc and O Ergüna

aDepartment of Pediatric Surgery, Ege University Faculty of Medicine, bDepartment of Pediatrics, Intensive Care Unit and cDivision of Neonatology, Izmir, Turkey

Aim of the study: Which patients with abdominal trauma or mechanical bowel obstruction (MBO) will necessitate surgery at the follow- up? How can we decide management strategy while the closure of abdominal wall defects (AWD)? Can we use a guide at the fluid resuscitation in septic shock? We aimed to investigate the utility of intra vesical pressure (IVP) measurement to answer these questions.

Materials and methods: A prospective study was performed between December 2009 and October 2010. IVP was measured to determine intra abdominal pressures (IAP). Intra abdominal hypertension (IAH; >12 mmHg) and abdominal compartment syndrome (ACS; >15 mmHg+a new organ dysfunction) were used as thresholds in decision making.

Results: IVP monitoring was used in patients with abdominal trauma (14), abdominal wall defects (8), fluid resuscitation in septic shock (7) and MBO (6). ACS developed in 2 (14%) of trauma patients and only these 2 patients required surgery. IAH/ACS was seen in 3 patients (38%) with AWD, and closure strategy was arranged according to IAP measurements. IAH was seen in 3 (43%) patients during the fluid resuscitation in septic shock, and early decompressive intervention was performed to prevent progression to ACS. IAH/ACS was seen in 3 (50%) of MBO patients, and only these 3 patients underwent surgery.

Conclusion: IVP measurement may be a useful adjunct to identify and determine the candidates for surgical treatment in trauma and MBO. Similarly, closure of abdominal wall defects and fluid resuscitation in septic shock may be performed and adjusted with regular IVP monitoring.

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OP45: Functioning adrenal tumors in children: clinical features and prognostic factors

N Dessouky, N Kaddah, W Mostafa, A Kholy and G Tagi

Pediatric Surgical Division, Cairo University Faculty of Medicine, Cairo University Specialized Pediatric Hospital, Egypt

Aim: This study aimed to evaluate the various clinical syndromes of these lesions, the different methods for their diagnosis, their pathologic findings, the different surgical approaches for their excision, and their clinical outcomes in correlation to their pathological features.

Methods: All patients with functioning adrenal tumors presenting to the Pediatric Surgical Division, Cairo University over a period of 24 years, between 1986 and 2010 were clinically analyzed. Full radiological studies and endocrinologic workups were performed. All patients were treated by surgery using different surgical approaches. The tumor's size and weight were recorded and its histological grading was performed according to Weiss criteria. Follow- up of the patients was achieved through clinical, radiological and hormonal assessments.

Results: The study included 29 patients–19 females and 10 males–with their ages ranging between 1.8 and 16 years (mean=6.2 years). Two sisters were affected with left-sided virilizing adrenocortical carcinoma. Twelve patients presented with features of virilism, 6 cases had signs of Cushing's syndrome, one girl with feminization, 7 cases with sustained hypertension, 2 cases with diarrhea and one case with seizures. Palpable abdominal masses were present in 7 patients: four with signs of virilization and three with Cushing's syndrome. Both sides of the adrenal gland were equally involved in 11 cases each, with bilateral lesions in one case of pheochromocytoma. Ten lesions were less than 5 cm in diameter, one of them was malignant, while 12 tumors were less than 100 gm in weight, and two of them were malignant. Medullary lesions included 6 cases of benign pheochromocytoma, 3 cases with neuroblastoma and a case of ganglioneuroblastoma. Among 19 patients with adrenocortical tumors, 7 had four or less positive Weiss histological criteria, all of them had favorable outcome while two of the other 10 cases remained disease-free with a follow-up which ranged between 3 months and 7 yearsThree cases developed local recurrence after surgery and 5 patients died postoperatively after partial response to chemotherapy, 4 of them had distant metastases.

Conclusion: Virilization is the commonest presentation, which is commonly due to carcinoma in females or adenoma in males. On the contrary, Cushing s syndrome is commonly due to carcinoma in males and adenoma in females. Palpable abdominal mass was rather uncommon and considered a late manifestation with poor prognosis. CT scan remains the standard accurate modality for their localization and during follow up. Complete removal of the tumor is the only effective treatment, the role of adjuvant chemotherapy or radiotherapy cannot be confirmed. Laparoscopic adrenalectomy needs to be tried and evaluated in small lesions. The determination of the neoplasm's behavior by morphologic and histological criteria can often be unpredictable, even small lesions can be malignant and potentially lethal. Careful clinical follow-up may remain the final indicator for the diagnosis in some of these tumors. A more advanced study to analyze the familial occurrence of adrenal tumors in children is needed and the possible role of exposure to toxic substances in its occurrence.

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OP46: Laparoscopic surgery for Choledochal cysts in children

N Dessoukya, T Yassina, KH Bahaaeldina, A Huseina and S Shehatab

aDepartment of Pediatric Surgery, Cairo University Faculty of Medicine, Cairo University Specialized Pediatric Hospital, Egypt and bDepartment of Pediatric Surgery, Alexandria University Faculty of Medicine, Alexandria, Egypt

Background: Cyst excision and biliary reconstruction is the treatment of choice for Choledochal cyst (CC). Laparoscopic approach for treatment of complex biliary diseases has proven to be possible, yet there are only limited reports of using minimally invasive surgery (MIS) in handling this problem in children. In general, few reports have compared Roux en-Y hepaticojejunostomy (RYHJ) and Hepaticoduedenostomy (HDD) for completion of the biliary-enteric (BE) anastomosis after CC excision.

Purpose: To review the different techniques of MIS for the management of Choledochal cyst in the pediatric age group with assessment of the benefits, results and complications of each technique in treatment of such disease in children. These results are compared to those obtained from the classic open surgical approach in correction of such anomaly.

Materials and methods: Thirteen cases with Choledochal cyst (Group-1) were studied and laparoscopicaly managed in the Cairo University Specialized Pediatric Hospital (CUSPH), from June 2007 till September 2010. Eight of them were females and 5 of them were males. Their ages ranged between 1 year and 11 years. The CC was laparoscopicaly dissected and excised with its ligation at the lowest possible level. The proximal end is divided with exposure of the common hepatic duct (CHD) or its confluence. In cases where the CHD larger than 10 mm, a (RYHJ) was performed through an enlarged umbilical port and then end to side anastomosis was completed by laparoscopic hand suturing technique (Group-1A). Cases where the CHD diameter is less than 10 mm, laparoscopic BE reconstruction was performed through a HDD (Group-1B).

The results were primarily compared to those obtained in 10 cases of CC performed during the same period, corrected via the open surgery technique (Group-2).

Results: The Choledochal cyst was type I in 17 cases (73.9%): 5 in each of G-1A and G-1B with 7 in G2, type II in 2 cases (8.7%): a case in G-1B and G2; and type IV in 4 cases (17.4%): 2 cases for each G-1A and G-2. The diameter of CC ranged between 2.3×2 cm minimum & 11×9.2 cm maximum with a mean of 5.1×3.9 cm. Laparoscopic excision of CC with BE reconstruction was completed in 11 cases (6 in G-1A and 5 in G-1B; in these later, total laparoscopic reconstruction was achieved. Two cases were converted to open surgery: a difficult case of laparoscopic BE anastomosis in G-1A and a case of bleeding from the wall of the CC in G-1B. Bile leakage resulted in 3 cases: 2 in G-1A and a case in G-1B. These have closed spontaneously in all these cases being prolonged for 2 weeks in one case. The mean duration of operation for laparoscopic group was 235 and 172 min in G-1A and G-1B respectively, while the mean duration of operation for open group was 133 min. The mean duration of hospitalization was 9, 7.5 and 11.5 days for G-1A, G-1B and G2 respectively.

Conclusion: Choledochal cysts in children can be effectively and safely managed by MIS. It requires advanced skills and considerable learning curve so as to allow meticulous dissection and suturing in a restricted operative field thus reducing the operative time, hospital stay and possible complications. To reduce reflux, choledocoduedenostomy for small caliber common hepatic duct, apparently is techniqualy easier to be completed laparoscopically with a shorter time for hospital stay. More advanced randomized studies are needed to be able to proper evaluate the results of the different techniques for laparoscopic management of Choledochal cysts in children in comparison to those of the traditional open surgery.

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OP47: The epidemiological study of major burn patients in central anatolia and recommendations for combatting burn injuries

İ Çiftcia, K Aslanb, Z Altunbaşb, F Karac and H Yilmazd

aUniversity of Selcuk Selcuklu Medical Faculty Pediatric Surgery Department, bKonya Education and Resaerch Hospital, cUniversity of Selcuk Selcuklu Medical Faculty Public Health Department and dUniversity of Selcuk Selcuklu Medical Faculty General Surgery Department

Aim: The studies about the prevalence of burns in national or provincial level which represent the entire population increase over time. The purpose of this study is to estimate the incidience of national burn population and reveal the properties of them by analyzing the burn patients applying from Konya and surronding population retrospectively.

Materials and methods: In the study 457 burn patients admitted to Konya Training and Research Hospital Burn Unit between 2008–2010 were reviewed retrospectively. The patients were hospitalized according to ABA (American Burn Association) criteria and all of them were major burns. Patient's age, sex, the agents causing burn injury, admission times to the health center, the area and depth of burn, the months when the burn occurred were analyzed.

Results: The female population was greater than male. 204 (44.6%) patients were between 0 and 5 age which were statistically significant. Second degree burns were found in 377 (82.7%) patients. The mean duration of application time to the health center was 252.8±892.5 min. Most of the burns were on head and neck region but this was not statistically significant. Scald burn up to 247 agents (54.1%) cases were in the form of burns. In second place flame burns 95 (20.7%) cases, 23 (5.1%) cases were electrical burns.

Conclusion: In this study, the incidence of burns and the properties of burn patients were confirmed from a sampling which represents all of the country population.

From this study we think that the plan for combatting burns should be as following.

The first step to combat burns is to protect children for the perevention of children burns.

Parent information and training should be essential in preventing children burns. Parents should be informed about the the seriousness and difficulty of burn treatment.

The reasons of scald burns should be determined. The traditional tea drinking habits have been reviewed and further prevention methods should be taken.

The persons exposed burn injury must be transferred to the health center immediately and safely. Then if necessary they have to be send to a special burns unit.

Burn treatment units must be managed from a single center which is connected to each other with a network.

It should not be forgetten that contact burns are usually seen on small areas but their effects are deep. So the treatment should de done according to this.

The domestic accidents play gerater role in burn injuriesand this affects children firstly and young ladies secondly. So the plan of the house designing should be done by thinking children. They must be get away from any factor that may cause burn injury and their parents should be trained about this subject.

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OP48: Traumas and pediatric surgery the evaluation of pediatric traumas in a metropolitan child trauma center in two years

F Akbiyik, F Özcan, S Demir, D Çalişkan, H Demirkan and T Tiryaki

Ankara Dişkapi Children's Hospital, Clinic of Pediatric Surgery

Introduction and aim: The child trauma cases who register to the child trauma center localized in Yildirim Beyazit Research and Training Hospital by the support of the pediatric surgery department of the our institution were evaluated to see the distrubution of diagnosis to be able to make new programs for the future.

Materials and methods: The records of 1546 children, younger than 18 years, who have applied to the center either by themselves, by 112 emergency system and/or by referral system from another hospital in the last two years were inspected retrospectively.

Results: The distrubution of the reasons for application among total cases were; 706 traffic accidents, 321 other symptoms related to trauma, 114 drug intoxication, 198 beating, 96 falling down, 79 firearm or perforating/cutting instrument injury and 32 carbon monokside intoxication. Among the children whom pediatric surgery consultation was required from (n:289), 75 cases were hospitalised. Laparotomy fro 4 cases, primary suturation for 4 cases, examination under general anesthesia for 3 cases and cystoscopy for one case were needed. Among the children whom orthopedia consultation was required from (n:480), 23 cases were hospitalised and gone under surgery. Among the children whom brain surgery consultation was required from (n:563), 45 cases were hospitalised and 20 among those were operated. Thirteen of the cases consultated by plastic surgery (n:179), 10 of the cases consultated by general surgery (n:57) and 4 of the cases consultated by cardiovascular surgery (n:83) were operated by the teams of those departments. Fourteen patients in total had died. Among those, two were intraoperative exitus cases during pediatric surgery. To sum up, 18% of the trauma patients was consultated by pediatric surgery department, 25% of those was hospitalised and only 4% was needed surgical procedure.

Conclusion: Travma cases require multidiscipliner approach. Pediatric surgery is one of the main disciplines for the evaluation of pediatric traumas. When planning to establish pediatric trauma units, health authorities should consider pediatric surgeons to exist sufficient in number and to work effectively.

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OP49: Perineal trauma in children: a standardized simple management approach

Amel Hashish

Department of Pediatric Surgery, Tanta University, Egypt

Background/purpose: The management of perineal trauma in children can be very challenging in absence of a well-defined institutional management protocol. The purpose of this study was to evaluate the result of implementing a standardized therapeutic approach to perineal trauma in children in our institution.

Methods: Thirty two patients with perineal trauma were treated at Tanta university hospital and affiliated hospitals during the period from May 2003 to July 2010. After initial assessment, resuscitation and treatment of any existing life threatening condition, the perineal with trauma was treated either by primary repair of all perineal soft tissue injuries without colostomy (group I, n=16), primary perineal repair with with covering colostomy (group II, n=11), or fecal diversion and wound drainage with delayed sphincteric repair if needed (group III, n=5). Each patient was assigned to a particular management depending on the presence or absence of full thickness anorectal injuries, anorectal lacerations, degree of wound contamination, and significant skin loss All patients were evaluated as regards to the type of trauma, findings of physical examination, type of management, postoperative wound infection or disruption, functional (anorectal continence) and cosmetic results.

Results: The ages ranged from 1 to 14 years. Two patients died due to associated head trauma and other concomitant injuries in group III. Significant wound infection occurred in 3 patients (one in each group), partial wound disruption occurred in 2 patients in group I. Normal anorectal continence was reported in 25 (80.6%) of 31 patients who are older than 3 years.

Conclusion: (a) The proposed simple algorithm for management of perineal trauma in children has facilitated decision making in emergency room (b) Primary repair of the anorectal sphincter and other injured soft tissue with or without covering colostomy is recommended (c) Fecal diversion without sphincteric repair should be reserved to cases with significant anorectal lacerations associated with gross contamination.

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OP50: The evaluation of trauma patients who admitted to a pediatric surgery clinic and the development of a new trauma score

Y Çolakoğlu and A Kazez

Department of Pediatric Surgery, Firat University, Faculty of Medicine, Elaziğ, Turkey

Adult trauma scores are not reliable in children. Also the reliability of Pediatric Trauma Score (PTS) is questioned. In this study, the development of a new pediatric trauma score was aimed.

Children who admitted to Firat University Hospital, Clinic of Pediatric Surgery for trauma were investigated. Data were collected from 410 children with trauma, retrospectively between June 2009 and January 2000, and prospectively betweeen July 2009 and December 2010. Patients were classified as ‘exitus’ (Group I) and ‘alive’ (Group II). ‘Trauma Evaluation Form’ was developed for evaluation. Patients' identity information, demographic data, details about trauma, and data of examination and laboratory results were written in this form. Revised PTS (R-PTS) was created with points of Abbreviated Injury Scale (AIS) extracted from patients' PTS points (R-PTS: PTS-AIS). Data were analysed using SPSS 17.0 for Windows. Independent Samples t, Ki-square and Mann-Whitney U test were used in analyses. Reliabilities of AIS, PTS and R-PTS were evaluated with ROC curve.

There was no statistically significancy found between mortality and age, weight, white blood cell count, abdominal injury, surgical interventions (P>0.05), while there was statistically significancy between mortality and Hgb, Htc, platelet, amylase, blood presure, respiratory, pulse, endotracheal intubation, CPR, blood transfusion, blunt trauma, liver repair, thoracotomy, tube thoracostomy, head- cervical trauma and thoracic injury (P<0.05).

Mean scores and predictive values were 4.6±2.6 and 0.50 for AIS, and 9.1±2.3 and 2.50 for PTS, 4.5±4.1 and −3.5 for R-PTS, respectively. Area Under the Curve (AUC); 0.099 unit 2 for AIS was found as 95% confidence interval at ROC curve and this was well below ‘acceptabl value’ and AUC was 0.933 unit 2 for PTS and this value was found as ‘perfect’. Also AUC;0.981 unit 2 for R-PTS was a higher value and it was found as ‘perfect’.

However, R-PTS is more reliable according to PTS, it should be tested for larger patient groups.

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OP51: Carcinoid tumor in appendicitis

A Sayana, A Arikana, T Özdemira, FN Narlia, HN Özera, H Turana, A Karagözoğlua and Ü Bayolb

aClinic of Pediatric Surgery and bPathology Laboratory Tepecik Educational and Research Hospital Yenisehir, Izmir

Aim: Carcinoids which are a group of neuroectodermal tumors are found in midgut 85 and 46% of these are found in appendix. They are asymptomatic because they are poor in serotonin residing cells and are randomly encountered in appendectomy material (0.3–0.8%). We present our cases to stress the clinical properties of these histologically diagnosed lesions.

Materials and methods: The retrospective clinical data of 14 patients, 9 female and 5 male, who are diagnosed as carcinoid tumour between ages of 3 and 14 among 1961 patients whom appendectomy is performed between years 2000–2011 are evaluated.

Findings: All of our patients are interned as pre-diagnosis of acute appendicitis with the complaints of right lower quadrant pain, nausea and vomiting within 1–4 days. All of the patients are operated after routine laboratory and imaging. Appendectomy is performed to 8 perforated and 6 phlegmanous appendix. In histopathological evaluation of the specimens, carcinoid tumor of 1–1.4 cm diameter is found in distal portion of the appendix. No extra handling is carried out because of the common knowledge of distal tumors with less than 2 cm in diameter rarely metastases. All patients are followed up with close controls and no complications are found during both early and late post operative period.

Result: There should be no unnecessary stress about the carcinoid tumors after appendectomies but patients should be closely followed up after correct evaluation of tumor properties. Further evaluations and interventions should be carried out in tumors with malignant properties or tumor size greater than 2 cm.

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OP52: Our clinical experiences in choledochal cysts in children

A Sayana, A Arikana, T Özdemira, HN Özera, M Cana, FN Narlia and Ü Bayolb

aClinic of Pediatric Surgery and bPathology Laboratory Tepecik Educational and Research Hospital Yenisehir, Izmir

Aim: In children, congenital dilatation of choledochus that defined as choledochal cyst is considerably rare. 2000 patients, 2/3 of them from Japan, were declared and 2/3 of these patients were female. By presenting patients in our clinic, it's aimed to emphasize the clinical properties of disease and treatment methods.

Materials and methods: In our clinic, clinical properties of 5 male and 6 female patients in 8/365–12 age group with the diagnosis of choledochal cyst, between 1995–2011 years, were analyzed retrospectively.

Findings: 2 patients were diagnosed with the cystic mass seen in antenatal USG. In one of patients, cystic mass under liver were seen in USG by reason of falling; diagnosis of choledochal cyst became definite by the result of computerized abdomen tomography and magnetic resonance cholangiopancretography (MRCP). It was learned that complains were abdominal pain, vomiting, fever in one patients and additionally obstructive jaundice in other 7 patients. For diagnosis, USG implemented to all patients, BT to 7 patients, HIDA to 3 patients, ERCP to 2 patients, cholangiopancretography to 2 patients and MRCP to 7 patients. In 3 patients type II and other patients, type I choledochal cyst were determined and diverticulectomy, cystectomy, roux-en-y hepaticojejunostomy were performed. In observation, invagination revised by manual reduction occurred in 1 patient, twice repeated cholangitis occurred in one patient, in another patient, who were performed ERCP, pacreatitis regressed by nonoperative following occurred after operation.

Result: Although choledochal cyst is seen rarely, it must be considered in patients having complains like vomiting, abdominal pain or intermittent obstructive jaundice. For patients who has cyst in liver hilus, MRCP is determined a better method than others because it isn't invasive for differential diagnosis and it shows bilier anatomy better. It's thought that cystectomy and roux-en-y hepaticojejunostomy are successful methods in terms of preventing late complications in treatment of type I choledochal cyst.

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OP53: Patients admitted to burn unit between 2005–2010: demographic data

A Karkiner, M Akgüner, G Temir, G Diniz, N Aksoy, A Dursun, Ö Okur, C Öztürk, M Yildiz, A Şencan, H Evciler, B Uçan, O Arslan and İ Karaca

Department of Pediatric Surgery, Dr. Behçet Uz Children's Hospital, İzmir, Turkey

Introduction: Although the incidence is low in developed countries due to preventive measures, burn injuries have an important morbidity and mortality rate. In this study the demographic properties of patients are evaluated.

Materials and methods: The patients treated in the burn unit between January 2005 and December 2010 were analysed retrospectively in means of age, sex, cause, state of referral, localisation, treatment modality, need of blood transfusion, duration of hospitalisation and follow-up.

Results: A total of 998 patients (616 boys and 382 girls) between 1 and 216 months (52.4±41.3), were taken into consideration. The cause was hot water in 724, flame in 95, hot milk in 56, hot meal in 53, termal contact in 28, hot oil in 21, electric in 15, and boiled grape juice in 6 patients. 485 patients were local and the rest were out of town. Localisation was face in 226, neck in 198, scalp in 51, trunk in 511, upper extremity in 546, back in 154, lower extremity in 412, gluteal in 117, and genital in 56 patients. Appropriate fluid resucitation for percentage of burn surface and systemic antibiotherapy was applied for all patients. Antibiotic embeded sterile gauzes were used as closed dressings. Blood transfusion (10–40 cc/kg) was done in 39 patients. Split thickness grefting were performed in 218 patients. Unfortunately, extremity amputation was performed in 6 patients due to irreversible necrosis. Overall duration of hospitalisation for all patients were 10.9±10.3 (1–106) days. 11 patients were lost.

Conclusion: Burn injuries due to several causes result in severe morbidity and mortality. Developed burn units play an effective and important role in treatment and follow-up of injured patients.

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OP54: Our 10 year experience with urethra ruptures: clinical series consisting of 12 cases

A Oral, M Yiğiter, T Dikmen, O Yalçin and AB Salman

Department of Pediatric Surgery, School of Medicine, Ataturk University, Erzurum, Turkey

Aims: To investigate the patients monitored and treated with Urethral Rupture (UR) and evaluate the treatment results as well as the factors contributing to it.

Materials and methods: We retrospectively investigated records of patients that received treatment at our clinic for UR between 2001 and 2011. The patients were evaluated in terms of age, gender, cause of injury, type of illness, accompanying pathology, treatment type, length of stay, complications and mortality.

Results: 12 patients with a diagnosis of UR were admitted to our clinic within the 10-year period. The mean age of patients was 91 months (ranging from 1 to 156 months). All of the patients were males. UR was caused by a traffic accident in 8 patients (61%), falling off a great height in 2 patients (15%), gunshot in 1 patient (7.6%) and in 1 patient where complication developed after a surgery at an external center (7.6%). All of the patients were evaluated with retrograde urethrogramThe complete to incomplete rupture ratio was 4/8. An insertion of a foley catheter was attempted in three complete rupture patients during the time of admission at the external center. Isolated UR was present in the 2 patients who fell off a great height. Treatment included insertion of a suprapubic urinary diversion with cystostomy catheter and observation in 3 patients (25%), urgent open urethroplasty in 4 patients (33%) and early urethral realignment as well as insertion of a cystostomy catheter catheter in 5 patients (41%). The mean length of stay was 26 days (ranging from 10 to 42 days). Perioperative exitus in one of the patients was due to hypovolemia. Postoperative follow-up was completed via sistoscopy and urethrography work up. After a 2-year follow-up period, 4 of the patients (33%) presented with no problems, 6 (50%) of the patients presented with urethral stenosis, 1 patient (8.3%) with perineal fistule and 1 patient (8.3%) with testicle necrosis. Permanent incontinence developed in 2 of the patients among the ones with complete rupture.

Discussion: There is a high complication risk even with the most ideal treatment approaches for UR. In our series, a complication occurred in 66% of the patients, stricture being the most common one. Whereas suprapubic urinary diversion with cystostomy catheter forms the most important step of the treatment, timing of operation should be determined through an evaluation of causes for complete/incomplete rupture accompanied by pelvic fracture and hematoma.

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OP55: Burned children who admitted to a burn center and general treatment modalities

C İrşia, K Karadeniz Ceritb, Z Derelic and AH Acard

aÇocuk Cerrahisi Uzmani and bGenel Cerrahi Uzmani, Dr. Lütfi Kirdar Teaching Hospital

Background: Burn during childhood is an important health problem. In this study we retrospectively analysed 0–17 year old burned children who were treated in a central burn hospital.

Materials and methods: The children treated in the burn center during January 2010–January 2011 were analysed.

Results: 106 children were treated. There were 58 boys, 46 girls. Median age was 3.7 year, median of hospitalization 8.6 days. The etiologic factors were 75% (n:69) hot water, 15% (n:21) milk/soup, 9% (n:15) flame and 1% (n:2) electrical burn. 22% of hospitalized child burn was above %20 body surface area. Circuler burn of any part of body that undergoes escaratomy-fasciatomy was <%4 (n:6) During the time of hospitalization %7 of patient receive treatment in intensive care unit and mortality was %3. In 2. and 3. degree burn, we used silver sulphadiazin with bizmut/clorheksidin containing dressing (n:58). In superficial burn we used bizmut /clorheksidin including dressing with basitrasin/rifampisin (n:33). The burn child with large area but not deeper surface area covered with silver containing dressing (n:18). We applied collagenase SF (a proteolytic enzyme) with bizmut containing dressing to the wound which was 3. degree burn and not infected (n:9). Xe-derma (a chemical pork skin) were applied to small areas, face after 1 week (n:4). 2. and 3. degree burns grefting applied at the median 12 day (n:41).

Conclusion: The aim of this study was to show retrospectively certain charecteristics of hospitalised burn children and their general treatment modalities.

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OP56: Ovarian cysts and laparoscopy in children: efficacy of late postoperative ultrasound examination in patient follow-up

DD Derelia, B Tokara, S Sahinb, N Akcar Degirmencic, MS Ardaa and H Ilhana

Departments of aPediatric Surgery, bPediatrics and cRadiology, Eskisehir Osmangazi University, School of Medicine

Objective: There is no consensus regarding the postoperative follow-up procedure of patients operated due to ovarian cyst. The ultrasonography (USG) which is a non-invasive method plays important role in diagnose and treatment of childhood ovarian cysts. In this prospective study, the regular USG follow-ups were performed in patients received laparoscopic surgery due to ovarian cyst during postoperative early and late-term period. The efficiency of laparoscopic intervention was evaluated by postoperative USG.

Methods: Forty patients received laparoscopic surgery due to ovarian cysts were included the study during 5-year period. The preoperative USGs, operation findings and postoperative 1, 3, 9-month and 1-year USGs of patients were evaluated.

Results: Totally 45 ovarian and paraovarian cysts were intervened laparoscopically. The age range of patients was from 13 days to 18 years old. During the early and late postoperative USG controls, reoccurred cysts were determined on the operated ovary, but those cysts were not in a size needing surgery. Based on the clinic and USG follow-up of the contralateral ovary, the second time laparoscopic exploration and intervention was performed for 5 patients with cysts that needed re-intervention at 1-year follow-up.

Conclusion: Laparoscopy is an effective treatment method for childhood ovarian cysts. The reoperation can be needed according to patient's clinic and ovarian cyst findings obtained by long-term bilateral ovary USG examination.

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OP57: Management of splenic trauma in children

C Turan, S Arslan, S Doğanaya, M Güzel, A Aslan, AB Dogan, Ö Yandim, KC Sulubulut and M Köpru

Departments of aPediatric Surgery, Radiology and bBiostatistics, Medical School of Erciyes University

Aim: To assess types of traumas, accompanying injuries, management and results of splenic traumas.

Materials and methods: We studied the cases of 90 patients who were treated for splenic injuries as a result of blunt abdominal trauma between 2005–2010. The age of the patients range from 1–17 (median age 8.3±5.4 years old) years of age. Sixty-four (71.2%) of the 90 patients were boys and 26 (28.8%) were girls. Age, sex, hospitalization time, mechanisms of traumas, acompanying injuries and management methods were recorded.

Results: Causes oftraumawere falls from height (46 patients, 51%), pedestrian traffic accidents (17 patients, 19%), passenger traffic accidents (11 patients, 12%), bicycle accidents (10 patients, 11%) and falling objects (6 patients, 6.6%). Splenic injury alone was observed in 57 patients (63.3%) and other organ injuries together with splenic injury in 33 patients (36.7%). Other organ injuries together were observed in the brain (12 patients, 13.3%), lungs (9 patients, 10%), liver (7 patients, 8%), kidney (4 patients, 4.4%) and small intestine (1 patient, 1.1%). Splenectomy was performed in six patients (6.6%) due to hemodynamic instability and small intestine repair due to small intestine injury in one patient (1.1%). None of these patients died from their injuries.

Conclusion: Alarge proportion of splenic injuriesrecover with conservative therapy. Some of the advantages of conservative therapy include short hospitalization time, less need for blood transfusion, and less morbidity and mortality. Falls from height and traffic accidents are important factors in etiology. The possibility of other organ injuries together with splenic injuries should be considered.

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OP58: Thyroid pathologies in childhood: 33 years of experience

R Özcana, S Aktemura, L Kabasakalb, N Sarimurata, E Erdoğana and G Tekanta

Departments of aPediatric Surgery and bNuclear Medicine, Istanbul University, Cerrahpaşa Medical Faculty, Istanbul, Turkey

Purpose: Examining cases that underwent surgical operation due to thyroid pathologies during childhood.

Cases and method: 30 cases that were operated between years 1978 and 2010 in our clinic due to thyroid pathology have been evaluated based on age, gender, diagnostic methods, surgical techniques applied and complications. Physical examination results, T3, T4, TSH levels, thyroid ultrasonography and scintigraphy results have been studied.

Results: 20 cases are female (66.6%), 10 are male (33.3%), average age is 6.8 (2.5–16) years. Of all the lesions, 19 (63.3%) were benign, 11 (36.6%) were malign. Benign pathologies were adenomatous hyperplasia (n=17), simple cyst (n=1) and cyst hydatic (n=1), whereas the malign were papillary (n=9), follicular (n=1) and mixed (n=1) carcinoma. T3 and T4 levels were normal in all of the cases. In scintigraphy, coldnodule was detected in malign cases, whereas hypoactive areas and diffused hyperplasia were detected in benign cases. Cystectomy or subtotal thyroidektomy was performed in benign cases; subtotal thyroidektomy and neck dissection were applied in malign cases. One of the cases was lost during anesthesia induction. Eosophagocutanous fistula and wound infection occurred after the operation in the case with the mixed carcinoma, however it was treated spontaneously. Thyroid ablation using radioactive iodine was applied due to local recurrence and lymphatic node metastasis in three cases with papillary carconima and one case with follicular carcinoma.

Conclusion: In the planned surgery of children due to thyroid pathology, the pathology should be identified by sampling a frozen during the operation. If the mass is benign, cystectomy or subtotal thyroidectomy should be applied. If the mass is malign, total thyroidectomy and neck dissection should be performed, together with thyroid ablation using radioactive iodine if necessary.

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OP59: Ovotesticular disorders of sex development: surgical diagnosis and management of 27 cases

N Dessouky

Pediatric Surgical Division, Cairo University Faculty of Medicine, Cairo University Specialized Pediatric Hospital, Egypt

Background: Ovotesticular disorder of sex development (OT-DSD) is defined as the simultaneous presence of both testicular and ovarian tissue in the same individual. It is considered the least common and least understood variant of DSD in humans.

Patients and methods: Twenty-seven cases with OT-DSD were diagnosed and surgically managed in Cairo University-Pediatric Hospitals over a period of 25 years (1984–2009). Their ages ranged between one month and 17 years with a mean of 2.3 years. After full clinical examination, cytogenetic, hormonal and radiological studies were accomplished, abdominal exploration with gonadal biopsies were performed via open surgery in the early phases of the study (till 1990) then laparoscopic approach became the standard approach afterwards. Surgical reconstruction was performed as a one-stage procedure in most cases including various techniques for genitoplasty, excision of contradictory internal genitalia, or tumors and surgery for gynecomastia.

Results: Genital ambiguity with predominance of the male phenotype was the most frequent complaint (77.7%) followed by gynecomastia in 14.8% and inguinal mass in 7.4%. Twenty one patients were raised as males at the time of presentation due to the relative average size of their phallus. The most frequent karyotype was 46,XX in 77.68.% of patients, followed by 46 XO/XY, 46XY and 46XX/XY while SRY was negative in all 46,XX. The prevalent gonad was ovotestis (OT=37%), followed by ovary (OV=31.48%) then the testis (TT=27.7% and the prevalent gonadal associations were OV+TT (40.74%)[lateral], OT+OV (25.9%), OT+TT (18.5%) {unilateral], and OT+OT (14.8%) [bilateral]. Gonads with testicular tissue were more frequent on the right side, while pure ovarian tissue was more common on the left. There was preference of male sex of rearing despite a severe degree of genital ambiguity. Bilateral OT were always located intra-abdominally. Four OT were located in labio-scrotal folds while this location occurred only in a single ovary. All OT were preferred to be excised. Two cases were reassigned as females at the age of 1.25 and 3 years, while one case reversed the sex to male at the age of 2 years. Two male patients developed dysgerminoma and gonadoblastoma at the age of 17 and 14 years old.

Conclusion: OT-DSD is a phenotypically and genetically a heterogeneous condition. Early diagnosis and sex assignment are essential to avoid psychological and social problems. Laparoscopy has an important role in surgical diagnosis and management of such cases. Scrotal gonads should be always explored. OT is preferably to be excised.

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OP60: Ultrasound guided internal jugular vein catheterization in children

A Ozela, H Ilhana, AA Cevikb, MS Ardaa, D Demet Derelia and B Tokara

Departments of aPediatric Surgery and bEmergency Medicine, Eskişehir Osmangazi University, School of Medicine, Eskisehir, Turkey

Background: Central venous catheter placement of the internal jugular vein (IJV) in infants and children guided by palpation of anatomical landmarks is a challenging procedure. To increase to success rate and to prevent possible complications, we designed and performed a prospective study on ultrasound (US) guidance for percutaneous puncture of IJV in pediatric ages.

Materials and methods: IJV cannulation was performed by B mode US-guidance (SonoSite TITAN, Bothell, WA 98021, USA) in 40 children. A small caliber probe using 10 MHz US wave was utilized. Before the puncture, depth, size, anatomical variations and position of IJV and carotid artery were defined. Cannulation time was also recorded. All the procedure was performed by the same group.

Results: Successful cannulation rate was 95%. In infants (under 12 months of age) the success rate at the first attempt was 83.3%, while it was 100% for children older than 12 months. The shortest time for successful cannulation was 1.28 min, and the mean time was 11±2.42 min. Three hematomas and three arterial punctures were recorded as complications.

Conclusion: The major advantage of the US-guided IJV catheterization is to visualize the structures at the puncture site before the attempt. US-guided IJV catheterization is very safe with high success rate and few complications.

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OP61: Can the modified tan-bianchi circum-umbilical approach be used exploring older children?

Hesham Abdelkader, M. Abdelatif, Ehab Elshafi, Khaled Elasmar M. Debeki and M. Shalabi

Pediatric Surgery Unit, Ain-Shams University, Cairo, Egypt

Abstract: Since Tan and Bianchi reported umbilical incision as an access for pyloromyotomy in infantile hypertrophic pyloric stenosis, many pediatric surgeons have used this approach for a number of other procedures. But most of these reports focused on the usefulness of such approach in neonates. This study aims to assess the clinical usefulness of the circum-umbilical approach for exploring the abdominal cavity of infants and older children with a variety of surgical intraabdominal diseases in order to achieve minimally invasive surgery with excellent cosmetic results.

Methods: All patients who underwent a circumumbilical skin incision for an exploratory laparotomy in the period June 2009–October 2010 were reviewed. Age, operative procedure, conversions to standard laparotomy, complications and follow-up were recorded.

Results: A total of 27 infant and child with ages ranging from 3 months to 8 years had 28 operative procedures. The indications were: nonrotation of midgut in 2; intussusception in 13; complicated V-P shunts in 4; Meckel's diverticulum in 2; gastrotomy for removal of an impacted foreign body from stomach in 1; pyloroplasty for caustic injury of the pylorus in 1, lymphatic mesenteric cyst in 1, and complicated appendicitis in 3. Conversion to a standard midline incision was necessary in one case. The complications encountered included wound infection in five; burst abdomen in one, and incisional hernia in two cases. Subsequent follow-up revealed that all incisions had healed and the scars were almost imperceptible as affirmed by parental satisfaction during outpatient clinic consultation.

Conclusion: The circumumbilical approach appears to be safe, flexible and easily reproducible approach providing adequate exposure for some abdominal surgeries even in older infants and children as it had been tried successfully in neonates. The low complication rate and pleasing aesthetic outcome are much appreciated by parents and operators alike.

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OP62: Evaluation of our patients with disorder of sexual development

N Arslana, S Demirezena, G Karagüzela, C Bonevala, İ Çetinerb, Ç Fettahoğluc, S Akçurinb, İ Bircanb and M Melikoğlua

Departments of aPediatric Surgery, bPediatrics and cChild & Adolescent Psychiatry, Akdeniz University School of Medicine, Antalya, Turkey

Background/aim: Disorder of Sexual Development (DSD) is a clinical syndrome which has nonhomogenous features from both diagnostic and therapeutic approches. In this study, we aimed to evaluate our patients with DSD subjected to surgical intervention.

Materials and methods: In this cross-sectional study including 29 patients between 2005 and 2011, the patients' files were retrospectively reviewed for demographic data, classification, surgical techniques, follow-up period and complications. Surgical indications were based on multidisciplinary evaluation.

Results: Ages of the patients ranged from 1 to 17 years (avarage: 9.4 yil). Twenty four patients were classified as female pseudohermaphrodite, four patients were male pseudohermaphrodite, an one patient had gonadal disgenesis. Primary reconstructive procedures were performed during cross-sectional time period in 21 cases, ramaining 8 cases had undergone surgery earlier. Flap vaginoplasty plus clitoroplasty was performed in ten cases, Passerini-Glazel genitoplasty in 5 cases, total urogenital mobilization in 4 patients, flap vaginoplasty only in 3 cases, hysterectomy with bilateral salpingo-oopherectomy in 3 patients, and other surgical interventions in 4 cases. Avarage follow-up time was 5.6 years. Eight cases had no vaginal dilatation, but 17 patiens were performed vaginal dilatation more than 3 times. Four patients were applied redo or complementary surgery because of cosmetic reasons/vaginal stenosis.

Conclusion: Nearly one fourth of the patient load orignated from extra cross-sctional time in our series. Female pseudohermaphroditism was major subgroup of DSD requiring surgical intervention. Surgical techniques were considerably varied by patient characteristics. High rate of vaginal dilation was noted and a limited number of cases needed secondary surgery.

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OP63: Delayed presentation of cervical lymphangioma: a case series

Sherif M K Shehata and aMohamed Elhiendy

Department of Surgery, Sections of Pediatric Surgery and aVascular Surgery, Tanta University Hospital, Tanta, Egypt

Background/purpose: Cystic cervical lymphangioma (CCL) is a congenital anomaly derived from lymphatic vessels with a progressive and painless growth that is rarely seen in adults. It is newly described as lymphatic malformation. Presentation after adulthood may represent a special entity of the anomaly. This study was carried out to present such case series of the rare special subgroup of CCL that presented after 18 years.

Patients & methods: Ten cases of CCL in adults have been presented. This subgroup was collected in the last 8 years from Tanta University Hospital and other affiliated hospitals. Presentations, findings and management strategies were described.

Results: This study included 10 patients; 7 females and 3 males with the age ranged from 18 to 48 years. Six cases were left sided and four were right sided. All cases presented by a swelling of an average duration of one year except in one case that have resolving swelling at infancy but re-enlarged at age of 48 years. One case had extension to the superior mediastinum. One case was aspirated once before but recollected. All cases were successively and completely excised by surgery. Histopathological examinations of all specimens confirm the diagnosis of CCL. All cases are doing well along the follow up period (6–72) months. No recurrences have been reported.

Conclusion: Our series document the existence of this rare subgroup of adult CCL, despite that the whole number of reported cases of adult CCL in the English literature is less than 200 cases. Most of adult cases were unilocular, easily dissected and completely excised rather than those who presented in infancy. With good surgical excision the recurrence in adult CCL is nil. CCL should be considered in the DD list of unilateral painless cystic swelling in the lateral side of the neck.

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OP64: The ligament which runs along the inguinal hernia sac of female children is not the round ligament of the uterus

M Hoşgör, C Öztürk, V Erikçi, OA Arslan, B Uçan, Ö Okur, M Yildiz, A Dursun and N Aksoy

Dr. Behçet Uz Children's Diseases and Surgery Education and Research Hospital, Izmir

Aim of the study: The ligament, which lies in inguinal hernia sac of girls, is accepted to be the round ligament of the uterus. Some studies reported that this ligament is not the round ligament and its presentation in the processus vaginalis may have a role in final ovarian position and inguinal hernia occurrence in girls. The present study was conducted to compare the histopathological structures of the ligaments found in hernia sac of girls and round ligaments of adult women.

Materials and methods: 26 ligaments (12 bilateral, 10 unilateral right, 4 unilateral left) obtained from 20 girls aged 3 months to 10 years during routine inguinal hernia repair and 18 bilateral round ligaments obtained from 9 women aged 41 to 56 years during total abdominal hysterectomy were examined immunohistochemically by using monoclonal antibody against skeletal muscle actin (ASMA) and a polyclonal rabbit antibody against estrogen receptor (ER). Haematoxylin-Eosin (H&E) stained paraffin sections were also examined under light microscopy.

Main results: H&E sections showed that most of the ligaments of female hernia consisted of striated and smooth muscle fibers, nerves and vessels. No striated muscle fiber was observed in the round ligaments of adult women. ASMA was detected 50 and 100% and ER 83 and 66% in right and left ligaments of bilateral hernias, respectively. ASMA was expressed 70 and 75% and ER 60 and 25% in unilateral right and left hernias, respectively. There was no expression of either ASMA or ER in any right and left round ligaments of adult women.

Conclusion: These findings showed that the ligament, which lies in inguinal hernia sac of girls, has not the same histopathological structure with the round ligament of the uterus in adult women. Further studies are necessary to describe this ligament and its role in occurrence of inguinal hernia in female children.

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OP65: The value of plain abdominal X-ray and ultrasound imaging in childhood appendicitis

A Ertürka, A Karamana, İ Karamana, YH Çavuşoğlua, İF Özgünera, B Yağiza, Y Taşçi Yildizb and D Erdoğana

Departments of aPediatric Surgery and bRadiology, Dr. Sami Ulus Children's Hospital, Ankara

Introduction/aim: Abdominal pain is one of the most common causes of hospital admittance in childhood. Here we aimed to evaluate the contribution of positive findings in upright abdominal X-ray and ultrasound imaging on diagnosis of acute appendicitis in children admitted with abdominal pain.

Materials and methods: The upright abdominal X-ray and ultrasound imaging of the children who admitted to our outpatient clinic with suspected acute appendicitis in the year 2010 were analyzed retrospectively. The patients were divided in to 2 groups. The children with a final diagnosis of acute appendicitis constitute the group I, while the children who required only observation in hospital or as outpatient for suspected appendicitis were group II.

Results: A total of 744 patients admitted to our outpatient clinic for suspected acute appendicitis during the year 2010. Group I constitutes of 350 patients while the group II has 394 children. The mean age of groups were comparable (P>0.05). Upright abdominal X-ray was available for the 87.5% of the patients while 78.5% of the patients underwent ultrasound imaging. Only 59.4% of the ultrasound examinations were carried out by our institution's radiology department while the rest (40.6%) were carried out elsewhere. In group I, the findings on plain abdominal X-ray which are suggestive of acute appendicitis were as follows; air-fluid levels at right lower quadrant (46.8%), lumbar scoliosis with left-sided convexity (10.5%), presence of fecalith (4.7%), blurring of the right properitoneal fat shadow (4.1%). The sensitivity of plain abdominal X-ray for acute appendicitis is 56.3% with a specifity of 66.9%. The diameter of the appendix could be measured only in 180 patients with ultrasound imaging. When the diameter of the appendix was measured ≥ 6 mm, than acute appendicitis could be diagnosed with 86.4% sensitivity while the unresponsiveness to compression can predict acute appendicitis with a sensitivity of 72.1%. In group I, the prevalence of appendicolith, abscess and elevated mesenteric echogenity on ultrasound imaging were 16.2, 5.5 and 37.5% respectively. Regarding the whole findings, the total sensitivity and specifity of the ultrasound imaging were 66.9 and 66.1% respectively.

Conclusion: Only half of the children with acute appendicitis have a positive finding on plain x-ray. Although variability exists depending on the experience of the radiologist, ultrasound imaging is one of the most sensitive imaging modality for the diagnosis of childhood acute appendicitis. In conclusion, we believe that acute appendicitis can not be diagnosed solely relying on imaging features and correlation of the imaging features with clinical parameters is essential.

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OP66: Ertapenem vs. standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

ÇA Karadağa, N Dalkiliçb, Ö Karac, S Çelebid, N Severe, A Yildizf and Aİ Dokucug

aDivision of Pediatric Infectious Diseases and bDivision of Pediatric Surgery, Sisli Etfal Training and Research Hospital

Aim: Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamisin, and metronidazole (AGM) has been used postoperatively for perforated appendicitis. Ertapenem, a group I carbapenem antibiotic, has been shown to be safe and effective in treating adults with complicated intra-abdominal infection (cIAI). We performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens in children.

Materials and methods: After internal review board approval, children found to have perforated appendicitis at appendectomy were randomized to either twice or once daily dosing of ertapenem (1 or 2 total doses per day) or standard dosing of AGM (9 total doses per day). Perforation was defined as an identifiable hole in the appendix. Patients were assessed for safety and tolerability throughout the study and for efficacy after completion of therapy. The operative approach, length of antibiotic use, and criteria for discharge were standardized for the groups.

Results: One hundred patients underwent appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptom, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. No serious drug-related laboratory adverse events was observed. The ertapenem group resulted in significantly less antibiotic charges then the AGM group.

Conclusion: Ertapenem regimen offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen. The results of this trial suggest that ertapenem may be useful option that could eliminate the need for combination and/or multidosed antibiotic regimens for the ampiric treatment of cIAI in children.

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OP67: Academic mentorship: a need in professional career

Sherif M Shehata

Department of Surgery, Section of Pediatric Surgery, Tanta University, Egypt

The university takes the responsibility to prepare the professionals of whatever specialty. The academic environment strengths the creativity need for future development especially for postgraduates. In the current era, the need to develop a research career side-by-side with the development of professional career is essential especially in medical career. Mentorship is a mandate for educational excellence whether professional or academic mentorship. In our circumstances, we are lacking mentorship training. Despite all the world development, the provision of researchers/ professionals is decreasing in the current decade as compared to sixties and seventies. High costs and lacking research opportunities constitute major limiting factors in 2008. Herbert Reynolds reported recently this problem in the field of health care.

As junior researchers and academician need training and supervision, also the mentors need to be trained and updated. This should constitute a major component in teaching and development of the university graduates. Creativity and research basics could be taught to the undergraduates as well as postgraduates. The new ideas and research is translated later to strategies in different professions with the resultant development of the whole community. Good guidance in beginning a research career is necessary and usually requires an expert and qualified mentor. Creative and spirited mentoring efforts are very important in career selection so current approaches need to be critiqued for improvement. The outcome of doctoral students is a critical issue to be standardized by reviewing the aim of this highest postgraduate degree graduates.

In a recent report from USA, the percentage of qualified mentors to lead research is diminished that present a risk in the strategic planning of profession that possibly reflected on community development. Teachers are not necessarily mentors for students because they have different duties which are not those of counselor or mentor. Our current situation and possible suggestions and solutions from the world experience with example from health care career as our specialty will be presented and discussed.

With the new university tasks and directions, the outcome of doctoral students as being senior leaders and researchers in their fields in our current postgraduate system is alarming. Appropriate mentoring needs to continue throughout the entire research and academic career. Ways to provide ‘mentoring’ better to be programmed, that result in improved measurable outcomes.

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OP68: Pediatric surgery specialty theses: a retrospective evaluation

E Aydin, Ş Emre and S Celayir

Department of Pediatric Surgery, Istanbul University, Cerrahpaşa Medical Faculty

Aim: This study is conducted to evaluate the Pediatric Surgical Residency Program Thesis retrospectively, which were done in the Pediatric Surgical Department of Cerrahpaşa Medical Faculty.

Materials and methods: A Questionnaire is send to the writers and a preliminary study is done. All the thesis were obtained from the department and faculty library and investigated in regard to thesis subject, type of investigation, duration, support and if they are presented or published.

Results: 47 of the total 49 thesis, which were done between 1978–2010 at the Department of Pediatric Surgery of Cerrahpaşa Medical Faculty were evaluated retrospectively. 31 thesis subjects were Gastrointestinal (GI) and 16 Urology (URO) subjects. 24 thesis (8 URO, 16 GI) were experimental, 23 (8 URO, 15 GI) were clinical. In URO thesis, bladder and hypospadias (n:5), in GI thesis Hirschsprung, GER ve Anal Atresia (n:3) most common subjects. Only 2 thesis could be financially supported. The thesis were given at the 3.7 year of residency. Pathology was the most common co-working department (n=10). During the thesis the work load of resideny program was the most common difficuly reported. 14 thesis (%29.7) were presented at national, 12 thesis (%25.5) were presented at international congres, 4 thesis were published (%8.5) at national, 10 (%21.2) thesis were published at international journals.

Conclusion: The thesis should be given ealier in residency program, should be financially supported, the conditions for a multidisiplinary work should be corrected to to increase the quality of the thesis and to improve their contribution to medical science.

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OP69: Noninfectious complications in patients on peritoneal dialysis

B Uçana, E Serdaroğlub, O Arslana, V Erikçia, N Aksoya, A Dursuna, C Öztürka, M Bakb and M Hoşgöra

Departments of aPediatric Surgery II and bNephrology, Dr. Behcet Uz Children's Hospital

Purpose: Our aim was to evaluate noninfectious complications in chronic renal failure patients treated by peritoneal dialysis (PD).

Materials and methods: 68 patients (30M/32F) (5 days–18 years) treated by PD more than 3 months between 2004–2010 were investigated. 6 patients were excluded because of previous inguinal hernia operation. PD catheters were introduced by laparoscopically, surgically or blinded. CAPD (chronic ambulatory peritoneal dialysis) treatment was initiated in patients under two years of age 800 ml/m2, in patients aged more than two years 1100 ml/m2. Inguinal hernia was repaired by high-ligation, PD was started on 3rd day. Patients with noninfectious complications were treated by decreasing dialysate volume, changing to automated PD or surgically.

Results: In 17 patients (27.4%), because of catheter obstruction revision and omentectomy were done. 3 patients needed secondary revision. Catheter obstruction was happened in 12 patients (70%) 1 month after PD initiation. Leakage was determined in 4 patients (6.4%) in early period. Ten patients (16.1%) had inguinal hernia (6 bilateral), 16 patients (25.8%) had pubic edema, 3 (4.8%) had hydrocele (2 bilateral), 3 (4.8%) had umbilical hernia.2 patients (20%) had bilateral recurrence after inguinal hernia repair. One of the patients with umbilical hernia was surgically operated. In 11 patients with pubic edema resolution was observed by decreasing dialysate volume and returning to automated PD. In 3 cases pubic edema persisted, in one of these patients PD was ended.

Conclusion: The rate of noninfectious complications are so high in PD patients. Noninfectious complications are needed surgical interventions however to end PD treatment becomes rarely necessary.

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OP70: Spigelian hernia accompanying cryptorchidism: cause or consequence? Unidentified syndrome? Review of literature with 4 cases

S Bilici

Department of Pediatric Surgery, Yuzuncu Yil University School of Medicine, Van

Introduction/aim: Spigelian hernia is rare in childhood. Fifty case have been reported to date. Among the boys with spigelian hernia 75% have also criptorchidism. Four cases with both spigelian hernia and criptorchidism hes been reviewed.

Materials and methods: Clinical characteristics of operated cases in which both spigelian hernia and criptorchidism present between years of 2002–2010 were examined retrospectively.

Findings: Individuals were 6 months-, 1 years-, 2 years- and 5 years-old. Patients were reported to have a lateral abdominal swelling congenitally. Two cases admitted to hospital for swelling and the other two for criptorchidism. Hernia was at right in two case, and at left in the other two cases. Patients were operated for both spigelian hernia and criptorchidism. In all cases testes were in hernial sac, gubernacula were not seen and there was not inguinal ducts. Hernia repair and orchypexia was applied.

Results: Also known as Lateral ventral hernia, spigelian hernia develops throughout semilunar line which lie from cartilage of 9th rib to pubic tubercle on aponuerosis of transversal abdominal muscle. In adults, it results from inraabdominal pressure and trauma while it is congenital in children. In children, high frequency of spigelian hernia simultaneous with criptorchidism the question if criptorchidism is a cause or consequence, or a syndrome of an unidentified simultaneousness is in discussion. As in the cases reported here, due to the absence of gubernaculum inguinal ducts and also because testes were in the hernial sac, the results supports the idea which indicates that they are a simultaneous syndrome.

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OP71: The comparison of the intestinal adaptation effects of subcutaneous and oral insulin in rats with short bowel syndrome

Ü Biçakcia, ÖK Tunçelb, B Bilgicib, B Tandera, E Aritürka, R Rizalara, Ö Alicic and F Bernaya

Departments of aPediatric Surgery, bBiochemistry and cPathology, Ondokuz Mayis University, Faculty of Medicine, Samsun, Turkey

Aim of the study: Insulin has been reported to have positive effects on intestinal adaptation after short bowel syndrome. The purpose of this study is to compare the intestinal adaptation effects of subcutanous and oral insulins in rats with short bowel syndrome.

Materials and methods: Thirty Wistar Albino rats were divided into three groups. Approval from the Animal Ethics Committee has been obtained. In all rats, the short bowel syndrome (SBS) was performed through 75% of small intestinal resection and end to end anastomosis. The control group rats underwent SBS only. In the second group oral insulin (1 U/ml) was administrated twice daily from third day to fourteenth day of surgery. In the last group, the insulin was administrated subcutaneously (1 U/kg) for the same period. All rats were killed on day 15. Outcome parameters were weight of small intestine, crypt length, villus depth, crypt/villus ratio, tissue levels of vascular endothelial growth factor (VEGF) and granolocyt-monocyst colony stimulating factor (GMCSF).

Main results: The main results were shown on the table. Intestinal weight was significantly more in oral insulin group and subcutanous insulin group than the control group (P<0.05). There was no difference between the groups according to villus length, crypt depth and villus/crypt ratio both in proximal and distal parts of the resected bowel (P>0.05). VEGF was not statistically significant between the groups (P>0.05). GMCSF was statistically more in the control group than the subcutanous groups (P<0.05), which indicates insulin accelerates the bowel repair.

Conclusion: Insulin has positive effects on intestinal adaptation in short bowel syndrome. Subcutaneous administration is slightly more effective than the oral administration.

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OP72: Comparison of the effect of contrast medium, air and ozone on ischemia/reperfusion injury due to experimental intussusception model

M Fedakar-Şenyücela, Ş Küpana-Ayvab, MK Aslana, T Soyera, N Aksoyc, Ü Kisac and MA Çakmaka

Departments of aPediatric Surgery, bPathology and cBiochemistry, cKirikkale University School of Medicine

Aim: It has been suggested that ozone is an antioxidant and may reduce ischemia/reperfusion injury due to intussusception reduction. Therefore, an experimental study was performed to compare the effects of contrast medium, air and ozone on ischemia/reperfusion injury due to intussusception.

Materials and methods: Thirty Wistar rats were allocated into five groups (n=6). After anesthetization, 2 cm of colonic segment, 5 cm distal to ileoceacal valve was removed in control group (CG). Intussusception was performed at 5 cm distal to ileoceacal valve by pushing the proximal intestinal segment distally by a stile in experimental groups. One hour later, in sham-operated group (SG), manuel reduction was performed. Reduction was performed by contrast medium in contrast medium group (CMG) (1/1 dilutediohexol, infusion rate; 2 ml/min) by air in air group (AG) (Pmax=40 mmHg) and by ozone (10 µg/ml, 0.5 mg/kg, Pmax=40 mmHg) in ozone group (OG). After one hour, 2 cm of colonic segment was removed. Intestinal tissues were evaluated for histopathological grades and oxidative injury markers(malondialdehyde- MDA, nitric oxide- NO and sulphidryl- SH values).

Results: Histopathologic evaluations revealed that mucosal injury score was significantly higherin AG when compared to CG and SG (P<0.05). There was no difference between the other groups (P>0.05). Biochemical evaluations showed MDA levels were higher in SG than in CG (P<0.05). MDA levels were significantly higher and NO levels were significantly lower in CMG, OG and AG in comparison with CG (P<0.05). There was no difference between OG and other experimental groups in both MDA and NO levels (P>0.05).

Conclusion: It has been demonstrated that none of the reduction methods in intussusception has superiority to another to prevent ischemia/reperfusion injury. The results obtained from OG is conversely show that ozone has an oxidant effect rather than an antioxidant activity. These results can be explained by the dose dependent efficacy of ozone theraphy.

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OP73: A 12-year experience with intestinal atresia

T Dikmen, M Yiğiter, A Oral, B Firinci, H Zeytun, O Yalçin and AB Salman

Department of Pediatric Surgery, Ataturk Univercity, Faculty of Medicine, Erzurum, Turkey

Aim: To evaluale the clinical and prognostic findings of patients who were treated at our clinic for intestinal atresia (IA) within the past 12 years.

Materials and methods: 43 patients who were treated for intestinal atresia at our clinic within a 12-year period were reviewed retrospectively. Sex, gestastional age, birth weight, type of IA, type of operation, associated anomalies, complications and mortality rates were analyzed.

Results: Female/male ratio was 24/19. Mean gestasional age and mean birth weight were 36.5 (30–41) weeks and 2361 (1080–4100) grams, respectively. 12 patients (27.9%) had jejunal atresia, 8 patients (18.6%) had duodenal atresia, 8 patients (18.6%) had ileal atresia, 5 patients (11.6%) had duodenal web, 4 patients (9.3%) had jejunal web, 4 patients (9.3%) had colonic atresia and 2 patients (4.7%) had colonic web. Intestional atresia was associated with the cardiovascular system 30.2% (13 patients), the gastrointestinal system 27.9% (12 patients), the urinary system 4.7% (2 patients) and the central nervous system 2.35% (1 patient). Resection and anastomosis were performed in 26 patients (60.5%), enterostomy was performed in 13 patients (30.2%) resection of web was performed in 2 patients (4.7%) and resection-anastomosis and enterostomy were performed in 2 patients (4.7%). 5 patients (11.6%) had intestinal perforation in the preoperative period. 11 patients (25.6%) had sepsis, 4 patients (9.3%) had brid ileus in the postoperative period. Mortality was reported in 15 of 43 patients (34.9%).

Conclusion: Rapid proliferation of the bacteria in the intestinal lumen leads to the invasion of the thinning intestinal tissue that is proximal to the obtruction by these bacteria. Therefore, sepsis appears to be the greatest problem in intestinal atresias nowadays. Newborn sepsis seems to be the most important cause of mortality in intestinal atresias.

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OP74: Near total pancreatectomy for Nesidioblastosis: Mansoura experience

Adham Elsaied, Mohammed El-Ghazaly, Basem Saied and Ashraf Elsharkawy

Pediatric Surgery Unit, Mansoura University Children's Hospital, Mansoura, Egypt

Background/purpose: Nesidioblastosis is a name used to describe congenital hypoglycemia. It is the most common cause of persistent Hypoglycemia in infancy with consequences such as seizures and brain damage. Treatment yielding avoidance of these sequele is essential. When medical therapy fails or complications are anticipated; early pancreatectomy is recommended to maintain euglycemia. The aim of this study is short term evaluation of Mansoura experience of near total pancreatectomy for Nesidioblastosis.

Patient and methods: During the period of May 2002 to May 2010, 13 patients suffering of persistent hyperinsulinaemic hypoglycemia (nesidioblastosis) were treated by near total (90–95%) pancreatectomy after failure of medical treatment. They were 8 females and 5 males and their ages at time of surgery ranged from 20 days to 27 months. They all suffered symptoms of nesidioblastosis; thermoregulatory problemsin 5 cases, tremors in 5, seizures in 3, irritability in 5, convulsions in 3, respiratory distress in 8, apnea in 4, hypotonia in 4, lethargy in 5 and feeding difficulty in 4. All cases were diagnosed following strict criteria that included bouts of hypoglycemia without acidosis coinciding withincreased insulin level. Follow up ranged from 3 months to 8 years.

Results: Primary success occurred in 2 cases (15%), 4 more cases (31%) sufferedtemporary diabetes mellitus and one case (8%) had a temporary pancreatic fistula. Eventually total cure occurred in 7 cases (54%). 6 cases (46%) suffered a variety of complications; persistent hypoglycemia in 2 cases, Persistent diabetes mellitus in 3, developmental delay in one, persistent neurological deficit in 2 and one case of mortality.

Conclusion: Near total (90–95%)pancreatectomy proves to be a suitable procedure for treatment of nesidioblastosis not responding to medical treatment and should be performed as early as possible.

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OP75: Impact of early drainage on survival rates in necrotising enterocolitis cases

N Gülçin, AC Celayir, C Şahin, G Kurt, O Bosnali and S Moralioğlu

Department of the Pediatric Surgery, Zeynep Kamil Women and Child Deseases Education and Research Hospital

Background/purpose: Necrotizing enterocolitis (NEC) is one of the major causes of morbidity and mortality in premature and/or newborn intensive care units. The aim of this study was to compare the mortality rates of operated NEC cases according to the surgical method at our institution.

Materials and methods: 73 cases (34 male, 39 female) operated at our institution between January 2006 and January 2010, were divided into two main groups. Group A (n=37); penrose-drain placement with local-anesthesia, abdominal irrigation, late abdominal exploration, Group B (n=36); early abdominal exploration. Results were reviewed prospectively. Mortality rates were determined according to the surgical approach.

Results: In group A, cases which showing clinical improvement were operated. Of the 37 cases, 7 cases died before abdominal exploration, 1 case survived without operation. Mean birth weight was 1597 g (616–3400 g), mean gestational age was 29.7 weeks (24–40 weeks), and survival rate was 38% (n=14) in group A. In group B, all cases were operated in early period after having fluid and electrolyte resuscitation. Mean birth weight was 1448 g (390–3500 g), mean gestational age was 30.5 weeks (23–40 weeks), and survival rate was 69% (n=25) in group B.

Discussion: In our study, mean birth weights and mean gestational ages were similar in both group A and B. However, mortality rates were high in group A. In Grade 2b and above NEC cases, early surgical intervention when the diagnosis has been established is advisable. However, in cases with severe NEC, abdominal drainage to and delayed surgery may improve survival rates.

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OP76: A trial to improve the outcome of neonates with bilateral cleft lip by early repair

Ahmad Mohammed El-Sadata and Marwa Mostafa El-Sonbatyb

aPediatric Surgery Department, Cairo University and bChild Health Department, National Research Center, Egypt

Purpose: Treatment of cleft lip during neonatal period is controversial, those who recommend delayed closure argue better esthetic results, midface growth disturbance may occur and the added risk of general anesthesia. The purpose of this study was to evaluate nutritional status, psychological impact and esthetic results when doing repair during neonatal period.

Methods: This was a prospective study of sixteen neonates with bilateral labial clefts. Assessment of nutritional status using anthropometrical parameters and clinical examination, assessment of suckling, esthetic results and parent satisfaction were done after surgical repair of cleft lip for at least six months.

Results: Better suckling was observed after operation. Weight, length and head circumference at birth and six months later were identical with reference curve value. The weight, length and head circumference curves lies between 5th and 97th percentiles. Good general condition of the infants was observed. High satisfaction was noted by the parents. Good esthetic results was also noted.

Conclusion: Early neonatal repair is recommended to manage difficulty of feeding, better growth and development, good esthetic results and high satisfaction of the parents.

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OP77: Healthcare-associated infections in surgical neonatal intensive care unit

AG Güler, R Tuncer, S İskit, M Alkan, Ü Zorludemir, C Parlakgümüş and Z Özçelik

Department of Pediatric Surgery, Çukurova University Medical Faculty, Adana, Turkey

Purpose: Helathcare-associated infections (HAIs) are the local or systemic infections that is not present at the begining of the hospitalization and starts at 48 h of the hospitalization. It may be blood stream, urinary tract, and surgical site infections, ventilator associated pneumonia, menengititis and clinical sepsis. İn our study we aimed to research the risk factors of HAIs.

Methods: We retrospectively evaluated files of the 264 newborn patients for HAIs with the criterias of Centers for Disease Control and Prevention (CDC) for 4 years of period.

Results: 48 patients are excluded from the study, because of infection, death or discharge from hospital within first 48 h. 73(%27) of the 264 newborn had HAIs. Findings are reviewed.

Conclusion: Additional invasive interventionsincrease the rate of HAIs and the mortality in newborns. Avoidance of unnecessary invasive interventions may reduce the risk of HAIs.

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OP78: Antenatally detected adrenal mass: extralobar pulmonary sequestration

S Tiryakia, A Çelika, Y Ertanb and O Erguna

Departments of aPediatric Surgery and bPathology, Ege University

Aim: Improvement in antenatal ultrasonography provided a significant increase in the antenatal diagnosis and evolution in the prognosis of many diseases. Adrenal masses represent an important part of the antenatal diagnoses and neuroblastoma deserves majority of attention through adrenal masses due to its clinical course. However differential diagnosis includes other entities to constitute different treatment plans. A rare cause of fetal adrenal mass is presented.

Case report: A five days old male infant admitted to our clinic with a left subdiaphragmatic mass identified during ultrasonography on the 26th week of gestation. Physical examination was unremarkable besides a left palpable kidney. Serum NSE level was 33 mg/l and US revealed a 5×4×3.5 cm suprarenal solid mass having a significant hyperechogenity and no calcification. Abdominal computerized tomography demonstrated an encapsulated mostly cystic suprarenal mass reported to be highly suspicious for neuroblastoma and magnetic resonance imaging revealed a high signal intensity in T2A images. At laparotomy, a 5×4 cm mostly cystic mass was found which gave an expression of having a pseudocapsule. It was strongly attached to the muscle fibers of left diaphragmatic crus. Serous fluid was poured out the mass after the mobilization. A vascular network originating from aorta and mostly providing a peripheral vascularisation was also identified. On microscopic examination, a disorganized lung tissue that was composed of alveoli, alveolar ductus and bronchioles was seen. Normal adrenal tissue was not observed. The patient was discharged on postoperative day 2 and 3 months follow-up is uneventful.

Conclusion: Every infant with an adrenal mass should undergo a postnatal throughout work-up and early manipulation because of the wide range of possible diagnoses and differences in treatment modalities. Extralobar sequestration should be kept in mind for adequate management.

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OP79: Pneumothorax in newborn infants: 5 years experience

C Güneya, M Çakara, O Koçakb, L Cankorkmaza, G Köylüoğlua and A Gültekinb

Departments of aPediatric Surgery and bPediatrics, Cumhuriyet University, Medical School, SIVAS

Aim: To assess the predisposing factors, frequency and mortality of pneumothorax (PTX) among the newborns hospitalized in a neonatal intensive care unit.

Materials and methods: We retrospectively reviewed 87 patient records with pneumothorax among the 3933 neonates between January 2006-December 2010 in our Neonatal Intensive Care Unit. They were analyzed according to gestational age, birth weight, type of delivery, precipitating event disorders, side of PTX, causes of PTX, Apgar score, respiratory management data (ventilator settings and blood gases), additional anomalies and the mean hospital stay.

Results: 52 patients were male and 35 were female. 59 neonates were premature and 27 neonates were mature, One patient was the postmature. The median gestational age of patients was 33.5 (24–42) weeks and mean birth weight was 2126 g (740–4700). Sixty-two deliveries were by cesarean section. There was etiological factor in 77 cases. Unilateral PTX occurred in 68 patients and bilateral PTX in 19 patients. Eighty patients needed mechanical ventilation. Mean PTX time was 4.9 days (1–47). Mean tube thoracostomy duration was 6.4 days (1–30). 62 patients underwent one or more of surfactant therapy. Overall, 31 neonates with PTX died. Respiratuar Distress Syndrome and mechanical ventilation were the most common predisposing factors for the development of neonatal PTX and mortality.

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OP80: Delayed diagnosis of congenital anomalies

YH Çavuşoğlu, A Karaman, İ Karaman, D Erdoğan and İF Özgüner

Department of Pediatric Surgery, Dr. Sami Ulus Maternity and Children's Hospital, Altindağ, Ankara, Turkey

Introduction/purpose: The hospital stay of the mother and her healthy newborn infant should be long enough to allow identification of early problems. Standardized international guidelines recommend a routine physical examination of all newborns before discharge, at least within the first 48 h of life. The aim of this study was to determine the extent of delayed diagnosis of newborns with early detectable congenital anomalies.

Materials and methods: Neonates admitted to our pediatric surgery clinic with a diagnosis of congenital anomalies between 2005 and 2010 were retrospectively reviewed. The cohort consisted of patients with anal atresia, esophagus atresia and congenial abdominal wall defects. A delayed diagnosis was considered to be one made 48 h or more after birth.

Results: A total of 451 newborn patients had been admitted to the clinic during this period. There were congenital anomalies requiring surgery in 236. A total of 119 patients had anal atresia, esophagus atresia or congenital abdominal wall defect that would be expected to be diagnosed at an early stage. All had been born in healthcare facilities. The diagnosis had been delayed in 24 (20.2%). The diagnosis had been made within the first 48 h but the family had still brought the discharged baby from home in eight babies. In total, the diagnosis had not been made appropriately and on time in 26.9%. The time of diagnosis was 3–15 days in those with a delayed diagnosis (median: 4.5 days). Eleven patients had a prenatal diagnosis and none in this group was diagnosed late but 55% had been referred by a newborn specialist and 45% by a pediatrician. The inpatient duration and survival rates were not different between those diagnosed late and on time (P>0.05).

Conclusion: However, Soranus recommended anal examination for all newborns in the second century, the delay in diagnosing congenital anomalies that should be diagnosed early was higher than previously thought. Despite the early diagnosis in patients with a prenatal diagnosis, we were unhappy about the fact that these babies who need a multidisciplinary approach had been born in hospitals without newborn or pediatric surgery departments. The lack of a difference in inpatient duration or mortality for babies with a delayed diagnosis leads to the question whether some of the newborns where the diagnosis is not made properly die before reaching pediatric surgeons.

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OP81: Our experience with gastroschisis in 11 years: factors affecting mortality and morbidity

D Erdoğan, MN Azili, YH Çavuşoğlu, İS Tuncer, İ Karaman, A Karaman and İF Özgüner

Dr. Sami Ulus Maternity and Children's Training and Research Hospital, Ankara, Turkey

Aim: The aim of this study is the evaluation of the patients who were treated with the diagnosis of gastroschisis and to establish the factors which have affects on morbidity and mortality.

Materials and methods: Twenty-nine patients who were managed for gastroschisis during 2000–2010 were rewieved retrospectively. Patients were analyzed in respect to gestational age, birth weight, associated anomalies, type of delivery, operative procedures, postoperative complications, total parenteral nutrition (TPN) related complications, and the factors affecting mortality and morbidity were assessed.

Results: 24% of the patients had associated anomalies. Eleven of the patients had elective reduction (Bianchi) in the incubator without anesthesia. Eight patients had delayed reduction with silo, and primary closure was performed on ten patients. Although type of delivery was determined to have effect on morbidity but not on mortality; it was shown that gestational age, birth weight and operative procedure which was performed didn't have any effect on morbidity and mortality. Duration of tolerance of oral intake, TPN and hospitalization were found statistically significant shorter in the group of babies delivered by caesarian.

Conclusion: Mortality of gastroschisis is reported to be decreasing in the literature with the development of antenatal care, neonatal intensive care and TPN. Mortality is found to be 34.5% in our series, which is higher than the world literature. While the most important causes of mortality were abdominal compartment syndrome and multiorgan failure in rather early years, long hospitalization and sepsis have been the main mortality causes in recent years.

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OP82: Impact of intensive care conditions on survival rates in cases with esophageal atresia

D Alver, AC Celayir, O Bosnali and S Moralioğlu

Department of the Pediatric Surgery, Zeynep Kamil, Women and Children Deseases, Education and Research Hospital

Background/purpose: Survival rates in esophageal atresia are dependent to associated cardiac anomalies, pneumonia, and birth weight. According to these variables, several classification systems have been described to predict survival rates. The aim of this study was to determine the impact of renewed and fully equipped 3rd level surgical NICU on survival rates in cases with esophageal atresia at our institution.

Materials and methods: Clinical records of the cases with esophageal atresia, operated between January 2004 and January 2011, were reviewed retrospectively according to NICU condition before and after July 2007.

Results: Before July 2007, 3 registered nurses (RN) at day-shift and 1 RN at night-shift were taking care to 27 beds, 2 infant incubators, and 2 ventilators in 350 square-meters pediatric surgery service at our department. After July 2007, a NICU was builded up, and our service was expanded to a 45-bed-service with another 350 square-meters. 4 RN at day shift and 2 RN at night shift were assigned to the NICU to take care to 6 infant incubators, 5 open-beds with radiant warmer, and 7 ventilators. All RN were trained in Neonatal Resuscitation, and were certified in Neonatal intensive care. According to changes, before and after July 2007, in NICU infrastructure, equipment, assigned RN numbers, and trained staff; we determined survival rates were increased from 57.5 to 75% in esophageal atresia cases in every risk groups.

Conclusion: With the increasing numbers of experienced staff and improved conditions in NICU, we determined survival rates are increasing in esophageal atresia cases with low birth weight, and/or severe cardiac anomalies. In cases with congenital anomalies requiring intensive care, fully equipped ICU centers with proper number of experienced staff are appropriate.

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OP83: Six years' experience in esophagial atresia: analysis of 52 patients

D Erdoğan, İ Karaman, YH Çavuşoğlu, İS Tuncer, A Karaman and İF Özgüner

Dr. Sami Ulus Maternity and Children's Training and Research Hospital, Ankara, Turkey

Aim: The aim of this study is the analysis of the patients who were treated with the diagnosis of esophagial atresia in our clinic during the last six years with respect to the literature.

Materials and methods: Patients who were treated for esophagial atresia between 2005 and 2010 were evaluated retrospectively. Birth weights, gestational ages, associated anomalies, operative procedures which were performed, postoperative complications and follow ups were determined. Patients were classified according to the criteria of Spitz (birth weight and major cardiac anomaly) and Waterston (birth weight, cardiac defect and pneumonia)and mortality rates were compared with those of world's literature.

Results: 52 babies were hospitalized and treated with the diagnosis of esophageal atresia in our clinic in the last six years. Gestational age ranged between 29–40 weeks while birth weight ranged between 1210–3750 g. In 67.3% of the babies cardiac anomalies existed, 25% of them being major cardiac defects. In 15.4% of the patients urogenital anomalies were seen. In seven patients anal atresia, in two patients duodenal obstruction, in eight patients VACTERL association accompanied whereas one had CHARGE association, one had Down syndrome, one had Scimitar syndrome. As analyzing the postoperative complications; anastomotic leakage developed in the 15.3% of the patients. Ten patients (19.2%) had esophagial strictures and required dilatations. There weren't any recurrence of TEF. There were 13 (29.5%) patients who had developed gastroesophagial reflux and needed medical therapy. Two of these patients required fundoplication later on. Eight of the patients died. Survival rate was found to be 84.6%.

Conclusion: Survival rate of esophageal atresia is increasing with the developments in neonatal intensive care, operations being performed in experienced hands, preoperative and postoperative care. It was found that associated anomalies were higher in the babies who could not be rescued; VACTERL association was identified as poor prognostic factor.

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Pediatric Urology Oral Presentations

OPU1: Granulocyte-colony simulating factor (G-CSF) promotes functional recovery from neurogenic bowel and neurogenic bladder secondary to spinal cord injury in rats

H Tuğtepea, M Erşahinb, ZN Özdemirc, H Toklud, I Kaygusuze, D Özsavcif, D Bangirg, G Senerd and BÇ Yeğenc

aDepartment of Pediatric Surgery, Marmara University, School of Medicine, Division of Pediatric Urology, Istanbul, Turkey bDepartment of Neurosurgery, Samsun, Samsung Training and Research Hospital, Turkey, cDepartments of Physiology, Marmara University, School of Medicine, dDepartment of Pharmacology, Marmara University, School of Pharmacy, eDepartment of Internal Medicine, Division of Hematology and Oncology, Marmara University, School of Medicine, fDepartment of Biochemistry, Marmara University, Faculty of Pharmacology, and gDepartment of Histology and Embryiology, Marmara University, School of Medicine, Istanbul, Turkey

Introduction: The hematopoietic granulocyte-colony simulating factor(G-CSF), recently uncovered as a neuronal ligand, was shown to improve outcome in various stroke models and myocardial infarction in the rats. The present study was aimed to elucidate the possible protective and antiapoptotic effects of G-CSF on spinal cord injury (SCI) and SCI-induced secondary damage of the urinary bladder and intestines.

Materials and methods: Wistar albino rats were divided as control, saline-treated SCI or G-CSF-treated (100 µg/kg/day, ip) SCI groups. A standard weight-drop method (100 g/cm force at T10) was used to induce a moderately severe SCI. One week post-injury, motor functions were assessed and intestinal transit indices were measured by using the propagation of arabic gum+charcoal mixture before the rats were decapitated. Spinal cord, bladder and ileum samples were obtained for the measurement of caspase-3 activity, malondialdehyde (MDA) and glutathione (GSH) levels, as well as histological examination.

Results: G-CSF improved motor function scores (P<0.05) and abolished SCI-induced delayed intestinal transit (P<0.001). SCI resulted in reduced GSH and increased MDA levels and caspase-3 activities in the spinal cord, bladder and ileum (P<0.05–0.001), while G-CSF-treatment inhibited the caspase-3 activity of the bladder (P<0.05) and spinal cord. Histological analyses also revealed the disruption of neuropil architecture and edematous urinary bladderin the SCI group, while in G-CSF-treated group neuropil architecture was preservedand bladder wall edema was reduced.

Conclusion: G-CSF could be considered as a potentially effective therapeutic strategy to treat neurogenic bowel and neurogenic bladder secondary to spinal cord injury.

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OPU2: The effect of imitanib on the experimental model of Encapsulating Sclerosing Peritonitis

H Tuğtepea, A Kahvecib, H Kayac, S Tuğlularb and Ç Özerb

Departments of aPediatric Surgery, Pediatric Urology, bInternal Medicine, Nephrology and cPathology, Marmara University School of Medicine

Introduction: Encapsulationg Sclerosing Peritonitis (ESP) is a rare yet morbid long term complication of chronic peritoneal dialysis, characterised by long term fibrosis. Imatinib is a thyrosine kinase inhibitor known for its antifibrotic effect in vivo and in vitro. In this study, we examined the effect of imatinibin on the ESP experimental model in rats.

Materials and methods: Twenty-eight non-uremic Wistar albino rats were seperated into four groups. In the control group 2 ml/day of serum physiologic was administered intraperitoneally for 3 weeks, in the second group (CG group) EPS was created by administering 2 ml/200 g chlorheksidin glukonate (%0.1) and ethanol (%15)/day intraperitoneally for 3 weeks; in the third group (resting group) a resting period after CG for 3 weeks; and in the last group (CG+IMA) 3 weeks after CG, 50 mg/kg/day of imitanib mesilate was administrated through a nasogastric tube for 3 weeks. At the end of the respective periods, a peritoneal equilibrium test (PET) was performed. The ultrafiltrate amount (UF), PET parameters (dialisate/plasma urea (D/Purea); [dialisate/plasma creatinine (D/Pcrea); dialisate 1st hour/dialisate 0th hour glucose (D/DOglu)] and peritoneal morphology was examined.

Results: CG resulted in functional and morphologic changes in the peritoneal membrane compared to the control group. When the CG+IMA group was compared to the control group, UF, D/Pcrea, D/D0glu and mesothelial cell activation was significantly increased. However, when compared to the resting group, mesothelial cell activity was the only difference observed, statistically.

Conclusion: Imatinib is a promising agent for the treatment of EPS after chronic PD.

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OPU3: Effects of tolterodine and trospium chloride on the renal damage induced by partial upper urinary tract obstruction

A Karamana, E Şamdancib and S Sayinb

Departements of aPediatric Surgery and bPathology, Medical Faculty of Inonu University

Aim: Chronic partial upper urinary tract obstruction is the common form of problematic obstruction in children. It causes great clinical concern because it is often difficult to diagnose and treat. Chronic partial upper urinary tract obstruction can damage kidney progressively. A considerable body of evidence indicates that increased renal pelvic pressure may contribute to renal parenchymalinjury in chronic partial upper urinary tract obstruction. In the present study, we aimed to examine efficacy of trospium chloride and tolterodine on the renal parenchymalinflammatory process and upper urinary dilatation in the rats.

Materials and methods: Thirty two rats divided into four groups: group 1 (control group), group 2 (obstruction group), group 3 (obstruction+tolterodine, 0.5 mg/rat, i.g. group), and group 4 (obstruction+trospium chloride1 mg/kg/rat, i.g. group). In groups, except group 1, partial upper urinary tract obstructionwas induced by embedding the upper quarter of the right ureter into the psoas muscle for 14 days. At the end of the experiment period, rats were sacrificed. Pelvic dilatation and parenchymal inflammation were evaluated with H&E staining. SMA, neuroglobin, and cytoglobin were examined with immunohistochemical staining.

Results: Group 2 animals demonstrated severe pelvic dilatation and parenchymal inflammation and increased SMA and neuroglobinstaining in wall of upper urinary tractus (P<0.05). Treatment of animals with tolterodine and trospium chloridemarkedly attenuated inflammatory alterations, reduced pelvic dilatation and decreased the intence neuroglobin staining.

Conclusion: The findings imply that increased renal pelvic pressure may contribute to renal parencymal injury in chronic partial upper urinary tract obstruction. Anticholinergic medications such as tolterodine and trospium chlorideexerts reno-protective effects probably by prevention of pelvic pressure increasing.

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OPU4: Ozone therapy prevents renal inflammation and fibrosis in rat model of acute pyelonephritis

B Çalişkana, A Güvena, A Özcanc, M Özlerb, O Bedird, İ Sürera and A Korkmazb

Departments of aPediatric Surgery, bPhysiology, cPathology and dMicrobiology, Gulhane Military Medical Academy, Ankara, Turkey

Introduction: Not only bacterial characteristics but also oxidative/nitrosative stress could play significant role in renal parenchymal inflammatory processes in acute pyelonephritis (APN). We evaluate the effect of ozone therapy (OT), on the renal function, morphology and biochemical parameters of oxidative stress in an experimental model of APN in rats.

Materials and methods: Forty Sprague Dawley rats were divided equally into five groups as control, APN, APN+Antibiotic, APN+OT and APN+Antibiotic+OT. APN was induced by injection of 0.1 ml freshly prepared E. Coli solution into the kidney. Control group was administered 0.1 ml of 0.9% NaCl solution. Treatment was begun 72 h after bacterial inoculation. Control and APN groups were given 0.9% NaCl solution, APN+Antibiotic and APN+OT were given either antibiotic (ciprofloxacine) or OT for five consecutive days. At the end of the seventh day, animals were killed via decapitation and trunk blood was collected. Both kidneys were harvested for antioxidant enzyme activity, tissue lipid peroxidation, protein carbonyl content and histopathologic examination.

Results: APN increased the renal glomerular and tubular dysfunction, oxidative stress parameters and antioxidant enzyme activities. Either antibiotherapy or OT markedly ameliorated renal dysfunction, the antioxidant status of kidneys and histopathological injuries subjected to APN. Interestingly, the combination of antibiotherapy and OT was much more effective.

Conclusion: OT was found to be effective in preventing renal inflammation and fibrosis by modulating oxidant/antioxidant status. Therefore, OT may be considered as an adjuvant therapy to classical antibiotherapy to prevent renal inflammation and fibrosis in APN.

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OPU5: Effects of medical ozone therapy on acetaminophen-induced nephrotoxicity in rats

S Demirbaga, B Uysalb, B Caliskana, A Guvena, A Ozcanc, I Surera and A Korkmazb

Departments of aPediatric Surgery, bPhysiology and cPathology Gulhane Military Medical Academy, Ankara, Turkey

Aim: Acetaminophen (APAP), also known as paracetamol, is the commonest cause of toxic ingestion in the world. Because overdose of APAP has life-threatening effects on kidney, treatment of APAP-induced nephrotoxicity has life-saving importance. Aim of the study was to evaluate the efficacy of medical ozone therapy in experimental model of APAP toxication.

Materials and methods: Twenty-one male Wistar rats (200–250 g) were randomly assigned into three groups containing seven rats each: Sham, control (only APAP treated) and APAP+ozone therapy groups. Rats were killed 48 h after administration of APAP. Urea, creatinine levels in the blood, and malondialdehyde (MDA), superoxide dismutase (SOD), and glutathione peroxidase (GSH-Px) activity in renal tissue were measured. Kidney tissues were stained with hematoxylin and eosin for histological assessment.

Results: APAP administration deteriorated the renal functions and significantly elevated renal MDA levels and depleted SOD and GSH-Px activities. Ozone therapy significantly reduced the MDA level, increased the SOD and GSH-Px activities, and normalized the renal histology.

Conclusion: In conclusion, our study results are consistent with encouraging data for ozone therapy on APAP-induced nephrotoxicity in rats by improving antioxidant mechanism and oxidative stress.

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OPU6: Interleukin (IL)-10 protects against testes ischemia/reperfusion injury in rats

H Öztürka, H Terzib, H Öztürka and G Buğdaycic

Department of Pediatric Surgery, Histology and Embriyology and Biochemistry, Abant Izzet Baysal University, Medical School

Aim: In this study, we aimed to investigate the effect of Interleukin (IL)-10 (IL-10) on histologic damage induced by testicular torsion-detorsion in rats.

Materials and methods: Twenty-one male Sprague-Dawley rats were separated into three groups, each containing 7 rats. A sham operation was performed in group 1 (control). In group 2 (I-R/Untreated), 1 h detorsion of the testis was performed after 6 h of unilateral testicular torsion. In group 3 (I-R/IL-10), after performing the same surgical procedures as in groups 2, Interleukin (IL)-10 was given intraperitonelly. In all experimental rats, ipsilateral orchiectomies were performed for histological examination and tissue malondialdehyde MDA), superoxide dismutase (SOD), glutathione peroxidase (GPX), Catalase (CAT) and Myeloperoxidase (MPO) activities.

Results: Testes I-R/Untreated resulted with increased tissue MDA and MPO levels and diminished SOD and GPx activities. These changes were almost found to be reversed in IL-10 treatment group. Histopathologically, the testes injury in rats treated with IL-10 was less than I-R/Untreated group. The testicular injury score was lower in group 3 rats compared to the group 2.

Conclusion: The current findings demonstrate that the IL-10 decreased the severity of testicular injury by reversing the oxidative effects of testes I-R.

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OPU7: The long term protective effects of short-interval postconditioning in testicular ischemia-reperfusion injury in rats

S Özkisacika, AO Erdema, Ö Durmaza, N Çulhacib, H Gürsoya and M Yazicia

Departments of aPediatric Surgery and bPathology, Adnan Menderes University Medical Faulty

Aim: Despite the prompt diagnosis and treatment of testicular torsion, there are problems with fertility and atrophy after testicular salvage. The aim of this study is to investigate the protective effect of short interval postconditioning on testicular atrophy in long term and determine the optimum time of reperfusion period.

Materials and methods: 40 adult male rats were divided into 5 subgroups: Sh (sham operated), TD (torsion+detorsion), PC5 (torsion+postconditioning−5 s), PC10 (torsion+postconditioning-10 s), PC20 (torsion+postconditioning−20 s). Torsion was created by rotating the left testis counterclockwise 10800 and then the testis was fixed to the scrotum with three sutures. Torsion was maintained for 4 h. The testicular artery was visualized and before detorsion of the testis, an atraumatic vessel clamp was applied to prevent reperfusion in all study groups. Then, detorsion of testis was performed. In the TD group the clamp was released just after detorsion; in the PC5 group, the clamp was released for 5 s and closed for 10 s (ten times); in PC10 group, the clamp was released for 10 s and closed for 10 s (ten times); and in the PC20 group, the clamp was released for 20 s and closed for 10 s (ten times). Then, all testes were reperfused and waited for 60 days in all study groups. Following this period, the rats were sacrificed and bilateral testes were removed and evaluated histopathologically. The Chi-square test was used for statistical analyses.

Results: In group PC5 in left testes, mean histopatologic grade was statistically significantly lower compared the others groups (P<0.05).

Conclusion: We can conclude that short interval postconditioning can protect the reperfusion injury of testis in long term and the optimum time of reperfusion during postconditioning is 5 s in the model of testicular torsion in rats. This technique seems easily applicable and for this reason similar technique may be used easily during testicular surgery.

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OPU8: The possible effects of oxidative stress, cytokine response and outoimmunite on infertility in children with undessended testes

M İmamoğlu, S Samut and H Sarihan

Department of Pediatric Surgery, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey

Undescended testicle, common case in childhood, is one of the most important one of causes of subfertility/infertility. However, in those cases, which is the cause of deterioration fertility has not yet been clarifield. We designed this study to figure out which of the three accused mechanisms; oxidative stress, cytokine response and autoimmune causes deterioration of the testicles in the one-sided and two-sided undescended testicle cases.

For the study, an experimental group with 88 children with undescended testicles and a control group with 44 healthy children were formed. MDA and IMA levels were monitored in both groups to assess oxidative stress. MDA levels were determined with TBARS Assay on serum samples of the both groups. The reducing biding capacity of albumin cobalt was evaluated with coulometric determination method was used to determine the IMA levels on serum samples of the both groups. In order to assess cytokine response in both groups, IL-6 levels in serum were measured with AssayMax Human IL-6 ELISA kit. Autoimmunity effect in both groups were evaluated with Indirect Immuno-fluorescent method, by using Euroimmun Spermatozoa (human) (Euroimmun, Lubeck, Germany) kits.

The statistical interpretation of the available data showed that the increase in MDA results of the experimental group is greater than the control group at statistically significant level (P=0.003). However, when IMA scores of the experimental and control groups were compared, no significant difference was observed (P=0.179). In the evaluation of cytokine response, it was observed that IL-6 results of the experimental group increased significantly higher than the control (P=0.019). When autoimmune is considered, although ASA results of the experimental group were higher, the groups could not be compared because the variance of the data was not suitable for chi-square test. Furthermore, there was no statistically significant difference when ASA positives were cumulatively evaluated (P=0.473).

The results of the present study to designate that oxidative stress and cytokine response may have substantial effects on etiology of sub-fertility/infertility developing in the long term on children with undescended testicles. However, have not a result obtained that autoimmunity may play role in etiology of subfertility/infertility.

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OPU9: Should circumcision during the summer months be a nightmare for pediatric surgeons? The views and deeds of a quiet surgeon in the periphery

E Türk

Department of Pediatric Surgery, Denizli State Hospital

Introduction: Circumcision is the most common procedure performed by pediatric surgeons and urologists and is part of the religious requirements of our country. The inability of hospitals to meet all the increased circumcision requests during the summer holidays can lead to these procedures being carried out by local people called circumcisers who lack adequate medical equipment and this causes some medical and social problems. This study suggests a solution to pediatric surgeons working at peripheral hospitals to solve this problem and emphasizes the importance of pediatric surgeons.

Materials and methods: Patients presenting at the Denizli State Hospital Pediatric Surgery Outpatients Department to undergo circumcision during the school holidays were divided into two groups. Patient who could communicate easily and were over 6 years old were circumcised under local anesthesia while children aged 0 to 6 or children over 6 but shy or with an additional abnormality detected during physical examination were circumcised under general anesthesia.

Results: A total of 886 patients presented at our outpatients department for circumcision between 1 June and 31 September 2010 and 676 children (76.2%) aged 6–17 years were circumcised under local anesthesia by a single pediatric surgeon with the help of medical officers. A total of 154 patients (17.3%) aged 0–6 and 25 patients (3%) older than 6 but with adaptation problems and 31 patients (3.4%) with an additional anomaly detected during physical examination were operated under general anesthesia.

Discussion: Pediatric surgeons working at a peripheral hospital can train the healthcare staff on the rapid, practical and healthy circumcision method they prefer and enable the circumcision of many children under local anesthesia. They can also examine the children before circumcision to diagnose any addition anomalies and prevent incorrect circumcision being performed by persons lacking a medical education.

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OPU10: The opinions of pediatricians regarding circumcision in Turkey

İ Ulman and A Avanoğlu

Department of Pediatric Surgery, Division of Pediatric Urology, Ege University Faculty of Medicine, Izmir

Circumcision is the most common surgical procedure performed in Turkey. There are differences in circumcision practice and culture unique to this country. Despite other countries where circumcision is common, neonatal circumcision is infrequently performed in Turkey. Since it has the potential of affecting parental decisions, the attitude of pediatricians regarding circumcision practice was evaluated in this study.

Materials and methods: In a recent national meeting of pediatrics, a group of pediatricians was subjected to an anonymous questionnaire following a point-counterpoint discussion on neonatal circumcision. There were 24 questions related to different aspects of circumcision. The answers were collected via an electronic poll with multiple choice answers.

Results: There were 134 pediatricians who agreed to attend the poll voluntarily. The number of responses for each question was between 125 and 134 (93–100%). The majority of the group (81%) responded in favor of circumcision in general. Half of the group was suggesting circumcision to between 1–25 patients/year. The majority (69%) thought that circumcision should be done before two years of age. However, only 12% stated that it should be performed in the neonatal period. Most pediatricians (75%) acknowledged increased risk of urinary infections and problems related to prepuce in uncircumcised boys. The majority (85%) thought that newborns feel pain, and anesthesia is necessary for neonatal circumcision. Only 13% were aware of the high neonatal circumcision rate in United States of America. They (97%) thought that only 5–15% of circumcisions are performed by physicians in Turkey. Nonretractable foreskin was described as phimosis indicating circumcision by 43% of the pediatricians. 76% were against manual retraction of the foreskin and not suggesting it to parents, because they (71%) thought nonretractable foreskin without complaints is normal in infancy. The majority (69%) thought that health insurance should cover circumcision. Most of the pediatricians (67%) thought that, there are serious problems that require radical changes and new regulations regarding circumcision practice in general in Turkey.

Conclusion: Pediatricians are closely involved in circumcision issue in Turkey. They have important opinions about different aspects of circumcision. Neonatal circumcision is not recommended by most of them. They have sound concerns about problems related to circumcision and favor radical changes in general practice of circumcision.

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OPU11: Knowledge attitude and behaviour of boys and parents about circumcision

N Çördüka, G Ünlüb, A Sarioğlu-Bükea, A Büberb, B Savrana and M Zincirc

Departments of Pediatric Surgery, Pamukkale University Faculty of Medicine, Child and Adolescent Psychiatry, Public Healty, Denizli

Aim: The aim of this study is to determine of knowledge, attitude and behaviour of previously circumcised early adolescent boys and their parents about circumcision.

Materials and methods: Half of the boys (n=816) studying in the 6th class of the primary school in our city center and their parents were includedin this cross-sectional descriptive study. 1336 questionnaires which prepared for the boys and for their parents separately (including 25 and 38 questions respectively) were collected.

Results: Median age of circumcision was 7.1 (0–14) years. 66% of the students were circumcised at the age of 7 and above, 26% of between 3 and 6 years, 8% of below 3 year of age. The level of education of 68% of mothers was primary school and below and 70% of mothers were housewives. The level of education of 51% of fathers were primary school and below and %53 of them were workers. 42% of boys were operated on by a traditional circumciser, 40% by a medical doctor and 18% by a health officer. 10% of the boys were circumcised during collective circumcision organizations. 64% of circumcision was performed at home. As the educational level of both the fathers and mothers increased, the rate of circumcision performed at home decreased significantly. When the parents were asked about their knowledge of complications of the circumcision the answers were as follows; 60% bleeding, 43% infection, 23% pain, 23% inaccurate surgery, 31% no idea. 20% of parents defined a complication during circumcision of their children namely; pain (12%), bleeding (7%), bad scar (1.5%) and infection (1.5%). Parents stated that they had their children circumcised for religious purposes (79%) and because its healthy (51%).

When the children were asked what they thought during their circumcision, the boys stated that, its was necessary to become a men (58%), it would heart much (50%), they would grow up (23%), it would bleed much (10%), his penis would get smaller (7%), he would lose his penis (5%). %25 of children felt pain during circumcision, 38% were frightened, 46% were worried, 38% cried, 37% felt pain after circumcision. The fear and worry was utmost in 3–6 years age group, and least above 7 years. Crying was utmost below 3 and least above 7. Pain after circumcision was significantly higher in 3–6 years age group. Boys circumcised in the 7 years and above age group were most content about the age of their circumcision.

Conclusion: Although the parents know about the complications of circumcision they still prefer circumcision at home. In this study about one fourth of boys were circumcised between 3–6 years of age although harmful effects of circumcision during the phallic period was ascertained.

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OPU12: Complication of circumcision: evaluation of 1900 cases

A Özkana, M Kayaa, M Okurb, A Küçüka and M Oruçc

Departments of aPediatric Surgery, bPediatrics, Duzce University School of Medicine and cIsparta State Hospital Plastic Surgery Clinic

Circumcision is excision of prepisium to reveal the glans penis. Indisputable the oldest known surgical procedure. Although undoubtedly the most commonly performed surgeryi n our country for years, kept outside coverage social security agencies process has often led to unauthorized non-medical person circumcision. This study was carried out by specialist physicians in a sterile operating room conditions, post-operation complications and complication rates of circumcision was performed to evaluate review of the literature.

In this study, circumcision was performed to 1916 child patients who were referred to our clinic in between July 2007 and September 2009. 16 patients with glandular hypospadias with intact prepisium and normal appearance were not included to the study. Early and late complications after circumcisions were evaluated retrospectively. Median age of 1900 boys who were included the study was 6.66±2.12 (0–17 years). Complication rate in our study was 5%. In our study, hemorrhage was the leading complication with 3.15%. The other complications were infection with 0.52%, adherance of mucosa or skin to the glans with 0.47% and complications related to anesthesia or local anesthesia with 0.42% with decreasing order.

Circumcision is a surgical procedure and like every surgical procedure, it needs maximum care with rules that must be obeyed and also the right technique must be used. Unwanted results can be seen after circumcision too. It is the duty of the physicians to try to prevent the unpredicted results and complications.

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OPU13: Circumcision: a safe operation or disastrous complication; management of sever penile shaft injuries

MS El-Debeiky and HA Soliman

Department of Paediatric Surgery, Ain Shams University, Cairo, Egypt

Background: Circumcision remains to be the oldest known surgical practice to Mankind. For ages, its popularity was based on religious and ethnic backgrounds. Nowadays, there is a growing worldwide acceptance of performing circumcision to all males particularly with the assumptions of decreasing the incidence of genital malignancies as well as sexually transmitted diseases. Despite the vast experience in performing circumcision with various techniques, it is not devoid of complications which are infrequently devastating and difficult to manage. The purpose of this study was to evaluate the outcome of a reconstructed penis after a sever shaft injury following circumcision.

Materials and methods: 14 patients with sever penile shaft injury after circumcision where subjected to staged reconstruction. Based on the remaining corporeal tissues and skin, the reconstruction was planned using local flaps, release of trapped corpora and excision of scar tissues as well as using more distant grafts with urethral reconstruction.

Results: All of the 14 patients achieved acceptable penile tissue length, erectile function and distal urethral meatus. Cosmetic appearance although appreciated by the parents is yet not comparable to the original.

Discussion: Despite the safety, short learning curve and frequent practice, circumcision seems to present a rare but serious risk. Penile shaft injuries are very challenging to reconstruct and requires a tedious planning and operation. Good results after reconstruction do not affect the necessity of a safe practice for circumcision to avoid the need for such reconstruction.

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OPU14: Isolated Fallopian Tube Torsion: a series of five cases

C Güneya, M Çakara, G Köylüoğluv and H Özerb

Departments of aPediatric Surgery and bPathology, Cumhuriyet University Faculty of Medicine, Sivas

Aim: Isolated Fallopian Tubal Torsion (IFTT) is a rare condition causing acute abdomen, there is no specific clinical or laboratory findings. The diagnosis can rarely be made before operation. We present five cases with IFTT.

Materials and methods: Ages ranged from 14 to 15 years. Duration of symptoms ranged from 6 h to 3 days. In three cases pain was colic form, the rest had blunt-skilled. Four patients had peritoneal irritation signs. Three patients complained of gastrointestinal symptoms. Mild leucocytosis was noted in one patient and all CRP values were negative. In ultrasonographic determination; in three patients cyst was detected in pelvic area, one patient had a mass. Ovarian blood supply was normal in three patients.

In surgery, IFTT was determinated in right for three patients and in left side for two patients. Cyst excision was performed in one patient after detorsion, in four patients salpingectomy was performed.

Discussion: IFTT is a very rare condition in childhood and early puberty. The correct diagnosis is usually not established until operation, and removing the tube is almost always necessary. Only few reports considered a possible preoperative diagnosis of adnexal torsion by ultrasound. In our cases, none get a preoperative diagnose by ultrasound. Although, IFTT is an exceptionally rare event, but it is imperative; if physicians know the clinical situations and imagining methods, fallopian tubes can be recovered with an early surgery. IFTT must be considered in patients with acute abdomen and cystic formations are determined in paraovarian region and the ovarian blood supply is detecded as normal.

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OPU15: Pyeloplasty in infants: effects on clinical, ultrasonographic and scintigraphic paramaters

S Demirezena, G Karagüzela, M Koyunb, F Aydinc, S Akmanb, E Alimoğlud, C Bonevala, F Güngörc and M Melikoğlua

Departments of aPediatric Surgery, Akdeniz University School of Medicine, Pediatricsb, Nuclear Medicinec and Radiologyd, Antalya, Turkey

Aim: There are different clinical and imaging approaches to diagnose uretropelvic junction (UPJ) obstruction and to determine optimal timing for surgical indication. In this study, it was aimed to evaluate clinical, ultrasonographic and scintigraphic findings in infants with UPJ obstruction who was undergone pyeloplasty.

Materials and methods: In the last 5 years period, patient's files of 20 infants who were performed pyeloplasty because of UPJ obstruction were reviewed. Indication for pyeloplasty was based on multidisciplinary evaluation and our instutional algorithm. Pyeloplasty was done using open surgical technique (Anderson-Hynes). Abnormalities in clinical outcome (significant bacteriuria, symptomatic urinary tract infection), ultrasonographic parameters (A-P diameter of renal pelvis, SFU grading) and scintigraphic findings (differentiated function, diuretic response) were noted before and after the pyeloplasty.

Results: Mean age at surgical intervention was 2.8±31.6 months, and mean follow-up time was 31.1±16.6 months in our series. Before and after pyeloplasty, the rates for significant bacteriuria were 8/20 and 2/20, respectively. Pre- and postoperative rates for symptomatic urinary infection were 9/20 and 3/39, respectively. Before and after pyeloplasty, mean A-P diameters of renal pelvis were 33.4±9.8 mm, 18.1±6.2 mm respectively. Pre- and postoperative mean SFU grading were 3.7±0.7, 2.5±1.5, respectively. Before and after pyeloplasty, mean differentiated functions were 35.7±15.6 and 42.0±15.2, respectively. While 3 patients had partial or complete diuretic response preoperatively, 13 patients showed diuretic response in postoperative period. One patient complicated with incisional hernia. No case required redo operation in our series.

Conclusion: Both clinical and ultrasonographic/scintigraphic parameters were markedly improved in infants undergone pyeloplasty. Surgical indication based on multidisciplinary and algorithmic approach contributes successful clinical outcome in patients with UPJ obstruction.

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OPU16: The effect of natrium hyaluronate on collagen tissue ocurred after anastomosis in pelviureteral anastomosis

M Yurtçua, ZF Babab and E Günela

Departments of aPediatric Surgery and bPathology, Selcuk University, Selcuklu Medical Faculty, Konya, Turkey

Aim: This study aimed to investigate the effect of natrium hyaluronate (NH) on the fibrosis tissue formation in experimental ureteropelvic anastomosis (UPA).

Materials and methods: Eighteen rabbits were divided equally into 3 groups: surgical (S), Sham (Sh), and NH. A 1-cm-length of the ureteropelvic segment was resected through a laparatomy incision and then anastomosis was performed. The rabbits were fed parenterally for first 48 h and orally on postoperative day 3. The rabbits were injected with saline (Sh group) and NH (NH group) twice a day via a 2F nephrostomy catheter into anastomoses linesduring the first 7 days after the surgical procedure. S group did not undertake any medication in their procedure. Intravenous pyelography was carried out on postoperative day 21. The rabbits were sacrificed and dissected under a dissecting microscope and examined for acute inflammation (AI), chronic inflammation: (CI), granulation tissue amount (GTA), granulation tissue fibroblast maturation (GTFM), collagen deposition (CD), reepithelialization (R), neovascularization (N), periferal tissue reaction (PTR)in the anastomosis lines 3 weeks later.

Results: In the NH group, AI scores were significantly higher than it was in the C group (P=0.009). GTA in the NH group were significantly higher than it was in the C group (P=0.020).

Conclusions: NH did not decrease fibrosis, but increased important parameters in wound healing such as reepithelialization and neovascularization in an experimental model of UPA in rabbits.

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OPU17: Approach to ureteropelvic junction obstruction in children: 23 year's experience

B Aydoğdu, S Sander, GA Tireli, O Demirali, Ü Güvenç and C Beşik Başdaş

Pediatric Surgery Clinic, Bakirköy Maternitiy and Children Hospital, İstanbul

Objective: Present our 23 years of experience in 211 patients with ureteropelvic junction (UPJ) obstruction on the basis of clinical data.

Materials and methods: Records of 211 patients who have been operated for UP-J obstruction between 1987 and 2010 are analysed retrospectively. Patients were divided into two groups: group 1 consisted of prenatally diagnosed patients (n=149), and group 2 consisted of symptomatic patients (n=62). Age of presentation / operation age, lenght of pre/postoperative followup periods, uroradiologic examination results, associated anomalies, surgical techniques and complications were analysed.

Results: There were 144 male and 67 female patients. Obstruction was left sided in 122 patients (% 57.8), right sided in 81 (% 38.2), and bilateral in 8 (% 4) patients. Mean age was 6 years (3 months to 12 years) in symptomatically diagnosed cases. Preoperative mean lenght of followup periods were 8.2 months and 5.5 months, ultrasonographic A-P renal pelvic diameters were 30.8 and 32.8 mm, relative renal functions in scintigraphy were % 38.6 and 34.7 in group 1 and 2 respectively. Postoperative mean pelvic diameters were 11.7 and 12.1 mm, renal functions in scintigraphy were % 39.2 and 38.6 in group 1 and 2 respectively. The most common complications encountered in the postoperative period were attacks of pyelenephritis which was responded to medical theraphy and recurrent UP-J stenosis which required reoperation. Total complication rates were % 8.7 in group 1 and, % 6.4 in group 2. The mean lenght of postoperative followup periods were 39.4 months in group 1 and, 39 months in group 2. Postoperative followup lasted in 10 years.

Conclusion: We think that, in patients with UP-J obstruction (prenatally or symptomatically diagnosed) whose pelvic A-P diameters rises above 30 mm and relative renal functions falls below % 40, or if there is a loss of renal function in consecutive scintigraphic studies, the treatment of choice is surgery instead of medical follow up.

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OPU18: Operative repair of ureteropelvic junction obstruction: long term experience of a single institution

ŞK Özela, R Özcanb, C Beşikb, M Eliçevikb, H Emirb, N Danişmendb, Y Söyletb and SNC Büyükünalb

Istanbul Bilim Universitya, I.U. Cerrahpaşa Medical Faculty, Department of Pediatric Surgery, Division of Pediatric Urologyb, İstanbul, Turkey

Aim: To present our experience about the surgical management of ureteropelvic junction obstruction (UPJO).

Materials and methods: Medical records of 295 patients operated for UPJO between 1978 and 2010 were reviewed retrospectively. Adequate data was available for 259 patients (Female:75, Male:184). Age at operation, type of obstruction, relative renal function, and outcome after surgery were abstracted. The follow-up ranges between 1 to 10 years.

Results: Of 259 patients (Right: 85, left: 143, bilateral: 31), 94 had prenatally diagnosed hydronephrosis and 165 were presented by various symptoms or incidentally. Intrinsic obstruction was present in 226 and, extrinsic in 33. The preoperative relative renal function was ≤ 30% in 56 patients and 30–59% in 203. Anderson-Hynes pyeloplasty was performed in 290 units; through lombotomy incision in 247 (mean age: 4.2 range: 1 month–17 years) and by laparoscopic approach in 43 (mean age: 6.5 years range: 2 months–17 years). Pelvicaliceal dilatation decreased or disappeared in 75.8% of cases whose ultrasonographic follow-up was complete. Renal function was improved in 40.6% of patients and remained stable in 31.2% of them whose scintigraphic follow-up was complete. Complications were anastomotic leakage (n:8), problems related to stenting (n:6), urosepsis (n:2), incisional hernia (n:3), bleeding (n:1), adhesive intestinal obstruction (n:1). In long term follow up stricture was observed in 20 patients. Redo operations and dilatations were performed to these patients.

Conclusion: Satisfactory results can be achieved with laparoscopic or open pyeloplasty. Pyeloplasty may improve pelvicaliceal dilatation and improve or stabilize renal function in majority of cases in long term follow-up whereas postoperative stricture is the most common complication of this operation which mandates secondary procedures.

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OPU19: Obstructive megaureter; evaluation of 18 patients

F Akbiyik, Z Akiş, M N Azili, E Şenel, E Mambet, Z Livanelioğlu, H Atayurt and T Tiryaki

Ankara Child Diseases Hematology and Oncology Education and Research Hospital Pediatric Surgery Department

Aim: Obstructive megaureter, generates 10% of cases with prenatal hydronephrosis. With the increasing cases of prenatal diagnosis, monitoring and treatment of the patients with obstructive megaureter changes in the last two decades have seen. In our clinic, patients treated surgically with the diagnosis of obstructive Megaureter presenting the results of treatment and follow-up will be discussed in the light of the literature.

Materials and methods: Between the years 2005–2010 with a diagnosis of obstructive Megaureter the current 18 cases of surgical intervention, hospital records were retrospectively reviewed. Referred to our clinic, all patients were determined Megaureter, USG, VCUG, renal scintigraphy was performed in. Patients had no reflux, the ureters also were evaluated with IVP necessarily after all of these studies were diagnosed with obstructive Megaureter. Cases were diagnosed with obstructive megaureter increasing renal pelvic diameter, decreased renal function and 1.3 cm in the ureter diameter on the requirements for surgical intervention was the diameter of the ureter.

Results: Six girls and 13 boys in total 18 cases were evaluated retrospectively. The average age of the patients 3 months–7 years of age was 2.01 years. In three cases, the right ureter, the left ureter in 14 cases, one patient had bilateral obstruction. Investigating the cause of hydronephrosis detected by prenatal diagnosis of 10 cases were received. Applying for one patient because of enuresis, eight case studies were diagnosed because of recurrent urinary tract infection. Two case of ureterocele accompanied by determining and in a case of renal and ureteral stones were found at the lower end on the same side.

One patient had a solitary kidney. One had a solitary kidney, the other case was in urosepsis was the first treatment option temporary ureterocutanestomy case. 15 Hendren type case with open surgery after cystoscopy after reduction of diameter of the ureter, ureteroneocystostomy in a case when the ureterovesical junction were enlarged with a balloon dilatatörü. Only two of 16 patients during cystoscopy narrow catheter is inserted into the ureter catheter has not passed the mouth of the ureter fourteen cases.

Discussion: Primary obstructive megaureter is a rare urinary system anomaly. There is no consensus on its threapy as yet. Monitoring is controversial especially on cases recognized by antenatal hydronephrosis. Although it has been stated that they can be followed by placing a double j stent, it has not been possible to place an endoscopic stent in majority of the cases in our series. In such cases a temporary ureterocutaneostomy is performed when required and conducting an ureteroneocystostomy by reducing the diameter of the ureter is the suitable option over one year age.

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OPU20: Upper urinary tract duplications

MN Azili, G Ekberli, F Akbiyik, E Şenel, E Mambet, Z Livanelioğlu, H Atayurt and T Tiryaki

Ankara Child Diseases Hematology and Oncology Education and Research Hospital Pediatric Surgery Department

Aim: Complete duplication of upper urinary tract, a rare complex anomalies. Such anomalies increasingly, after the diagnosis of intrauterine finding of hydronephrosis is detected. Treatment of patients with complete upper urinary tract duplications, there is not a standard option. The reason we have operated on 20 patients with upper urinary tract duplication and the results were presented and treatment options.

Materials and methods: Between 2005–2010, 20 patients were operated in the upper urinary tract duplication were analyzed retrospectively. Patients with clinical findings, USG, VCUG and renal scintigraphy and biochemical analysis examined the results of the surgical intervention was decided. All patients are still followed up by calling the intermittent controls.

Results: Their ages range from 5 days to 13 years of age 3 males 17 females a total of 20 patients were evaluated from hospital records backwards. 4 cases were diagnosed prenatally hydronephrosis, two patients because of incontinence and in 14 patients with recurrent urinary tract infection was diagnosed. Prenatally ureterocele was found in 2 cases and 2 months of endoscopic ureterocele incision. Cases were re-evaluated 1 year old, the upper pole dysplasia was detected, and heminephrectomy was performed. During the same period, 2 prenatally and 3 were diagnosed with recurrent urinary tract infection due to a single system ureterocele total of 5 cases, were treated by ureteroneocystostomy. In 3 cases due to ectopic ureter, dilatation of the upper pole was detected and hemi nephrectomy was performed, in one case due to ectopic ureter, lower pole dysplasia was determined and lower pole heminephrectomy was performed, heminephrectomy upper pole of the cases in one, had a lower pole ureteropelvic junction obstruction and underwent pyeloplasty. Vesicoureteral reflux was detected in 13 cases. Reflux was detected in 7 cases, open surgery was performed with the anti-reflux surgery. In 3 cases with excision of the dilated ureter, ureteroneocystostomy was performed after ureteroureterostmy, in 4 cases ureteroneocystostomy was performed side to side replaced of the ureters. Six patients were diagnosed with reflux grade 3–4 STING applied. In four cases the control of the VCUG examination showed no reflux, in the two cases degree of reflux had declined and follow-up for urinary tract infection developed, to be followed without the need for an additional intervention was appropriate.

Conclusion: Upper urinary tract duplications are rare, complex anomalies. This is a very detailed evaluation of such patients should be made patient-specific treatment plan. From heminephrectomy to endoscopic ureterocele incision, many different surgical procedures may be needed, with experience in specialized centers, treatment and follow-up is important.

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OPU21: Is upper pole heminephrectomy necessary in complete duplex system complicated with ureterocele?

B Ucana, I Karacaa, E Serdaroğlub, O Arslana, C Özturka, O Okura, M Yildiza, H Evcilera and M Hosgöra

Department of Pediatric, Surgerya, Dr. Behcet Uz Children's Hospital,, Department of Nephrologyb

Purpose: For treatment of complete duplex system complicated with ureterocele (CDSU), nonfunctional upper pole heminephrectomy is recommended. However, long-term follow-up of these patients showed that secondary procedures are required. In this report, we present the results of common sheath reimplantation (CSR) and excision of ureterocele (EU) as the first-line treatment of CDSU with or without functioning upper moiety.

Materials and methods: Between 2002 and 2009, we reviewed 14 patients (mean age 52 months, 9F/5M) with unilateral CDSU (6 right/8 left). 6 cases had intravesical and 8 cases had extravesical ureterocele. There was vesicoureteral reflux (VUR) in 10 cases, in 8 to the lower pole and in 2 to both moieties. 10 had nonfunctional upper pole. In all cases, transurethral incision of ureterocele (TUI) or CSR were performed as the first-line treatment. The median follow-up was 3.9 (1.5–7) years.

Results: TUI was performed in 3 patients with no reflux initially, 2 of them had VUR during follow-up. All 14 cases underwent CSR and EU. 2 case had grade 2 VUR postoperatively and still under follow-up. No patient required secondary procedure. Postoperatively, 5 patients had one episode of urinary tract infection (UTI), one had 3 episodes, and one had recurrent UTI's. No patient had hypertension except one with morbid obesity. Proteinuria and incontinence were not detected in any case.

Conclusion: The results of CSR and EU of CDSU cases are succesful. Any complication of nonfunctional upper moiety wasn't recorded during follow-up. In CDSU cases, excision of nonfunctional upper moiety is not recommended.

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OPU22: Management of patients with ureteroceles

P Oğuzkurta, SS Ezera, E İncea, A Temiza, N Cengizb and A Hiçsönmeza

Departments of aPediatric Surgery and bNephrology, Başkent Üniversitesi Faculty of Medicine, Ankara, Türkiye

Aim: We aimed to evaluate the management and outcome of the patients who were operated for uretroceles in our clinic.

Materials and methods: We evaluated the charts of the patients who were operated with the diagnosis of ureterocele between April 2002 and October 2010 for age, sex, presenting complaints, diagnostic work-up, surgical procedures and outcome, retrospectively.

Results: There were 9 girls and 7 boys with a mean age of 13.31±19.40 months. In twelve patients the diagnosis was made through the evaluation of antenatal hydronephrosis and in 4 patients it was made following a urinary tract infection. The ureterocele was right sided in 11 patients, left sided in 4 and bilateral in 1 patient. It was related to a single system in 2 patients and a-double system in 14 patients (6 were bilateral). Voiding cystourethrography revealed reflux in 9 patients. The initial operation was endoscopic incision of the uretrocele in 4 patients. The following operations were upper pole heminephrectomy without lower tract reconstruction in 2 patients, upper pole heminephrectomy with lower tract reconstruction in 5, preservation of upper pole with lower tract reconstruction in 9 patients. In 2 patients postoperative voiding cystourethrography revealed reflux.

Conclusion: Majority of the patients with uretroceles are diagnosed through the evaluation of antenatal hydronephrosis in the postnatal period. Uretroceles are usually associated with double urinary system. The treatment options should be looked over according to the clinical findings of the patients. In this series although endoscopic incision of the uretrocele was performed to overcome the initial clinical findings, corrective surgical procedures were performed with satisfactory results.

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OPU23: Therapeutic approach in children with ureterocele: a ten-years experience

M Siğa and A Önen

Department of Pediatric Surgery and Division of Pediatric Urology, Dicle University Medical Faculty Diyarbakir, Turkey

Aim: We aimed to investigate the record of our ureterocele cases for the last decade.

Materials and methods: A total of 26 children who treated for ureterocele between 2000 and 2010 were investigated.

Results: Fifteen were girl and 11 were boy. Mean age was 2.4 years (7 days–14 years). Five patients had antenatal diagnosis, while 10 presented with UTI, 4 with abdominal pain, 3 with urethral prolapsus of ureterocele, 2 with difficulty in voiding, one hematuri, and one incidentally diagnosed. Renal damage was present in 21 patients. Three patients had additional pathology (two utereal stone, one bladder fistula). Overall, 11 patients developed VUR. As the primary intervention, endoscopic puncture was performed on 15 patients, endoscopic insicion on 10, and open ureterocele exision and ureteral reimplantation on one patient. During the follow-up period, 3 patients required ureteral reimplantation due to persisten reflux and UTI, while 6 required parcial nephrectomy due to UTI breaktrough and nonfunctioning upper pole. At the last follow-up, 18 patients were free of symptom, 4 lost the follow-up, two had reflux, and 2 died.

Conclusion: Ureterocele is mostly associated with duplex system. UTI is the most common symptom presented with ureterocele; one of the most important cause of renal damage is UTI that occur when there is a delay in diagnosis and treatment. Therefore, early diagnosis and treatment may decrease permenant renal damage. Endoscopic decompression of ureterocele which is minimally invasive, simple, safe and has a high success rate, should be the first modality of choice in the surgical treatment of children with ureterocele. This procedure is sufficient by itself in the majority of such patients. However, partial nephrectomy should be the second choice of treatment in children with recurrent UTI and no improvement of non-functioning upper pole.

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OPU24: Use of HYACYST in the treatment of recurrent urinary trcat infections in children

M Kiliça, S Çakmaka and İS Ardaa

aPediatric Surgery Clinics and bDepartment of Pediatric Rize University Faculty of Medicine Surgery

Introduction: Recurrent urinary tract infection (RUTI) may cause difficulties both in diagnosis and treatment. Although urinary tract anomalies may present with infection many patients may develop RUTI without any anatomical abnormality. In this study, we present our results using HYACYST, which consists of sodium hyaluronate, in the treatment of RUTI.

Materials and methods: 17 patients (aged between 3 and 7 years old; 15 female, 2 male) were included in the study. All patients underwent urinary system investigation by ultrasonography, voiding cystourethrography and renal scintigraphy. 120 mg sodyum hyaluronate/50 ml was instilled through a urinary catheter and left inside the bladder for one hour. All patients have been treated prior to the application of HYACYST. Urine culture was repeated one week and one month after the last instillation.

Results: The number of RUTI were changed between 3 and 6. Enuresis nocturna (5 patient), enuresis diurna (1 patient), and suprapubic pain (7 patient) have been associated complaints to RUTI. Infection recurred in only 2 patients (11.7%). 5 patients were free of enuresis nocturna.

Discussion: The intravesical application of HYACYST inside the bladder possibly reduces the recurrent urinary system infection by producing a protective effect on the glycominoglycan layer. We think that it is a good alternative for the treatment of RUTI in children.

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OPU25: Xantogranulomatous Pyelonephritis in children

A Sayana, A Arikana, T Özdemira, HN Özera, M Cana, FN Narlia, A Karagözoğlua and Ü Bayolb

aClinic of Pediatric Surgery and bPathology Laboratory Tepecik Educational and Research Hospital Yenisehir, İzmir

Aim: Xantogranulomatous Pyelonephritis is a rare chronic infection of the kidney. Typically it develops in the obstructive uropathy background caused by kidney stones and may be misdiagnosed as malignancy. Diagnosis is made with the histopathological examination of the nephrectomy material. Our clinical experience is presented to stress the clinical importance of this pathology.

Materials and methods: Nephrectomy specimens of 112 male and 79 female patients who were operated in our clinic in 1995–2011 are evaluated retrospectively. The clinical and histopathological properties of 7 male and 4 female patients at ages of 5–13 whom had the XP diagnosis are demonstrated.

Findings: In XP, the prolonged infection and dearanged local immunity in the background of obstruction is responsible for granulomatous infiltration and lipid laden macrophage deposition. In all of our patients, systemic infection symptoms such as fever and flank pain are observed. In imaging studies, the X-ray of the patients revealed 5 stag-horn type stones but all patients had urinary calculi in different locations. XP diagnosis is made with CT scans but in 3 patients, a differential diagnosis of tumor necessitated MRI which also showed the same patterns of CT. In patients with no kidney function on DMSA scintigraphies nephrectomy is carried out and histological diagnosis was made as XP. No early or late complications are seen.

Result: XP should be considered in patients with prolonged kidney infections due to stasis secondary to infection. Although the concrete diagnosis is made with post operative histopathological examination, CT and MRI may prove to be helpful in preoperative period.

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OPU26: Is voiding cystouretrography mandatory in children with multicystic dysplastic kidney?

S Tiryakia, AY Alkacb, E Serdaroglub, M Bakb, A Avanoglua and I Ulmana

aDepartment of Pediatric Surgery Ege University and bDepartment of Pediatric Nephrology Buhcet Uz Children's Hospital

Aim: Despite being one of the most common congenital anomalies, controversy around follow-up of multicystic dysplastic kidney (MCDK) continues. The aim of this study was to reveal the necessity of voiding cystourethrography (VCUG) in all MCDK patients.

Materials and methods: Hospital records of 102 patients with MCDK followed in two different institutions between 1994–2009 were reviewed retrospectively considering vesicoureteral reflux.

Results: Eighty-nine of 102 patients with MCDK had undergone VCUG. Vesicoureteral reflux (VUR) to contralateral kidney was detected in 14 patients. VUR grades were as follows: 2 cases in, 5 cases in grade II, 6 cases in grade III and 1 case in grade IV. Four patients required antireflux procedure (3 subureteric injection, 1 ureteroneocystostomy), all others had spontaneous resolution. None of the patients experienced renal failure. The relation between hydronephrosis (HN) and urinary tract infection (UTI) with VUR was evaluated. VUR was significantly more frequent in patients with UTI (38.5%) compared to the ones without (6.3%) (P<005); however, relation with HN was not as significant. Considering two parameters together, VUR was detected in 6.4% of patients with no UTI or HN, 20% of patients with UTI or HN and %57.1 of patients with UTI and HN.

Conclusion: As a result of higher incidence of VUR, VCUG was mostly accepted as a custom component of assessment of the patient with MCDK formerly. Our results support the current idea that most of the contralateral reflux accompanying MCDK is mild and resolves spontaneously. Also UTI has a strong relation with VUR however HN does not. Therefore, we prefer to limit the VCUG indication only for MCDK patients experiencing UTI and expect a high probability of VUR in patients having UTI and HN together.

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OPU27: Syringocoele in children: renal and bladder outcomes

H Tuğtepe, I Mushtaq, P Cuckow, P Duffy, N Smeulders, J Dhillon, D Desai and A Cherian

Department of Paediatric Urology, Great Ormond Street Hospital for Children, London, United Kingdom

Aims: We report our experience with this rare anomaly in children from a single centre highlighting their renal and bladder outcomes.

Materials and methods: A retrospective review of case notes with a diagnosis of syringocoele between 1994 and 2008 was carried out at our institution. Ultrasonogram(US), micturating cystourethrogram (MCUG) and cystoscopy were performed in all patients. Plasma creatinine was available at presentation and GFRs were done for all patients with renal impairment (plasma creatinine >50 micromol/litre) at follow up. Continence was noted in older children and in the younger ones ultrasound was used to assess bladder function. Invasive urodynamics was performed in selected cases.

Results: Thirteen patients were identified with age at presentation ranging from 0–50 months (mean=8.3). Mean follow-up period was 69 months. Seven patients (54%) had antenatal findings with upper tract dilatation in six and two of them in addition had a distended bladder. The remaining presented with urinary tract infection. All were treated cystoscopically. At presentation five (38%) had impaired renal function of which two belonged to the antenatal group. Two of five progressed to chronic renal failure, while the rest continue to have impaired renal function. Day time continence was confirmed in 7. In the rest US confirmed a normal bladder with good emptying. One patient had high baseline pressures and poor emptying on urodynamic assessment.

Conclusion: Close follow up of patients with syringocoele is necessary as upto 40% of the children have renal impairment of whom nearly two fifths progress to renal failure. A minority have bladder dysfunction.

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OPU28: Repair of posterior uretral rupture in children

O Uzunlu, R Özcan, Ş Emre, M Eliçevik, H Emir, SN Cenk Büyükünal, N Danişmend and Y Söylet

Department of Pediatric Surgery, Division of Pediatric Urology, I.U. Cerrahpaşa Medical Faculty, İstanbul, Turkey

Aim: To present our results for the repair of posterior urethra rupture (PUR).

Materials and methods: The medical records of 19 children (Male:18, Female: 1) with PUR were analyzed retrospectively. The mean age is 7.9 (range: 3–14). Thirteen patients were referred to our clinic after previous operation(s); 9 delayed primary repair and 4 after failed primary early repair and the other 6 were presented primarily. Of 9 patients who underwent delayed repair, the operation was performed via transpubic approach in 7, posterior sagittal approach in 1, perineal approach in 1. Four patients were operated for PUR repair after failed primary repairs; redo repair in 2 (transpubic:1, posterior sagittal 1) and appendicovesicostomy in 2. Six patients were presented primarily; early PUR repair during laparotomy for associated injury(s) was performed in 3 and, delayed repair via transpubic approach in 3. The urethra (n:17) was reconstructed primarily in 13 patients, with preputial flap in 2, buccal mucosa in 1, and appendix interposition in 1.

Results: Among 17 PUR repairs, patent uretra was established in 11 (65%) and 6 had strictures (35%). Of 11 sucessfull repairs, 8 (early primary repair:3, delayed primary repair:2, redo repair:1) have socially acceptable urinary continence and 3 (delayed primary repair:1 repair:2 redo) have urinary incontinence. 6 patients (delayed primary repair:5, redo repair:1) underwent dilatations for the strictures and after all, 1 underwent appendicovesicostomy after failed redo repair, 3 were scheduled for appendicovesicostomy, 2 are still on follow-up.

Conclusion: Delayed primary urethral repair with transpubic approach is prefered technique for PUR repairs in our clinic. If emergent laparotomy is indicated, early primary repair could be performed. Urethral stricture is the most common complication after PUR repairs and it does not usually respond to dilatations. Redos are usually failed in these patients. Appendicovesicostomy is an alternative treatment modality for challenging stricture and after failed repair(s).

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OPU29: Our experience about repair of hypospadias

M Güzel and U Şenel

Dr. Dogan Baran Hospital For Women's and Children's Diseases, Nigde

Objective: To reveal our results for repair of the proximal and distal type hypospadias.

Materials and methods: The mean age of the 138 patients was 4.9 years (11 months–16 years) and these patients were operated between May 2006-December 2010. 106 patients had distal hypospadias and 32 patients had proximal hypospadias. 76 cases of distal type were operated with MAGPI procedure, Snodgrass was preferred for other 32 cases with distal hypospadias. All patients with proximal hypospadias were operated by the Snodgrass method, except one patient that operated with Duckett tube flap method. The average length of follow-up of the patients was 18 months (2–24 months).

Results: All patients admitted to the clinic after operation. Urinary catheters were removed on 7th day and patients were discharged. Urethrocutaneous fistula developed in three patients and urethral stenosis in one patient with distal hypospadias. There were five urethrocutaneous fistula in patients operated for proximal hypospadias. Because of the dorsal penile hematoma in a patient after surgery, a revisional intervention required later. None of the patients except this patient had poor cosmetic appearance.

Conclusion: Complication rates of both two groups were similar although the complication rate for proximal hypospadias is higher than distal ones in general.

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OPU30: Clinal experiance in hypospadias for five years

C Köse, G Göllü, M Bingöl Koloğlu, A Yağmurlu, T Aktuğ and H Dindar

Department of Pediatric Surgery, Ankara University School of Medicine

Purpose: Hipospadias is one of the most observed congenital anomalies at male children. The study aims to reveal the operation results of the children who were operated due to hipospadias.

Materials and methods: The 134 male patients' files were elaborated backwards that were operated between the January 2005–January 2011 due to hipospadias. The demographic data, mea location, operation method, the time of the removing of the bandage and removing the urinary catheter, complications and reoccurance were recorded.

Results: 29 of the 134 boy - with the ranging ages between 3 months to 13 years old - had glanular megameatus (%22), 72 had subcoronal or coronal (%54), 16 had midpenil (%12), 17 had penoscrotal hipospadias (%13). Snodgrass intervened to the 68 of the cases, uretral mobilization to the 26, GAP-Zaontz (glans approximation procedure) to the 21, Ducket to the 6, Mathieu to the 5, penoscrotal transposition to 4, MAGPI to the 3 and Barcat to one patient. Urinary catheterization was ceased at the day of 7. The meas of the five patients with the penoscrotal placement were gradually moved above. Six patients had sistofix placement. The fistula was determined to be most frequent complication with range of %20, additionally two children developed diverticula and one developed narrowing. Related the reoccurance repairment was performed again on three patients.

Conclusion: The basic surgical technical's allow the hipospadias repairment no matter where the mea is located or which technique is used.

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OPU31: The modified Snodgrass repair in distal hypospadias: to obtain more cosmetic appearance and reduce complication rate

U Koltuksuza, B Savranb and SE Odabaşa

aPamukkale University Medical Faculty Department of Pediatric Surgery, bKütahya Evliya Çelebi State Hospital Clinic of Pediatric Surgery

The Snodgrass hypospadias repair is becoming the most frequently used technique for distal hypospadias repair. Excellent cosmetic results and low complication rates were documented in many series.

Modified technique was applied in 30 primary distal hypospadias cases between 2007 and 2010. ‘U’ shaped incision circumscribed the hipospadiac orifice was advanced to the glans borders at both side, forwarded laterally about 3–4 mm, advanced again vertically and, combined with circumcision incision. After midline incision, the urethra tubularized up to glans border. The stitch was continued to conjoined glans wings up to vertical incisions. Second layer sutures were applied separately to strengthen the anastomosis. After repairing the chordee if exists, circumcision was added and the operation was ended.

The orifices were calibrated once in two patients after two weeks of the operation. Only one fistula was seen and fistula repair was applied after 6 months of the operation.

In all patients, suturing ventral skin to mucosa instead of glans was improved the cosmetic appearance. Low complication rates obtained because of the glans penis modifications.

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OPU32: Evaluation of the two-layer urethroplasty in the hypospadias repair

G Gündoğdua, D Avlanb, H Taşkinlarb, A Naycib and Hb

Departments of aPediatric Surgery and bBiostatistics, Mersin University Medical Faculty

Aim: To evaluate the results of a single surgeon's performance, the two layer continue urethroplasty in hypospadias repair.

Materials and methods: Records of 57 children between 2009 and 2011 years were investigated. Localization of the native urethra meatus, width of the urethral plate, chordee, additional tissue for urethroplasty coverage, presence of former surgery, surgical choice were corrolated with the results.

Findings: In follow up the 57 cases; 3 of them had stricture in the new urethra meatus and glans dehiscence occured in two severe proximal hypospadias children undergone to staged urethroplasty. None of the children had fistula formation. Results were documented in the table.

Discussion: Most of hypospadias cases can be repaired by popularized techniques, however all centers have their own standardizations. We detected that two layer urethroplasty has ideal results especially in distal hypospadias and it has low complications in proximal hypospadias and in staged repaire as urethral meatus strictures which can be managed easily. Two layer urethroplasty is feasible technique with low complication rates in hypospadias surgery.

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OPU33: The necrosis of ventral penile skin flaps: a complication of hypospadias repair with snodgrass technique

M Abeş and Ü Bakal

Adiyaman State Hospital, Department of Pediatric Surgery, Adiyaman

Aim: It is sometimes hard to repair the ventral side of penile skin primarily after chordee release and urethroplasty during hypospasias repair. Preparing either preputial Ombredanne or Byars skin flaps is the procedure of choice for this common problem. We aimed to review the cases with necrotic flaps of whom Snodgrass urethroplasty was performed for hypospadias repair retrospectively.

Materials and methods: Eighty three patients with hypospadias were operated with the Snodgrass technique by two pediatric surgeons between January/2008 and December/2010. Neourethra was covered with dartos flap prepared from penile shaft and preputium in all cases. Either preputial Ombredanne or Byars skin flaps were used to repair the ventral defects of cases in whom the primary closure of ventral skin was not possible.

Results: The median age of the patients was 4 years (between the age of 1–14). The location of the urethral opening was at the coronal level in 25 of the patients (30.12%), at the distal penis in 33 of patients (39.75%), at the midpenis in 10 of patients (12.04%) and at the proximal penis in 15 of the patients (18.07%). The ventral skin closure of 10 penile hypospadias cases was not performed primarily so the defects were closed with either Byars flaps (8 cases) or Ombredanne flaps (2 cases). Five of these cases (4 of Byars flaps and 1 of Ombredanne flaps) experienced flap necrosis. In 4 cases, the necrosis was superficial and treated successfully with medical therapy but the necrosis of the remaining case was full thickness and ended up with an urethral fistulae. The mean hospital stay of the cases without complication was 7 days whereas the cases with flap necrosis stayed for a longer period at the hospital (mean=14 days)

Conclusion: The dartos flaps of penile shaft and preputium are used to cover the neourethra and to lower the incidence of fistulae. We think that after hypospadias repairs, by decreasing the preputial vascularization, they result in flap necrosis which causes postoperative complications and longer hospital stays.

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OPU34: Postoperative care does not prolong length of hospital stay after distal hypospadias repair

M Kaya, Ç Aydiner and S Sancar

Sevket Yilmaz Education and Research Hospital, Department of Pediatric Surgery, Bursa, Turkey

Purpose: The aim of this study was to present the outcomes of children with distal hypospadias who operated on outpatient basis.

Materials and methods: A total of 47 consecutive children underwent surgical repair of hypospadias in an outpatient setting. Urethroplasties were performed by the following techniques: stentless meatal advancement-glanuloplasty (MAGPI) type repair or glans approximation procedure (GAP) for glandular hypospadias (14) and tubularized incised plate (TIP) urethroplasty for coronal and midpenil hypospadias with an indwelling urethral catheter or short stent (33). The indwelling urinary catheters were managed by the double diaper technique. Patients were discharged within 24 h after operation.

Results: Dressings and catheters were removed on the postoperative day 2 and 6, respectively. Voiding difficulty and urinary retention on early postoperative period were observed in 8 patients. Except meatal stenosis in 4 cases and meatal retractions in 2 cases, there were no major complications in any of our patients during the follow-up period, no postoperative fistula or urethral stricture.

Conclusion: In children, a urethral stent or indwelling catheter, the drug therapy and the dressing is not a reason to stay in hospital long-term in distal hypospadias repair.

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OPU35: Combination of two techniques for an aesthetic healing and double-layer covering of neourethra in distal hypospadias repair: de-epithelialized batman's wing-flaps

Z Dökümcü

Department of Pediatric Surgery, Rize University Faculty of Medicine Rize

Introduction: Aesthetic and functional healing of penis is the major goal in hypospadias repair. Along with many techniques, de-epithelialized local skin flap and ‘batman excision’ of the ventral skin for a natural looking skin allocation were previously introduced. A combination of these two techniques is presented for double-layer covering of neo-urethra with natural penis appearance.

Materials and methods: Following the placement of a stay suture from the glans ventral skin of penis is marked as previously introduced (Batman skin lining). As a difference from the technique, de-epithelialized ‘batman’s wing-flaps' are prepared expanding over the edges of the hooded prepuce rather than excision of the whole layer. Degloving of the penile skin and urethroplasty is then carried out. These flaps are attached to the bases of both glans wings in a blazer jacket fashion to cover neo-urethra combined with spongioplasty proximally. Two layers of flaps and tightly approximating glans wings are acquired to support neo-urethra and provide relaxed skin sutures while healthy healing is secured.

Conclusion: De-epithelialized ‘batman's wing-flaps’ may be an alternative which maintains 2 layers of support for the neo-urethra with natural appearance of the glandular reconstruction in distal hypospadias repairs.

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OPU36: Kutlay technique in correction of distal hypospadias

İ Geçita, D Işikb, N Pirinççia, S Bilicic, M Güneşa, B Atikb and K Ceylana

aDepartments of Urology, bPlastic and Reconstructive Surgery and cPediatric Surgery Medicine School of Yuzuncu Yil University

Purpose: Kutlay technique which is hold a principle by well vascularized two meatal based skin flap is a new surgical technique described for cases with distal hypospadias. The aims of this study present to the technical details of Kutlay's correction and discuss to the efficiency of this new surgical technique.

Materials and methods: A total of 31 patients had been underwent distal hypospadias repair since 1 year. Their age ranged between from 18 month to 13 years. Inclusion criteria were primer distal hypospadias associated with or without chordee, and exclusion criteria were association with surgery repair history. All of the operations were performed by the same surgery team. The period of follow-up was ranged from 2 to 12 months.

Results: Ectopic meatus of these patients were located 60% in subcoronal region and 40% in coronal region. Six patients had chordee as an additional anomaly in their penis. Three of these patients were circumcised. The mean hospital stay was 5.8 days. The fistula was not observed except one patient. Neourethral dehiscence meatal stenosis, wound infection, penil torsion or hematoma were seen in none of the patients. Persistent or recurrent chordee was not observed in patients with chordee before the surgery. Neourethral caliber and cosmetic appearance were satisfactory in all patients in the follow-up period of this study. In postoperative period, all children have a voiding with a single straight urinary stream in a forward direction.

Conclusion: We do believe that Kutlay technique should be given preference in patients with distal hypospadias because of low complication rates, functional and cosmetic outcomes.

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OPU37: Late uroflowmetric evaluation of children underwent hypospadias repair

F Tatlisöz, A Yildiz, S Çetiner, N Sever, ÇA Karadağ, M Akin and Aİ Dokucu

Paediatric Surgery, Department Şişli Etfal Training and Research Hospital

One of the late term problems of the cases that have been operated for hypospadias is functional voiding disorder and it may be related with urethral stricture and/or diminished urethral compliance. The uroflowmetric assessments take a significant place due to the fact that it reflects the normal function of the urethra by gaining a good flow rate, easily proceeded and it's a widely used noninvasive test.

Uroflowmetry was performed in 61 patients, aged 3 years to 12 years, who underwent hypospadias repair mostly using tubularized incised plate urethroplasty (TIPU) for different types of hypospadias between 2007 and 2009. Uroflowmetric assessments were performed regardless of the operation date and the type of hypospadias (distal penile, midpenile and proximal penile), according to the postoperative time that has passed, between 2007 and 2009. We compared the changes of the case group with the control group that consists of the 43 cases with the same age range that present no systemic disease and/or symptoms that is confirmed with physical examination.

A comparison between the cases who underwent hypospadias repair and the control cases revealed that the repaired hypospadias cases have generally abnormal uroflowmetric values and voiding patterns. Especially, the abnormal uroflow values and voiding patterns were raising correspondingly with the type of hypospadias while it's getting closer to proximale. Operated cases were excreting the same volume of urine slower and in a longer period of time in comparison with the control cases.

Another finding that has determined in the operated case group is that the longer neourethra caused longer voiding time. Years of clinical follow-up revealed that the uroflowmetric abnormalities are permanent with the minimal normalization after the first year of surgery.

Although clinically asymptomatic, some abnormal uroflowmetric values are present in long term of operated hypospadias cases. It's realised that abnormal uroflow values are increasing parallely to the severity of hypospadias in related the cases and it's not getting normalized during the years postoperatively.

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OPU38: The effect of urethral catheter's size on meatal stenosis formation in children undergoing tip urethroplasty

SC Karakuşa, N Kokua, İ Ertaşkinb, E Parmaksiza and H Kilinçaslanc

aDepartment of Pediatric Surgery, Gaziantep Children Hospital bDepartment of Pediatric Surgery Düztepe Yaşam Hospital and cDepartment of Pediatric Surgery Bezmialem Vakif University

Purpose: Tubularized incised plate (TIP) urethroplasty has become the most commonly used method in patients with distal and mid-shaft hypospadias in recent years. Although there has been modified techniques described in order to reduce meatal stenosis, it is still a common problem. In this study, we aimed to elucidate any relationship between the size of urethral catheter and meatal stenosis formation in children undergoing TIP urethroplasty.

Materials and methods: We retrospectively reviewed 123 children who underwent TIP urethroplasty for hypospadias between June 2008 and December 2010 at Gaziantep Children Hospital. They were assigned into two groups according to urethral catheter used. One group (group A) comprised 82 patients (mean age: 4.4±3.6 years) with tubularized neourethra over a 6 Fr catheter, as the other group (group B) included 41 patients (mean age: 5.5±4.1 years) with tubularized neourethra over a 8 Fr catheter. The patients were followed up for a mean period of 8.3±4.2 months in group A and 7.2±3.9 months in group B.

Results: There were no significant differences between the groups according to their age, follow-up time and location of urethral meatus (P>0.05). Meatal stenosis formation in group B was markedly higher than that in group A (P=0.023). Number of meatal dilatation was higher in group B compared to group A (P=0.014).

Conclusion: We suggested that tubularization of urethral plate over a small-sized (6 Fr) catheter, without age dependent, prevents from meatal stenosis by reducing foreign body reaction and pressure injury and by hindering secondary healing.

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OPU39: Hypospadius why complications ! When redo surgery ! The impact of relevant factors

Mohammed J Aboud

The Maternity and Child Teaching Hospital/Al-Qadisiya -Iraq Ministry of Health

Introduction: Great advances have been made in surgery for the correction of hypospadias. Proximal hypospadias remains the greatest challenge, but despite many innovations and much progress, surgery can fail. The new generation of paediatric surgeon has high ambitions in managing patients with hypospadias. More than 200 reconstructive procedures have been described for hypospadias repair. Despite large number of operative techniques for hypospadias repair, the complication rate is very high.

Objective: To evaluate the factors that may influence the results of surgery after hypospadias repair at The Maternity and Child Teaching Hospital, pediatric surgery unit, Al-Qadisiya/Iraq.

Patients & methods: It was a retrospective observational study. Files of all patients who had Hypospadias repair were retrieved and analyzed with a view to identify the factors which may influence the results of surgery for Hypospadias. Patients with complete record available were included in the study, whereas those with incomplete data were excluded. Fortycases (out of 115 cases of hypospadius) of fistula, stricture, retrusive meatus, meatal stenosis, torsion, open distal urethra & urethral diverticula with combination of two or more, were managed by from 1st of January 2005 to the end of December 2009. We looked at the number and type of initial and redo repairs they had. A minimum of at least 6 months was allowed to elapse between operations. To formulate an idea of the type of redo repair we would use, the clinical examination focused on the location and size of the urethral meatus, the status of the urethral plate and genital skin, the severity of residual chordee and the amount of scarring.

Results: There were 40 patients, aged 1–12 (mean 3.8) years, with failed hypospadias repairs. All operated on by the same surgeon, with a minimum of 12 months of follow-up. The initial severity of the hypospadias were as follows: perineal (2), penoscrotal (7), proximal shaft (4), mid-shaft (16), distal shaft (7), coronal (3) and mega-meatus (1). Of all the patients, 27 had 1 repair, 10 had 2 repairs and 3 had 3 repairs. The initial repairs comprised 13 tubularized island flaps (TIFs), 14 Snodgrass tubularized incised plate (TIP) techniques, 8 Mathieu repairs, 2 Meatal Advancement and GlanuloPlasty Incorporated (MAGPI) technique, 1 Pyramid, and 2 Thiersch-Duplay repair. Twenty-seven of 40 patients had 1 redo operation, 9 had 2 redo operations, 3 had 3 redo operations and 1 had 4 redo operations, for a total of 58 redo operations. Of these, 34 were TIP techniques (58.6%), 8 were Mathieu (13.7%), 8 were TIF repairs (13.7%), 4 were onlay island flaps (6.8%) and 4 were buccal mucosal grafts (6.8%). Follow-up was 1–3 years (mean 1.5 years). The final locations of urethral meatus included glans (29), corona (7), mid-shaft (3) and penoscrotal (1). Complications after redo surgery comprised 4 urethrocutaneous fistulae, 2 meatal stenoses, 1 urethral stricture and 3 dehiscences).

Conclusion: Surgical techniques for the repair of hypospadias are being developed continuously, implying that no single procedure is considered a panacea for hypospadias repair. Admittedly, it is difficult to follow patients for a long time, and it is even harder to predict who will have complications that will merit closer follow-up. Success in hypospadias surgery depends on good team work. Trained anesthetists allow early surgery with adequate postoperative pain relief. successful hypospadias surgery is minimal tissue handling, tension free reconstruction, the use of well vascularized tissue, knowledge of repairs are indicated and preservation of urethral plate. Using these principles, excellent cosmetic and functional results can be expected for treatment of hypospadias. All types of repair involve straightening the penis by removal of chordee. The pediatric surgeon selects the appropriate operative procedure and carries it out with meticulous techniques. A good nursing team ensures a smooth recovery. Although single stage reconstruction carries a slightly higher complication rate, its advantages far outweigh that of the conventional staged approach.

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OPU40: Penoscrotal transposition and proximal hypospadias repair by combined Glenn-Anderson and Bracka methods

C Taneli, A Genç, Ö Yilmaz, C Günşar, A Şencan, C Özcan, A Gültekin and E Mir

Celal Bayar University, Faculty of Medicine, Department of Pediatric Surgery, Manisa

Aim: Penoscrotal transposition can be partial or complete. Severe proximal hypospadias, ventral chordee and bifid scrotum may be frequently present penoscrotal transposition cases. Reconstruction of these cases are complex that may need multi-session surgery. We aimed to perform two different methods simultaneously to these specific cases. Thus with less anesthesia and surgical intervention performance, functional, cosmetic penis and scrotum could be achieved.

Materials and methods: Five patients with incomplete penoscrotal transposition and severe proximal hypospadias-ventral chordee were taken into the study. Glenn-Anderson method for scrotal transposition and first stage of Bracka repair for proximal hypospadias were performed simultaneously.

Results: Bracka ureteroplasty repair is a two stage method performed in severe proximal hypopadias-ventral chordee. We performed Bracka first stage and Glenn- Anderson repair simultaneously on the same session to all patients. Bipolar cauterization was used for bleeding control and we leave a tie-over dressing of Vaseline gauze to secure the preputial graft further. We used a silicone catheter for urinary diversion for 7–10 days. Two repair methods were performed to all patients without any difficulties. The operation time period was reasonably extended by performance of the two methods. Mean operation period was approximately 2 h. No postoperative extensive bleeding and edema was encountered in any of the patients. In one case proximally localized hematoma was collected under the graft but this hematoma did not prevent the graft revascularization. In all cases with this combined method neourethral plate was achieved successfully without any scar tissue for second stage tubularization. Six month later, second stage Bracka uretroplasty was performed to all cases. In one case urethral fistula has developed and fistula repair was necessary.

Conclusion: We believe that Genn-Anderson and Bracka two stage uretroplasty repair methods can be easily performed simultaneously and without any complications. By combination of the two methods, scrotal transposition, ventral chordee repair was performed. A neourethra plate was achieved for second stage of Bracka for tubularisation.

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OPU41: Webbed penis with or without hypospadias: a decade of experience

Sherif M Shehata

Department of Pediatric Surgery, Department of Surgery, Tanta University Hospital, Tanta, Egypt

Background/purpose: Webbed penis is a disease includes a high insertion of the scrotum ventrally (penoscrotal web), penoscrotal band and definite true web. This penile anomaly may associate hypopsadias or not. This study was carried out to present such case series of the rare anomaly along one decade in children.

Materials and methods: 42 boys with webbed penis had been treated over 10 years. This group was collected in the last 10 years from Tanta University Hospital and other affiliated hospitals. Thirteen cases had associated hypospadias while the remaining 29 cases have no hypospadias.

Results: This study included 42 males with the age ranged from 1 to 13 years. 13 cases associated with hypospadias of distal type except one of mid penile type. The hyposapdias group constitute group A where 8 of webbed penis variety, 4 of penoscrotal band and one of true penoscrotal web. The remaining 29 cases constitutes group B where 8 of penoscrotal band and 21 of webbed penis variety. In all cases even with hyopspadias we dealt with the web before the hyposapdias repair in the same sessioin to make proximal straightening and no associated distal chordee in these 13 cases. We repaired cases of band or true web by excision while we used the inverted V-T technique to correct the webbed penis. All cases doing well at the follow up period that ranged between 6 and 126 months. Residual shortening reported once and mild ventral curvature twice.

Conclusions: This series documents the existence of this rare group of penile anomaly even reports the true penoscrotal web. In cases associated with hypospadias correction of the proximal chordee results in alleviation of chordee and no distal chordee were expected. Inverted V-T technique is an excellent technique for correction of webbed penis and scar is hidden in the penoscrotal junction with minimal complications reported in the long follow up period.

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OPU42: Our experience in the treatment of vaginal and cervicovaginal atresia patients

G Karakurta,b, S Şiyvea,b, O Ateşa,b, G Hakgüdera,b, M Olgunera,b and FM Akgüra,b

Department of Pediatric Surgerya and Division of Pediatric Urologyb, Dokuz Eylül University, Medical school, İzmir

Aim: Isolated vaginal and cervicovaginal atresia are rare mullerian anomalies. We want to share our approach to the patients with isolated vaginal and cervicovaginal atresia.

Materials and methods: The records of 3 patients with isolated vaginal and cervicovaginal atresia who underwent repairment between 2007–2011 were evaluated retrospectively. The age, initial symptoms and radiological findings were compared. Surgical tecniques and postoperative complications were evaluated. During the follow-up patients were examined physically and underwent vaginoscopy.

Results: The mean age 3 patients was 12.6 years (12–13 years). All patients administered with abdominal pain and amenorrhea in the pubertal period. One patient had C2-C3 vertebral fusion and 1 patient had scoliosis. There was no other accompanying pathology or anomaly. Hematocolpos, vaginal and cervicovaginal atresia were diagnosed with ultrasonography and magnetic resonance imaging of the pelvis in all patients. Two patients had vaginal and 1 patient had cervicovaginal atresia. One patient had dilatation of right tuba and 1 patient had left hydroureteronephrosis due to compression. In the first patient with vaginal atresia, proksimal end of the vagen was brought closer to the perineal region laparoscopically and a perineovaginal anastomosis was performed and a neovagina was created. In the other 2 patients, the uterus was reached with Phannenstiel incision, the uterine bands were released, and the pull-through of the vagina were completed. In 2 patients we excisized endometriosis foci. During the follow-up the first and third patients developed vaginal stenosis and underwent dilatation. Now they are using vaginal mold.

Conclusion: Isolatedvaginal atresia is a rare anomaly. Surgical treatment of this anomaly is stil contraversial. In these patients keeping the uterus has both psychological and physiological advantages, but an adequate lumen and capacity of the vagina is hard to maintain.

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OPU43: Procnostic importance of y deletion and Thrombophilia panel in undescended testicles

S Çetinkurşun, K Hekimler, A Narci, A Özgöz, EÖ Boyaci, FM İçduygu, AA Tuncer and N İmirzalioğlu

Departments of Pediatric Surgery and Genetics, Afyon Kocatepe University Medical Faculty, Afyonkarahisar, Turkey

Introduction and aim: Undescended testicle occurs if one or both of the testicles cannot descend into Dartos layer. It is one of the most common congenital malformations in males (1%). Possible complications are infertility and development of cancer. Familial recurrence in undescended testicle has been reported between 2–10%.

AZF microdeletions in undescended testicle cases may result in partial or total loss of semen quality. Therefore, in patients with the diagnosis of undescended testicle, presence of AZF deletions may be important for determining the fertility prognosis. To eliminate the possibility of structural and numerical abnormalities in such patients, chromosomal analysis was planned. Additionally thromborisk panel was evaluated to find out if MTHFR C677T polymorphism is present because anti-Mullerian hormone (AMH) takes part in the first phase of testicular descent and MTHFR C677T polymorphism has been reported to increase the concentration of AMH.

Materials and methods: In this study, Y-chromosome microdeletion analysis (AZFa (SY82, SY84, SY81), AZFb (SY127, SY142, SY164), AZFc (CDY, BPY2, SY255, SY254, RBM1, SY277), AZFd (SY145, SY152, SY153) using PCR_RFLP method, thromborisk panel (factor 5 Leiden, factor 5 Cambridge, prothrombin, MTHFR (C677T), MTHFR (A1298) using real time PCR method, and chromosomal analysis were done in the blood samples taken from 40 children with undescended testicle and 40 healthy children.

Results: There were no structural or numerical chromosomal abnormalities or Y chromosome microdeletions in both groups. Evaluation of thromborisk panel did not reveal any statistical differences between two groups (P>0.05). In the undescended testicle group, presence of unilateral or bilateral undescended testicle did not affect the incidence of polymorphism (P>0.05).

Conclusion: Long-term follow-up of fertility in our study groups will be more valuable to justify our results. For evaluating the MTHFR polymorphisms, studies in larger scale are needed.

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OPU44: What is the situation in the periphery of our country while the age of surgery for undescended testes continues to decrease?

E Türk, CM Bilen, F Karaca and Y Edirne

Department of Pediatric Surgery, Denizli State Hospital, Denizli, Turkey

Introduction: Undescended testis is an important childhood condition that requires early surgery due to increased risks of infertility, malignancy and torsion. The current approach to the time of surgery varies between centers but operating at 3 to 24 months is recommended. However, the orchiopexy age in our country is higher. We retrospectively evaluated the undescended testis cases treated surgically at 2 different pediatric surgery clinics in this study.

Materials and methods: A total of 387 patients operated on at the Ordu Obstetrics Hospital and Denizli State Hospital Pediatric Surgery Clinics between 2005 and 2010 were retrospectively evaluated for the age of surgery and the treatment method used.

Results: A total of 387 patients (198 right, 160 left and 29 bilateral for a total of 416 testes) treated surgically by 4 different pediatric surgeons were divided into 2 groups as those operated before and after 2 years of age. The first group consisted of 238 patients (61.5%) and the second of 159 patients (38.5%). The mean age was 6.3 years (3–13 years) and 15.7 months (3–24 months) in the first and second groups respectively. The procedures used were surgery in 369 patients, laparoscopic orchiopexy in 11 patients where the testis could not be palpated and orchiectomy in 7 patients because of an atrophic testis.

Conclusion: We found that most operated undescended testis cases were older than 2 years while the mean age was bigger than 12 months in those operated before this age. The values from our country are quite high, taking into account the suggestion of lowering the age of undescended testis surgery to 3 months in recent studies. We recommend emphasizing primary care services, increasing the awareness of families and making use of pediatric surgeons in suspected cases.

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OPU45: Ten years analysis of orchiectomy indications

A Kaymakçi, MA Özen, HM Mutuş, M Korkmaz, M Çağlar, Ç Ulukaya Durakbaşa, Aİ Anadolulu and H Okur

Department of Pediatric Surgery MOH Istanbul Goztepe Training and Research Hospital,

Aim: Performing orchiectomy in a child is a tough decision. There is scarce data giving a wide perspective on indications for this condition. This study aimed to evaluate orchiectomized patients in our clinic.

Materials and methods: Patient records of years 2001–2010 were analyzed retrospectively. There were 104 patients who underwent orchiectomy. Preoperative diagnoses, orchiectomy indications, and histopathological results were evaluated.

Results: The age range was between 6 h–17 years (mean 6.4 years). The etiological causes that yielded orchiectomy were nonpalpable testis with nubbins in 60 cases, testicular torsion in 21, recurrent undescended testis in 12, tumors in seven, iatrogenic atrophic testis in three and bilateral hemorrhagic testicular infarct in one. Among the torsioned testicles, five were also undescended. Histopathology showed various degrees of testicular atrophy in 74 samples. Among torsioned testes, there were diffuse hemorrhagic necrosis in 20 and one had only diffuse hemorrhage without necrosis. In testicular tumor cases, four had mature cystic teratomas, one had germ cell tumor, one had non-Hodgkin lymphoma infiltration, and one had acute leukemic infiltration.

Conclusion: This study showed that in children orchiectomies are usually done for benign conditions. In approximately one third of the cases, the initial diagnoses leading to orchiectomy were potentially preventible etiologies like testicular torsion, recurrent or iatrogenic undescended testis.

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OPU46: Boys with epididymal cysts have larger testes than normal

V Erikçi, N Aksoy, C Öztürk, M Yildiz, A Dursun, Ö Okur, B Uçan, O Arslan and M Hoşgör

Department II of Pediatric Surgery Dr. Behcet Uz Children's Hospital

Purpose: Treatment of epididymal cysts (EC) in children is controversial. We retrospectively studied the clinical presentation and outcome of management of EC between June 2009–January 2011.

Materials and methods: 869 scrotal ultrasound reports were analyzed, and age, testicular sizes, associated scrotal pathologies were recorded.

Results: EC was detected in 32 of 869 (3.7%), 539 had other scrotal pathologies (62.0%), 298 (34.3%) had normal ultrasound (N). The mean ages of EC and N were 11±4.5 years and 7.9±4.3 years, respectively (P<0.001). The mean sizes of right and left testes in EC were 29.09×16.87×15.14 mm and 28.84×16.81×15.0 mm, respectively. In N group, the right was 18.05×10.19×8.95 mm and the left 17.94×10.20×8.94 mm, respectively. After adjustment according to age, testicular sizes were statistically greater in EC group (P<0.001). Scrotal pain was the most frequent symptom in 18, incidental diagnosis in 11, scrotal mass in 3. The cysts were solitary in 25, multiple in 7. The EC location was 17 in right, 13 in left, and bilateral in 2, no difference in locations between the EC and N was determined (P>0.05). Follow-up ranges from 1 to 20 months. Complete involution was detected in 8 (25.0%) and a decrease in cyst size in 5 cases (15.6%). Surgical cyst excision was performed in 6 patients (18.7%) because of persistent scrotal pain and/or no regression in cyst size. 13 patients are still under follow-up.

Conclusion: Children with EC have larger testes than boys without cysts. Surgical excision of epididymal cysts is recommended in intractable scrotal pain, and no regression of cyst size.

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OPU47: Scrotal approach for pathologies of inguinoscrotal region

M Kaçar, Ç Aydin, N Kiliç and E Balkan

Department of Pediatric Surgery, Division of Pediatric Urology, The Medical Faculty of Uludag University, Bursa, Turkey

Aim: The goal of this study was to review our series of scrotal incisional approach for pathologies of inguinoskrotal region to evaluate operative times, success rates and complications.

Materials and methods: A total of 75 scrotal incisional approach were performed in 66 patients with inguinoscrotal pathologies between 2005–2010 years. This technique involves manipulation of the testis down to the scrotum so that it is secured between the thumb and index finger as fixation is performed.

Results: Patient age ranged from 8 months to 11 years (mean 3.8 years). Fifty four patients (60 testes) were operated for undescending testis. 30 of the patients (55.6%) had right sided, 18 of the patients (33.3%) had left sided and rest of them (11.1%) had bilateral undescending testis. In 43 children (49 testes), the testis was distal to the external inguinal ring (group I). No need for inguinal incision and the average operation time was 26 min in group I. In 11 patients (11 testes), the testis was located within the inguinal canal (group II). Only 1 patient required conversion to a traditional inguinal incision and the average operation time was 43 min in group II. The processus vaginalis was patent in 36 testes (73.4%) in group I and 10 of 11 testes (90.9%) in group II. Twelve patients (15 intervention) were operated for inguinal hernia (n=8) and hydrocele (n=7) (group III). Average operation time was 26 min in group III. The only complicatins were 5 wound infections (6.6%) which were successfully treated.

Conclusion: Comparable success and complication rates, and a more cosmetically appealing result compared to the traditional inguinal incision make scrotal incision an attractive alternative.

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OPU48: Ascending testis after inguinal hernia repair

M Abeşa, B Petikb and Ü Bakala

Adiyaman State Hospital, Departments of aPediatric Surgery and bRadiology, Adiyaman, Turkey

Aim: Failure to replace the testis back in the scrotum during inguinal hernia repair causes iatrogenic undescended testis. Sometimes despite testis replacing into scrotum, it spontaneously ascend to inguinal canal and causes ascending testis. These cases were evaluated retrospectively.

Materials and methods: The medical records of 910 boys who had undergone inguinal hernia repair between August 2003 and December 2010 were reviewed retrospectively. In all cases hernia repairs were performed using Mitchell-Banks method. Testis was pulled into the scrotum after hernia repair. All cases were checked after surgery to evaluate whether testis was in scrotum or not. Routine testicular palpation for position was also performed in control examination which was mean 4 days (3–5 days) after the operation.

Results: Median age of the cases was 2 years (range 2 months–15 years). Ascending testis was detected in 4 cases (0.43%) during control examination. Scrotums of these cases were hypoplasic and/or there were retractile testes. Their ages were between 1–3 years. In two cases problem was bilateral and in two cases at right. Human chorionic gonadotropin treatment (hCG) was given to three cases. Two cases improved. Scrotal orchiopexy was performed to two cases.

Conclusion: Besides iatrogenic undescended testis, sometimes testes ascend to inguinal canal spontaneously as it occurs in retractile testis cases after hernia repair at the early postoperative period and it causes undescended testis. These cases may be benefit from hCG treatment if they are detected at early postoperative period. Scrotal orchiopexy may be necessary at late postoperative period. We suggest both scrotal orchiopexy and hernia repair to the cases with retractile testis and/or scrotal hypoplasia accompanying inguinal hernia.

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OPU49: Evaluation of contralateral kidney, liver and lung after ESWL in rabbits

M Fedakar-Şenyücela, Ş Küpana-Ayvab, MK Aslana, T Soyera, Aİ Demetc, Ü Kisac, M Başard and MA Çakmaka

aDepartments of Pediatric Surgery, bPathology, cBiochemistry and dUrology Kirikkale University School of Medicine

Aim: Studies examining the structural and functional effects of ESWL have concentrated on the shocked kidney. An experimantal study was carried out to evaluate the effects of ESWL on the contrlateral kidney, liver and lung by histopathological and biochemical methods.

Materials and methods: Twelve New Zealand rabbits were allocated to two groups (n=6). Both kidneys, liver and lung tissues of control group (CG, n=6) were harvested without any intervention. In the ESWL group (EG), right kidneys were exposed to 3000 shock waves at 14 kV energy by using ESWL device three times every other day. Rabbits in EG, were sacrificed on the 1st. day and both kidneys, liver and lung tissues were harvested. Kidneys were examined histopathologically for the presence of glomerular and tubular injury, interstitial edema, congestion, inflamation and fibrosis. Livers were examined for hepatocyte vacuolisation, congestion, portal inflamation and fibrosis. Lung tissues were also examined for loss of normal structure, emphysema, interstitial congestion-edema, prominent alveolar septal vessels, interstitial inflamation, intraalveolar hemorrhage, intraluminal hemorrhage, peribronchial edema, congestion, inflamation in bronchial wall and epithelial desquamation. Biochemical analysis of tissue samples were performed for oxidative injury markers(malondialdehyde-MDA, nitric oxide-NO and sulphidryl-SH values).

Results: Histopathologic evaluations revealed that tubular injury was found in both kidneys, portal fibrosis in liver and peribronchial congestion in lung in EG (P<0.05). Biochemical evaluations of both kidneys showed MDA levels were higher in EG than in CG (P<0.05).

Conclusion: This study has been demostrated that ESWL may affect contrlateral kidney, liver and lung histopathologically and oxidative injury of contrlateral kidney may occur after ESWL.

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OPU50: Evaluation of ESWL related alterations in renal pelvis and proximal ureter by OH-proline levels

M Fedakar-Şenyücela, MK Aslana, T Soyera, M Balcib, Aİ Demetc, Ü Kisac, M Başard and MA Çakmaka

aDepartments of Pediatric Surgery, bPathology, cBiochemistry and dUrology Kirikkale University School of Medicine

Aim: Although effects of ESWL on renal parenchyma are well known, it's effect on extrarenal collecting system have not been evaluated previously. An experimental study was carried out to evaluate the ESWL related alterations in renal pelvis and proximal ureter by histopathologic methods and OH-proline levels.

Materials and methods: Twelve New Zealand rabbits were allocated to two groups (n=6). Right renal pelvis and proximal ureter of control group (CG, n=6) were harvested without any intervention. In the ESWL group (EG), right kidneys of subjects were exposed to 3000 shock waves at 14 kV energy by using electro-hydraulic type, 3rd generation Stonelith V5 ESWL device three times every other day. Rabbits in EG, were sacrificed on day 7 and renal pelvis and proximal ureter were harvested. Tissues were examined histopathologically for the presence of edema, inflamation, congestion, hemorrhage, fibrosis and vascularization. Tissue collagen levels were also compared between groups. Biochemical analysis of tissue samples were performed for hydroxyproline concentrations.

Results: Histopathologic evaluations in both renal pelvis and ureter showed no difference between groups for edema, inflamation, congestion, hemorrhage, fibrosis and vascularization grades (P>0.05). Also, tissue collagen density did not show any significant difference (P>0.05). When tissue hyroxyproline levels were compared, no difference was found in ureter samples (P>0.05), however tissue hyroxyproline levels were significantly higher in EG than CG in renal pelvis (P<0.05).

Conclusion: Although no histopathologic alteration due to ESWL was detected in renal pelvis and proximal urether, increased OH-proline levels in renal pelvis can be suggested as a finding of tissue injury.

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OPU51: Urinary tract stones in children: evaluation of the changing therapeutic strategies for the last two years

F Özcana, MN Azilia, F Akbiyika, G Bayram Kabaçamb and T Tiryakia

Ankara Child's Diseases Hematology Oncology Education and Departmant of aPediatric Surgery and bResearch Hospital, Radiology

Aim: Urinary tract stones in children can be seen with different incidences, depending on the different geographic regions, genetic and socio-economic situations. Of all the stone cases, 2–3% of the cases are seen in children. Infection is the the most important etiological factor. However, in children's cases metabolic causes should not be ignored particularly. In the treatment of urinary tract stones, parallel developments had been observed in the age group of children and in the age group of adult together with technological developments. In our clinic, the modern concept of endourological treatments of the urinary tract stones can be made at the beginning of the year 2009 for the necessary infrastructure is completed. Cases of urinary tract stones were treated in our clinic since 2009 and the treatment options were evaluated retrospectively.

Materials and methods: Between 2009–2010 a total of 83 patients referred to our clinic with the diagnosis of urinary tract stones. In all of the cases, the stone placement, terms of procedure and complications were evaluated retrospectively.

Results: All of the cases, 35 were female and 48 were male. While 49 patients were applied for kidney stones (59.1%), cystinuria was detected in 10 cases (12%). While 10 cases were treated by ESWL, surgical interventions were performed in 39 patients. After PCNL was performed to 14 of the cases, URS was performed to 9 patients and in 16 of the cases, open surgery was performed, and then all of the patients became stone-free (6 months–19 years, mean 8.06 years, patients who were operated were16 girls and 23 boys). 11 of 13 cases (15.6%) of the lower end of ureter stone were treated by endoscopicly and two of them were treated with open surgery (7 of the cases were at left and 4 of the cases were at right side, 2 of the cases were bilateral, 7 girls, 6 boys, 2–17 years, mean age 8.36). Identified 20 cases of bladder stones (24.1%) were broken with placed in 10 F percutaneous trocar of laparoscopy (7 girls, 13 boys, 2–16 years, mean age 7.55). One case of stone in the urethra (1.2%) was identified in the fossa navikularis and removed under general anesthesia. In our series, there is no nephrectomy or loss of renal function after the approaches. While no patients requiring blood transfusion after PNCL, in two of the cases; because of fever and urinary tract infection they required prolonged antibiotic therapy. In a patient with distal ureteral stone, because of iatrogenic injury in ureterovesical junction, the patient have been explored.

Conclusion: In our series, the patients with bladder stones are found to be higher according to the literature. While more than a majority of bladder stones have been seen because of infections in patients that related to socio-economic status, we think that the cause seen many cases of cystinuria were seen can be related with being a reference center. Most cases of bladder stones and cystinuria detected in male children and the cases of cystinuria diagnosed around the age of 1, except that a significant cause of stone was infection. Modern approach to treatment, to use staged minimally invasive treatments avoiding complications and preserve open surgical procedures, should be essential. Open surgical procedures should be kept for the patients developing complication.

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OPU52: Treatment and follow-up the patients with cystine stones in childhood

F Özcan, M N Azili, E Şenel, F Akbiyik, E Mambet, Z Livanelioğlu, H Atayurt and T Tiryaki

Ankara Child Diseases Hematology and Oncology Education and Research Hospital Pediatric Surgery Department

Aim: Cystinuria, characterized by a defect in renal tubular reabsorbsiyon of dibasic amino acids and cystine is an autosomal recessive disease. Urinary tract calculi in childhood, accounted for 6–8% creates cystinuria patients. Recurrence rate of cystinuria in excess of 60% of the cases should be monitored closely as a multidisciplinary group of patients because of the form. Cystinuria due to the treatment of urinary tract stones examined the cases of our results to evaluate the current surgical procedures.

Materials and methods: Cystinuria due to surgical intervention in patients with urinary stone developing in the last year, were retrospectively reviewed. In all cases the diagnosis was confirmed by chemical analysis of the stone. Surgical procedures in patients diagnosed with cystinuria, and the results were evaluated.

Results: The age range varied between 6 months and 17 years (mean 5.27 years) 9 male patients, were evaluated. Refers to the five cases were due to bilateral renal stones, cystinuria was diagnosed in the investigation. Two case, the siblings were diagnosed with cystinuria. Four patients previously under treatment in other clinics, which went three times and repeat renal surgery in unilateral kidney stones were being formed. The first diagnosed cases in the two cases were bilateral stoghorn stones and obstruction, two-sided treated with open surgery, the other three cases were were treated with URS. These cases also had repeated endoscopic procedures. Three of the cases in previously operated by PNCL, one of the open surgery was made with stone-free.

Discussion: The goal of treatment in patients with cystinuria is to prevent new stone formation and to resolve the existing stones. Medical treatment, provide high amounts of fluid intake, to keep the pH alkaline, with a low sodium diet is to reduce cystine excretion. Stones may occur despite aggressive medical therapy. Cystinuria stones because they are resistant to ESWL, PNCL or open surgery can be performed. Modern approach to treatment, to use staged minimally invasive treatments avoiding complications and preserve open surgical procedures, should be essential. Open surgical procedures should be kept for the patients developing complications.

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OPU53: Therapeutic approach of babies with upper urinary tract calculi

A Önen, M Siğa and MK Çiğdem

Department of Pediatric Surgery and Division of Pediatric Urology, Dicle University Medical Faculty, Diyarbakir, Turkey

Introduction and objective: We evaluated children younger than 1 year of age who associated with upper urinary tract calculi.

Materials and methods: A total of 38 babies who treated for upper urinary tract calculi between January 2010 and December 2010 was evaluated.

Results: Twenty-two were boy and 16 were girl. Mean age was 6.4 years. 21 (65.6%) patients with renal calculi and 2 (22.2%) patients with ureteral calculi were younger than 6 month. Overall, urinary calculi was present in 58 renal and 10 ureteral unites. Stone presented on right side in 6 patients, left side in 9, and bilateral in 23 patients. Hydration and lemonade was given in 15 patients, hydration, lemonade and prophylactic antibiotic in 14 patients as conservative treatment while surgical intervention required in 7 patients. Overall, 56 out of 58 (96.6%) kidney with stone and 3 out 10 (30%) ureter with stone were treated conservatively. There was no difference between right and left sided calculi in terms of conservative or surgical treatment. Similarly, there was no difference between girl and boys.

Conclusion: Such invasive diagnostics as IVU, CT and renal scan are not necessary in asymptomatic babies who do not need interventional therapy; detailed urinary ultrasound is the only diagnostic test needed. Surgical intervention is the therapeutic approach in babies associated with symptomatic urinary calculi. The vast majority of renal stone in young babies are smooth, unformed, and thus asymptomatic. Therefore, the majority of these babies neither need invasive diagnostics nor surgical treatment; they can easily be treated conservatively. However, a significant number of babies who associated with ureteral stone are symptomatic and thus need surgical intervention.

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OPU54: Therapeutic approach and possible risk factors for surgical need in infants with urinary calculi

A Önen, M Siğa and MK Çiğdem

Dicle University Medical Faculty, Department of Pediatric Surgery and Division of Pediatric Urology, Diyarbakir, Turkey

Introduction and objective: We evaluated young infants who surgically treated for urinary calculi in our clinig during the last three years, with particul attantion to identify possible risk factors for surgical need in such cases.

Materials and methods: A total of 32 infants who surgically treated for urinary calculi in our clinic between 2008 and 2010 was evaluated.

Results: Seventeen were boy and 15 were girl. Mean age was 18.3 months; all was older than 6 months (7–24 months). Stone presented on right side in 6 patients, left side in 6, bilateral in 15, bladder alone in 4, and urethra in one patient. 21 (65.6%) patients had more than one Stone. Overall, 32 patients had urinary Stone in 61 urinary unites. Stone size was greater than 4 mm in all patients. None of the patients had significant urinary anomaly. Twenty-five (78.1%) patients underwent minimally invasive surgerical intervention. However, 7 patients who had bilateral and multiple urinary tract unite stones required open surgery. A total of 71 surgical intervention was performed in 54 urinary unites of 32 infants (mean number of surgery, 2.3). Six patients required reoperation for residual stone (ESWL in 5, URS in one).

Conclusion: Possible risk factors for surgical necessity are age (over 6 month), multiple stone, bilateral stone, multiple side stone, diameter of stone (≥4 mm), and presence of symptom. Minimally invasive surgical intervention is safe and effective for the majority of infants who need surgery for urinary stone. However, open surgical approach seems to be a reasonable alternative in very young infants who associated with bilateral and multiple urinary tract unite stones; it may decrease the number of anaesthesia and surgery in such cases.

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OPU55: Our experiences with ureteroscopic stone management in prepubertal children

KU Özkan, V Bakan, A Mil and Ş Öztürk

Department of Pediatric Surgery Kahramanmaras sutcuimam University Medical faculty

Purpose: We retrospectively reviewed our experience with ureteroscopy (URS) for ureteric stone disease in prepubertal children.

Materials and methods: We retrospectively reviewed the records of all children who underwent URS at our institution for ureteral stone disease between September 2007 and March 2011. Patients demographics, stone location and size, preoperative and postoperative stenting, intraoperative active dilatation, stone free rates and complications were noted.

Results: A total of 46 patients (33 male, 13 female and mean age 75 months) underwent 60 rigid URS (7.5 Fr). procedures for 53 ureteral stones. Stones were located in the midureter in 8 patients and distal ureter in 38 patients. 33 stones were at the left side ureters and 20 stones were at the right side ureters. Five patients had more than one stone on the left side and two patient had bilateral distal ureteral stones. Mean size of ureteral stones was 8.9 mm ranging from 4.9 mm to 17 mm. A total of 25 rigid URS procedure had been performed without any active ureteral dilatation. A total of 21 patients underwent 35 passive dilatations of initially inaccessible ureters (eleven patient:once, four patients: twice, four patients: three times and two patients: bilaterally). Stent remained indwelling for 2 to 4 weeks. 36 patients had the URS procedures once, 4 patients had twice and 4 patient three times. Most of patients who had an ureteral dilatation on preoperative ultrasonograpic examination did not need dilatation for URS but the severe eudema of the ureteral orifice was the exception. Stones were fragmented by the pneumatic lithotripter. One ureteral orifice was needed to be cut endoscopically for extracting the stone which is adhered to the mucosal wall. One stone migrated to the proximal ureter. In four patients stone extractions were performed with basket catheter only. One patient who had bended catheter migrated up to the proximal ureter and the other who had the biggest ureteral stone were needed open surgery. The stone free rate was % 93.4 for all patients with all performed procedures. One ureteral extravasation and 4 postoperative hematuria had been observed. After the procedures, 15 patients (% 32.6) who did not have preoperative stenting had postoperative stent placement for 2 t o 5 days because of extravasation, eudema of the entire ureter and orifice and hematuria.

Conclusion: URS treatment of ureteral stones without active dilatation can be performed safely and effectively in prepubertal children. Passive ureteral dilatation should be performed for some cases not only to obtain ureteral access but also to reduce the need for post operative stenting.

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OPU56: Efficiency of ureterorenoscopy in treatment of ureter stones in children

F Çelik, M Kaçar, N Kiliç and E Balkan

Department of Pediatric Surgery, Division of Pediatric Urology, The Medical Faculty of Uludag University, Bursa, Turkey

Aim: In this study, we aimed to present results of ureterorenoscopy used in treatment of ureter stone in children.

Patients and methods: Ureterorenoscopy (8 Fr ureteroscope) was performed to treat ureter stone in 18 patients (10 male and 8 female) between February 2008 and December 2010. We recorded retrospecvitely symptoms, localisation of stone, size and amount, stone clearance rate and complications.

Results: Mean age was 8.8 years (n:4–16). Stones located in right ureter in 8 patients and in left ureter in 10 patients. The presenting symptoms of the patientswere abdominal pain (n:4), flank pain (n:5), hematuria (n:4) and urinary system enfection with fever (n:5). Stones locations were UV junction in 7 patients, distal 1/3 ureter in 6 patients, proximal 1/3 ureter in 4 patients and mid-ureter in 1 patient. Stone sizes were in between 5–14 mm. There were 3 stone in 2 patients, 2 stone in 1 patient and 1 stone in the others. 2 patients had family urinary stone history and 1 patient had dublex sytem. There were hydronefrosis in different grades in 14 patients. Mean operation time was 20 min (10–30 min). 5 patients were needed open surgery. Stones were extracted after lithotripsy by basket catheter. Double J stent used in 11 patients. We achieved complete stone clearance in 10 patients (78.5%). Second URS was applied to 3 patients who were residual stones and complete stone clearance was achieved. Postoperative urinoma was determined only in one patient and this patient was treated with using drenage catheter.

Conclusion: URS is a safe and an effective method in children who are choosen appropriately. Complication ratio can be decreased by using correct enstruments and careful application.

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OPU57: Surgical problems in temporary peritoneal dialysis

Ü Biçakcia, G Gençb, B Tandera, M Günaydina, O Özkayab, C Aygunb, Ş Küçüködükb, R Rizalara, E Aritürka and F Bernaya

Departments of aPediatric Surgery, bPediatrics, Ondokuz Mayis University, Faculty of Medicine, Samsun, Turkey

Aim: Injuries on tracheobronchial tree (TBT) in children are rare, but their mortality is high. We aimed to evaluatethe children with TBT injuries treated in our department.

Materials and methods: Between 2009 and 2011, four cases with TBT injuries aged between 2 and 16 (2F, 2M) were treated. The outcome parameters were age, type of injuries, clinical follow up, methods of diagnosis and treatment. All patients had PA and lateral chest X-ray and chest CT.

Results: Three patients had traffic acccident an done had an inhalation injury. In three cases, bone fractures at chest and subcutaneous emphysema on the chest wall were accompaning to the TBT injury. One patient underwent early thoracatomy and primary repair, two others had delayed primary repair. One patient with inhalation injury needed conservative with management endotracheal intubation only. Before thoracatomy, a rigid bronchoscopy has been utilized. Three patients had a complete healing. One 16 years old boy with delayed primary repair needed to undergo a lung resection inspite of a tracheobronchial stent application.

Conclusion: Early management in TBT injuries has a critical importance. Early primary repair of injuried bronchus and lower age may provide a better prognosis.

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OPU58: Laparoscopic and open surgical approaches of chronic ambulatory peritoneal dialysis

Ü Biçakcia, G Gençb, B Tandera, M Günaydina, O Özkayab, R Rizalara, E Aritürka and F Bernaya

aDepartments of Pediatric Surgery and bPediatrics Ondokuz Mayis University, Faculty of Medicine, Samsun, Turkey

Aim: The patients with end stage renal failure (ESRD) who had chronic ambulatory peritoneal dialysis (CAPD) have been evaluated.

Materials and methods: Between January 2002 and September 2010, all patients with CAPD have been evaluated according to age, sex, complications, cause of ESRD, catheter insertion type, presence of peritonitis, catheter survival rate, kt/V rate.

Results: The summary of the results is shown on the tables. Rate of the peritonitis is significantly less in patients with laparoscopic approach. Patients with peritonitis were significantly younger than those who had no attack of peritonitis. No significant difference has been found between the open and laparoscopic approaches according to development of complications. Catheter survival rate for the first year was 95%, and for the five years 87.5%. The mean kt/V which indicates the effectiveness of peritoneal dialysis was 2.3±0.6. No difference was found between laparoscopic and open aprroach according to kt/V.

Conclusion: The complication rate of CAPD was low and laparoscopic approach seems to have less complications. Catheter survival rate was excellent.

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OPU59: Laparoscopic diagnosis and treatment of nonpalpabl testis

Ü Adigüzel, Ç Aydin, N Kiliç and ME Balkan

Department of Pediatric Surgery, Division of Pediatric Urology, The Medical Faculty of Uludag University, Bursa, Turkey

Aim: Approximately 20% of cryptorchid testicles are nonpalpable. Diagnostic laparoscopy has changed the surgical approach to nonpalpable testes (NPT). The aim of this study was to determine the value of laparoscopy in managing patients with NPT.

Materials and methods: Between August 2001 and February 2011, we retrospectively reviewed the medical records of 80 patients with NPT who underwent laparoscopy. In patients with intraabdominal viable testes, two stage laparoscopic Fowler-Stephens orchiopexy has been carried out.

Results: The patients' ages ranged from 8 months to 15 years (mean, 4 years). Eighty-eight NPT were identified in 80 cases. Twenty-four (27%) of all testes had intraabdominal, 33 (37%) had cord structures entering the internal inguinal ring, 29 (33%) had intraabdominal blind-ending cord structure, and 2 (2%) had testicular agenesia. In 23 testicles of 24 intraabdominal testes, we performed a two stage laparoscopic Fowler-Stephens orchiopexy and one of these testes were performed laparoscopic orchiectomy. During the laparoscopic procedure no testicles were identified in 29 patients, and the procedure was stopped. Inguinal exploration were performed to 33 testes who had cord structures entering the internal inguinal ring. There was no intraoperative complication in all patients. After one year examination we found 3 atrophic and 20 normal size testes in which were performed two stage laparoscopic Fowler-Stephens orchiopexy. Of 20 normal size testes followed up beyond 1 year, 17 (85%) testes were positioned in the lower scrotum and 3 (15%) testes in the high scrotum.

Conclusion: In pediatric age group, the laparoscopic approach is safe and feasible. Furthermore, the laparoscopic orchiopexy presents excellent results in terms of diagnosis and therapy of the nonpalpable testes. However, atrophy of the testes or upward migration of the testes can occur during follow-up, so we suggest watchful, periodic follow-up evaluating viability and location of orchiopexed testes that are located in the lower scrotum in the immediate postoperative period or during short-term follow-up.

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OPU60: Two-stage Fowler Stephens orchidopexy for intraabdominal testes

H Emir, Ş Emre, R Özcan, A Alptekin, M Eliçevik, SN Cenk Büyükünal and Y Söylet

Department of Pediatric Surgery Division of Pediatric Urology, Istanbul University Cerrahpasa Medical Faculty

Aim: To evaluate the clinical outcomes of patients who underwent two-stage Fowler-Stephens (TSFS) procedure for intra-abdominal testis retrospectively.

Patients and methods: The medical records of 39 children (Mean age:64 months, range: 11 months–11 years) who underwent TSFSprocedure between 1992–2010 were analyzed retrospectively. During laparoscopic evaluation in the first stage, if an intraabdominal testis can not be pulled to the contralateral internal inquinal ring, we perform TSFS procedure. Otherwise we perform single stage orchidopexy and this group of patients, disorders of sexual developments, vanishing testes are not included in this study. In the second stage, if there is not testiculat atrophy, orchidopexy is performed either by a standart open surgical procedure or laparoscopically. The testis is mobilized to the scrotum on a flap of peritoneum containing the collateral vessels. The follow-up period ranges between 3 months and 16 years (mean: 5.7 years).

Results: TSFS procedure was performed for 48 intraabdominal testes in 39 patients (Right:16, left: 14, bilateral: 9). The mean interval between the two stages was 7.3 months (r: 3–13 months). Three testes were recorded as a small testis in the first laparoscopic evaluation. In the second stage, orchiectomy was indicated for testicular atrophy in 2 testes (4%), including the one which was defined as a small testis at the first stage. Orchidopexy was performed in the other 46 testes by standart open surgical procedure in 30 and laparoscopically in 16. One testis can be mobilized to the distal inguinal canal and the other 45 testes was located in the scrotum uneventfully except one with a pedicule injury. Of these 45 testes on the follow-up, 40 were palpable in the scrotum and testicular atrophy developed in the 5, including the testes which were noted as small at two stages. The succeess rate of TSFS orchidopexy is 83% (40/48).

Conclusion: Two stage is an effective treatment modality for intraabdominal testes if the spermatic cord have inadequate lenght to reach the scrotum. At present time we have been performing the second stage laparoscopically also.

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OPU61: Laparoscopic traction for the abdominal testis

Sameh Shehata

Head of Pediatric Surgery Department, Alexandria University, Egypt Middle East Reprst. of the WOFAPS

Aim: The aim of this study was to assess the medium term results of the technique of laparoscopic traction for the abdominal testis, specifically the use in high abdominal testis and the possibility of application in bilateral cases simultaneously.

Materials and methods: The lower pole of the testis is attached with 2/0 Vicryl stitch which is fixed above the contralateral anterior superior iliac spine. The testis is fixed in position for 6 weeks. A second Laparoscopy is performed to locate the testis intrascrotally. Follow up was done after 6–18 months to check position and size of the testis and color Doppler was performed to check the vascualrity.

Results: Twenty five children with intra-abdominal testis were operated upon laparoscopically between January 2005 to April 2009. Age ranged between 1 and 6 years (mean 1.6 years). Seven testes were right sided and 16 left sided and two cases bilateral (n=27 testes). 18 testes were low lying and 9 high abdominal testes Three tastes had slipping of the traction suture Position of the testis after minimum of 6 months postoperatively: High scrotal in 6 cases, Mid scrotal in 13 cases, Low scrotal in 7 cases. Atrophy in none, conversion on to Fowler Stephens in one. Follow up ranged for 6 to 18 months with (mean 12.7 months). Doppler study showed normal vascualrity both venous and arterial.

Conclusion: Laparoscopic traction for the abdominal tests is a safe and effective technique. The technique was modified from the original version to simplify the postoperative care the mechanism of elongation is probably due to the weight of intestine gradually stretches the tensed testicular artery Further extension of the technique to the high abdominal testis and the possibility of performing bilateral simultaneous traction add more dimensions and versatility for the technique.

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OPU62: Surgical treatment of varicocele in children

M Çağlar, MA Özen, Ç Ulukaya Durakbaşa, HM Mutuş, M Korkmaz, A Kaymakci, Aİ Anadolulu and H Okur

Department of Pediatric Surgery, S.B. Goztepe Training and Research Hospital, Istanbul

Introduction: Varicocele is not a common childhood disorder. It can only be considered as a disease of the adolescent. There are not universal principles regarding the diagnostic and therapeutic approaches to this disease in pediatric surgical practice. This study aims to evaluate the patients operated on for varicocele in a pediatric surgical clinic.

Materials and methods: The patient file records are retrospectively evaluated for those operated on for inguinal pathologies between the years 2000–2010. The ages, symptoms, Doppler ultrasonography (US) findings, operations performed and complications are recorded for those with varicoceles.

Results: The varicocele patients constituted 0.5% of all patients operated on for various inguinal pathologies. There were 28 patients with 31 involved sides. The mean age was 13 (11–17) years. Left side was involved in 24, right in one and both sides in three. The principal complaints were scrotal swelling, scrotal pain and inguinal pain and/or local discolorisation, in descending order. There were grade 4 varicocele in two sides, grade 3 in five, grade two in 1 and grade 1 in three, according to the preoperative US records that were available at the time of this study. The operative technique was inguinal (Ivanissevich) approach in 21 patients with 24 involved sides. It was retroperitoneal (Palomo) technique in 7 patients with 7 involved sides. No short term complication occurred in any. Long term follow up was available in 14. Among these, two (14%) had recurrence and both had undergone repair by Palomo technique. A re-operation was done for both, one by Palomo and one by Ivanissevich technique. The latter developed a hydrocele of the involved side and a tertiary surgery was done for this reason.

Conclusion: For pediatric surgeons, varicocele operations are relatively rarely practiced. Its importance lies in its potential role in male infertility. Various surgical options exist. However, it is generally agreed that no operative technique is ideal. The most common surgical complications are recurrence and hydrocele development. Because the number of patients followed up on a long term basis is limited in the present series, strict conclusions are not to be withdrawn. On the other hand, the complications occurred in those who had undergone both artery and vein ligation.

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OPU63: Laparoscopic nephrectomy in children

M Küçükaydin, S Arslan, KC Sulubulut, Ö Yandim, AB Doğan and A Aslan

Department of Pediatric Surgery, Erciyes University, School of Medicine Kayseri

Background/purpose: The laparoscopic nefrectomy is prefered as the standart of care with potantial advantages of less postoperative pain, shorter hospitalization, earlier return to normal activity and more acceptable cosmetic results. Laparoscopic nephrectomy in children were retrospectively reviewed in this study.

Materials and methods: From October 2006 to December 2010, laparoscopic nephro-ureterectomy 24 (%75) and partial nephrectomy 8 (25%) was performed in 32 consecutive children, 13 (40%) girls and 19 (60%) boys aged between 1 mounts and 13 years (median, 5.5 years). Renal disease was in the right side in 11 (34%) patients and in the left side in 21 (66%). Atrophic kidney 13 (40%), Multicystic dysplastic kidney 6 (19%), non-functioning kidney secondary to obstruction, reflux or ectopic ureter 5 (%16), double collecting system 5 (16%), renal hydatid cystic 2 (%6), and renal artery stenosis 1 (%3) of the patients. Information including operation time, blood loss, length of hospital stay, and postoperative complications.

Results: The laparoscopic procedure was feasible in all cases and did not require conversion to open surgery or perioperative transfusion in any case. The mean operation time 80 min (range, 60–110 min). The median hospital stay of the patients was 5.8 days (range, 2–8 days).

Conclusions: Laparoscopic nefrectomi approach should be considered if nephrectomy is indicated in every age, even if newborns. There are the advantages that simplify the surgical technique, minimize surgical trauma and morbidity, thereby improving cosmetic results and reducing hospital stay in every age group.

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OPU64: Laparoscopic assisted pyeloplasty in small infants

M Küçükaydin, KC Sulubulut, S Arslan, AB Doğan, A Aslan and Ö Yandim

Department of Pediatric Surgery, Erciyes University, School of Medicine Kayseri

Background and aim: Pediatric urologic operations that can now be regularly performed using the minimally invasive surgery (MIS). One of the procedures is laparoscopic dismembered pyeloplasty (LP) for hydronefrotic kidney with ureteropelvic junction (UPJ) obstruction. LP is very difficult for small infant. Laparoscopic assisted pyeloplasty (LAP) is an an innovative alternative MIS. In this study, we want to present our experiences with LAP in the small infants.

Materials and methods: Between December 2008 and September 2010, 30 small infants underwent LAP. The babies (22 male, 8 female) were in the age range of 8 days to 60 days (mean 35 days). The UPJ obstructions were left sided in 19 cases (63%), right sided in 9 (30%) and bilateral in 2 (7%). All of the patients were detected to have UPJ obstruction during the antenatal evaluation. Using a 3/4 mm camera and two 3 mm working ports, UPJ was mobilized by a transperitoneal laparoscopic technique. The UPJ was brought out with a sling through a tiny flank incision and a standard dismembered pyeloplasty was performed over a double J stent.

Results: Mean operative time was 60 min (range, 50–90 min). Incision was smallerthan 1, 5 cm in all, and the average postoperative hospital stay was 4 days (range, 3–6 days). Follow-up ranging from 3 to 20 months showed reduction in hydronephrosis and improvement in renal function of all the operated units.

Conclusion: Laparoscopic assisted pyeloplasty is especially recommended in small babies where laparoscopic pyeloplasty is difficult.

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OPU65: The effects of intraabdominal pressure increase during laparoscopy in male rats on fertility

L Sapan, M Imamoglu, A Alperen, A Calapoglu, S Samut and H Sarihan

Department of Pediatric Surgery, Trabzon, Karadeniz Technical University, Faculty of Medicine, Turkey

Backround: In clinical and experimental studies, it is shown that laparoscopy leads to ischemia and reperfusion injury in intraabdominal organs. Testes is one of the organs mostly affected by increased intraabdominal pressure (IAP). In our experimental study, we investigated that influence on fertility in male rats during performing laparoscopy due to IAP.

Materials and methods: 24 male rats were divided into 3 groups. Group A assigned to rats without undergone pneumoperitoneum. In group B and group C pneumoperitoneum occurs under 10 and 20 mmHg IAP, respectively. IAP was sustained using otomatically working laparoflator resulting pnömoperitoneum. At group B and group C pnömoperitoneum was maintained for 60 min and then laparoscopy was completed by desuflation. 6 weeks after laparoscopy, right and left testes of all rats where removed. Germ-cell assesment was done using histologically testes biopsy scoring (TBS) and testes injury grading. Persentage of apaptosis was eveluated by method of flow citometry. All results were analysed statistically.

Results: In assessment of testes injury grading, we obtained grade I, grade II and grade III for group A, group B and group C respectively. As a result, we found that testes injury grading increases with IAP. For germ cell evulation in testes biopsy, we obtained TBS. TBS 9-10 for group A, TBS 9-8-7 for group B, TBS 8-7-6-5-4 for group C. Consequently, we conculed that TBS scoring is decreased with IAP, germ cell injury is increased with IAP and spermatogenesis was impaired with IAP. In assesment of testes tissue apoptosis, we obtained apoptosis %4.4 for group A, % 22.4 for group B and %31.0 for group C. We concluded that apoptosis increased in testes with IAP and spermatogenesis was impaired with IAP.

Conclusion: We observed that IAP which is performed for laparoscopic operation leads to degeneration histologically in testicular tissue, regarding as proportional to pressure level. We obtained that resultant degeneration and severe germ cell injury mostly occurs in 20 mmHg IAP.

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OPU66: Posterior urethral valve: our experiences

Y Çalişkan, M Kaçar, N Kiliç and E Balkan

Department of Pediatric Surgery, Division of Pediatric Urology, The Medical Faculty of Uludag University, Bursa, Turkey

Aim: We aimed to share our experience related with posterior urethral valve (PUV) in this study.

Materials and methods: Totally 43 cases who were followed and treated with PUV diagnosis in our department between 2000 and 2010 were investigated retrospectively. Cases were examined in terms of operation age, clinical presentation, associated anomalies, presence of antenatal diagnosis, presence of vesicourethral reflux (VUR) and additional surgical procedures.

Results: Age of the first operation were between 6 days and 9 years. Type Ι PUV was detected in all of the cases and it was fulgurated. Second fulguration procedure was applied to 4 cases due to residual valve. First clinical presentation symptom were difficult urination (n:16) and urinary infection (n:8). Antenatal hydroureteronephrosis was detected in 19 of cases. Associated anomalies were observed in 10 cases. In voiding cystourethrography, bilateral VUR was detected in 11 cases and unilateral VUR was detected in 4 cases. Uretereneocystostomy was required due to grade 4–5 persisting VUR in 10 cases. In static renal scan, non-functionality was found in 2 kidney unit and function less than 40% was found in 11 kidney unit. Additional urological operation required in 23 cases. Mean follow-up period was 40 months (3–120 months).4 cases are followed-up because of chronic renal failure. Clean intermittent catheterization is applied to 16 cases. 23 cases are followed without any clinical problem.

Conclusion: PUV appears with antenatal hydroureteronephrosis in the newborn period and with various urinary system complaints in infants and children. Early diagnosis and timely PUV fulguration stops the progressing kidney damage and decreases proceeding to chronic renal failure.

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OPU67: Is the treatment of PUV without a vesicostomy beneficiary for the either the patient or the urinary system?

C Sahin, A Cerrah Celayir and G Kurt

Department of Pediatric Surgery, Zeynep Kamil Women and Child Diseases Education and Research Hospital, Istanbul, Türkiye

Introduction/aim: Patients operated for puv with or without creating a vesicostomy were evaluated with their long-term results in order to compare the methods and show the superiority of the method without a vesicostomy.

Materials and methods: 21 patients with PUV treated between January 2005–2010 at our department were evaluated for this study.

Results: Typical appearence of PUV was present with 13 patients. Patients without having the typical appearence of PUV were diagnosed with cystoscopy. Vesicostomy was created in 8 patients (group 1) and cystoscopic fulguration was performed initially in 13 patients (group 2). No statistical difference was present between GFR values of these two groups on first admission. When compared preoperatively significant difference detected between PMR, BUN and Creatinine values whereas no significant difference was found for other parameters, moreover renal AP diameters. Patients of two groups were assessed on postoperative 3th and 6th months ultrasonographically and again no statistical difference was present. Group 1 patients were evaluated 12 months later; right and left kidney dimensions remained unchanged, parenchymal thickness was increased, pelvis AP diameter decreased. Both ureter diameters were unchanged. Bladder wall thickness decreased. PMR was decreased. Protein amont detected in urine was decreased. BUN values were constant and blood Creatinin values decreased. In Group 2, all the results were same as group 1 patients except the decrease of ureteral diameters.

Conclusion: No difference found between renal function deterioriation or progression to chronic renal failure in PUV patients after performing fulguration directly or creating a vesicostomy before fulguration. Moreover following fulguration CIC was taught to families and started immediately after the procedure. However some families had not adapted and neglected CIC procedure therefore prevented the regression of hydroureters. Accomodating vesicostomy seems better and easier than performing CIC for the families.

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OPU68: Long term outcomes of posterior urethral valve

A Yucak, Ş Emre, R Özcan, M Eliçevik, Y Söylet, N Danişmend, C. Büyükünal and H Emir

Department of Pediatric Surgery, Division of Pediatric Urology, İI.U. Cerrahpaşa Medical Faculty, stanbul, Turkey

Aim: To present out come of our posterior valv patients.

Patients: The medical records of 117 patients with PUV between 1993–2009 were analyzed retrospectively. 67 patients had prenetally diagnosed hydrourethonephrosis (HUN) but only 29 were evaluated postnatally without a urinary tract infection (UTI). 88 patients were presented by UTI (n:45), micturation problem (n:34), urinoma (n:4) and hematuria (n:6). Before the cystoscopy, peritoneal dialysis catheter was inserted in 9 patients and nephrostomy in 4. All patients underwent cystoscopic valv ablation, except 11 who underwent vesicostomy because of instrument limitations. Two patients underwent vesicostomy and 3 ureteroneocystostomy at other centers. The patients were followed-up by repeat cystoscopy, ultrasonography, VCUG, renal scans and urodynamic studies. A second intervention (n: 45)(38%) was indicated for persistent HUN and UTI; (nephrostomy n: 7, nephrectomy n: 5, jj stent n:3, ureterostomy n: 3, ureteroneocystostomy n: 12, subureteric injection n: 15). On long-term follow-up 31 patients have chronic renal insufficiency (35%) and 7 had renal transplantation. 88 patients (75%) were on regular follow-up. 5 patients had undergone bladder augmentation, 7 had undergone mitrofanof procedure. 20 are on clean intermitent catheterization (%23), 16 are on double micturation (% 18) and 52 are on timed voiding (%59). 14 patients have occasional urinary incontinence (16%). Recurrent UTI was present in 11 patients (13%).

Conclusions: Even if in the diagnosis of prenetal HUN, patients can refer to hospital in late period. Also in most patients, endoscopic valve ablasion is possible, PUV is a life long disease and requires multidisciplinary approach.

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OPU69: Comparison of two different injectable implant material in endoscopic treatment of vesicoureteral reflux in children

M Kaçar, F Çelik, N Kiliç and E Balkan

Department of Pediatric Surgery, Division of Pediatric Urology, The Medical Faculty of Uludag University, Bursa, Turkey

Aim: The aim of this studyis to compare the efficiancy of two different injectable implant material in endoscopic treatment of vesicoureteral reflux (VUR) in children retrospectively.

Materials and methods: Between 2007–2010, 123 (75 female, 48 male) patients were underwent endoscopic treatment because of VUR. The injectable material were pyrolytic carbon coated beads [PCCB (Durasphere)] (group I) and dextranomer-hyaluronic acid [DHA (Vurdex, Urodex, Dexell)] (group II) in 23 (31 ureters) and 100 (136 ureters) patients respectively. On cystoscopy, we evaluated localizationsand anatomical appearances of ureteral orifices. Both groups were compared in terms of efficiancy retrospectively. Fisher's chi-square test was used to compare the results and demographic characteristics of both groups and P<0.05 was accepted as a statistical significance.

Results: The mean age of the patients is 7.04 (1–17 years) and 6.33 (1–16 years) years in group I and group II respectively. Patients were evaluated according to the localization of reflux, grade of reflux and types of ureteral orifices. Both groups were similar according to the age, sex, grade of reflux and types of ureteral orifices (P>0.0.5). Mean follow-up period was 1.2 years (6 months–4 years). In both groups, there were no complications in early postoperative period. There are no stattistically signifficante difference between two groups in terms of success rate (P>0.05). Ureteral reimplantation was performed in 4 ureters and 17 ureters in group I and group II respectively. Rigidity of the catheter, easily blokage of the catheter during the injection and loss of visualisation after the leak of the material were disadvantages of the group I.

Conclusion: Endoscopic injection is a simple, safe and effective treatment of VUR in children. The success rates of PCCB and DHA were similar.

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OPU70: Our experiences with endoscopic dextranomer/hyaluronic acid copolymer (deflux) injection

KU Özkan, Ş Öztürk and A Mil

Department of Pediatric Surgery Kahramanmaraş Sutcu Imam University Medical Faculty

Purpose: We present the results of endoscopic use of dextranomer/hyaluronic acid copolymer (Deflux) for VUR grade I I-V in children.

Patients and methods: Between January 2007 and March 2011, 73 children (51 female, 22 male) underwent 133 endoscopic subureteral injection of Deflux as an outpatient procedure. The median age was 5.7 years (12 months to 17 years). Reflux was unilateral in 46 cases(30 left side, 16 right side) and bilateral in 27, affecting 100 ureters. Reflux grades was II to V in 10 (10%) cases, 51 (51%), 19 (19%) and 20 (20%), respectively. All patients have been followed for 3 months to 2 years. Three months postoperatively a voiding cystourethrogram (VCUG) was performed. Second and third injections were performed for the patients who had not resolved reflux after first injection of deflux. 29 ureters had second and 2 ureters had third deflux injections. One unilateral reflux was associated with ureteropelvic junction (UPJ)obstruction, one patient had multicyctic displastic kidney on contrlateral side. One grade V reflux was following ureterocel incision. Three reflux were associated with double collecting system of which one was on the upper pole and other on the lower pole. One grade III reflux was on the pelvic kidney. Five patients had bladder sphincter dyssynergy with persistant reflux and nine of 100 ureters had ureteral dysplacement.

Results: The reflux was corrected in 46 (46%) of the 100 ureters after a single injection, and resolved after a second and third injection in 22 (22%) and 1 (1%) ureter, respectively. The overall cure rate per grade was 100% for grade II, 76.4% for grade III, 57.8% for grade IV and 45% for grade V. No intra or postoperatively untoward effects were seen in any of these patients with the use of dextranomer/hyaluronic acidcopolymer as an injectable material.

Conclusion: The endoscopic treatment of VUR with Deflux is a feasible outpatient procedure, requires minimal operating room time and is associated with low morbidity. Double collecting system, ureteral dysplacement, bladder sphincter dyssynergy and high grade of reflux had adverse effects on cure rates.

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OPU71: Endoscopic treatment of vesicoureteral reflux in infants with a history of prenatal hydronephrosis

G Ekberli, MN Azili, F Akbiyik, E Şenel, E Mambet, Z Livanelioğlu, H Atayurt and T Tiryaki

Ankara Child Diseases Hematology and Oncology Education and Research Hospital Pediatric Surgery Department

Aim: STING procedure has changed treatment of VUR. It is widely acknowledged that the likelihood of VUR resolution depends on the grade of reflux. Vesicoureteral reflux in infants with prenatal hydronephrosis also have high grade reflux. Surgical treatment suggest at one year old. Renal function may impair while waiting period in these cases. We evaluated the effectiveness and safety of subureteral Deflux injection for managing vesicoureteral reflux in infants with a history of prenatal hydronephrosis.

Materials and methods: Between junavary 2006 and October 2010, 17 infants underwent endoscopic subureteral injection with DX/HA (Deflux) for high grade primary VUR. All of patients were diagnosed with VUR on investigation for prenatally diagnosed hydronephrosis.

Results: There were 16 boys (95%) and one girl (5%). Median age at STING procedure was 5 months (range 3 to 8 months). Reflux was unilateral in 6 infants and bilateral in 11. Reflux was grade IV to V in 3 (15%), 14 (85%), respectively. Reflux resolved in one ureter after a single endoscopic injection and it was down graded to grade II in 2. In this group VUR was corrected endoscopically in 3 children with grade IV/V VUR. DMSA scan in all infants revealed renal scarring. 14 patients required open surgical procedure after one year old.

Discussion: The management of infants with VUR has become increasingly controversial. Moreover there has been a relatively recent paradigm shift following the introduction of early treatment by endoscopic injection therapy. Management of infants with VUR should take into consideration the likelihood of spontaneous resolution, the likelihood of recurrence of UTI and the risk of developing renal parenchymal abnormalities. The resolution rate for studies with infants diagnosed prenatally severe grade is less than 15%. Endoscopic treatment with Deflux for high grade VUR in infants with prenatal hydronephrosis is a safe, but ineffective. We do not recommend endoscopic treatment in infants with high grade VUR.

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OPU72: Endoscopic treatment of vesicoureteral reflux with polyacrylate polyalcohol copolymer in children: promising primary results

Z Dökümcü, F Huseynov, A Avanoğlu and İ Ulman

Department of Pediatric Surgery Division of Pediatric Urology, Ege University Faculty of Medicine Izmir

Purpose: In the last decade, endoscopic treatment (ET) of vesicoureteral reflux (VUR) has moved forward in the algorithm of VUR management especially with the evolution of non-biodegradable synthetic materials. Reports indicate that there is a strong tendency to inject more volumes of bulking agents for more successful results in literature. In this study, we aimed to present short term results of ET of VUR with a new bulking agent with high molecular mass.

Materials and methods: From August 2009, all VUR patients assigned for endoscopic treatment underwent subureteric injection with polyacrylate polyalcohol copolymer (PPC, Vantris) in our institution. Hospital records of all patients are reviewed and demographics, symptoms, characteristics of ureters and bladders, injected volumes and postoperative symptoms with VCUG controls were evaluated.

Results: A total of 49 patients (25 girls, 24 boys) with a mean age of 6.12 years (1 month–20 years) were included in the study. Febrile urinary tract infections (69.5%) were the major complaints. Fifty six percent of the patients aged above 5 years (n=30) had urinary incontinence and 7 (14.5%) male patients had antenatal hydronephrosis. In 23 (46.9%) children, VUR was secondary to bladder-sphincter dysfunctions (16) and posterior urethral valves (7). VUR was unilateral in 28 and bilateral in 21 cases. Thirty-five of the total 70 (50%) injected ureters had high grade (4–5 degrees) VUR. The mean injected volume of bulking agent was 0.98±0.58 ml. Reflux disappeared in 81.4% (57/70) of the ureters with a single injection at postoperative 3–9 months' VCUG controls while it downgraded to grade 1–2 in 6 (8.5%). At the end of a mean follow-up of 11.2 months, VUR recurred in 1 (1.4%) and contra-lateral VUR developed in 6 ureters. In postoperative period, symptoms and urinary infections persisted in 19.1 and 12.7% of the patients, respectively. No complications occurred during the follow-up period.

Conclusion: Initial results of our complex group of patients suggest that PPC may be used safely and satisfactorily for correction of VUR in children. Injection volume and therefore the cost seem reasonably low even in high grade or complicated secondary reflux cases. Further prospective randomized controlled studies and long-term outcome data of these patients are needed.

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OPU73: Endoscopic treatment for vesicoureteral reflux in infants below 1 year of age: primary results

Z Dökümcü, A Avanoğlu and İ Ulman

Department of Pediatric Surgery Division of Pediatric Urology, Ege University Faculty of Medicine Izmir

Introduction: Renal parenchymal injury occurs early in infancy in most of the vesicoureteral reflux (VUR) cases. Due to improved results of endoscopic treatment (ET) of VUR in recent years, this approach is gaining popularity as an alternative to conservative management in infants. In this study, our primary results of ET for VUR in infants below age of 1 year are presented.

Materials and methods: Hospital records of VUR patients aged below 1 year and underwent subureteric injection with polyacrylate polyalcohol copolymer in our institution in August 2009–December 2010 are reviewed. Patient demographics, symptoms and findings as well as radiological, scintigraphic and cystoscopic characteristics of renal units, injected volumes and postoperative ultrasound and voiding cystourethrogram (VCUG) controls were evaluated.

Results: Eight patients (5 boys, 3 girls) with a mean age of 7.8 months were included in the study. Five patients had history for febrile urinary tract infections and remaining three had antenatal hydronephrosis. Eight out of 13 ureters had high grade VUR. All patients except one with renal agenesis showed hypoaciticty or decrease in split renal function (>5%) on scintigraphy. Mean injected volume was 0.94 ml (0.2–2 ml) to ureteric orifices which had mostly (8) ‘golf hole’ or wide appearance. Hydronephrosis resolved in 6 of 7 preoperative hydronephrotic kidneys. Reflux disappeared in 12 out of 13 ureters (92.3%) with a single injection at postoperative 3–9 months' VCUG controls while it downgraded to grade 2 in 1. Neither recurrence nor any complication was detected in mean follow-up period of 11.3 months (5–15 months).

Conclusion: Our results in a small study group strongly promise that ET may be performed securely and successfully in infants aged below 1 year. Further prospective controlled studies with higher number of patients are needed.

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OPU74: Endoscopic treatment of high grade vesicoureteral reflux in children: results of single injection

Z Dökümcü, A Avanoğlu and İ Ulman

Department of Pediatric Surgery Division of Pediatric Urology, Ege University Faculty of Medicine Izmir

Introduction: Success rate of endoscopic treatment in high grade vesicoureteral reflux (VUR) is low with single injection and repeated injections are often needed in literature. In this report, primary results of single injection with a high-molecular mass bulking agent in high grade VUR are presented.

Materials and methods: Hospital records of all VUR patients underwent subureteric injection with polyacrylate polyalcohol copolymer (PPC, Vantris) in our institution in August 2009–December 2010 are reviewed. Only renal units that were exposed to high grade VUR were included in the study. Patient demographics as well as radiological, scintigraphic and cystoscopic characteristics of renal units, injected volumes and postoperative ultrasound and voiding cystourethrogram (VCUG) controls were evaluated.

Results: Twenty-seven patients (18 boys, 9 girls) with a mean age of 4.7 (1 month–17 years) years had 35 renal units receiving high grade (4–5) VUR. In 11 chidren (40.7%) VUR was secondary to posterior urethral valve (6) and bladder-syphincter dysfunction (5). Preoperative investigations revealed hydronephrosis in 66.6% and renal parancyhmal damage with decrease in function (>5%) in 75% of the kidneys. Ureteral orifices had ‘Golf hole’ (52.3%) and wide (33.3%) appearances in cystoscopic evaluation. Success rate at postoperative 3–9 months' VCUG controls was 80% (28/35) with a mean injected volume of 1.12 (0.4–3) ml. VUR was downgraded in 2 ureters. Previous histories of endoscopic VUR treatment were positive in 4 of 5 remaining unsuccessful cases. Success rate in ‘golf hole’ ureteric orifices was 90.9%. Hydronephrosis regressed in 61.1% of the preoperative hydronephrotic kidneys. Neither recurrence nor any complication was detected in mean follow-up period of 12.3 months (5–16 months).

Conclusion: Our results of endoscopic treatment of high grade VUR are promising after single injection, even in ‘golf hole’ orifices that are generally avoided for endoscopic treatment. Long-term data and prospective controlled studies are needed.

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OPU75: Endoscopic treatment of vesicoureteral reflux in complicated secondary cases: early results

Z Dökümcü, A Avanoğlu and İ Ulman

Ege University Faculty of Medicine Department of Pediatric Surgery Division of Pediatric Urology, Izmir

Introduction: Bladder-syphincter dysfunctions and bladder outlet obstructions compose the majority of secondary vesicoureteral reflux (VUR) cases. Due to affected bladder dynamics, treatment of VUR in these patients is more challenging with higher recurrence rates. In this study, early results and effectiveness of endoscopic treatment for VUR in complex secondary cases are presented.

Materials and methods: Hospital records VUR patients underwent subureteric injection with polyacrylate polyalcohol copolymer in our institution in August 2009–December 2010 are reviewed. Cases received appropriate treatment for bladder-syphincter dysfunction or bladder outlet obstruction for at least 3 months are included in the study. Patient demographics, symptoms and findings as well as radiological and scintigraphic characteristics of renal units, cystoscopic appearances of bladders, injected volumes and postoperative voiding cystourethrogram (VCUG) controls were evaluated.

Results: Twenty three patients (12 girls, 11 boys) with a mean age of 8.4 (1–20) years were included in the study. Underlying pathologies were bladder-syphincter dysfunction (16) and posterior urethral valve (7). Ten (43.4%) patients had previously been operated for VUR. History for febrile urinary tract infections (FUTI) and urinary incontinence rates were 68.1 and 81.2% respectively among the group. Half of 30 renal units had high grade VUR and decrease in split renal function (>5%) on scintigraphy. Cystoscopy revealed moderate-high trabeculation of detrusor in 78.9% of the bladders. Mean injected volume was 1.17 (0.2–3) ml. Reflux disappeared in 24 out of 30 ureters (80%) with a single injection at postoperative VCUG controls while it downgraded to grade 1 in 2 (6.6%). Symptoms of FUTI and urinary incontinence relieved or disappeared in 82.3 and 69.2% of the patients, respectively in a mean follow-up period of 11.5 (5–16) months. No postoperative complication was noted.

Conclusion: Endoscopic treatment may be performed safely with even higher rate of success than expected in complex patients with secondary VUR. Our results may address that bladder dysfunction may be treated more easily with prevention of VUR, and hence urinary tract infections. Further prospective controlled studies with long-term results are needed.

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OPU76: Endoscopic treatment of moderate and high grade vesicoureteral reflux in children

M Küçükaydina, S Arslana, AB Doğana, KC Sulubuluta, A Aslana, Ö Yandima, MH Poyrazoğlub and Z Gündüzb

Departments of aPediatric Surgery and bPediatric Nephrology, Erciyes University, School of Medicine, Kayseri, Turkey

Background and aim: Renal parenchymal injury in vesicoureteral reflux (VUR) occurs early, in most patients before age 3 years. It is generally believed that prevention of urinary tract infections may decrease the amount of renal parenchymal damage. Endoscopic treatment for VUR has become an established alternative to long-term antibiotic prophylaxis and ureteral reimplantation. We retrospectively evaluated the effectiveness and safety of dextranomer/hyaluronic acid copolymer (DHAC) injection for moderate and high grade VUR in children.

Materials and method: Between January 2002 and July 2010, 215 patients, including 130 boys (60%) and 85 girls (40%), with an average age of 4.2 years (range 4 months to 13 years) underwent endoscopic treatment for VUR with DHAC (Deflux, Urodex, Vurdex, Dexel). VUR was unilateral in 155 patients (72%) and bilateral in 60 (28%) (275 refluxing ureters). Reflux was grade II in 15 ureters (5.6%), III in 128 (46.6%), IV in 108 (39%) and V in 24 (8.8%). Dimercapto-succinic acid scan (DMSA) was performed in 215 children before injection and it demonstrated renal scarring in all the patients.

Results: All patients underwent endoscopic treatment on an outpatient basis. VUR completely resolved in 205 ureters (74.5%) after a single injection of DHAC and it was downgraded to grade I in 26 (9.4%). Of the ureters 55 (20%) required a second injection and 22 (8%) required a third injection and 35 üreters (12.7%) in 20 patients underwent antireflux surgery to resolve reflux.

Conclusion: Endoscopic treatment with DHAC is safe and highly effective for eradicating moderate and high grade VUR in children. Early intervention with endoscopic DHAC injection in children with moderate and high grade VUR may protect against renal scarring.

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OPU77: Comparison of histopathological traits of ureters in cases of ureterovesical junction obstruction and vesicoureteral reflux

D Çalişkana, MN Azilia, A Kaçarb and HT Tiryakia

Department of aPediatric Surgery and bPathology, Ankara Child's Diseases Hematology Oncology Education and Research Hospital

Background/purpose: Reduction in the number of nerves and defective innervation has an obstructive role in etiopathogenesis. Number of the nerves and alpha smooth muscle actin expression wereinvestigated with the purpose of evaluating of neural innervation and muscle morphology in the disorders of the ureterovesical junction such as ureterovesical junction obstruction (UVJO) and vesicoureteral reflux (VUR).

Materials and Methods: 11 pathology specimens of obstructed distal ureters excised at operation for ureterovesical obstruction were compared with the 7 ureteric pathology specimens which were excised of vesicoureteral reflux during the operation retrospectively. The segment of the obstructed ureter of the ureterovesical obstruction was analyzed completely while at the VUR two samples were randomly selected and stained with S-100 and alpha-smooth muscle actin were run by immunochemistry. Data analysis was performed using SPSS for Windows 11.5 package program. Chi-square test for categorical variables were analyzed by, Fisher's exact outcome. P<0.05 was considered statistically significant for the results.

Results: In VUR group, the average of immunohistochemical staining with S-100 was 27.8±8.54, while the average staining of the UV group was 14.0±5.77 (4–20) and have been found to be statistically significant (P=0.002). Alpha smooth muscle actin expression in patients with VUR was diffuse while in the UVJO group it was variable and was statistically significant (P<0.001).

Conclusion: With the last immunohistochemical techniques, it has become possible to detect neural innervation defects with the use of markers like S-100 and muscle tissue pathology by alpha smooth muscle actin expression. Today, the pathophysiology of obstructive uropathy is still poorly understood with the full meaning. In this study, the patients with UVJO compared with VUR, demonstrated the inability of nerve cells and muscle cells at the ureteral specimens of obstructive uropathies. We think that new studies about the pathophysiology would be useful in disease recognition and the development of new treatment options.

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OPU78: Ureterocystoplasty in pediatric patients with unilateral nonfunctioning kidney

T Özdemir, A Arikan, H Turan, A Sayan and N Narli

Tepecik Training and Research Hospital, Department of Pediatric Surgery, Izmir

Aim: Bladder augmentation with a material covered with uroepithelium yields mucus, stone and infection free bladder. Using ureter in bladder augmentation results in a neobladder with appropriate layers and uroepithelium. In this study feasibility and benefits of ureterocystoplasty in patients requiring bladder augmentation.

Materials and methods: Medical records of patients who were undergone ureterocystoplasty between January 1992 and December 2010 were researched. Causes of hydroureteronephrosis, pathologies yielding augmentation, improvement rates of bladder capacity and compliance were recorded.

Results: During the time period, 13 patients were undergone ureterocystoplasty. Seven were girls and 6 were boys. Mean age is 5 years (3–13 years). All the patients had unilateral nonfunctioning kidney with massive hydroureteronephrosis. Causes of hydroureteronephrosis were posteror urethral valve in 5, obstructing megaureter in 2, neurogenic bladder in 3, ectopic obstructing ureterocele in 2 and bladder pseudotumor in 1 patients. Bladder capacity was increased and compliance was improved in all patients. Mean bladder capacity was increased from 95 ml (30–200 ml) to 260 ml (150–440 ml) (mean 300%). Compliance was improved [from 1.0–5.2 ml/cmH2O (mean 2.3), to 22–55 ml/cmH2O (mean 42)]. No uninhibited bladder contractions were detected in urodynamic study after 6 months.

Conclusion: Ureter is an ideal substitution material for the patients with small bladder capacity and poor compliance. Metabolic complications are much less and results in with good urodynamic results.

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OPU79: Important problem after bladder augmentation: incontinence

T Özdemir, A Arikan, HN Özer, A Sayan and N Narli

Department of Pediatric Surgery, Tepecik Training and Research Hospital, Izmir

Aim: The aim of this study is to assess the results of bladder augmentation procedures in a eighteen years' period.

Materials and method: Between 1992 and 2010 42 patients were undergone bladder augmentation. Medical records of the patients were researched and causes yielding augmentation, procedures and follow-up were recorded.

Results: Twenty eight of the patients were males, 14 were females. Pathologies yielding augmentation were bladder extrophy (31/42), neurogenic bladder (7/42), bladder tumor/pseudotumor (3/42) and persistent cloaca (1/42). Twenty nine of patients were undergone ileocystoplasty, 13 were undergone ureterocystoplasty. Mitrofanoff procedure was performed in 38 of 42 patients. Mean follow-up time is 7 years (2 months–16 years). Most common problem requiring subsequent interventions is incontinence. For this purpose, open surgical procedures (11/42), bladder neck injections (3/42) were performed. In 4 girl bladder neck was closed. Mucus and stone formation were inevitable complications among ileocystoplasty group. Various surgical procedures were performed for these patients. Three unilateral nephrectomies were performed because of subsequent kidney dysfunction. No additional surgical interventios were required among the patients in ureterocystoplasty group.

Conclusion: Most important pathology disturbing the patients after bladder augmentation other than the factors about the substitution material is incontinence. Surgical/invasive interventions are necessary to overcome this problem. If the incontinence remains unsolved despite various efforts closure of bladder neck is inevitable.

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OPU80: The comparision of urodynamic findings in children with urinary incontinence before and after bladder neck sling procedure

M Kaçar, N Kiliç and E Balkan

Department of Pediatric Surgery, Division of Pediatric Urology, The Medical Faculty of Uludag University, Bursa, Turkey

Aim: The goal of this study was to review our series of the bladder neck sling (BNS) techniques to evaluate in terms of continence, urodynamic findings and postoperative complications.

Materials and methods: Between 2008–2010, 17 (7 female, 10 male) patients were operated on because of urinary incontinence. In these patients, rectus fascia flap rotated 3600 around the bladder neck and was sutured to the symphysis pubis. The six patients were excluded from the study because of the additional augmentation cystoplasty operation. The remaining 11 patients (3 female, 8 male) were evaluated according to the postoperative continence status, preoperative and postoperative urodynamic findings, concomitant pathologies applied with additional surgical procedures and complications.

Results: The mean age of the patients is 9.3 years (3–16 years). The primary pathologies were meningomyelocele (n:8), anal atresia (n:1), sacrococcygeal teratoma (n:1) and urethral hypoplasia (n:1). All the patients were on clean intermittent catheterisation (CIC) programme. Different additional surgical procedures such as Mitrofanoff procedure (n:9), ureteroneocystostomy (n:4), MACE (n:3), nephrectomy (n:1) and nephrolithotomy (n:1) were carried out. Mean follow-up period was 1.3 years (6 months–2.8 years). Urodynamics were obtained in all patients preoperatively, and the earliest of 6 months postoperatively. The mean bladder capacity was 266.27 ml (100–450 ml) and the mean compliance was 5.90 (1–8) preoperatively. Postoperatively, mean bladder capacity was maesured 297.22 ml (160–470 ml) and mean compliance was measured 6.22 (3–15). Only one patient had detrusor instability at the postoperative urodynamic study and this patient increased anticholinergic therapy dose. None of the patients were decreased bladder capacity and compliance. The patients who remained dry between two CIC application were considered as a continante. Two patients (18.9%) were incontinent in the early postoperative period. Both of them underwent bladder neck injection and they were dry.

Conclusion: BNS helps to the children to provide long-term continence without causing negative impact on urodynamic parameters.

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OPU81: The efficiency of antegrade continence enema procedure in children

M Kaçar, N Kiliç and E Balkan

The Medical Faculty of Uludag University, Department of Pediatric Surgery, Division of Pediatric Urology, Bursa, Turkey

Aim: The aim of this study was to review our series of the efficiency and complications of the antegrade continence enema (ACE) procedure for faecal incontinence in children.

Materials and methods: Between 2005–2010 ACE procedure was performed on 10 (4 female, 6 male) patients for fecal incontinence with a mean age of 12.1 years (7–18 years). Appendix vermiformis was used in 7 patients and caecal tube was used 3 patients for the ACE procedure. Patients were evaluated according to concomitant pathologies applied with additional surgical procedures, fecal continence state and complications retrospectively.

Results: The primary pathologies were meningomyelocele (n:9) and spinal hemangioma (n:1). All the patients were on clean intermittent catheterisation programme and mitrofanoff procedure was performed all the patients for this reason. Otherwise, different additional surgical procedures such as bladder neck reconstruction (n:9), bladder augmentation (n:5) and ureteroneocystostomy (n:4) were carried out. The stomas were anastomosed to the umbilicus (n:3) and the right lower quadrant (n:7). Stomas were kept catheterized for 3 weeks postoperative then once daily enema programme with 500–750 ml isotonic saline was initiated. To reduce the risk of stomal stenosis, patients were instructed to catheterize their ACE each time they catheterized their Mitrofanoff and none of the patients developed stomal stenosis. Mean follow-up period was 1.5 years (4 months–3.1 years). ACE stoma was closed in the early postoperative period and became unavailable in one of the patients because of the non-compliance to the treatment. 3 of 9 (33.3%) patients developed obstructions and revision was performed. Postoperative fecal continence achieved in 8 of 9 patients (88.8%) and minimal soiling continued in the remaining.

Conclusion: ACE procedure is very effective to treat fecal incontinence in children, and it has a positive effect on quality of life. Frequently encountered problems such as stomal stenosis were reduced with the frequent catheterization of the stomas.

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OPU82: Secondary tethering and untethering of spinal cord in children: impact on clinical and urodynamical course

Z Ural, Y Erşahina, A Avanoğlu and İ Ulman

Department of Paediatric Surgery, Division of Pediatric Urology aDepartment of Neurological Surgery, Division of Pediatric Neurological Surgery, Ege University Faculty of Medicine, Izmir, Turkey

Aim: Repaired myelodysplastic defects are prone to development of secondary tethered cord (STC). The decision of releasing secondary tethered cord (STC) in myelodysplastic children remains a challenge. We studied the impact of tethering and untethering on clinical and urodynamical course.

Materials and methods: A retrospective chart review was performed for myelodysplastic children with STC who were presented between 1994 and 2009 in a single tertiary referral center. 23 patients with SCT were enrolled in this study. Inclusion in the study based on the avaliability of baseline urodynamic evaluation under medical management, preoperative and postoperative urodynamic investigations. We analysed UDS's to define a measurable change in detrusor and/or sphincter behaviour regarding to cystometric bladder capacity (CBC), maximal detrusor pressure (MDP), leak point pressure (LPP), overactivity, normoactivity or underactivity of detrusor and sphincter. Severe lower urinary tract malfunction (LUTM) was defined as maximal detrusor pressure (MDP) and/or leak point pressure (LPP) greater than 60 cmH2O, moderate LUTM as MDP and/or LPP 40–59 cmH2O and mild LUTM as MDP and/or LPP less than 40 cmH2O.

Results: Tetheringpresented withorthopedic symptomsin 15and urological symptomsin 9 ofthe patients. 13patients experienced changes in LUTM status. Four from severe to mild, 4 from mild to severe, 3 from moderate to mild, 2 from severe to moderate. Tethering altered detrusor behavior in 6 patients and sphincter behaviour in 1. Previously normoactive detrusor became underactive in 2 patients and overactive detrusor became underactive in 4. Overactive sphincter became underactive in a patient. After untethering, 5 children returned back to their presymptomatic clinical pattern and 7 children returned back their presymptomatic urodynamic patterns.

Conclusion: Myelodysplasia is a dynamic disorder for children. Early or late clinical and urodynamic alterations can be due to STC. SCT needs to be considered before any surgical intervention.

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OPU83: Risk factors of renal parenchyma injury in the congenital neurogenic bladder

G Gündoğdua, D Avlanb, H Taşkinlarb, D Yiğitb, A Naycib, H Kilinçaslana, A Delibaşc and B Taşdelend

aDepartment of Pediatric Surgery, Bezmialem Vakif University, Departments of bPediatric Surgery, cPediatrics, Nephrology and dBiostatistics, Mersin University Medical Faculty

Aim: To evaluate the factors determinining the renal parenchymal injury in children with congenital spinal cord defects.

Materials and methods: Records of 80 children with congenital spinal cord pathology were evaluated. Renal parenchymal injury was considered with dmsa. Age, gender, vesicoureteral reflux, recurrent urinary tract infection, urodynamics findings, medical management (clean intermittent catheterizaton, antibiotic prophylaxis, anticholinergics) and age of treatment initiation were investigated parameters to be involved with renal parenchymal injury.

Findings: 80 cases (38 m, 42f) were enrolled in the study. The pathologies distributed as follows;myelomenigocele, tethered chord syndrome, diastometamyelia, sacral agenesia, syrngomyelia (58, 13, 4, 3, 2 respectively). Mean age was 66.7 months (min 2, max 204). Mean follow up time was 20.5 months. 18 (22.5%) children have renal scarring. Female gender (P<0.05), vesicoureteral reflux (P<0.001), recurrent urinary tract infection (P=0.001), medical managment of neurogenic bladder (P=0.006) and treatment delay (after 1 years of age) have statistically significance with the renal scarring. Even the increased external sphincter activity (DLPP >40 cmH2O) have found to increase the scarring risk 1.952 times, but no statistically significance was found (P=0.217) in the study. Scarring risk was found to be increased 1.103 times for each months of treatment initiation. Vesicoureteral reflux is the most prominant factor of renal scarring.

Conclusion: Female gender, vesicoureteral reflux, recurrent urinary tract infections, management of neurogenic bladder and delayed treatment were corrolated with renal scarring in children with congenital neurogenic bladders. To preserving the renal functions of these children; we suggest to adjust treatment modalities considering the risk factors.

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OPU84: Pelvic floor tonicity affects the urodynamics parameters of children with myelomeningocele

G Gündoğdua, D Avlanb, H Taşkinlarb, D Yiğitb, A Naycib, A Delibaşc and B Taşdelend

aDepartment of Pediatric Surgery, Bezmialem Vakif University, bDepartments of bPediatric Surgery, cPediatrics, Nephrology and dBiostatistics, Mersin University Medical Faculty

Aim: We detected a pressure rise in abdominal pressure (Pabd) tracing in some of routine urodynamics studies of children with myelomeningocele (MMC). In the present study, we investigated this phenomenon and its causes.

Materials and methods: 43 children with MMC were enrolled in the study. Gradual and slow increase in Pabd tracing accompanying the filling was sought in the procedures. End filling and initial Pabd gradient more than 3 cmH2O was accepted increased Pabd. If the defined pressure increase was detected, the bladder was evacuated for confirming pressure-filling relation. Age, gender, urodynamics position, pelvic floor tonicity, cystometric capacity were corrolated with the pressure increase.

Findings: Pabd increase was observed in 18 (41.8%) children. Mean Pabd gradient was found 4.78±1.63 cmH2O. Age, gender and urodynamics position has no corrolation with the pressure alteration. Decreased pelvic floor tonicity and decreased cystometric capactiy have corrolation with the pressure alteration (P=0.003 and <0.001, respectively).

Conclusion: Regarding to our study, we think bladder repositions to posteriorly during filling according to decreased pelvic floor tonicity in children with MMC. This pressure alteration is more obvious with increase in bladder capacity. Urodynamic studies of children with MMC should be carefully evaluated for determining this phenomenon and avoiding unappropriate measurement of the parameters.

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OPU85: The effects of urotherapy on clinical findings and uroflowmetry results in children with dysfuncional voiding

T Bayraka, İ Gökşinb and A Önena

aDepartment of Pediatric Surgery Dicle University Medical Faculty Section on Pediatric Urology Urodynamics Unite, Diyarbakir and bHarran University Institute of Health, Şanliurfa

Aim: In this clinical study, we aimed to determine the effects of urotherapy on clinical findings and uroflowmetry results in children with dysfunctional voiding.

Materials and methods: Those children aged between 8 and 12 with dysfunctional voiding who underwent uroflowmetry prior and after urotherapy in the year 2010 were evaluated. Residual urine volume was accepted as pathologic when it was greater than 20 ml or 10% of expected bladder capacity.

Results: Of the 25 patients, 15 were girl and 10 were boy. Mean age was 10 years. The age and gender were found to be nonsignificant on uroflowmetric parameters when comparing the results prior to urotherapy (P>0.05). The symptoms were significantly resolved after urotherapy (P<0.05). Although statistically was not significant, additional pathologies resolved mainly after urotherapy. Type of voiding was significantly better after urotherapy (P<0.05). However, voiding time and urine flow rate was not significantly affected from urotherapy (P>0.05). Although statistically was not significant, residual volume decreased mainly after urotherapy.

Conclusion: Urotherapy improve clinical findings, associated pathologies, voiding type, and residual volume in children aged between 8 and 12 with dysfunctional voiding. Residual urine volume should be accepted as pathologic when it is greater than 10% in children younger than 6 years of age, while it is greater than 20 ml in children 6 years of age or older.

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OPU86: Possible risk factors and their effects on success of urotherapy in children with dysfuncional voiding

İ Gökşina, T Bayrakb, A Önenb and F Gözc

aHarran University Institute of Health, Sanliurfa, Turkey, bDepartment of Pediatric Surgery Dicle University Medical Faculty Section on Pediatric Urology Urodynamics Unite, Diyarbakir, Turkey and cDepartment of Nursing, Harran University High School of Health, Sanliurfa, Turkey

Aim: We aimed to determine possible risk factors and their effects on success of urotherapy in children with dysfunctional voiding.

Materials and methods: A total of 25 children with dysfunctional voiding who treated in the year 2010 were prospectively evaluated based on prepared evaluation forms and protocols. Prior and after urotherapy Health Related Life Quality was measured by Kid-KINDL test. Gender, age, phone based motivation, type of toilet, number of siblings, relative marriage, economic status of family, working mother, mothers age, education status of mother were recorded as possible risk factors.

Results: Fifteen were girl and 10 were boy. Mean age was 10.04±1.36 years. There were no significant difference between prior and post-urotherapy results in terms of mean overall health related life quality score, mean subgroup scores, mean scores for gender and number of siblings (P>0.05). Gender, age, phone based motivation, type of toilet, number of siblings, relative marriage, economic status of family, working mother, mothers age, education status of mother did not significantly effect the success of urotherapy (P>0.05).

Conclusion: Urotherapy did not improve health related life quality. Similarly, gender, age, phone based motivation, type of toilet, number of siblings, relative marriage, economic status of family, working mother, mothers age, education status of mother did not effect the success of urotherapy. However, we think that the limited number of our cases might affect our results. Larger series are needed for more objective result.

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OPU87: Sleep quality and quality of life in children with Enuresis Nocturna Aktigrafi relation method

S Alkana, P Ertanb, Ö Yilmazc, H Yükselc and H Yilmazd

aDepartments of Pediatrics, bDepartment of Pediatric Nephrology, cDepartment of Pediatric Allergy and dNeurology Celal Bayar Univercity School of Medicine

Five years at least two times per week to adults and enuresis is defined as the kidnapping of at least one ml of urine. Most children have a deep sleep, who wets bed. Actigraphy including sleep-wake cycle is a device that measures the motion-sensitive microsensors. Polysomnography has been developed as an alternative to provide ease of use and the prevalence has increased in recent years.

The purpose of this study, sleep disorders seen in patients with monosymptomatic nocturnal enuresis, and subjective analysis as well as to expose actigraphy. Pediatric Nephrology, Celal Bayar University School of Medicine study, 40 monosymptomatic enuretic patients admitted to 20 age group without any systemic complaints were similar to the intact group. Sleep parameters in these patients were compared with the control group. Subjective tests of Pittsburgh sleep quality index, enuretic patient group was statistically significant. ‘Actual wake time’, ‘Actual wake time %’ ‘total activation score’, ‘Fragmentation Index’ shaped actigraphy sleep parameters in children with monosymptomatic enuretic children the same age group were significantly higher in solid. ‘Actual sleep time’, ‘actual sleep%’, ‘sleep efficiency’ shaped actigraphy enuretic sleep parameters were significantly lower in children. The results of this study, a negative impact on the quality of sleep and sleep disorders in monosymptomatic nocturnal enuresis is caused. This situation affects the quality of sleep, nocturnal enuresis and the non-invasive method is shown with the actigraphy.

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General Pediatric Surgery Posters With Discussion

PP1: Enterostomy complications in children

A Şengün, İ Kiriştioğlu and H Doğruyol

Department of Pediatric Surgery, The Medical Faculty of Uludag University, Bursa

Children with congenital or acquired in the treatment of many diseases is necessary temporary or permanent enterostomies. Enterostomy can lead to morbidity and mortality. In this study; the complications of children with enterostomy were investigated.

The study was between 2001–2011years and was based on 84 cases which was reached their datas from 117 cases with enterostomy. 57 of the cases were boys (%67.8). There were 55 (%65.5) cases in the neonatal period, 12 (%14.3) cases in the infancy and 17 (%20.2) cases older than one year old.

The reasons of enterostomy; Anorectal malformation (n=28), Necrotizing enterocolitis (n=17) were the first two, and than volvous, Hirschsprung disease, ileus, jejunoileal atrezi followed them. The localisation of colostomies was sigmoid colon (n:25), ascending colon (n:4), descending colon (n:3), transvers colon (n:2). The most common type of colostomies was diverting ostomy (n:21). There were 25 cases with ileostomy and 5 cases with jejunostomy. 17 cases had double-ostomy (jejuno-ileostomy and colostomy). 3 cases were subjected to a Hartmann's procedure.

Enterostomy complications were, in frequency, severe peristomal dermatitis (n:7), evisceration (n:6), prolapsus (n:3), stomal necrosis (n:3), severe stomal bleeding (n:2), ostomy stenosis (n:1), wound infection (n:2) and intestinal obstruction (n:1); total rate was 29.7% (n:25). In 8 of these patients (32%) required surgical revision. Six cases which had evisceration underwent relaparotomy, and were primer repaired. One case with ostomy necrosis was revised. The other case which ostomy was non active was again created by laparotomy. Other cases were conservatively treated. There was no death due to complications of stoma.

Enterostomy complications in children remains substantial. Approximately one third of patients, who developed early complications, surgical revision is necessary.

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PP2: Colorectal polyps: clinical experience

Ç Ulukaya Durakbaşa, M Çağlar, S Fettahoğlu, A Baş, M Korkmaz, HM Mutuş, A Kaymakçi and H Okur

Department of Pediatric Surgery, S.B. Göztepe Training and Research Hospital, Istanbul

Introduction: Colorectal polyps (CRP) are among the common causes for rectal bleeding in children. Most are benign. They rarely have malignant potential or may be associated with syndromic malformations. This study aims to present a clinical experience on CRP with an emphasis on utility of colonoscopy in these patients.

Patients and methods: File records of patients treated for CRP between the years 2001–2011 were retrospectively evaluated in terms of age, sex, diagnostic methods, localization of polyps and pathological results. The use of colonoscopy was initiated within the last year of the study period in the relevant clinic.

Results: There were 61 patients with a median age of 5 years (1–15 years). There were 37 (60%) males and 24 (40%) females. The presenting complaint was rectal bleeding in 59, a protruding mass in one and rectal prolapsus in another one. The polyp was palpable by anorectal examination in 54 and removed by transanal route. Colonoscopy was done with successful removal in all except one for the remaining 8. It yielded multipl polyps throughout the colon in one and a single polyp in transverse colon in one, in sigmoid colon in one, proximal rectum in two and in rectum in three. The transverse colonic polyp could not be colonoscopically excised due to the 2-cm-diameter with borad base and was hence removed by colotomy. Histopathology results were available at the time of this review in 58 and consistent with juvenile polyps in 43, hamartamatous polyps in 2, hyperplastic in 2, pseudopolyp in 2, adenomatous in 7, lymphoid in one and inflammatory fibroid in one. Among the adenomatous polyps, three showed low grade dysplasia. There were no associated syndromic malformations.

Conclusion: Rectal polyps are usually palpated and removed by anorectal route. On the other hand, the incidence of rectal polyps that cannot be palpated by anorectal examination and colonic polyps should not be underestimated. The polyps are benign in most children. Colonoscopic examination increases the diagnostic accuracy and adds to the treatment keeping the possible presence of premalignant conditions in these children.

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PP3: Surgery of complicated anorectal fistulas

A Musayev

Department of Newborn and Children Operation*Pediatrics Institute named after K. Faradjov BAKU-AZERBAIJAN

Aim: The aim of this study is to illustrate the use of surgery for the treatment of complicated anorectal fistulas. The therapy plan for rectovaginal fistulas, rectal myco necrosis, anal abscess, pararectal fistulas have been discussed by our doctors.

Introduction: The medical history of patients from the period 2009–2010 whom were followed in our clinic with following problems: anorectal abscess, fistulas, rectal myco necrosis, pararectal fistula and rectovaginal fistula were evaluated in our study.

Methods: 17 infants (4-boys/15 girls) with average gestational age 13 months who were admitted to our clinic were included in the study. Most of them applied secondly and thirdly (after another clinic centers). Patients underwent 29 surgery operations: 4-patients H-type rectovaginal fistula, 7-rectovestibular fistula, 3-local anorectal abscess, 2-patients anal myco necrosis. 7-patients had premier operation, 10 patients had seconder operation.

We evaluated appearance of rectovestibular fistula after myconecrosis at 1 patient. 1 patient underwent endorectal pull-troug. Three patients with premier surgery operation had vestibular suturing, another endorectal suturing. Patients with second operation had a stoma.

Results: According to the many authors, rectovaginal fistula operation must be conducted after 3 months. Most of patients were admitted to our clinic after fistula appearance.

Appearance of fistulas after anorectal infection is often difficult for the cure. Doctors have to avoid fistula closing complications. Point of increasing of the complications rate is vaginal repair. Our goal in our practice was to decrease risk of stoma infections. We have lost one patient with anal myconium necrosis. Rectovaginal field of surgery is always difficult for pediatric surgeons and need to be discussed.

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PP4: Minimal invasive management of childhood intussepciton dramatically reduces the requirement of open surgical reduction

U Ateş, G Küçük, G Göllü, M Bingöl Koloğlu, A Yağmurlu, T Aktuğ and H Dindar

Department of Pediatric Surgery, Ankara University School of Medicine

Aim: Minimally invasive approaches are beginning to be employed in the management of pediatric patients with intussusception who fail radiographic reduction. The utility of laparoscopic reduction has significantly reduced the need of classical open reduction. We aimed to present our experience supporting the success of radiologic and minimal invasive approach in children presented with intussusceptions.

Patients and methods: The charts of patients who were treated for intussusception between January 2006 and January 2011 were reviewed. The data including age, gender symptoms and findings at admission, type of reduction and follow up were recorded and evaluated.

Results: Eighty-two patients whose ages range from four months to thirteen years (median of 2 years) were admitted because of abdominal pain, restlessness, abdominal distention and bloody stool. Fifty-one (62%) of these patients were male and 31 (38%) were girl. Radiologic reduction either by ultrasound visualization (n:45 or Ba enema (n:13) was successful in 70.7% of the patients. Laparoscopic reduction was successfully done in 20.7% (n:17) of the patients. 8.5% of the patients in whom laparoscopic reduction was unsuccessful underwent laparotomy. Manuel reduction was performed in 4 patients whereas resection and anastomosis were required in three of the patients. Meckel diverticula (n:2) and lymphadenopathy because of Burkitt lymphoma (n:1) were the leading points in those patient who required intestinal resection and anastomosis. Recurrent intussusception was seen in four of the cases who had underwent radiologic reduction and managed by laparoscopic reduction.

Conclusion: Either radiologic and laparoscopic reduction is successful in %90 of pediatric patients presented with intussusception. Our data shows that the utility of laparoscopic reduction has significantly reduced the need of classical open manuel reduction. It seems that only the patients with underlying leading points requires resection and anastomosis.

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PP5: Initial experience in single-port transumbilical laparoscopic-assisted appendectomy

SC Karakua, N Kokua, İ Ertaşkinb and M Demircic

aDepartment of Pediatric Surgery, Gaziantep Children Hospital bDepartment of Pediatric Surgery Düztepe Yaşam Hospital and cDepartment of Radiology Gaziantep Children Hospital

Purpose: The three-port method is commonly used for laparoscopic appendectomy alternative to open surgery. We report our experience in treating acute appendicitis with single-port transumbilical laparoscopic-assisted appendectomy (SPTLA) that have been described in the past decade.

Methods and results: Between December 2009 and March 2011, 10 consecutive patients (mean age 11.6±3 years; 8 male and 2 female) with acute appendicitis underwent SPTLA. SPTLA was successfully performed on 7 patients while conversion to open surgery was needed in three patients whose abdominal ultrasonography could not be able to demonstrate appendicitis. No complications occurred during operative period. The mean operating time of SPTLA performed successfully was 52.1±11.7 min and the mean post-operative hospitalization period was 3.7±1.1 days. One early postoperative complication (suppuration of the umbilical wound) with no major complications were observed.

Conclusion: SPTLA surgery is a feasible and safe approach especially for uncomplicated appendicitis visualized by ultrasonography.

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PP6: Anatomy and pathologies of inguinal and lower abdominal wall regions determined by laparoscopic exploration

B Tokar, MS Arda, H İlhan, D Demet Dereli and A Topaloğlu

Department of Pediatric Surgery, Eskişehir Osmangazi University, School of Medicine, Eskisehir, Turkey

Aim: In pediatric surgery, to know the anatomy of inguinal and lower abdominal wall region with their neighboring structures provides a better orientation to the region during surgery and prevents possible complications. In this study, the videos of laparoscopic exploration of this region were retrospectively evaluated. Anatomy of these structures and relation of this anatomy to the pathologies were investigated.

Methods and results: Video records of laparoscopic exploration of this specific region in 124 children with an age range of 3 days to 17 years were included into the study. Anatomic structures and pathologic findings of the region determined by laparoscopic exploration, such as inguinal hernias, hydrocele extending to the retroperitoneal area, intraabdominal testis, varicocele, other congenital inguinal and lower abdominal wall defects were evaluated. In videos showing the anatomy of inguinal and lower abdominal wall region, normal anatomic appearance of these structures and relation of this anatomy to the pathologies were investigated. In differential diagnosis of confusing cases, especially for nonpalpable testis, laparoscopic exploration of the region contributed significantly in diagnosis and planning of the treatment. This presentation shows the normal anatomy and specific anatomical changes determined in the pathologies of the region.

Conclusion: To know the intraabdominal anatomy of inguinal and lower abdominal wall regions with their neighboring structures provides a better preoperative planning and operative decision making.

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PP7: Evolution of laparoscopic surgery in a Training and Research Hospital

T Özdemir, A Arikan, HN Özer, A Sayan and M Can

Department of Pediatric Surgery, Tepecik Training and Research Hospital, Izmir

Aim: Laparoscopic procedures are gaining wide acceptance in pediatric surgery. In this study we evaluated the chronologic evolution of laparoscopic procedures in our clinic.

Patients and methods: Between 2007 and 2011 146 various laparoscopic procedures were performed. Types of procedures were evaluated retrospectively regarding to years.

Results: In 2007–2008 period, laparoscopic procedures were limited in diagnostic procedures as ambiguous genitalia, nonpalpable testes. During 2008–2009, laparoscopic appendectomies, ovarian cyst excisions/oopherectomies, renal cyst excisions were additionally performed. After 2009, advanced procedures as cholecystectomy and funduplications were begun to be performed.

Conclusion: Diagnostic laparoscopic procedures are the best choices for the learning period of laparoscopy. Appendectomy and simple ovarian surgical procedures can be performed subsequently. Advanced procedures like funduplication and cholecystectomy must be tried after the ‘learning period’.

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PP8: Pulmonary contusion in children

A Sayan, A Arikan, T Özdemir, FN Narli, HN Özer, M Can, H Turan and A Karagözoğlu

Tepecik Educational and Research Hospital Clinic of Pediatric Surgery, Yenisehir, Izmir

Aim: In children, pulmonary contusions due to blunt chest trauma and is seen as an important cause of mortality is conjunction with other system injuries. Admitted to our clinic because of general body trauma and lung contusion patients presenting lesions are essential.

Materials and methods: Between 1995–2011 in our clinic cranial, spinal and orthopedic trauma, 982 patients admitted for trauma are the primary there. 236 patients diagnosed with lung injury in 79 male, 48 female patients with lung contusion were reviewed retrospectively. Patients routine blood, urine examination, plain radiographs, ultrasonography, computed tomography of lung contusion was seen during such investigations and close monitoring of patients were taken to the intensive care conditions.

Findings: Of the patients 98 (77.2%) or non-vehicle traffic accident in 29 (22.8%) were caused by falls from height, or other causes. Only patients with isolated pulmonary contusion in 8 (6.3%) were seen, in others, and other system injuries associated with intra-abdominal organ injuries were determined. Close monitoring of the patients after trauma, including 17 two-sided pneumothorax and hemothorax in 36, then developed and applied to tube thoracostomy. Widespread bilateral lung contusion with severe trauma suffered by other systems apart from other patients, 12 patients need lung ventilation unheard of treatment, or 8 of these patients died. Patients recovered smoothly after lung contusion.

Result: In children, pulmonary contusion as a result of blunt chest trauma is seen frequently. General body trauma patients presented with pulmonary contusion should be considered at any time and the investigation quickly, but not affected by any other system, the centers of monitoring conditions in the intensive care of patients with pulmonary contusion is thought to be necessary.

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PP9: Management of tracheobronchial tree injuries

M Günaydina, B Tandera, BD Demirela, Ü Bicakcia, Ş Paksub, N Aşilioğlub, A Başoğluc, R Rizalara, E Aritürka and F Bernaya

Departments of aPediatric Surgery, bPediatrics and cThoracic Surgery, Ondokuz Mayis University, Faculty of Medicine, Samsun, Turkey

Aim: Injuries on tracheobronchial tree(TBT) in children are rare, but their mortality is high. We aimed to evaluatethe children with TBT injuries treated in our department.

Materials and methods: Between 2009 and2011, four cases with TBT injuries aged between 2 and 16(2 F,2M) were treated. The outcome parameters were age, type of injuries, clinical follow up, methods of diagnosis and treatment. All patients had PA and lateral chest X-ray and chest CT.

Results: Three patients had traffic acccident an done had an inhalation injury. In three cases, bone fractures at chest and subcutaneous emphysema on the chest wall were accompaning to the TBT injury. One patient underwent early thoracatomy and primary repair, two others had delayed primary repair. One patient with inhalation injury needed conservative with management endotracheal intubation only. Before thoracatomy, a rigid bronchoscopy has been utilized. Three patients had a complete healing. One 16 years old boy with delayed primary repair needed to undergo a lung resection inspite of a tracheobronchial stent application.

Conclusion: Early management in TBT injuries has a critical importance. Early primary repair of injuried bronchus and lower age may provide a better prognosis.

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PP10: Thoracoscopic approach to posterior mediastinal masses

U Ateş, G Küçük, G Göllü and A Yağmurlu

Department of Pediatric Surgery, Ankara University School of Medicine

Aim: The aim is to present the experience on thoracoscopic surgery in posterior mediastinal masses.

Patients and methods: A retrospective chart review of five patients with posterior mediastinal mass who were planned to undergo thoracoscopic surgery was performed. Demographic data, complains, location and dimensions of the mass, presence of Neuron specific enolase (NSE) positivity, operating time, feeding time, time of chest tube removal postoperatively presence of intraoperative and postoperative complications and histopathological results were evaluated.

Results: Three of the patients were male and two were female who had chest pain (n=3), coughing (n=2), dyspnea (n=1) and weight loss (n=1) between the years 2009–2011. Median age was 10 (8 months–10 years). The masses were 40–75 mm (mean of 45 mm) in diameter in computer tomography. NSE was above normal in two patients. The surgery was begun thoracoscopically in all patints. Mean of operating time was 130 min (95–210 min). The surgery was converted to thoracotomy in one patient because of excessive adhesions. The paitents were fed on postoperative first day and the mean of chest tube removal was 5 days (3–8 days). Histopathological examination revealed neuroblastoma in two patients whose NSE were above normal, leiomyoma, lymphangioma and schwannoma. The patients had no complication postoperatively in their follow-ups.

Conclusion:Thoracoscopy is safe and feasible in total excision of posterior mediastinal masses when performed by experienced pediatric surgeons on minimally invasive surgery.

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PP11: Our experience of Morgagni hernia in children

A Abilova, Ş Emrea, Özcana, S Kuruoğlub, G Topuzlu Tekanta, N Sarimurata and E Erdoğana

Departments of aPediatric Surgery and bRadiology, Istanbul University Cerrahpasa Medical Faculty, Istanbul

Aim: Presentation our experiencewith cases Morgagni hernia between 1980–2011.

Materials and methods: Records of 25 patientstreated between 1980–2011 were evaluated retrospectively.

Signs: 19 of 25 patients was maleand 6were girls. The averageapplicationtime 33 months (1 month–16 years).

14 of patients presented with upperrespiratorytractinfection, 4 inthe lowerrespiratorytractinfection, 4 in respiratorydistress,1 in hepatosplenomegaly. Diagnosis was made with thorax CT in 11 patients, with X-ray opaque enema in 5 patients, with AC X-ray in 1 patient, with thorax CT and confirmed by X-ray opaque enema in 8 patients. Downsyndrome in 2 patients, 1 patient with Marfan syndrome, 1 case of atypical facial appearance, cardiac abnormalities seen in 2 patients was additional abnormalities. 4 patientswas done primary repair with laparoscopically, 21 patients with laparotomy. 3 patient was found bilateral, 1 patient left, in others right Morgagni hernia. Open surgical repair in those hospital stay an average of 12 days (2 days–6 months), while the cases undergoing laparoscopic repair lenght of hospital stay was 2 days. İn one patient during the operation due to the difficulty of intubation was opened tracheostomy andtracheostomy closed after 6 months of follow-up was discharged from the intensive care unit. Hernia recurrence was detected in 1 patient because of respiratory distress after the operation and repair of laparotomy was performed again.

Results: Morgagnihernia often progressess with respiratory problems, should be taken care before and after operation. ansabdominal approach is a safe and effective method for Morgagni hernia repair. Laparoscopicapproach significantly reduces the duration of hospital stay.

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PP12: The risk factors for morbidity and mortality in newborns with pneumothorax requiring tube thoracostomy

N Gülçin, A Cerrah Celayir and İ Cici

Department of the Pediatric Surgery, Zeynep Kamil Women and Child Deseases Education and Research Hospital, Istanbul

Background/aim: The aim of this studywas designed to determine risk factors affecting mortality and morbidity in newborns with pnuemothorax treated by tube torakostomy in neonatal intensive care units of our hospital.

Material/method: Between January 2005 and January 2011, 55 newborns (23 Female/32 Male) with pneumothorax, who were treated with tube thoracostomy in NICU's, were analysed retrospectively. The patients were evaluated in regard toage, demographic characteristics, associated with primary lung disease, the presence of additional abnormalities, pneumothorax side, the ventilation requirement, drainage duration, hospitalisation and mortality rates.

Results: Pneumothorax requiring drainage detected in 55 cases, of this 23 female, and 32 male; and mean age of diagnosis was 3.31 days. The main symptoms were respiratory distress, takipnea and syanosis. 41patients were premature ranged from 24 weeks to 36 weeks. 14 patientswere born at 37 gestational weeks. Postmature patient was not available. 61% had right, 33% had left, 6% had bilateral pneumothorax. 29 patients had primary pulmonary disease. 20 patients had additional abnormalities. While 41 patients had needed ventilation before tube thoracostomy, 40 patients had needed the ventilator after tube thoracostomy. Fonetik olarak okuyu Sözlük - Ayrintili sözlüğü görüntüle. The mean duration of drainage was 7.16 days in 15 patients recovered with healing, 40 patients died and the mean duration of drainage was 5.1 days. 3 patients with bilateral pneumothorax had died. Mean hospitalisation was 15.5 days in patients whorecovered, and 12 days in patient who died.

Conclusion: The prematurity, underlying primary lung disease and mechanical ventilation are predisposing factors for the development of the pneumothorax. Neonatal Pneumothorax has high mortality rate. Early diagnosis and treatment of pneumothorax is important in reducing mortality. Pneumothoraxshould be ruled out in newborn with mechanical ventilation if overall situation of newborn breaks down suddenly.

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PP13: Tracheobronchial foreign body aspirations

M Çağlar, Ç Ulukaya Durakbaşa, H Okur, HM Mutuş, M Korkmaz, A Kaymakçi, M Sert, MA Özen and A Baş

Department of Pediatric Surgery, S.B. Göztepe Training and Research Hospiatl, Istanbul

Introduction: Foreign body (FB) aspiration (FBA) is more commonly seen in infants and young children. It is a dangerous and potentially fatal situation for which emergency inetrvention is required. This presentation aims to evaluate those children suspected of having FBA in terms of presenting complaints and findings, ages, the type of the FB aspirated and the success of intervention.

Materials and methods: A retrospective analysis of rigid bronchoscopies done for suspected FBA was analyzed through patient files.

Results: There were 51 children with a median age of 1 (5 months–14 years) year who underwent 55 bronchoscopic examinations for suspected FBA. There were 25 males and 26 females. The presenting complaint was sudden onset of cough and choking during feeding, choking right after a FB is put into the mouth or persistent cough and wheezing without a FBA history. Direct radiographies (PAR) were available in 45 cases fort his study. It was normal in 12 (27%), showed unilateral hyperaeration in 28 (62%), infiltration in 3 (7%) and atelectasis in 2 (4%). There was solid mass image at the right uper obe localization in one of the patients with atelectasis. Bronchoscopy revealed needle in 4, dried seeds/fruit in 4, paper pin in one and no FB in 3 among those patients with normal PAR. Among 28 patients with hyperaeration, 25 was found to have FBA. There was no history for FBA in two of these. A FB was detected in 2 out of 3 patients with atelectasis. A scheduled surgery was planned for one of these having solid mass image. In total, a FB was detected in 41 (80%) of children who underwent bronchoscopy. The FB was located in right bronchial tree in 24, left bronchial tree in 11, trachea in 3 and both bronchial trees in 3. The extracted FB were dried seeds/fruit in 26, needle in 4, carrots in 3, other foods in 3, mini bulb in 1, paper pin in 1, pencil lead in 1 and pen cap in 1. The FB (needle) could not be extracted in one although it was visualized. She underwent open surgery. Right middle lobe bronchus was injured in one patient during bronchoscopy and a primary repair was done by thoracotomy. Severe respiratory distress developing after bronchoscopy necessitated mechanical ventilation in one. A second look bronchoscopy was done in 4 patients at the same admission because of suspected FB remnants and retained FBs were extracted in 3 of these. There were no mortalities.

Conclusion: FBA in children requires urgent action. The intervention is difficult, requires expertise and risky. The awareness of parents about these facts is utmost importance because majority of aspirated FBs are dried seeds/fruits. Bronchoscopic evaluation should be done in all children having suggested findings like cough and choking during feeding even if the PAR is normal. Moreover, persistent cough and wheezing should raise the suspicion for FBA, especially if the physical and PAR findings are suggestive.

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PP14: Children with diafragmatic hernia: an 11-year experience at a single-center

Yalçin O, Oral A, Yiğiter M, Zeytun H, Dikmen T and Salman AB

Department of Pediatric Surgery. Ataturk Univercity, Faculty of Medicine, Erzurum, Turkey

Aim: Diafragmatic hernia is herniation of the abdominal contents to the thorax. In this study, we analyzed the clinical, radiologic, and prognostic findings of patients who were treated at our clinic due to diafragmatic hernia within the past 11 years.

Methods: We retrospectively reviewed the medical records of 72 patients treated for diafragmatic hernia between November 1999 and December 2010. Sex, age at diagnosis, weight, associated anomalies, radiologic findings, hernia type, hernia sac, herniated contents, operation performed, complications and postoperative outcomes were analyzed.

Results: Male/female ratio was 50/22. Minimum age was 1 day and maximum age was 12 years. The weight of the patients ranged from 1100 grams to 30 kilograms. 30 patients (41.7%) had cardiac anomaly, 2 patients (2.8%) had urinary system anomaly, 1 patient (1.4%) had ITP and 1 patient (1.4%) had thrombocytopenia. 1 patient (1.4%) had hypothyroidism, 4 patients (5.6%) had Down syndrome of which one of them also had pectus excavatum deformity. For diagnostic purposes, all patients had a plain chest X-ray, 50 (69.4%) patients had contrast enema, 3 (4.2%) patients had upper gastrointestinal contrast study and 14 patients (19.4%) had tomography. In addition, 1 (1.4%) patient had a fluoroscopy and 1 (1.4%) patient had an ultrasonography. As for the types of hernia, 40 (55.6%) patients had bochdalec, 27 (37.5%) patients had morgagni and 5 (6.9%) patients had diafragmatic hernia covering the left portion of the diafragm that did not include the anterior and posterior rims. Hernia sac was present in 39 (54.2%) patients. Corrective operations consisted of primary repair in 67 patients (93.1%) and prosthetic patch repair in 5 patients (%6.9). 61 patients (84.7%) had a hernia in colon, 55 patients (76.4%) in low bowel, 25 patients (34.7%) in stomach, 28 patients (38.9%) in spleen, 22 patients (30.6%) in liver, 8 patients (11.1%) in kidney and 1 patient (1.4%) in pancreas. 30 patients needed mechanical ventilation. Mean mechanical ventilation time was 8.3±11.65 (Min:1, Max:59) days. Mean length of stay in the hospital after operation was 8.6±8.9 (Min:1, Max:59) days. Complications included pnomotoraks in 7 patients (9.7%) and laceration of the liver in 1 patient (1.4%). 15 (20.8%) patients died. Of those who died, 11 patients (73.3%) had cardiovascular anomalies (9 patients diagnosed with pulmonary hypertension, 1 patient with tricuspid valve regurgitation and 1 patient with a large PDA) and 1 patient (1.4%) had a urinary anomaly. 2 patients (13.3%) died of sepsis. Magnesium sulphate, ilioprost; an anologue of prostacyclin (PGI2), nitric oxide (NO) and dopamine were used for the treatment of pulmonary hypertension. 9 of the 12 patients with pulmonary hypertension died (P<0.01). There was no statistically significant difference between age and mortality (p:0.493), sex and mortality (p:0.127), weight and mortality (p:0.537) and age of operation and mortality (p:0.537).

Conclusion: Although the available literature states that diafragmatic hernia occurs more often in females than males, we found that this type of hernia was more prevalent in males (69.4%) in our sample. 9 of the 12 patients with pulmonary hypertension died and this seems to show a serious relationship between pulmonary hypertension and mortality in patients with diafragmatic hernia.

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PP15: Evaluation of our esophageal atresia cases: an experience for 20 years

A Bilirim, M Yurtçu, E Günel and A Abasiyanik

Department of Pediatric Surgery, Selcuk University, Meram Medical Faculty, Konya-Turkey

Aim: This study aimed to reveal the problems and progresses observed in the newborns with esophageal atresia treated in our department.

Materials and methods: The study population consisted of 118 newborns with esophageal atresia treated during the last 20 years retrospectively. Patients were divided into 2 groups as Group I (1991–1998) and Group II (1999–2010) according to the years of diagnosis. All patients were assessed regarding the prenatal history, time of surgery, anomalies, complications, and mortality rates.

Results: The mean weight of the cases was 1960±5.35 g. 75% of deliveries was performed in hospital and 25% at home. 85% of the babies was in term and 15% was preterm. Polyhydramnios story was detected in 55% of babies. The mean admittion time of the cases was 5.9±1.42 days. The associated anomaly rate was 39%. Patients in group I were operated immediately, and the ones in group II were operated in elective conditions. Primary repair and end-to-end anastomosis were carried out. The most common intraoperative complication was iatrogenic pleural opening. The most common early period postoperative complications were pneumonia and atelectesia; late complication was gastroesophageal reflux. Overall mortality was 56% and this rate was 76% for group I and 45% for group II (P=0.001). Respiratory insufficiency, pneumonia, and anastomotic leakage were the most common causes of mortality.

Conclusions: Our study showed that corrected intensive care conditions and the developments in surgical techniques decreased preoperative and postoperative complications and mortality rates in esophageal atresia.

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PP16: Beneficial effect of glutamine for corrosive esophagitis in children

OA Arslan, V Erikçi, B Uçan, C Öztürk, Ö Okur, M Yildiz, A Dursun, N Aksoy and M Hoşgör

Dr. Behçet Uz Children's Diseases and Surgery Education and Research Hospital, Izmir

Introduction: Accidental ingestion of caustic substances in children can lead to weight loss and malnutrition due to dysphagia and stricture formation. The amino acid glutamine is depleted in hypermetabolic states as trauma, burns and major surgery. Oral supplamental glutamine was administered to selected patients with advanced-grade corrosive esophagitis for nutritional support. Except one, patients had no stricture formation or dysphagia. We report these unexpected results in patients with advanced corrosive esophagitis after oral glutamine supplamentation therapy.

Materials and methods: Between March and October 2010, 55 patients with caustic ingestion were admitted. All patients underwent diagnostic endoscopy within 24 h with flexible video-esophagoscope. Among them, 10 patients (18%), 5 male/5 female, age range 1.5–15 years had grade 2A (2), grade 2B (3), grade 3 (5) corrosive esophagitis. Enteral nutrition was started after 24 h in all patients. 10 patients additionally received L-glutamine 0.5 mg/kg/day, orally in water or juice during meals. 3 weeks after caustic exposure, 10 patients had contrast esophagography.

Main results: One of ten patients with grade 2B corrosive esophagitis had swallowing difficulty although his esophagography was reported as normal. 26 days after ingestion, endoscopy and dilatation with semirigid dilators were performed. During endoscopy, complete mucosal healing was observed, there was no stricture formation. However, 3 weeks after another endoscopic dilatation was repeated because of swallowing difficulty. After second endoscopic dilatation, dysphagia was resolved completely and no further dilatation was necessary. Other patients had no difficulty in swallowing and their esophagographic examination did not show any stricture formation during follow-up.

Conclusion: Although the number of the patients in this report is small, oral glutamine supplamentation therapy may have contributed to these unexpectedly good results. Further studies are needed to clear the role of glutamine supplamentation in advanced-grade corrosive esophagitis to enhance mucosal healing and prevent stricture formation and dysphagia.

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PP17: Esophageal foreign bodies in children

HM Mutuş, Ç Ulukaya Durakbaşa, A Bayar, M Çağlar, M Korkmaz, M Sert and H Okur

Department of Pediatric Surgery, MOH Istanbul Goztepe Training and Research Hospital

Aim: Esophageal foreign body (FB) impaction is a common pediatric emergency. This study aimed to analyze the characteristics of ingested material and patients as well as management.

Materials and methods: A retrospective analysis of patient records was done for the years 2007–2010 inclusive.

Results: There were 73 patients with esophageal FB. Forty-two (57.5%) were boys and 31 (42.5%) girls. The median age was 28 months (5 months–14 years). Five patients (6.8%) were below 12 months, 39 (53%) were between 12 and 36 months, 10 (13.7%) were between 36 and 60 months, and the remaining 19 (26%) were older than 60 months of age. The diagnosis was done by history and chest X-ray. The FB was dislodged at the level of aortic arch in 54 (74%), mid-esophagus in 11 (15.1%), distal esophagus in 7 (9.5%), and pharynx in one (1.4%). All interventions were done under general anesthesia. FB were extracted by rigid esophagoscopy in 36 (49.3%) patients, by Magyll forceps in 17 (23.3%), by Foley catheter in 19 (26%), and by flexible esophagoscopy in one (1.4%). The ingested objects were coins in 60 (82.2%) cases, round batteries in 3 (4.1%), various objects like hair pins, safety-pins or magnets in 9 (12.3%), and chicken bone in one. There were no perioperative complications.

Discussion: Most FB ingestions occur between the ages of 1 and 3 years. Esophageal FB can be extracted using various surgical techniques ranging from simple extraction by forceps to esophagoscopy. The surgeon should not only be familiar with all these techniques but also have all necessary equipment ready at hand including a facility which can provide general anesthesia as needed.

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PP18: The use of a self- expanding absorbable stent in treating childhood caustic esophageal injuries: a preliminary report

I Sürer, C Atabek, W Padshah, B Çalişkan and B Altan

Gulhane Military Medical Academy

Esophageal stenting is a popular form of treatment of benign caustic esophageal injuries in our country. The aim of the study was to investigate effectiveness of the self expanding absorbable stenting in caustic esophageal injuries in children.

Materials and methods: Absorbable polyglycolicacid stents were placed in 4 children with corrosive esophageal injuries under general anesthesia after long term teflon rigid stenting.

Results: The stents were placed and stayed in all patients with no complication. After stenting oral intake was not allowed for 1 week then all patients could take semi-solid or solid foods with no dysphagia. Stent location control was performed by X-ray for first 3 months at monthly basis then bi-monthly.

Conclusion: The use of this absorbable stenting is an effective and safe method in treating childhood corrosive esophageal injuries.

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PP19: The value of pediatric appendicitis score and laboratory findings on the diagnosis of pediatric appendicitis

İS Tuncer, İ Karaman, A Karaman, İF Özgüner, YH Çavuşoğlu, E Yilmaz, ÇE Afşarlar, HA Maden and D Erdoğan

Department of Pediatric Surgery, Dr. Sami Ulus Children's Hospital, Ankara

Introduction/aim: Pediatric appendicitis score (PAS) is a scoring system which is improved to simplify the diagnosis of appendicitis in children. In this article it is aimed to investigate the efficiency of PAS and additional laboratory data in diagnosing appendicitis.

Materials and methods: Between 1st January 2010 and 31st December 2010, patients admitted to our department that are followed up and treated with an initial diagnosis of acute abdomen were reviewed retrospectively. Patients which were operated and histopathological examination confirmed the diagnosis appendicitis is defined as 1st group, and the patients with negative exploration and the ones that are non-operated are defined as 2nd group. Groups are compared in terms of demographic data, hospitalization time, PAS and laboratory data.

Results: A total of 562 patients (321 male, 241 female) with an initial diagnosis of acute abdomen are admitted to our department in the one-year period. There were 350 patients (224 acute, 126 complicated appendicitis) in the 1st group, and 212 patients (31 negative exploration, 181 follow-up) in the 2nd group. While the preoperative hospitalization time between the acute and complicated cases did not have significant difference (P>0.05), complicated cases had a long postoperative hospitalization time (P<0.001). PAS had significant difference between the acute, complicated and negative explorations (P<0.001). PAS was increased proportional to the severity of the appendicitis (P<0.001). White blood cell count, neutrophile count, neutrophile percentage, neutrophile/lymphocyte (N/L) ratio, and C-reactive protein (CRP) rates were significantly higher in the appendicitis group (P<0.001). The PAS components of fever (in the 1st group 29.1%) and the migration of pain to right-lower quadrant (in the 1st group 6.2%) had at least contribution to the scoring. Instead, the usage of N/L (81% higher in the 1st group) and CRP (76% higher in the 1st group) values increases the sensitivity of the score from 88.6 to 91.1% in diagnosing appendicitis.

Conclusion: Addition of the N/L ratio and CRP vales may increase the diagnostic ability of the PAS which is composed of clinical and laboratory indications.

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PP20: The reliability of clinical and laboratory and radiologic findings in diagnosis of childhood apendicitis

G Kurt, A Cerrah Celayir and C Şahin

Zeynep Kamil Women and Child Deseases Education and Department of Pediatric Surgery, Research Hospital, İstanbul

Introduction/aim: ‘Is there a way to reduce perforated apendicitis, without increasing negative appendectomy’ in order to find answer the question, this study was designed in diagnosis of the childhood apendicitis to determine the effectivity of the findings of clinical examination, results of the laboratory and radiologic investigements.

Materials and methods: Between April 2007 and April 2010, 864 patients with suspected surgical acute abdomen admited to our clinic. We designed to evaluate physical examination findings, laboratory and radiological tests and pathological findings as prospectively.

Results: 864 patients were devided into 4 groups.1) Nonsurgical abdomen pain, 2) Negative apendectomy group, 3) Acute apendicitis group and 4) Perforated apendicitis Group. Female to male ratio was 1/2.15 in all apendicitis group. The duration of symptoms was 2.68 days for prescholl childeren (less than 6 years of age) and 1.79 days for elder childeren. Percentage of perforation under the age of 6 was 50 and 20.2% for elder childeren. Vomiting, abdominal pain, tenderness, rigitidy and rebound were significantly higher in apendicitis group. Between 4 groups; leukocytes, neutrophils, fibrinogen and CRP levels were significantly different. Leukocyte and Neutrophil percentages were similar in under the age of 6 and more than 6. Under the age of 6, the levels of fibrinogen and neutrophill were significantly high. Only 35.2% of apendicitis cases had positive signs in X-ray radiogram. The radiogram was valuable for prescholl childeren. The correct diagnosis rate was 60.7% with US. The specifity was 76.9%, false positive ratio was 23%, positive predictive value was 91.3% and negative predictive value was 32.6% for US. There was no significant difference according to age for US.

Conclusion: Despite the increasing technological opportunities, the ratio of perforation in patients with acute apendicities, had increased. On the other hand negative apendectomy rates tend to decline. We need some new algoritms for evaluation of acute abdomen insteated of new diagnostical studies.

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PP21: What is the diagnostic value of neutrophil/lymphocyte ratio in childhood abdominal pain?

L Elemena, K Topçub, G Ekingena, K Karaoğlua and D Oruçc

aDepartment of Pediatric Surgery Kocaeli University Medical Faculty bDepartment of Pediatric Surgery Turkish Ministry of Health Gebze Farabi Research and Training Hospital and cDüzce University Health School

Background: The evaluation of the abdominal pain in children is usually influenced by the way of expressing the pain by the patients, anatomical differences and the divergences of the pain characteristics. Recently neutrophil/lymphocyte ratio was reported to be valuable in the diagnosis of acute appendicitis. This study was designed to test the efficiency of neutrophil/lymphocyte ratio compared with total leukocyte count, CRP and sedimentation.

Patients and methods: Between January 2005 and 2011, 266 patients with abdominal pain and who were admitted to pediatric surgery clinics were retrospectively evaluated according to age, sex and the cause of the abdominal pain. The patients were grouped into 3. The patients with acute appendicitis were taken in group 1 (n=108), complicated appendicitis in group 2 (n=82) and the patients with mesenteric lymphadenitis were taken in group 2 (n=76). The values of neutrophil/lymphocyte ratio, total leukocyte count, CRP and sedimentation were collected from the computerized database of our hospital. The data were expressed as mean±standard deviation and analyses were performed with Students-T, One-way ANOVA and Dunnett tests; and the p was considered as significant at <0.05.

Results: Two-hundred and sixty-six patients were included in the study (Male: 155, female: 111). The age distribution of the patients was 9.81±4.07 years. All groups were comparable according to sex and age distributions. Evaluation of CRP in group 1 (4.01±5.32 mg/l) group 2 (8.15±8.12 mg/l) and group 3 (2.84±4.38 mg/l) (P<0.05) revealed a significant difference. Also total leukocyte count differed significantly with values, group 1 (14.59±5.07/mm3), group 2 (17.49±6.18/mm3) and group 3 (12.45±4.22 /mm3) (P<0.05). Sedimentation values in group 1 (22.81±17.04 mm/h), group 2 (41.62±27.14 mm/h) and group 3 (12.05±14.17 mm/h) (P<0.05) were significantly different. Comparison of neutrophil/lymphocyte ratiorevealed a significant difference between group 1 (8.19±7.89), group 2 (10.97±7.71) and group 3 (6.70±5.42) (P<0.05). The diagnostic significance of CRP values in group 1 versus 2 was differrent (P<0.05), but group 1 versus 3 was not different (P=0.33). The diagnostic significance of total leukocyte count in group 1 versus 2 (P=0.002), group 1 versus 3 (P=0.007) and group 2 versus 3 (P=0.000) were significant. Similarly, the diagnostic significance of sedimentation in group 1 versus 2. (P=0.000), group 1 versus 3 (P=0.000) and group 2 versus 3 (P=0.000) were different. The diagnostic value of neutrophil/lymphocyte ratio in group 1 versus 3 was not significant (P=0.28), while group 1 versus 2 (P=0.047) and group 2 versus 3 were significant (P=0.000).

Discussion: Despite the recent medical literature advocating that the neutrophil/lymphocyte ratio would be more valuable in discrimination of appendicitis from the non-surgical causes of abdominal pain, our results indicate that only total leukocyte count and sedimentation values differed significantly between the groups. We believe that, biochemical paramaters can only be used adjunct to the physical examination in childhood abdominal pain.

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PP22: Is blood serum amiloid a level helpful in diagnosis of childhood appendicitis?

A Akay, G Ekingen and L Elemen

Department of Pediatric Surgery Kocaeli University Medical Faculty

Aim: To evaluate the predictive value of serum amiloid A (SAA) in childhood abdominal pain compared with sedimentation and total leukocyte count.

Materials and methods: Between January 2010 and 2011 the patients, who admitted with acute abdominal signs were included in the study and grouped into 3. Group 1 contained the patients with acute appendicitis and taken to operation. Group 2 contained the patients who admitted with acute abdominal signs and observed non-operatively. Group 3 contained the patients admitted to the emergency service with the syptoms other than related to abdominal pain. Blood samples for evaluation of SAA, sedimentation and total leukocyte count were collected on admission from all patients. In Group 1, the blood samples were collected soon after the operation and on the post-operative 24th hour. In Group 2, the same tests were made similtaneously after and on the 24th hour of admission. The statistical analyes were performed with One-way ANOVA and post-hoc Tukey tests. The data were presented as mean±standard deviation. P was significant at <0.05.

Results: Each group contained 23 patients. The sex and age distrubution of the groups were similar. Evaluation of SAA values revealed a significant difference between the groups with the values; Group: 1 935219.0±169387.3 mg/l, Grup 2: 235691.3±133271.4 mg/l and Grup C: 308615.7±280936.7 mg/l (P<0.000). Statistical comparison of total leukocyte count in Group 1 (16223.0±5072.7×103/μl), Group 2 (13333.0±7900.4×103/μl) and Group 3 (13304.3±4448.6×103/μl) were comparable (P=0.17). The comparison of sedimentation in Group 1 (17.69±11.68 mm/h), Group 2 (16.08±12.58 mm/h) and Group 3 (10.95±12.36 mm/h) were also comparable (P=0.15).

Discussion: We believe that blood SAA measurement is more predictive than total leukocyte count and sedimentation in presumption of surgery in childhood abdominal pain. These results need to be evaluated with further studies.

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PP23: Management of gallstone disease in childhood

SS Ezera, P Oğuzkurta, E İncea, A Temiza, B. Özerb and A Hiçsönmeza

aDepartment of Pediatric Surgery and bGastroenterology, Başkent University Faculty of Medicine Ankara, Türkiye

Aim: The aim of our study is to report our experience in management ofgallstone diseases (GD).

Materials and methods: 70 patients who were operated for biliary tract stones between April 2000 and December 2010 were evaluated for demographic data, symptoms, etiological factors, imaging methods, treatment modalities and outcome, retrospectively.

Results: Mean age was 9.8 years (0.5–16). There were 30 boys and 40 girls. 30 patients had a history of recurrent abdominal pain while 3 had acute cholecystitis, 5 had a history of jaundice, and 14 had a history of ceftriaxone therapy. 32 patients had hematological disease. In all patients ultrasonography was the initial examination. 2 patients had choledochal dilatation. 8 patients had dilatation of intra and extrahepatic bile ducts. 11 patients had cholecysto-choledochal stones and the remaining patients had gall bladder stones. Magnetic resonance cholangiopancreatography (MRCP) was used in 6 patients. Two patients had gallstone-induced pancreatitis. 10 patients underwent stone extirpation via endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomybefore surgical intervention. 24 open and 46 laparoscopic cholecytectomies were done. Hepaticojejunostomy was done in one patient because of severe distal choledochal stenosis. Mean hospitalization time was 3.4±5.4 days.

Discussion: GDs are increasingly being diagnosed in childhood in recent years; mainly due to wide spread use of ultrasound. Although gall stones are mainly reported to be idiopathic, they may be related to antibiotic use, hematological disease and parasitosis. MRCP should be used as a valuable imaging method to evaluate biliary system. ERCP if available should be performed before surgery for choledochal stones to avoid surgical complications during chlecystectomy.

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PP24: Traumatic brain injury among Greek children

E Rachmani, C Panteli, T Feidantsis, P Saravakos, T Rarri and A Zavitsanakis

Aristotle University of Thessaloniki, 1st Department of Paediatric Surgery, ‘G. Gennimatas’ Hospital, Thessaloniki, Greece

Aim: Traumatic brain injury (TBI) is the commonest type of paediatric trauma. The aim of this study is to estimate the incidence and demographics of TBI in children visiting the Emergency Department and describe further management.

Methods: The case notes of all children up to 14 years of age who were treated at the Emergency Department in the year 2009, after sustaining a TBI were studied retrospectively. Demographics, mechanism and site of injury, associated injuries, diagnostic workup, patient disposition and follow up arrangements were recorded. Simple descriptive statistics were used to summarise the data.

Results: Out of 6872 paediatric visits to the Emergency Department 2370 children with TBI were seen within the 12-month period. Of those, 64% were boys. Children between 1 and 5 years of age were more susceptible to TBI (48%). The predominant causes of injury were falls (69%) followed by road traffic accidents (17%). Two hundred and sixty nine children (11%) were admitted for observation; of those, 19% had a CT. All children who had been hospitalised received a follow up appointment.

Conclusion: Visits due to TBI represent a significant proportion of the Emergency Department caseload. Better understanding of the epidemiology of paediatric TBI is important for raising public awareness and implementing prevention measures as well as for educating health professionals and improving structured assessment and management.

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PP25: Laparoscopic cholecystectomy in children

H Akpinar, C Köse, U Ateş, G Göllü and A Yağmurlu

Department of Pediatric Surgery, Ankara University School of Medicine

Purpose: Laparoscopic cholecystectomy is a common surgical operation performed by adult surgeons. Even though there are several training cases bile duct pathology is less encountered among the pediatric patients compared to adult population. Accordingly, the aim of this study is to present the cases operated Laparoscopic cholecystectomy related to bile duct pathology.

Patients and methods: The files of the patients that had been operated laparoscopic cholecystectomy were elaborated backwards. The cases were evaluated in terms of demographic data, indications, operation time, comorbidity, time of hospital stay and complications.

Results: Fifty patients included 25 boys and 25 girls. Median age was 12 (3–17). 44 of children had gallstone (hereditary spherositozis (n=8), Wiscott Aldrich syndrome (n=2), Sickle cell anemia (n=2), Wilson disease (n=1), Idiopathic trombocytopenic purpura (n=1), other (n=30)), polip (n=4), (n=1), acalculozis cholesystitis (n=1). Mean operation time was 65 min (20–120). At ten patients splenectomy, at one patient Nissen fundoplication, at one patient orchydopecsy and circumcision performed concomitantly. No complications were encountered neither during operation nor post operatively.

Conclusion: All of the pediatric surgents who are familiar with the minimal invasive surgery shall aim to perform enough laparoscopic cholecystectomy and eventually prevent the children population being operated by the adult surgeons.

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PP26: Thyroid surgery in childhood: our 5-years' experience

S Demirezena, G Karagüzela, N Arslana, S Akçurinb, İ Bircanb and M Melikoğlua

Departments of Pediatric Surgerya, and Pediatricsb, Akdeniz University School of Medicine, Antalya, Turkey

Background/aim: Surgical procedures directed to thyroid gland are performed relatively infrequent. In this study, we aimed to evaluate our patients which were undergone thyroidectomy.

Patients and methods: Eleven patients who were performed thyroid surgery during last 5 years were retrospectively reviewed. Surgical indication was established by multidisciplanary approah. Patient's files were searched for demographic/clinical features, labrotory tests (T3, T4, TSH, thyroglobuline), imaging methods (ultrasonography, scintigraphy), fine needle aspiration biopsy (FNAB), surgical technique, histopathology, follow-up and morbidity (hospital stay, complications).

Results: Seven patients were girl and four were boy. Patient's age ranged 6 to 18 years. The most common symptom was servical mass (5/11), others included hypo/hyperthyroidism related symptoms. Thyroglobuline level was increased in four patients consisting of one patient with thyroid cancer. Ultrasonography showed anechoic (cystic) mass in one patient, others have hypo/iso/hyperechoic patern. In seven patients, thyroid scintigraphy revealed cold nodule including two patients with thyroid cancer. FNAB was reported as benign in five patients including two patients with cancer, and inadequate in two patients. Totally 12 surgical procedure were performed (total lobectomy, subtotal/subtotal/total thyroidectomy, complementary thyroidectomy). In five patients who were applied harmonic scalpel for vascular/tissue dissection and no wound drain, mean hospital stay was 2.0±0.7 days. In remaining patients, mean hospital stay was 3.2±1.7 days. Histopathological examination showed bening lesion in 9 patients and thyroid carsinoma in 2 patients. Avarage follow-up period was 18 months ranged between 1–48 months. Only complication was transient hypoparathroidism in one patient.

Conclusion: In our series, although we frequently used thyroglobuline, US, scintigraphy and FNAB, all those methods remained inconclusive to determine benign and malign tumors. However, evolving use of harmonic scalpel together with no drain approach contributed decreasing morbidity.

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PP27: Double hepaticoenterostomy anastomosis as a modification in Kasai portoenterostomy? (Experience with 25 cases)

Ahmed M. El Sadata and Marwa M. El-Sonbatyb

Pediatric Surgery Department, Cairo Universitya, Child Health Department, National Research Centerb, Egypt

Introduction: Biliary atresia is a devastating disease due to inflammatory process that affect intrahepatic & extrahepatic bile ducts that leads to progressive liver cirrhosis and portal hypertension with their sequelae. The surgical solution needs to be carried on as early as possible by an experienced surgeon. Technical points regarding the operation itself & its modifications need to be considered while undertaking the procedure.

Methods: In this study twenty five patients for which double anastomosis were carried on between the liver and the ascending jejeunal loop, the procedure was guided by the site where maximal bile flow from liver after proper dissection on the porta hepatis especially in cases of anomalies as preduodenal portal vein and early bifurcated portal vein.

Results: Follow up period of one year for the cases, early postoperative complications as bile blockage, burst abdomen or bile blockage or signs of hepatic failure.

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PP28: Our experience about laparoscopic cholecystectomy

T Özdemir, A Arikan, N Narli, A Sayan and A Karagözoğlu

Tepecik Training and Research Hospital, Department of Pediatric Surgery, Izmir

Aim: Cholecystectomy is not performing frequently in children. As minimal Access surgery gained acceptance among pediatric age cholecystectomies are performing laparoscopically. In this study medical records of the patients who undergone laparoscopic cholecystectomy were reviewed.

Materials and methods: Between 2009 and 2011, laparoscopic cholecystectomy was performed in 12 children. Demographics, pathology yielding cholecystectomy, operative records and postoperative course of the patients were evaluated.

Results: Five of the patients were boys and 7 were girls. Mean age was 4 years (3–12 years). All the patients had cholelythiasis. Cause of cholelythiasis was hypercholesterolemia in 4, hemolytic disease in 6 and obscure in 2 patients. Operation time was 3 h and 20 min in first patient and decreased gradually to 1 h and 20 min in subsequent patients. Single preoperative complication was biliary spillage due to rupture of the gallbladder and encountered in 4 patients. While mean hospitalization period was 1.4 days (1–2 d) in patients without this complication, discharge of the patients with biliary spillage could be possible at mean 2.3 days (2–4 d).

Conclusion: Laparoscopic cholecystectomy is a safe procedure during childhood. Cosmetic results are satisfactory and short term of hospitalization is a great advantage.

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PP29: Gastrografin in the management of Adhesive Small Bowel Obstruction (ASBO) in children: a pilot study

Hesham Abdelkader, Mohammed Abdel-Latif, Khaled El Asmar, Ihab Al-Shafii, Amr Abdel-Hamid, Mohammed ElDebeiky and Alaa F. Hamza

Ain Shams University

Introduction: ASBO is a common problem in children with previous abdominal surgery. Management protocols usually start with conservative approach that may be successful in some cases, whereas in others it will end eventually by laparotomy. Our aim was to assess the role of gastrografin in the conservative management of ASBO.

Materials and methods: During the period January 2009 to July 2010, 33 patients with ASBO were presented at the Pediatric Surgery Unit at the Ain Shams University Hospitals. Patients who failed to improve after 48 h of conservative management in the absence of signs of strangulation were subjected to gastrografin administration. Patients were evaluated clinically and radiologically to determine the resolution of the adhesive attack, with estimation of hospital stay time.

Results: 33 patients were admitted for 35 attacks of ASBO. Four patients were explored immediately after initial resuscitation. After 48 h of conservative management, seventeen attacks had resolved, while two cases were explored within this period. The remaining 12 attacks were subjected to gastrografin administration. Eight (66.6%) of them had their attack clinically and radiologically resolved within 3–12 h (average 7.5 h). Their average hospital stay after gastrografin administration was 19.25 h. The other four patients were explored, as the contrast showed complete small bowel obstruction with failure to reach the cecum.

Conclusion: Gastrografin may have a valuable role in the management of ASBO, whether diagnostic or therapeutic, but a randomized controlled trial is needed to prove its effectiveness in reducing surgical intervention rate and hospital stay time.

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PP30: Long term results of untwisted adnexia

A Canmemiş, A Yildiz, N Sever, M Akin, ÇA Karadağ and Aİ Dokucu

Paediatric Surgery Department, Şişli Etfal Training and Research Hospital

Adnexial torsion in females is one of the rare cause of acute abdomen. 15% of adnexial torsion are discovered in children and infants. Primary pathology is rarely discovered preoperatively and operative findings can be misleading. Adnexial torsion are found in 2% of cases operated with the diagnosis of acute appendicitis.

Methods and cases: Cases operated due to adnexial torsion between june 1997 and December 2010 were evaluated retrospectively. Adnexes which had underwent detorsion have been reevaluated with Colour Doppler Ultrasound and tumour markers. All pathological results were reviewed.

Results: Classical management of ovarian torsion consists of resecting the twisted adnexa to avoid the risk of malignant spread were the main treatment modality in our instution untill May 2007. And then time simple detorsion of twisted adnexia and biopsied became our first choice of treatment. Of thirteen cases operated due to adnexial torsion, eleven cases underwent oophorectomy and two cases to detorsion before May 2007. Of sixteen cases, seven cases underwent detorsion with laparoscopically, four cases with open approach after May 2007. Only five cases were operated with oophorectomy. All cases except two, who underwent detorsion of adnexia, were assessed with colour Doppler ultrasound. Of thirteen untwisted adnexia cases, nine children have been assessed in long term. Eight viability of adnexes were evaluated with USG an done with magnetic resonans imaging. In one case adnexia could not be found, viability found normal in six cases, high arterial resistance in one case. None of the twisted adnexia showed malignancy.

Conclusion: Considering the low rate of malignancy, difficulty of assessing ovarian viability and returning of viability in even grossly black haemorrhagic adnexa allowed us to apply detorsion in all adnexial torsion. Only in cases diagnosed prenataly may be due to long duration of torsion, can be separated from this treatment choice.

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PP31: A rare cause of adrenal hyperplasia in children: primary pigmented nodular adrenocortical disease

S Tiryakia, A Celika, Y Ertanb, N Elmasc, DG Simsekd, O Korkmazd, O Erguna and S Darcand

aDepartments of Pediatric Surgery, bPathology, cRadiology and dPediatric Endocrinology, Ege University

Aim: Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of Cushing syndrome in children. It presents with adrenocorticotropic hormone independent hypercortisolism which is caused by multiple, pigmented nodules of hyperplastic adrenocortical cells. A case who had undergone a comprehensive diagnostic search, yet could only confirmed with surgical exploration is presented.

Case report: A 16 year-old girl was admitted to our clinic with Cushing Syndrome and no response to high-dose dexamethasone supression test. She had truncal obesity, moon face, purple striae on abdomen, glucose intolerance, osteoporosis, amenorea but no hypertension. Free urinary cortisol level was 208 µg/24 h and a lack of diurnal decline (28 mg/dl in the morning and 26 mg/dl at night) was detected. She had no stigma of Carney complex. Adrenal glands were described as normal with computed tomography and magnetic resonance imaging and a slight suspicion of hyperplasia was reported in iodomethylnorcholesterolscintigraphy. Laparoscopic exploration was performed with a suspicion of PPNAD, and revealed a slightly hyperplastic left adrenal gland with multiple pigmented nodules. Unilateral adrenalectomy was performed. Histologic examination revealed multiple unencapsulated brown yellow nodules of varying sizes were seen within the cortex; the nodules were composed of compact and clear cells with abundant cytoplasmic brown Lipofuscin pigment. In the postoperative month three, diurnal rhythm is still abnormal however cortisol levels decreased to 7 mg/dl in the morning and 6 mg/dl at night.

Conclusion: Diagnosis of PPNAD should be kept in mind in patients with corticotropin-independent Cushing Syndrome especially when no adrenal hyperplasia/nodules or any other foci releasing cortisol can be identified. As unilateral adrenalectomy has been proposed as a safe and effective alternative in some patients, unilateral adrenelectomy might be choice of treatment to avoid long-term replacement therapies in children with a close endocrinologic follow-up.

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PP32: Evaluation of surgery versus medical approach and the role of guide lines in the management of gastroesophageal reflux in pediatrics

Mohammed J Aboud

The Maternity and Child Teaching Hospital/Al-Qadisiya-Iraq Ministry of Health

Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal problems that occurs in children. The term refers to the presence of gastric contents proximal to the stomach. It is not uncommon for many infants to have recurrent problems of spitting up and vomiting during the first year of life. Treatment of GERD is directed at the various identified pathophysiological components. The majority of infants can be successfully treated conservatively while awaiting improvement as spontaneous maturation of the physiological antireflux mechanisms occurs. The goals of an antireflux operation are to relieve reflux symptoms, decrease GERD-related complications and hospitalizations, and halt the use of antireflux medications.

Objective: This study represented the alternatives for managing the acute and chronic symptoms of uncomplicated GERD in patients who may require long-term treatment. It summarizes the role of guide lines and available evidence comparing the efficacy and safety of medical, and surgical interventions in the treatment of GERD, particularly after long-term follow up.

Materials and methods: From January 2005 to January 2010, 26 children have been treated for GER, 14 with medical approach (primarily involves prokinetic agents and acid suppression therapy) and 12 with antireflux surgery (6 with Thal, s operation and 6 Nissen fundoplication) at the Maternity and Children Teaching Hospital in Al-Qadisiya, Iraq. A review of the hospital records of these patients was performed. Twenty one of these children have been followed for an average of 12 months; the remaining 3 have been lost to follow-up. Questions addressed in this report are: What is the evidence of the comparative effectiveness of medical, and surgical treatments for improving objective and subjective outcomes in patients with chronic GERD? Is there evidence that effectiveness of medical, and surgical treatments varies for specific patient subgroups? What are the short- and long-term adverse effects associated with specific medical, and surgical therapies for GERD?.

Results: The number of patients requiring antireflux medications decreased from 12 patients (46.1%) before antireflux surgery to 4 (15.3%) after antireflux surgery, 3 were restarted on antireflux medications within 1 year after surgery. Vomiting was the most common presenting symptom of recurrent reflux, which occurred an average of 3–8 months following the initial antireflux or fundoplication. Recurrent reflux occurred in 3 children and was documented with upper gastrointestinal radiography.

Conclusion: Investigation of these diseases can be specific and accurate. Therapy is available, but no drug will stop reflux. Some children suffer intractable GERD with secondary complications GERD despite medical treatment. Failure of therapy could mean patients require surgical intervention. Antireflux surgery and fundoplication is well established as the surgical treatment for medically refractory GERD occurring in childhood. High technical standards and rigorous report of the results are required for keeping a relevant place of pediatric surgery in the treatment of this disease.

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PP33: The application of mesh plug technique in the repair of difficult cases of recurrent indirect inguinal hernia in boys

Khalid S Shreef

Pediatric Surgery Unit, Zagazig University, Egypt

Background/purpose: The recurrence of indirect inguinal hernia remains high, vary from less than 0.5% to approximately 4%. Recurrence may be attributed to tearing of a friable sac, a slipped ligature at the neck of the sac or failure to ligate the sac high at the internal ring. In boys, re-operations are difficult and require tedious and careful dissection of the dense fibrous tissue resulting from the earlier surgery. There are definite risks of damaging the vas deferens and testicular vessels. The aim of this study is to evaluate the feasibility and outcome of using the mesh plug technique in the repair of certain difficult cases of recurrent indirect inguinal hernia in male infants and children.

Patient and methods: This prospective study was carried out at the pediatric surgery unit, surgical department, Zagazig University Hospitals, Egyptduring the period from April 2008 to September 2009. The study included 10 boys with recurrent indirect inguinal hernia. Inclusion criteria applied during surgery were: marked adhesions and fibrosis surrounding the cord, distorted anatomy of the inguinal region and patulous internal ring.

Results: A total of 10 operations were performed. All patients were male presented with recurrent indirect oblique inguinal hernia; their ages ranged from 3 months to 2 years with the mean age (12.1 months). All cases had severe adhesions surrounding the cord structure with marked distortion of the anatomy. 2 cases had associated patulous internal ring. The operative time ranged from 20–30 min. The follow- up period ranged from one month to 11 months (mean 5.8 months), during the follow-up period no major complications were noted.

Conclusion: The application of mesh plug technique in the repair of difficult cases of recurrent indirect inguinal hernia in boys is easily applicable, safeand not expensive.

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PP34: Childhood peripheral skin and soft tissue abscesses

ÇE Afşarlara, A Karamana, G Tanirb, İ Karamana, E Yilmaza, D Erdoğana, HA Madena, YH Çavuşoğlua and İF Özgünera

Departments of aPediatric Surgery and bPediatric Infectious Disease, Dr. Sami Ulus Childen's Hospital, Ankara

Introduction/aim: Community associated peripheral skin and soft tissue abscesses are common in childhood. In this study we aimed to investigate the demographic features, abscess localization, causative microorganisms, treatment modalities, and efficiency of the administrated antimicrobiological agents of the patients admitting with peripheral abscess.

Materials and methods: In a period of January 2005 to July 2010 patients admitting to our department complaining of peripheral localized abscess were investigated retrospectively. Abscesses were classified into three groups as head&neck, body, and extremity abscesses according to the localizations. Demographic features of the patients, abscess localization, treatment modalities, causative microorganisms, antibioteraphy, inpatient and/or outpatient treatment durations were considered by investigating the patient records of our hospital's automation system. Organ specific and postoperative surgical abscesses were excluded.

Results: For a period of 5 years with a mean age of 2.55 (ranging 17 days to 17 years) totally 90 cases (49 male, 41 female) admitted to our department. While the head&neck abscess were common in girls (65.4%), extremity abscesses were common in boys (68.4%). Commonly head&neck and body abscesses were hospitalized. Most common microorganisms isolated from the cultures were staphylococcus aureus (53.8%) and streptococcus strains (14.1%). There was no statistically significance between the type of microorganism and abscess size, localization and hospitalization (P>0.05), but increasing of the abscess size correlated with hospitalization. The most common administrated antimicrobiological agents were amoxicillin/clavulanate and sulbactam/ampicillin (76.6%). Outpatient and inpatient treatment durations had statistically significant difference (respectively 9.5±2.3 days, and 13.4±4.1 days) (P=0.001) and the mean hospitalization was 8.3±4.2 days.

Conclusion: Primary treatment of the community associated peripheral abscesses is surgical drainage. Regardless of the isolated microorganism, abscess size and localization were effective on the decision of outpatient versus inpatient treatment. The MRSA stains have an increasing isolation in the cultures of community-associated skin and soft tissue abscesses in the western populations for the last years, but any MRSA stain was isolated in the cultures of our study group. Although the antibiotic treatment is controversial, we suppose that the choice of sulbactam/ampicillin and amoxicillin/clavulanate preparations is effective in empiric treatment of childhood community associated skin and soft tissue abscesses.

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PP35: Surgical treatment of craniofacial haemangioma

Kamal Abdel-Elah Aly

Department of Surgery, Mansoura University Hospital, Pediatric Surgery Unit, Mansoura, Egypt

Background/purpose: Infantile haemangiomas are the commonest tumors of infancy with an incidence of up to 12%. Craniofacial area are affected in 60% of cases which represents a theraputic challenge. The purpose of the study is to evaluate indications, results and complications of early surgical management of craniofacial haemangiomas.

Materials and methods: 28 cases with craniofacial haemangiomas (18 females and 10 males) were subjected to surgical treatment between 2006–2010. for each patient, age, sex, site, indication of surgery and post operative complications were recorded.

Results: All cases of the study had single lesion. Surgery consisted of complete, one stage excision with primary closure (19 cases) or closure with local flaps (9 cases). Postoperative complications (17.9%) included partial disruption (2 cases), haematoma formation (one case), partial skin necrosis (one case) and infection(one case).

Conclusion: We can conclude that, the surgical treatment is the prime goal in cases of haemangioma so far it is resectable. Especially if obstructing vital functions. There is no way to stay beside haemangioma waiting whether involution will occure or not.

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PP36: The usage of pancreofric for the treatment of newborn meconium ileus

Allahverdi Musayev and Nesib Quliyev

Department of Newborn and Children Operation*BAKU-AZERBAIJAN, Pediatrics İnstitute named after K. Faradjov

Introduction:the oral pancreofric in association with classic techniques helps to avoid the surgery operation at newborn with meconium ileus (cystous fibroid-CF). We obtained best results after using of the oral pancrefric. The aim of this study is to illustrate the use of pancreofric as alternative for surgery in meconium ileus.

Method: The medical history of 43 patients between 2009–2010 whom were followed in our clinic with CF were evaluated in our work. We observed patients with gestational age ranging from 3.2–6.3/365 days (19-boys/ 24 girl). Clinical complaints: abdominal distention, vomitting, absence of meconium, respiration disturbances, complication of general state, intraperitoneal gas. Evaluating of intestinal dilatation and liquid-gas level. Pathologyc indicators were not founded according to the laboratory examination. Mutational examination was not conducted. We admitted patients with ileus diagnosis and meconium absence. Laparatomy was administered to 2 patients and patients had seconder recovery. At the practice we observed full recovery at 41 patients. Microcolone had been revealed at 24 newborn according Ba colon rentgen examination. According to the intrauterine sonography of intestinal atresia had been diagnosed at 2 patients. Patients received nasogastric probe with 250 mg pankreofric doze per day 2×125 mg and clyster. We observed meconium and faeces after 2–3 days.

Result: Our goal was to use pancreofric in the treatment of meconium ileus. The results of the investigation gave the possibility to decrease the level of surgery operation by using medical therapy.

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PP37: Can intra vesical pressure measurement be used as a guide at the diagnosis and the management of necrotising enterocolitis?

E Divarcia, A Çelika, M Yalazb and O Ergüna

aDepartment of Pediatric Surgery and bDivision of Neonatology, Ege University Faculty of Medicine, Izmir, Turkey

Aim of the study: We aimed to investigate the utility of intra vesical pressure (IVP) measurement at diagnosis and management of necrotising enterocolitis (NEC).

Materials and methods: A prospective study was performed between December 2009–October 2010 in neonatal intensive care units. Neonatals were divided into two groups; Group 1: patients without NEC, Group 2: patients with NEC. Group 2 also divided into two groups; Group 2-S: Surgical treatment, Group 2-M: Medical treatment.

Results: No significant discrepancy was found in weight and age groups between group 1 (n=15) and group 2 (n=10) (P>0.05).5 patients in group 2 underwent surgery. Mean IVP values were; group 1: 3.1±0.6, group 2: at pre-diagnosis 4.5±1.5, diagnosis 7.4±5.1 and post-diagnosis 6.4±2.7 mmHg. Mean IVP values were listed as; group 2-S: pre- diagnosis 5.6±1.3, diagnosis 10.2±6.1 and postoperative period 8.2±2.5 mmHg, group 2-M: at pre- diagnosis 3.4±0.6, diagnosis 4.6±1.3 and post- diagnosis 4.6±1.3 mmHg. IVP values in group 2 were significantly higher than group 1 (P<0.05). There wasn't significant difference in IVP values between group 2-S and group 2-M.

Conclusion: We found the utility of IVP measurement in diagnosis of NEC. Determination of surgical treatment decision by IVP measurement was failed due to lower patient numbers in our study. Studies with larger patient numbers are necessary to clarify usefulness of IVP monitorization at management of NEC patients.

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PP38: Our experiences in the treatment of meconium peritonitis

H Taşkinlara, C Erdoğana, AH Turhanb, G Gündoğdua, D Avlana, A Aticib and A Naycia

Departments of aPediatric Surgery, bPediatrics, Mersin University School of Medicine, Neonatal Intensive Care Unit

Aim: Meconium peritonitis is a chemical inflammation of peritoneum occuring after intestinal perforation in antenatal period.

Materials and methods: Sevenpatients' files were studied retrospectively which had been operated for intestinal perforation in newborn period with the diagnosis of meconium peritonitis between the years between December 1999–December 2010.

Findings: Of our patients three (%42) were female, four (%58) were male. Five of seven patients were operated when one day old, one was when two days old and one was when four days old. The diagnosis was made through calcifications and free air in abdominal X-ray, intestinal echogenity, free fluid in abdomen, pseudocyst or mass formation with antenatal/postnatal ultrasonography. Stoma formation was performed in 4 patients, primary end-to-end anastomosis was performed in 3 patients. Only one of our patients died to whom a drain had been placed in a different facility and was referred to our clinic when she was 4 days old.

Discussion: Meconium peritonitis is a sterile, chemical peritonitis that occurs after the spillage of meconium into the peritoneal cavity due to intestinal perforation during the antenatal period. The delay of diagnosis increases the mortality and morbidity. We suggest that mortality and morbidity can be reduced by early intervention, Antenatal sonographic findings of polyhydramnious, ascites, intra-abdominal calcifications and increased bowel echogenicity can be warning of meconium peritonitis. We suggest that mortality and morbidity from meconium peritonitis may be reduced by early diagnosis and intervention.

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Pediatric Urology Posters With Discussion

PPU1: Reconstruction of vaginal stenosis with perianal skin flap and oral mucosal graft in persistent cloaca

C Tanelia, A Gença, Ö Yilmaza, C Özcana A Gültekina and İ Akila

Departments of aPediatric Surgery and bPediatric Nephrology, Celal Bayar University, Faculty of Medicine, Manisa

Vaginal stenosis is a common complication after intensive reconstructive surgery in genital area. Usually it is very hard to dilate the stenosis and further redo-surgery is necessary. Vaginal reconstruction operation with perianal skin flap and oral mucosa graft in a 17-year-old girl who had vaginal stenosis due to intensive operations of persistant cloaca anomaly is presented. In the present case, perianal skin flap was used to dilate the vaginal orifice stricture and further transfer of oral mucosa grafts to vaginal mucosa. Oral mucosal grafts obtained from inner cheek and inferior lip were prepared in two separate pieces. Flaps were later placed to 9 and 3 h positions in the vaginal wall sutured by 4/0 absorbable polyglycolic sutures. Silicon vaginal stent (Silimed Brazil) were placed in the vagina to ensure the graft position to remain at the selected position. Vaginal stent was removed on postoperative 7th day and once daily vaginal dilatation was performed with Hegar dilatator. The patient was externalized on postoperative 10th day and daily dilatation with estrogen cream was applyed. The patient performed daily dilatation for 6 months and at the number 19 Hegar dilatator diameter the dilatatins were performed at 2–3 times per week intervals. The patient is now under follow-up for 1 year and performing the dilatations with number 22 Hegar dilatator for 2 times a week. Perineal skin flap and oral mucosa graft are safe and effective method in vaginal reconstruction. By this method sufficient vagina width which responds to dilatation can be achieved. The vaginal silicon stents aid in the graft position to remain stationary at the fixed position and did not show any adverse effects on the circulation. It is necessary to perform regular dilatation with estrogen creams to achieve appropriate satisfactory vagina. The patients are need follow-up for a long time after vaginoplasty.

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PPU2: Metanephric stromal tumor in a child: a rare renal neoplasm

MN Azilia, A Kacarb, BS Cihanc, HA Demird and HT Tiryakia

Departments of aPediatric Surgery, bPathology, cRadiology and dOncology, Ankara Child's Diseases Hematology Oncology Education and Research Hospital

Introduction: Metanephric stromal tumor (MST) is a rare benign stromal tumor of the kidney. In our clinic, we operated a case of renal mass and diagnosed the MST, presented here in and discussed in the light of the information in the literature.

Case report: A six-year-old male child presented with frequently recurring urinary tract infection. He has been followed by different medical centers in the last 2 years with 2×2 cm sized simple cyst in the middle portion of the left kidney by ultrasonographic examinations. At our center the ultrasonography revealed a simple cyst surrounding a semisolid mass at the left kidney. Computerized tomography and Magnetic Resonance Imaging also demonstrated the same lesion. On voiding cysto-ureterogram, grade 4 vesico ureteral reflux (VUR) was determined at the right kidney. At the operation, STING procedure was applied for the grade 4 VUR at the right kidney and a left hemi-nephrectomy was performed for the semisolid renal mass. Histopathologically the 5×4×2.5 cm left heminephrectomy specimen composed of bland spindle cells distributed haphazardly by entrapping tubules and glomerules and producing fine collarettes around some tubules. The cysts were lined with a one layered flat or cubic epithelium that occasionaly demonstrates a hob-nail appearence. Immunohistochemically, the tumor stroma showed diffuse expression for CD34 and CD99, while complete negativity was obtained with S100, desmin, smooth muscle actin, CD117 and beta-catenin and detected as MST. On the postoperative 8 th day the patient was discharged uneventfully.

Discussion: Wilms' Tumour is the most common kidney tumour in childhood, lately, some new kidney-specific entities have been recognised like MST. This tumor is usually centered in the renal medulla. Histopathologically, it is important to differentiate MST from mesoblastic nephroma and clear cell sarcoma of the kidney. In most cases complete excision is curative. Left hemi-nephrectomy was performed who had grade 4 VUR on the contrlateral kidney and there is no necessary for the use of chemotherapy. As for a summary, we report a case of metanephric stromal tumor of childhood, the discrimination of this neoplasm from the other malignities of the kidney can avoid unnecessary nephrectomy and chemotherapy.

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PPU3: Primary renal synovial sarcoma: the first pediatric case

İ Akillioğlu, S Yücesan and A Hiçsönmez

Department of Pediatric Surgery, Başkent University, Faculty of Medicine

Primary renal synovial sarcoma (PRSS) is a recently reported and extremely rare neoplasm. Only 40 cases have been reported and it is very difficult to differentiate from other renal masses. Precise diagnosis is imperative for proper therapy and requires specific histochemical, molecular/genetic testing.

To our knowledge, our case/this report constitutes the first of PRSS in the pediatric population and represents the youngest patient reported with this neoplasm. We describe the clinical presentation, surgical treatment technique and outcome of a 17-month-old girl with PRSS of the right kidney.

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PPU4: Rare cause of dysuria: eosinophilic cystitis

A Abilova, R Özcana, E Polatb, S Dervişoğluc and H Emira

aDepartment of Pediatric Surgery, bClinical Microbiology, and cPatology, Cerrahpasa Medical Faculty, Istanbul University

Aim: To presenting case a rare disease in the literature which diagnosed with eosinophilic cystitis.

Case: 5-year-old malepatient, admitted starting 4 months ago and raging last 1 month with complaints of dysuria and urinary incontinence. İn his history because of dysuria have been investigated in Iran and considered eosinophilic cystitis based on cystoscopy-biopsy, but not treated patients admitted by us. There was no pathological finding physical examination. Bladder wall thickness of 15 mm were measured by ultrasonography. There was nodilatation of the uppersystem. The patient's witch no-property in urine analysis out ofleukocyte 5–6 in voiding cystourethrography is filling defect of the left lateral wall. Computed tomography was observed diffuse up to 18 mm wall thickness ofleft anterolateral wall. Examination of the urine for schistosoma there was no schistosoma eggs. In cystoscopylefthalf ofthe bladder was trabeculated and bladder mucosa was irregular, bladder capacity was very low. There was notumorormass. Submucosa including punch biopsy was compatible with nontumoral eosinophilic cystitis. Schistosoma can't ruled out but consulted by the microbiology department and were treated with praziquantel for 5 days. Eosinophilic cystitis is diagnosed patients and were followed starting with trimethoprim-sulfamethoxazole and antihistaminic (Cetirizine). During the follow up the patient's symptoms regressed and 3. month ultrasound control while bladder capacity was 139 cc wall thickness 3.9 mm, 26 cc presence of residual was measured 8 mm. Cetirizinedosewas tapered. İn 8. months Be prtesented on the burning during urination. In US while the bladder capacity was 190 cc, the left anterolateral wall thickness was 5.4 mm, 28 cc the presence of residual was seen in 8.1 mm. on Control CT wall thickening of bladder was observed decreased than former CT. Cetirizine was started to cases again with a normal Uroflowmetri. Follow upseen the complaintsfullyresolved. Currently is followed.

Results: Patients which admitted with complaints of dysuria should be considered in differential diagnosis rarely encountered of in children with eosinophiliccystitis. In the literature antibiotic, antihistaminic and cortisol are used. Our case treated with a combination of trimethoprim-sulfamethoxazole and Cetirizine the complaints were decreased.

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PPU5: Use of autolog platelet rich fibrin in uretracutaneous fistula repair: report of a case

T Soyera, M Çakmaka, MK Aslana, MF Şenyücela and Ü Kisab

aDepartments of aPediatric Surgery and bBiochemistry, Kirikkale University, School of Medicine, Kirikkale, Turkey

Platelet rich fibrin (PRF) is known as an autogenous source of growth factors obtained from the sera of the patient. PRF supports collagen synthesis and tissue repair and accelerates wound healing. We aimed to present our initial experience about the use of autologous PRF in a patient with an urethracutaneous fistula after hypospadias repair.

A 3 year-old boy who underwent Snodgrass repair for coronal hypospadias with recurrent urethracutaneous fistula reserved for autologous PRF application during fistula repair. After two layer fistula repair, 5 ml of serum was obtained from the patient and centrifuged in sterile dry glass tube with 3000 rpm. Three layers were obtained from the serum are; red layer consists of red blood cells, upper most layer consists of plasma without cells and middle layer consists of PRF (Choukroeun method). TZF was handled in sterile fashion and placed on two layered urethral repair and closed with skin. Postoperative period and 3 months follow-up were uneventful.

Autologous PRF can be used during uretracutaneous repair to support the repair and accelerate the wound healing. PRF is an autogenous source of growth factors which is easy to use and obtain. Therefore, it can be used as a novel alternative method for support tissue in fistula repair. However, in order to evaluate the effect of PZF on urethral repair, randomized controlled trails are needed.

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PPU6: Urethreal prolapsus in twin siblings

N Arslan, G Karaguzel, S Demirezen, C Boneval and Melikoğlu

Department of Pediatric Surgery, Akdeniz University School of Medicine, Antalya

Introduction/aim: Urethral prolapsus is typically a self limited condition and rarely requires surgical intervention. Herein, we aimed to discuss clinical approach in cases of urethral prolapsus in twin siblings appearing matasynchroneously.

Case 1: A 7 year old girl presented with swelling in vulva, hemorrhagic and malodorous vaginal drainage. On physical examination, a doughnut like mass lesion at external urethral meatus was detected showing edema, hyperemia, strangulation (partial, superficial). Vaginal opening was intact and the patient was able to micturate spontaneously. Pelvic ultrasound showed no abnormality. Based on the diagnosis of complete urethral prolapsus, conservative management was initiated (perineal hygiene, laxative, anti-inflammatory medication). Patient's complaints somewhat improved but because of ongoing malodorous drainage, the patient underwent vaginoscopy and cytoscopy. There was no foreign body and bladder neck was competant. Conservatif management was continued with urethral catheterization (5 days) and adding topical estrogen for the next period of 1 month. Six months after the diagnosis, the patient was doing well except an asymptomatic perimeatal mucosal prominence.

Case 2: One and half months after case 1, case 2 was presented with similar complaints. Physical examination showed perimeatal edema, prominence and hyperemia without strangulation. There was no voiding difficulty and vaginal abnormality. Similar conservative approach (topical estrogen, laksative, perineal hygiene, antiimflammatory drug) was initiated with clinical diagnosis of urethral prolapsus. Patint's complaints gradually reselvod within 15 days and she was completely improved three months after the diagnosis.

Conclusion: Although conservative management sometimes lasts longer in childhood urethral prolapsus, it is a reasonable approach in uncomplicated cases. While endoscopic evaluation may be required in certain situations, surgical intervention may be indicated in cases of resistant to conservative management.

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PPU7: Posterior urethral valve laser ablation in newborn

İ Ötgün, G İnal and T Acer

Department of Pediatric Surgery, Başkent University Faculty of Medicine, Ankara/Turkey

Introduction: Posterior urethral valve is a congenital lower urinary system obstruction in males that is observed in 1/5000–8000 live birth. Childhood is the most frequent cause of obstructive uropathies. Therapy choices are limited because urethral diameter is small in newborns. A newborn case is presented here that posterior urethral valve laser ablation has done.

Case: After the radiological investigation of the newborn case which has bilateral hydronephrosis and massive ascite in the abdomen, posterior urethral valve was detected. Urethral valve in the anterior part of the posterior urethra was observed in sistoscopy. Urethral valve ablation was performed by the help of the laser probe that was pass through 3F sistoscop. The case has followed by the foley catheter in the postoperative period for two weeks. The outcome is well.

Discussion: Posterior urethral valve is usually excised by the resectoscopy. But it is not suitable to use resectoscop in newborn period. So that it is mostly delayed for therapy. Consequently laser ablation is an important alternative treatment choice in newborn period.

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PPU8: The factors that could efect the urinary continance at the late repair of extrofia vesica

T Acer and İ Ötgün

Department of Pediatric Surgery, Baskent University Faculty of Medicine, Ankara, Türkiye

Introduction: During the repair of the extrophia vesica, that is done within 48–72 h of life, symphisis pubis could also be repaired primarily at the same time with bladder and abdominal wall repair. If the repair is done later or if the parts of symphisis pubis were very apart or after the unsuccessful extrophia vesica repair, for the closure of the symphisis pubis osteotomy is needed, with need of augmentation at cases with low bladder capacity.

Case: At administration of the 3 day old girl to our hospital, physical examination revealed that bladder mucosa of the patient was insufficient for the closure of the bladder. Bladder augmentation at a later age decided. The patient was lost for two years and admitted to our hospital when she was 3-year-old. The patient entered operation room according to the plan of ileal augmentation and iliac osteotomy. During the operation, a thick fibrotic band found between the two parts of the pubis. As, it was discovered that the bladder has enough tissue, it is decided to close the bladder primarily. It was thought that the fibrotic band between the pubic parts is steady and strong enough, so that the plan of iliac osteotomy was left. Bladder neck separated from urethral plate. The graft prepared from paravesical skin, united at the midline, between the bladder neck and the urethral plate to lengthen the urethral structure. Bladder closed, urethra repaired and encircled with some part of the muscle tissue of the pelvis. At the cystoscopy that was done five months later, the urethra was 1.5 cm length, without any stricture. The bladder capacity was 55 cc. After 9 months, the patient was capable of urinary continence for 2 h.

Conclusion: This is an atypical case, in which the bladder tissue hidden behind the fibrotic band gave the possibility to reconstruct a bladder with enough capacity. Also, we think that the lengthening of the urethral structure by using paravesical skins and the resistance maintained by encircled pelvic muscle around new urethra, helped to have a continent bladder. As our case indicates, it should be kept in mind that primary closure of the bladder could be possible, before deciding augmentation.

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General Pediatric Surgery Posters

P1: A primitive method in 21th-century-turkey for the treatment of inguinal hernia: burning

B Aydoğdu

Bakirköy Maternitiy and Children Hospital, Pediatric Surgery Clinic, İstanbul

Objective: We present a primitive method which is used for the treatment of inguinal hernia in a spesific region of Turkey, despite all the techniqual advances and the increasing number of physicians.

Patients: In Mardin Maternitiy and Children Hospital, Pediatric Surgery Clinic between 2009 and 2010, 43 patients who have inguinal hernia unilaterally or bilaterally, revealed scarred tissue on the swelling inguinal region due to burning. Mean age of patients was 2.5 years (1–12 years). It was understood this is a belief that the burning of the swelling inguinal region with a fire heated stone or metal object, would heal the inguinal hernia.

Conclusion: It is very thought-provoking that despite Turkey has been reached the higher position at the ranking of the world of science during the years of 2000s, there is still such a primitive method for the treatment of a disease. It is very important that the social-educational aspects of our professions is as important as the academical aspect, for the settling the form of scientific thought in society.

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P2: The first male thoracoschisis case and a literature survey

İ Karaman, A Karaman, YH Çavuşoğlu, D Erdoğan and İF Özgüner

Department of Pediatric Surgery, Dr. Sami Ulus Children's Hospital, Ankara

A male newborn presented with the intestines herniating together with a solid mass from a defect 3 cm below the left nipple on the anterior thoracic wall. Riedel's lobe, attached to the left liver lobe, and the transverse colon were seen to be herniating through the defect at the region of the 8th intercostals area on the left at surgery. A fibrous band extending from the lower defect border to the bladder was present. The hernia content was reduced inside the abdomen and the fibrous band, Riedel's lobe and necrotic-appearing omentum were excised. Thoracoschisis is a very rare congenital anomaly and there are only 4 cases reported so far. This is the first isolated thoracoschisis case with no accompanying diaphragmatic hernia.

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P3: Litospermic asid prevents ischemia/reperfusion injury of the rat small intestine

H Öztürka, H Terzib, G Buğdaycic, H Öztürka

Departments of aPediatric Surgery, bHistology and cEmbryology, Biochemistry, Abant Izzet Baysal University, Medical School

Aim: The purpose of the present study was to investigate whether Lithospermic acid (LA) can reduce oxidative stress and histological damage in the rat small bowel subjected to mesenteric I/R injury.

Methods: The study was performed on three groups of animals, each composed of 7 rats: group SO, sham operation; untreated I/R; group LA, I/R plus Lithospermik asid pretreatment group. Intestinal ischemia for 45 min and reperfusion for 60 min were applied. Ileum specimens were obtained to determine the tissue level of malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPX), Catalase (CAT) and Myeloperoxidase (MPO) activities and histological changes.

Results: Intestinal I-R/Untreated resulted with increased tissue MDA and MPO levels and diminished SOD and GPx activities. These changes were almost found to be reversed in LA treatment group. Histopathologically, the intestinal injury in rats treated with LA was less than I-R/Untreated group.

Conclusion: Lithospermic acid attenuates mesenteric ischemia-reperfusion injury in rat intestine by increasing tissue SOD and GPx activitiesand decreasing MDA, and MPO levels. Lithospermic acid also improves morphological alterations, which occurred after periods of reperfusion.

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P4: Giant mesenchymal hamartoma of the liver in a child treated with selective hepatic artery embolization and right hepatectomy

R Tuncera, S İskita, E Aksungurb, F Doranc, S Türkera and M Alkana

Departments of Pediatric aSurgery, bRadiology and cPathology, Çukurova University Medical Faculty

Aim: Mesenchymal hamartoma of the liver (MHL) is an uncommon tumor and is usually diagnosed in the first 2 years of life. The tumor is mainly cystic but occasionally solid mass is seen. Treatment of choice is complete excision. If the tumor is considered unresectable the surgical options include liver transplantation and hepatic arterial embolization. The authors report a case of solid stromal predominant MHL in a 18-month-old female infant treated with selective hepatic artery embolization and right hepatectomy.

Case: Preoperative radiological examination revealed a huge, unresectable, hipervascular, completely solid mass in the right lobe of the liver. An open biopsy was performed. Histology findings show an MHL. Selective right hepatic embolization was performed. The tumor was successfully removed by right hemihepatectomy 14 days after embolization and the postoperative course was uneventful.

Conclusion: Hepatic mesenchymal hamartomas are best treated by complete excision, but if the lesion is massive, embolization of the hepatic artery before hepatic lobectomy may be considered as a surgical alternative method.

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P5: Breast intraductal papillomatosis in an adolescent girl

DB Embleton, A Bayraktaroğlu, S Çetinkurşun and F Aktepe

Departments of Pediatric Surgery and Pathology, Afyon Kocatepe University Medical Faculty

Introduction: Intraductal papilloma is a discrete benign tumour of the epithelium of mammary ducts. On the other hand, papillomatosis is defined as a minimum of five clearly separate papillomas within a localized segment of breast tissue. Juvenile papillomatosis (JP) of the breast is defined as severe ductal papillomatosis occurring in women less than thirty years old, but the terminology is controversial. The first finding may be a palpable mass or bloody nipple discharge. The definitive diagnosis is confirmed by biopsy. Treatment of the JP is total resection with preservation of the normal breast. Here we present a intraductal papillomatosis case that is seen at adolescent period.

Cases and methods: A 14-years old girl was admitted to our outpatient clinic with complaints of a right breast mass which was present for 5 months. There was no history of nipple discharge. Physical examination revealed an upper outer quadrant right breast mass. Mass was hard in consistency, about 4×1 cm in size with smooth margins. Axillary regional examination was normal. Ultrasonography revealed an irregular heterogeneous, hypoechoic breast mass of 41×16 mm with cystic areas localized in the upper lateral quadrant of the right breast. Excisional biopsy was planned. Operation was performed with lateral right breast semicircular incision. The mass was originating from milk ducts. It was reported as benign in frozen section examination. The mass was removed totally, protecting the areola. Pathology result was intraductal papillomatosis. The patient was discharged on postoperative second day. Follow-up with ultrasonography was planned in every 3 months and family members were warned about development of breast cancer. There was no recurrence in the follow-up period of 3 months.

Discussion: Juvenile papillomatosis usually presents with a breast mass instead of bloody nipple discharge as seen in our case. Although total excision is sufficient for benign intraductal papillomatosis, recurrence is frequent and there is a risk for malignancy both for the patient and the family members. Patients must be properly followed up at regular intervals.

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P6: Gastrointestinal stromal tumor: a rare cause of jejunoileal intussusception in a 6-years-old girl

M Günaydina, AT Bozkurtera, Ü Biçakcia, B Tandera, S Barişb, R Rizalara, E Aritürka and F Bernaya

Departments of aPediatric Surgery and Pathology, bPathology, Ondokuz Mayis University, Faculty of Medicine, Samsun, Turkey

Introduction: Gastrointestinal stromal tumors (GIST) are mesenchymal neoplasms that account for only 0.1–3% of all gastrointestinal malignancies.

Case: A 6-year-old girl was admitted to the emergengy room with abdominal pain and bilious vomiting for three days. Ultrasonographic examination revealed an 8-cm-long intussuscepted intestinal segment resembling target sign. There was a 26×28×23 mm non-peristaltic anechoic cystic tissue indicating a duplication cyst. On laparatomy, ileocecal valve was normal with many lymph nodes around; biopsies were taken from. There was a 20-cm-long intussuscepted segment at the proximal ileum just next to the jejunum. After manuel reduction, a 2-cm long oedematous segment resembling duplication cyst forming lead-point has been found. The segment was excised and primary anastomosis was performed. She was discharged on the fifth postoperative day. The histopathologic examination revealed the excised ileal segment had a GIST measuring 2.5 cm with a mitotic rate of 2–3 mitoses per 50 high power Wilds (low risk group) showing infiltrative growth pattern. On immunohistochemistry assay, some of the tumor cells were CD117 and CD34 positive whereas all of them were SMA and S100 positive but CD10 negative. Staining index with Ki67 was 5%. Surgical margins were free of tumor. The lymph nodes were reactive. She was referred to the pediatric oncology department for further evaluation.

Conclusion: GISTs are common in adults, and they may lead to intussuception. To the best of our knowledge, this is the first childhood case of GIST causing jejunoileal intussusception in the literature.

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P7: Surgical resection of segmenter jejunoileal lymphangiectasia in a child:a case report

Cİ Öztorun, H Demirkan, E Şenel and T Tiryaki

Ankara Pediatric Hematology, Oncology Education and Research Hospital, Pediatric Surgery Clinic

Entrance: Primary intestinal lymphangiectasia (Waldman's diease) is a rare disorder, characterized by dilated intestinal lacteals. The primer treatment is dietary modification. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia.

Purpose: In this case, we report that a girl 13 years old with protein loosing enteropathy diagnosis and surgical treatment of segmental involvement.

Findings: She was in gastroenterology control with protein losing enteropathy diagnosis since eight years. She had a dietary treatment and medical treatment. Although dietary and medical treatment the clinical ve laboratories findings wasn't seen improvement. The scintigraphy report was revealed right lower quadrant region of the abdomen wake jejunoileal involvement in field, were followed nonhomojen increased pathological activities. So we decided surgery. In the operation; bowel in jejunoileal region seemed more edema and solid than other segments of bowel and 60 cm part of jejunoileal region was resected. After surgery the clinical and laboratories findings improved in the patient.

Conclusion: Even though, the major treatment for primary intestinal lymphangiectasia is dietary modification, surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia.

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P8: What does a pediatric surgeon do in a peripheral hospital?

M Türker and B Bahadir

Aksaray Şammaz Vehbi Ekecik Women And Children Health Hospital, Pediatric Surgery

The number of pediatric surgeons working at provinces is fewer than the ones working at metropolis. The aim of this study is to determine the patient profile referred to new pediatric surgeons who are obligated by public service to provinces in our country.

A retrospective chart review of 4172 patients, with an age range of newborn to eighteen years, living in a population of 396.000 people who were evaluated by a pediatric surgeon in 2010 was performed.

Nine hundred and thirteen (21.8%) of 4172 patients who were evaluated in pediatric emergency, consultation and outpatient clinic were treated by hospitalization. Twelve percent of the patients (n=112) who were treated in inpatient clinics had burn and 3.1% (n=29) ingested corrosive substance. Seven hundred and eleven patients were operated and because of operating room conditions, the patients under 10 kg couldn't be operated except for emergency and short interventions. Circumcision (n=167), inguinal hernia-hydrocele repair (n=199), appendectomy (n=157) (10% laparoscopically), orchiopexy (n=52), abscess drainage (n=30), removal of foreign body from upper esophagus (n=20), frenuloplasty (n=20), excision of spermatic cord cyst (n=20), hypospadias repair (n=11), urethral chordee repair (n=8), ovarian cyst excision (n=4) (50% laparoscopically), bridectomy (n=4), intussusception reduction (n=3), (33% laparoscopically), Meckel diverticulum excision (n=2) (50% laparoscopy-assisted), paraphimosis reduction(n=2), rectal polyp excision (n=2), testicular detorsion (n=2), meatoplasty (n=1) and management of volvulus (n=1) were performed. Chest tube was inserted to 37 patients in newborn intensive care unit (n=18) and emergency (n=19). One hundred and forty seven children were evaluated for multitrauma and six of them were operated. There was no mortality except a patient who was operated after a high-energy trauma.

The number of pediatric surgeon specialists required in a city could be determined by recording the patients evaluated by pediatric surgeons, not by other specialists like general surgeons, urologists, plastic surgeons etc. It should be kept in mind that besides the pediatric surgeons' education and skills, the presence of anesthesiologists, equipments and trained nurses on pediatric surgery is very important for pediatric surgeons in order to operate in peripheral hospitals.

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P9: Respiratory papillomatosis arising in the trachea and lungs without laryngeal involvement presenting with a misdiagnose of asthma

M İmamoğlu, S Samut, M Tuşat, Hİ Çakmak, D Başar, S Sağ, F Tandoğan and H Sarihan

Department of Pediatric Surgery, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey

Respiratory papillomatosis in children is a rare disease with an incidence of 4.3/100 000 children. To the best of our knowledge there is no reported case ofrespiratory papillomatosis in literaturearising in the trachea without laryngeal involvement. Due to its interesting nature we present a case of respiratory papillomatosis arising in the trachea and lungs, with its similar clinical and radiological features often misdiagnosing as asthma.

A 15-years-old boy admitted to emergency department in severe respiratory distress. He had been suffering from coughing, wheezing breathing and exercise-induced asthma episodes since last 3 months, the symptoms having gradually worsened over the recent weeks. He had diagnosed as asthma with recurrent bronchitis, and despite treatment with inhaled bronchodilators and steroids, his symptoms worsened. Cysts in the lung tissue were detected by chest X-ray. Computerized tomography (CT) of the chest revealed an intraluminal tumor arising from the right side of the trachea, confirming the presence of cysts in the lung tissue with typical appearance of chronic pulmonary diseases. Bronchoscopy performed under general anesthesia demonstrated a spherical and irregular-surfaced mass attached to the tracheal wall through a narrow pedicle occluding about 70% of the lumen. The tumor was removed completely with biopsy forceps. Pathologic examination of the specimens revealed a squamous cell papilloma.

We present this case to emphasize that in patients with persistent asthma-like symptoms chest CT should be performed and when cyst-like changes are present presence of respiratory papillomatosis should be considered in differential diagnosis.

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P10: Ileal triplication

Meltem Çağlara, Çiğdem Ulukaya Durakbaşaa, A. Bahar Ceyranb, H. Murat Mutuşa, Ahu Bayara and Hamit Okura

Departments of aPediatric Surgery and bPathology, S.B. Göztepe Research and Training Hospital, Istanbul

Aim: Duplications of gastrointestinal tract are relatively rare anomalies. On the other hand, triplications are extremely rare. This report presents a triplication case operated on with the presumptive diagnosis of intestinal duplication.

Case report: A-9-month old male infant was referred with an antenatally diagnosed intraabdominal ‘cystic’ mass. The history was uneventful. His physical examination was normal except for a right undescended testis. An abdominal ultrasonography revealed a right-sided multilobulated 41×31×29 mm mass with double lumen at the level of umbilicus. It harbored internal echogenic septa and punctate debris material. An abdominal CT scan revealed similar findings. An elective operation was undertaken. There was an ileal mass very close to ileocecal valve resembling a spherical duplication cyst. An ileocecal resection involving the mass was performed with ileocolonic anastomosis. The postoperative course was uneventful. The pathological examination showed there were three lumina in the cut-surface, one belonging to ileum and the other two to a-1.5 cm-wide ‘duplication’ and a-0.5 cm-wide ‘triplication’, respectively. Microscopy showed the latter two had a separate wall in-between having lamina propria, submucosa and muscularis propria. They shared a single outermost longitudinal muscle layer with normal ileum. The duplicated and triplicated structures did have separate mucosal layers both of which were mainly composed of gastric mucosa with antral glands.

Conclusion: Published data reveals seven reports on intestinal triplications among which there is only one case with ‘ileal triplication’. Almost all had associated serious systemic malformations. Although the diagnostic methods and treatment employed are not very different from intestinal duplications, the rarity of this malformation is worth discussion.

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P11: Myofibroblastoma of breast in a male infant

T Soyera, Ş Ayvab, MF Şenyücela, Ç Şenyücelc, MK Aslana and M Çakmaka

Depratments of aPediatric Surgery, bPathology and cRadyoilogy, Kirikkale University School of Medicine, Kirikkale

Breast masses are very rare in infants and premature telarche due to excessive endojen or exogen estrogens is the most common presentation during infancy. Bening and malign breast masses, especially in male infants are very rare. A 10-month old male baby with a left breast mass which is diagnosed as myofibroblastoma is discussed to evaluate the clinical features and treatment modalities of breast myofibroblastomas in children.

A 10 months-old male infant with left breast mass lasting for the last 3 months was admitted. Physical evaluation revealed 3×2 cm, soft, semi-mobile breast mass originating from left areola without a bony attachment. The patient who had normal systemic examination underwent complete surgical excision of breast mass under general anesthesia. Histopathologic evaluation showed a primary stromal tumor of breast arising from spindle cells which surrounds the normal breast tissue with rich collogen and adipose tissue deposits. Immunhistochemical analysis of mass revealed vimentin, CD34 and desmin positivity with strong bcl-2 staining and diagnosed as myofibroblastoma of breast. The postoperative course was uneventful and the patient has been still in follow-up.

Myofibroblastoma is a stromal tumor of breast, occurring especially in elder males. This breast mass has a close relationship between androgen receptors and has not been reported in infants previously. Myofibroblastoma of breast should be differentiated from gynecomastia and infantile myofibroblastic tumors. Although myofibroblastic tumors regress spontaneously, myofibroblastomas should be totally excised. Myofibroblastoma of breast should be kept in mind in the differential diagnosis of infants with a breast mass.

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P12: Chemotherapeutic retroconversion of immature teratoma of the ovary: a case report

E Yilmaz, A Atici, A Karaman, YH Çavuşoğlu and D Erdoğan

Ankara Dr Sami Ulus Maternity and Children Training and Education Hospital

Introduction: Although ‘growing teratoma syndrome’ (GTS) or ‘chemotherapeutic retroconversion’ is frequently reported for the malign germ cell tumors of the testis, it is rarely reported for immature teratomas of the ovary. Here we present a 13 year old girl who had surgery for immature teratoma of the ovary with liver metastasis and developed mature teratoma on peritoneal surfaces 5 years after the initial surgery and chemotherapy.

Case: A 13 year old girl had surgery for immature teratoma of the right ovary and it's metastasis to liver in our clinic. She received 6 courses of BEP (Bleomycin, Etoposide, Cisplatin) therapy after the surgery but another 4 courses of ICE (Iphosphamide, Carboplatin, Etoposide) therapy was required 1 year after the surgery for the relapsing metastasis of immature teratoma at the left lobe of the liver. During routine follow up, five years after the first surgery, 3 masses with mixed solid and cystic appearance were detected on ultrasound which were confirmed with CT imaging. At surgical exploration 3 solid masses of 1 to 2 cm in diameter were excised from peritoneal surfaces near the inferior region of the right liver lobe and former metastasis sites were also excised for biopsy. Histopathological examination revealed that the masses were compatible with mature teratoma while the former metastasis sites were free of tumor. The patient is on follow up for 1 year without any therapy and without event.

Conclusion: GTS or chemotherapeutic retroconversion is 2 different names used to describe the same clinical entity. It describes the growth of immature teratoma despite chemotherapy after initial chemotherapy. This entity is rare in ovarian teratomas and is due to the unresponsiveness of the mature teratoma which was in fact differentiated or ‘matured’ from the initial immature teratoma. If an unresponsive relapsing mass is identified in patients with a history of surgery and chemotherapy for immature teratoma of the ovary, the possibility of differentiated or ‘matured’ teratoma must be kept in mind.

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P13: A case report of fetal endometrioid cyst: need for a new insight in endometriosis

M Demircana, A Güngöra, A Karamana, E Şamdancib and Ö Çelikc

Departments of aPediatric Surgery, bPathology and cObstetrics and Gynecology, İnönü University, Medicine School, Malatya

Although intraabdominal cysts in fetus and newborn are seen very frequently, it has not been found any case of endometrioid cyst in newborn or fetus in literature.

Here, in this poster we report a case of fetal intraabdominal cyst with a diameter of 65×43 mm which was diagnosed by prenatal ultrasound and followed up until delivery. The cyst was excised by laparotomy at 1 day after delivery. Histopathological confirmation of the endometrioid cyst was obtained. Because this newborn is the first case of fetal endometrioid cyst, it presents us a new insight about the etiologyof disease which is not yet fully understand and is still open to debate.

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P14: Congenital peribronchial myofibroblastic tumor: a rare lung mass

S İskita, C Parlakgümüşa, S Türkera, A Açikalinb, D Gümürdülüb, R Tuncera and Ü Zorludemira

Departments of aPediatric Surgery and bPathology, Çukurova University Medical Faculty, Adana, Turkey

Purpose: A rare case of prenatally diagnosed congenital peribronchial myofibroblastic tumor (CPMT) is presented.

Case report: Mass and hydrothorax was detected in the right hemithorax of the fetus during prenatal ultrasonography at 36th week of gestation. Baby was intubated in the delivery room for severe respiratory distress and ventilatory support was begun. As a right thoracic mass and RDS findings were detected on his first x-Ray, surfactant treatment was performed. RDS was resolved after 6 days of ventilatory support. His thoracic CT evaluation revealed a pulmonary solid mass of lower lobe. Thoracotomy and lobectomy was performed with diagnosis of congenital cystic adenomatoid malformation type III at 12 days of age. However CPMT was reported after histopathological examination. The postoperative course was uneventful and the baby has been asymptomatic during 5 months of follow up.

Conclusion: CPMT is a very rare mass but must be remembered at the differential diagnosis of prenatally diagnosed congenital lung lesions.

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P15: Case report of an ischioheteropagus with immature teratoma, covered cloacal exstrophy, omphalocele, hemibladder, hemiuterus, and intestinal duplication

B Aksua, H Gençhellaçb, M İnana, O Temizözb, M Derelia, Z Dörtdoğana, MA Tekina, S Ayvaza and ÜN Başarana

Departments of aPediatric Surgery and bRadiology, Faculty of Medicine, Trakya University, Edirne, Turkey

Introduction: Conjoined twin is a very rare pathology live birth. Parasitic twin which is a special type of conjoined twins is exceptionally rare. We present an unusual case of ischioheteropagus with an immature teratoma, covered cloacal exstrophy, omphalocele, hemibladder, hemiuterus and intestinal duplication.

Cases: A 1-day-old baby girl came to our hospital born through a 40-week. Birth weight of the fetus was 3150 g including both autosite and parasite, had 2 parasitic limbs (arm and leg) attached to the pelvic girdle of the perineum. A wholly developed labium majus and minus was observed between the right limb and the parasitic leg. Also in the same area, adjacent to the bottom of the labia, an anus was observed opening out as a fistule. Semi-developed labium majus and minus were observed between the left limb and the other parasitic extremity. A covered cloacal extrophy with dimensions as 6×5 cm was observed to originate from the undeveloped half of the labium majus and minus. The colon was opening out with an ostium. The baby had a giant hypogastric omphalocele. The omphalocele contained a duplicated small bowel (5 cm in diameter) and large and small bowels, and a fascial defect with approximately 10 cm in diameter. A satellite solid mass with 3 cm in diameter was observed above the umblical cord. Cystic like mass lesion similar with the doppler ultrasonographic images was observed in the magentic resonance imaging with T2 majority starting from the sacrococcygeal level extending to retroperitoneum of intrapelvik region with dimensions of 7.5×7×4.5 cm and multiloculated bilobate contours. The tumor (immature Teratoma) were totally excised. The duplication cyst was resectioned and anastomosed. With conserving the vascularisation of the both parasitic extremities, the omphaloselwas repaired with a pediculed flep.

Results: The defect of the abdominal wall has been repaired with fleps have been procured from the tissues of the parasitic fetus. The management of such a case with multiple pathologies should be multidisciplinary. Radiological methods play a major role in discriminating of pathology from normal anatomy of patients with complex anomalies.

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P16: Waugh's syndrome: the association between intestinal malrotation and intussusception

S Samut, M Tuşat, Hİ Çakmak, D Başar, S Sağ, F Tandoğan, M İmamoğlu and H Sarihan

Department of Pediatric Surgery, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey

Background: It has been reported that intestinal rotation and fixation abnormalities accompany some of the intussusception cases in infancy (Waugh's Syndrome). This selected group of patients was evaluated by their clinical symptoms, radiologic findings and treatment approaches and spesific differences were searched.

Materials and methods:14 cases between the years 1994 and 2010, aged 6–13 months, who were operated for intussusception and found to be with rotation and fixation abnormalities had been investigated in detail. Literature was also reviewed.

Results: In two cases intussusception occurred after the Ladd procedure for malrotation. Intussusception was confirmed by USG, that was performed for discomfort and NG -drainage- increase on the fourth day in the first case; and discomfort and vomiting with bile on the ninety day in the second case. The other 11 cases all had discomfort and vomiting; however the half of the cases had fever and blood-stained stools. In their stories; since the infancy 5 had intermittent vomiting, 4 had constipation, 3 had diarrea attacks and 2 had growth retardations. The diagnosis was confirmed with USG and the mass was at the left-upper side in 7; at the left-down side in 2; at the midline in 2 and at the right-upper side in 2 cases. Radiologic reduction was tried but failed in 2 cases. In the operation 8 had ileocolic, 5 had ileocaecal and 1 had ileoileal intussusception. In 7 cases Ladd bands accompanied to classic type malrotation and additional Ladd procedure was performed 5 cases had caecum fixation abnormalities. In one case volvulus developed including intussusception segment. There were enlarged lymph nodes of the mesentery in all cases. Only one patient needed resection. The follow-up of the cases between 14 months and 3 years had reported no symptoms.

Conclusions: (a) Symptoms of malrotation may present in the story. (b) The mass was localized frequently on the left quadrant or midline. (c) Radiological reduction may be unsuccessful. (d) In some of the cases Ladd bands, volvulus and duedonal stenosis can accompany the primer pathology and when misdiagnosed morbidity can increase. 5) Malrotation with LAP and malfixation of the ileocaecal mesentery may be leading factors in allowing the terminal ileum to pass into the caecum under the influence of leading points.

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P17: Isolated paracardial cyst: prenatal diagnosis and intervention with postnatal early exploration

L Elemena, K Karaoğlua, E Çalişkanb, A Günlemezc, Y Anikd and K Yildize

Departments of aPediatric Surgery, bGynecology, cPediatrics, dRadiology and ePathology, Kocaeli University Medical Faculty

Introduction: Isolated paracardial cysts, defined as cystic structures adjacent to or originating from the heart, are rare and etiologically heterogeneous congenital abnormalities. These lesions have a wide spectrum of anomalies extending from neuroenteric cysts to thmic cysts. Paracardial cysts are uncommon prenatal findings and only a handful of similar cases have been reported in the medical literature with prenatal interventions and postnatal early explorations.

Patient: The 26 weeks old fetus of a 31 year-old healthy mother was diagnosed to have a 3×2 cm paracardial cyst in the left anterior mediastinum and percutaneous cyst aspiration was performed. As the cyst was found to be enlarging and exerting pressure on the fetal lung on the later weeks of the pregnancy by ultrasound examination, fetal magnetic resonance imaging was performed. The presumptive radiological diagnosis was a thmic cyst. Percutaneous aspiration of the cyst was performed once more on the 31st gestational week and the patient was delivered with a planned sectio on the 35th weeks of the gestation. As the patient had severe dyspnea during his follow–up in the neonatal intensive care unit, he was taken to operation. A left sided thoracotomy revelaed a 3 cm diameter cystic structure adcacent to the pericardium and originating from the timus. Thus, partial excision of the csyt with partial excision of the left lobe of the timus was performed. Histopathological examination of the cyst was consistent with a thymic cyst. The patient developed left diaphragmatic paralysis and he underwent a diaphragmatic plication.

Result: The patient is stil followed in the neonatal intensive care unit 70 days after the first and 20 days after the second operation due to pneumonia.

Discussion: Congenital paracardial cysts have a wide spectrum of anomalies. Although, these lesions are known to regress during the last weeks of the gestation the cyst in the present patient did not. Prenatal diagnosis of a paracardial cyst gives the surgeon opportnity of early planning of an operation in a dyspneic newborn in the early postnatal period.

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P18: Desmoplastic small round cell tumor of gastrocolic ligament

Ç Ulukaya Durakbaşaa, MA Özena, IE Zemherib, A Yörükc, M Korkmaza, M Çağlara, HM Mutuşa and H Okura

Departments of aPediatric Surgery, bPathology and cPediatric Oncology, S.B. Goztepe Research and Training Hospital, Istanbul

Aim: Desmoplastic small round cell tumor (DSRCT) is a highly aggressive malignant tumor without a clear origin. Its first description as a distinct pathological entity dates back to 1989. A DSRCT is not usually suspected in the evaluation process of an abdominal mass. This report presents a child with DSRCT.

Case report: An 8-year-old male with an incidentally found abdominal mass was referred. The history was unremarkable. The physical examination revealed an upper abdominal, highly mobile mass and was normal otherwise. Blood biochemistry including tumor markers were within normal limits. An ultrasound followed by computerized tomography scan showed a lobulated solid intraabdominal mass measuring approximately 10×10×7 cm located inferomedially to the liver and anteriorly to the kidney. It had no connections with intraabdominal solid organs. There were multiple paraaortic lymphadenomegalies. At operation, a pediculated and torsioned solid mass located in the gastrocolic ligament with a blood supply thorough parasitic vessels arising from the ligament was found. It was totally excised. A lymph node sampling was also done. Histopathology revealed a DSRCT with capsular and peripheral fatty tissue infiltration. There was diffuse positivity with CD56, vimentinanddesmin and focal positivity with CK. The immunoreactivity was negative for sinaptophysin, chromogranin, myoglobin, CD117, CD45and WT. Thesampledlymph nodes were negative for tumor. The child was scheduled for an intense chemoradiotherapy program and is currently under therapy 10 months after the operation. He is free of relapse or metastasis.

Conclusion: DSRCT is a rare mesenchymal tumor that usually occurs in the abdomen of adolescent males. The manifestations are usually nonspecific as in the presented case. Single or multiple lobulated intraabdominal soft tissue masses with no apparent organ of origin is the typical preoperative investigative finding. Although the prognosis is regarded poor, total surgical resection is considered the major determinant of survival. This tumor should therefore be born in mind during surgery in cases with suggestive findings.

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P19: Rare diaphragmatic tumour: endodermal sinus tumor

B Kiliç, T Günendi, Ç Münevveroğlu, F Gün, T Salman and A Çelik

Department of Pediatric Surgery, Istanbul University Istanbul Medical Faculty

Primary malignancies of the diaphragma are rare. Sarcoma is the most common clinical entity in children. Symptomatic tumors of the diaphragm reveal themselve by development and invasion directions. Yolk- sac tumours are germ- cell malignancies mostly originating testis and ovaries. However anterior mediastinum or extragonadal localization has been reported previously. In this study we report an endodermal sinus tumour originating from diaphragm because of it ‘s rare localization.

Case: 3 years old, male patient admitted to a pediatric emergency department for couhing and was transfered to our clinic wiht the pre- diagnosis of pleural effusion. Abdominal computed tomography established a mass lesion in 6. segment of the liver. On physical examination respiratory sounds were reduced right hemitorax and liver mass palpable. As high as AFP was 11955 ng/ML. On laparatomy, right transdiaphragmatic mass lesion was observed and removed totally including the effected part of the right hemidiaphragm. The pathological specimen revealed an endodermal sinus tumour and the patient is on follow-up for his chemotherapy protocol.

Results: Diaphragmatic malignancies are extremely rare. In lesions lying from abdomen to mediastinal area, diafragmatic tumours should also be kept in mind.

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P20: Surgical planning of congenital H-type anovestibular fistula

H Taşkinlar, O Karak, İ Killi, G Gündoğdu, D Avlan and A Nayci

Department of Pediatric Surgery, Mersin Universitey School of Medicine

Congenital H-type anovestibular fistula without anal atresia is an extremely rare anorectal malformation. Surgical planning ranges from primary fistulectomy to with or without colostomy, to anterior or posterior anorectoplasty. However, there is no consensus regarding its surgical management. The clinical presentation, diagnosis and management of congenital H-type anovestibular fistula are discussed with review of relevant literature. We describe a 2-month old baby-girl who presented with stool at the vestibulum after a left vulvar/labial inflamation. On physical examination, anus was in normal location and size. An opening at the vestibulum at four o'clock position, and a fistulous communication between this opening and the anus, above the dentate line was found. After management of the local inflamation, the patient underwent a primary fistula repair. However, the fistula recurred. Afterwards, a protective diverting sigmoid colostomy and anterior sagital anorectoplasty was performed. Up to now, there is no relapse of the fistula. As conclusion, congenital H-type anovestibular fistula should not be underestimated. We suggest that anterior sagital anorectoplasty can be used for congenital H-type anovestibular fistulas with excellent functional and anatomical results.

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P21: Successful treatment of a breast lymphangioma with intralesional bleomycin injection

L Elemen and K Karaoğlu

Department of Pediatric Surgery, Kocaeli University Medical Faculty

Aim: To report a patient with a breast lymphangioma who was treated successfully with intralesional bleomycin.

Patient: A 2 year-old female patient admitted with the swelling of the left breast. Her medical history was significant for congenital hypothyroidism and Down syndrome. Physical examination revealed a 2×3 cm soft mass on the left breast, which was later diagnosed with the ultrasonography as a retroareolar lymphangioma of 36×13×22.5 mm dimensions. The patient was taken to operation and 2.5 mg intralesional bleomycin injection was performed after aspiration of chylous fluid from the cyst. The cytopathological examination of the fluid was consistent with lymph. The patient was discharged on the following day and remains well without complications for a follow-up of 2 months. The diameter of the retroareolar cyst was found to decrease to 0.3 mm on the follow-up ultrasonography.

Discussion: The great majority of the lymphangiomas in the childhood period is cited in cervical, axillar, mediastinal, retroperitoneal, inguinal and oral regions. Retroarelolar localization is rarely reported. Although, the definitive therapy for the cystic lymphangiomas is the surgical excision, only half of the lesions can be totally excised. Alternative therapies are developed due to hypertrophic scar formation, long-term lymphatic leakage, high incidence of recurrence, infection, and sub-total excision because of adherence to vital organs. Recently, the use of bleomycin, which is a systemic chemotherapeutic drug, intralesionally was reported to be successful. Thus, we used bleomycin intralesionally with the fear of damaging retroareolar and ductal structures in the breast. We believe that, bleomycin injection may be used as an alternative to surgical excision when the lesion is localized in a critical region.

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P22: What to do in cases with appendicular plastron

G Ekingen, L Elemen and K Karaoğlu

Department of Pediatric Surgery Medical School University of Kocaeli

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P23: Intestinal gangrene due to mesenteric thromboembolism caused by thrombophilia mutations

L Cankorkmaz, G Köylüoğlu and C Güney

Department of Pediatric Surgery, Cumhuriyet University School of Medicine, Sivas, Turkey

Background: Altered balance between the fibrinolytic and procoagulant systems might significantly contribute to the pathophysiology of thrombus formation. Thrombophiliatic mutations always cause a tendency for venous thrombosis. The prevalence of venous thromboembolism in the childhood is 1/100 000.

Case report: A 15-year old boy applied to emergency clinic with progressively increasing abdominal pain for four days. Associated symptoms were bilious vomiting, and non-passage of stools. There was not any special information in his history. Surgery was advised.

On examination, body temperature was 37.8°C, blood pressure was 80/40 mmHg, pulse was 106/min., WBC was 10.200/ml, Hb was 14.4 g/dl and CRP was 386 mg/dl. The abdomen was distended, tender and rigid with no bowel sounds. A provisional diagnosis of with acute abdomen was made, and he was explored. Through a midline incision, the abdomen was explored and a massive gangrenous bowel was observed involving the distal ileum, cecum, ascending colon and proximal threefourths of the transverse colon. Resection of necrotic intestinal segment following ileocolostomy was performed in patient. Resection specimens were reported as transmural infarct by pathology.

Conclusion: In the genetic analysis, heterozygous (Factor V H1299R (R2), β- Fibrinogen-455 G-A, PAI-1 4G-5G 4G/4G) and homozygous (GPIIIa L33P (HPA-1) platelet, ACE D/D genes) mutations were found. Warfarin therapy was suggested for prophylaxis by hematology. We concluded that genetic analysis is very important and could be helpful to understand the ethiology of embolism seen in childhood.

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P24: A rare pathology confused with tumor: massive ovarian edema

A Sayana, A Arikana, T Özdemira, H N Özera, H Turana, M Cana, A Karagözoğlua and Ü Bayolb

Tepecik Educational and Research Hospital aClinic of Pediatric Surgery and bPathology Laboratory Yenisehir/IZMIR

Aim: Compared to adults, ovarian tumors are seen rarely in children but massive ovarian edema is a tumor-like pathology and leads significant confusion in diagnosis. A case taken into surgery with pre-diagnosis of ovarian tumor in our clinic is presented to emphasize the importance of pathology.

Materials and methods: A 13-year-old patient with vomiting complaint, abdominal and pelvic ultrasonography (USG) result findings taken by reason of menstrual irregularity in another center and with the pre-diagnosis of two-sided ovarian tumor was admitted to our clinic. In our clinic, USG was repeated, additionally doppler USG, abdominal and pelvic computerized tomography (CT), magnetic resonance imaging (MR) and routinebloodexaminations were performed were analyzed.

Findings: It's learned that there was menstrual irregality, adding abdominal pain and vomiting for last 15 days in patient's story. At both USG, cyst having a diameter of 65 mm in left ovarian, at doppler USG in right solid and cystic anechoic mass 96×48 mm size, in left cystic anechoic mass having a diameter of 51 mm were detected. At CT and MR, in right exceeding large ovarian tissue including micro cysts in, in left cystic mass with septation extending to the front and back of the uterus were detected. Patient was taken into surgery with the pre-diagnosis of two-sided ovarian tumor. During the operation it was seen that left ovarian had a shape of solid cystic mass 110×90×40 mm size and torsioned 720 degrees; also there was a left paratubal serous cyst 40×40×10 mm size. It was detected right ovarian had a shape of solid cystic mass 50×40×40 mm size. Left ovarian detorsioned by extracting paratubal cyst, but although hemorrhage/bleeding's not regressing so salphingooferectomy and mass was extracted completely. Biopsy were performed from right ovarian and operation completed upon the report that biopsy is benign. As result of histopathological examination, biopsy diagnosed as polycystic ovarian and extracted mass diagnosed as massive ovarian edema.

Results: Massive ovarian tumor is a rare pathology in children. However, massive ovarian edema can't be discriminated from tumor and only can be definitely diagnosed as the result of histopathological examination. Therefore, we think that ovarian can be protected during the surgical intervention by considering massive ovarian edema for patients thought to have ovarian tumor.

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P25: A cystic mass on the ligamentum falciforme: report of a rare case

B Yağiza, YH Çavuşoğlua, D Erdoğana, EC Boduroğlub, A Karamana, E Yilmaza and İF Özgünera

Departments of aPediatric Surgery and bPathology, Dr Sami Ulus Maternity and Children's Hospital

Masses of the falciform ligament are rare. A 16 year old boy without any known disease is incidentally diagnosed as having an intrabdominal cystic mass. According to the preoperative clinical and radiological assesments the patient was introduced to the operation as mesenteric cyst but found to have a ciliated cystic mass located among the sheets of the falciform ligament irrelevant of the abdomen. Pathologicalexamination revealed a ciliated cyst which is thought to arise from the endoderm of the foregut. To best of our knowledge this ist he first case of ciliated cyst in the falsiform ligament. Here we present a rare ciliated cyst of probable foregut endodermal origin which was thought to be located in the abdominal cavity but found among the sheets of the peritoneum.

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P26: A female anorectal malformation with congenital pouch colon and colovesical fistula: a case report

B Demiroğullaria, G Ekingen Yildizb, İO Özena, B Cana, N Kalea and AC Başaklara

aDepartment of Pediatric Surgery, Gazi Üniversity Faculty of Medicine and bDepartment of Pediatric Surgery, Kocaeli Üniversity Faculty of Medicine

Aim: The incidence of congenital pouch colon (CPC) is varied from 2 to 37% in all anorectal malformations (ARM). It is seen 3 to 7 times higher in males than females. In this report we aimed to present a female case with such a rare malformation.

Materials and methods: A fiftheen month-old girl with CPC and ARM was admitted to the hospital. She was performed ileostomy, colostomy and vesicostomy in the second day of her life. She had growth retardation, diarrhea, recurrent urinary tract infections, right pelviectopic athrophic kidney, urogenital sinus (2 cm lenght of UGS) and uterus didelphius. After she reached the approprite weight, the pull through procedure was done. After whole body preperation, colovesical fistula was separated through posterior sagittal approach. Then the patient was turned to supine position and all ostomies were broken down. Type 2 CPC was tubularized and anastomosed to the ileum. A protective ileostomy and hartman procedure were performed proximally to the anastomosis. After tube cystostomy, the position was changed into prone again. Vaginal oriffices were united together after cutting the septum and total urogenital mobilization was performed. A 2 cm lenght urethra was created from the UGS mucosa. At the end the ileostomy was matured in supine position. Following the wound healing, ileostomy was closed. One year after the surgery, she was receiving loperamide 3 times a day, constipating diet and had daily 3 bowel movements with soiling, perineal rashes. She started to gain urinary continence.

Conclusion: CPC was seen more complicated in female ARMs and requires more complicated surgery. Soiling and perineal rashes are the main problems needs to be solved in this group of patients.

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P27: Surgical repair of Treves' field mesenteric hernia: use of purse string technique

M Çakmak, MF Şenyücel, MK Aslan and T Soyer

Department of Pediatric Surgery, Kirikkale University, School of Medicine, Kirikkale

Treves field mesenteric hernia (TFMH) is a rare cause of intestinal obstruction. TFMH is defined as a mesenteric defect in terminal ileum, encircled by a branch of ileocolic artery. TFMH has a wide spectrum of clinical findings ranging from an intermittent partial bowel obstruction to strangulation. The surgical treatment of mesenteric defect depends on the viability of bowel and resection with primary anastomosis is the most common choice of treatment. A 4 year-old girl who underwent laparotomy for acute abdomen is presented to discuss the clinical features and treatment modalities of TFMH. Also, purse string technique is proposed as a novel surgical method for large mesenteric repair.

A girl patient with a one-day history of colicky abdominal pain underwent laparoscopy. Laparoscopic evaluation revealed bloody peritoneal fluid and compromised bowel. After conversion to laparotomy, bowel protrusion through a 15×12.5 cm mesenteric defect in the field of Treves' field and midgut volvulus were detected. After reduction of volvulus, large mesenteric defect was repaired by purse string technique. After an uneventful postoperative period, she has been still following up.

TFMH is a rare cause of small bowel obstruction. Because of non specific clinical findings, most of the cases diagnosed during laparotomy. Rarely, mesenteric defect repair is performed without requiring resection and anastomosis. The purse string technique proposed here is found easy to perform and safe in children with more anatomical aspect.

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P28: Bilateral ovarian cystadenofibromas: a rare case report

A Karamana, M Doğanb, E Şamdancic and M Demircana

Departments of aPediatric Surgery, bRadiology and cPathology, Inonu University, Faculty of Medicine, Malatya, Turkey

Cystadenofibromas are benign tumors of the over and are very rare in first decade. This disorder may appear as a multilocular cystic mass with solid nodular components mimicking malignant ovarian tumor. Preoperative diagnosis is required to avoid excess surgical procedure. In this study we present a case of an 10-year-old girl with bilateral ovarian cystadenofibromas who presented with sudden onset of right low quadrant abdominal pain. CT of the pelvis and abdomen showed bilobulated cystic right ovarian mass with solid component. Intraoperatively, bilobulated cyst with solid component contained within the right ovary and 1 cm solid lesion within left ovary were found. Frozen section showed benign cystadenofibromas. Conservative surgery was performed and both of lesion were excised. Our patient made an uneventful recovery. We recommend that the diagnosis of cystadenofibroma is considered prior to performing radical surgery.

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P29: Isolated common hepatic duct perforation after a blunt abdominal trauma: a case report

E Yilmaza, İ Karamanb, ÇE Afşarlarb, A Karamanb and İF Özgünerb

aBakirköy Dr.Sadi Konuk Research and Training Hospital and bDr Sami Ulus Maternity and Children Training and Education Hospital

Introduction: Biliary duct injuries after blunt abdominal trauma is extremely rare and the diagnosis is difficult. It is often associated with other organ injuries. Here we present a patient with common hepatic duct perforation solely following blunt abdominal trauma.

Cases: 1.5 year-old girl was evaluated because of an abdominal pain lasting for 3 days. It was learned that there was a history of fallen down on a seat and an increase in abdominal pain for a day when detailed history was taken. General appearance was moderate. She had mild dehydration, prominent abdomen, abdominal tenderness and defence. The bowel sounds were hypoactive. Ultrasonography and computed tomography findings were normal except free fluid in the abdomen. Bilious fluid was seen on paracentesis and it was decided to an operation. No abnormality was found except a 3 mm sized perforation that was located on the posterior side of the junction of common hepatic duct with cystic duct. T-tube placed in the perforated floor. It was withdrawn on postoperative 21st day. In the following 4th day the drain in the lodge was taken and the patient was discharged. The patient's postoperative follow-up on 1 month, 3 months and 6 months, the ultrasound examination, liver function tests and bilirubin levels were normal.

Conclusion: Bile duct injuries following blunt abdominal trauma is rare and usually with additional organ injuries. Our case presented with the isolated main hepatic duct injury. Generally, bile duct perforations reported with severe injuries, such as traffic accidents, but have been extremely rare reported after minor traumas. Even families find trivial, to questionize minor injuries may be important in reaching the correct diagnosis of abdominal pain. T-tube drainage is an appropriate method of treatment.

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P30: First case of bruck syndrome with gastroschisis

ÇE Afşarlara, HN Peltek Kendircib, D Erdoğana, İF Özgünera, YH Çavuşoğlua, A Karamana and S Çetinkayab

Departments of aPediatric Surgery, and bPediatric Endocrinology, Dr. Sami Ulus Children's Hospital, Ankara

Introduction/aim: Bruck syndrome is a rare disorder featuring the unusual combination of skeletal changes resembling osteogenesis imperfecta with congenital contractures of large joints. According to our knowledge only 24 patients are reported in the English literature. Although the genotypic and phenotypic features of the Bruck syndrome are heterogeneous, the reported case is the first association of Bruck syndrome with gastroschisis.

Case: A female baby with a history of prenatal diagnosis of gastroschisis was delivered by cesarean section because of fetal distress at 36th gestational week with a birth weight of 1350 g from a 19-year-old healthy woman in our hospital. Afterwards, patient was transported to our pediatric surgery department. On physical examination she had gastroschisis complicated with jejunal perforation, and contractures at the elbows, hips, and knees and club foot bilaterally. She had a crepitating, tender swelling on the left femur and babygram revealed a left femur fracture. An emergency operation including resection of the 20 cm necrotic perforated jejunum initiating from ligament of Treitzs and primary anastomosis and reduction of the bowel segments to the abdominal cavity were performed. Postoperative third day she had an additional fracture on the left humerus, both the fractures were followed up with splints. She tolerated oral feeding within the ninth postoperative day. The presence of the congenital joint contractures in addition to multiple bone fractures promoted the diagnosis of Bruck Syndrome and pamidronat treatment began. After reaching a weight of 2000 g she was discharged at the postnatal 30th day. Cyclic pamidronat treatment was given to her in a period of 3 months. She is now 7 months of age, gaining weight without any gastrointestinal complaint, and does not have any additional fractures with the ongoing pamidronat treatment.

Conclusion: Although prematurity and low birth weight is common with gastroschisis, additional system anomalies are uncommon. Conversely association of Bruck syndrome with gastrochisis has not been reported until now, thus the reported case is unique.

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P31: Rapidly growing giant ovarian cyst: serous cystadenoma

A Oral, M Yiğiter, H Zeytun, O Yalçin, T Dikmen and AB Salman

Department of Pediatric Surgery, Ataturk Univercity, Faculty of Medicine, Erzurum, Turkey

Abstract: Beningn ovarian neoplasms originating from epithelial tissue are common in women. However, they are rarely seen in pediatric population, especially in the first decade of life.

Case: Nine years old girl was admitted to our emergency department with sudden weight gain, abdominal distention, frequent urination. On his examination there was abdominal distention. Urinanalysis results were normal. Plain abdominal films showed intestinal gas shadows at upper and lateral abdomen. The ultrasound showed a cystic structure from epigastrium to pelvis, displaced the intraabdominal organs the upwards and laterally A round radiopacity located inside of this hypodense cyst was determined on CT scan and it was 32×22 cm. Tomour markers (AF:0.61 mlU/ml and βHCG:4.1 mlU/ml) were normal. During operation, we saw a 30×30 cm mass extending from the epigastrium to the pelvis originating from the left ovary. We didn't see a normal ovarian tissue. The mass was removed totally. According to pathologic examination, the solid material was defined as serous cystadenoma which weight is 4905 grams and lining simple one layer epithelium. The patient was discharged on postoperative 5th dayand postoperative course was uneventful.

Conclusion: Epitelial ovarian neoplasms are incresed after 3rd decade and they are extremely rare before 1st decade (%8). Most of the cyst are asymptomatic and generally found incidentally. But diagnosis depends on complications, as like torsion, at rapidly growing mass. Our patient is a rare case who admitted with sudden weight gain and distension. The real analize of complex cystic lesions or rapidly growing lesions are only possible with explorations and pathologic examination.

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P32: A rare cause of appendicitis: intestinal parasites

A Sayana, A Arikana, T Özdemira, A Karagözoğlua, H Turana and Ü Bayolb

aClinic of Pediatric Surgery and bPathology Laboratory, Tepecik Educational and Research Hospital, Yenisehir, Izmir

Aim: Obstruction of the lumen of appendix is the first inflammatory triggering event in appendicitis. Although the lymphoid hyperplasia in systemic infections is the most common cause of this obstruction in children, parasite balls may also cause obstruction. Our cases are presented to demonstrate the clinical features of this pathology.

Materials and methods: Appendectomy is performed to 1282 male and 679 female patients between the years 2000–2011 in our clinical with the diagnosis of appendicitis. A retrospective analysis revealed 21 patients, 12 male and 9 female parasites caused appendicitis.

Findings: In all cases clinical evidence combined with imaging revealed appendicitis. During the operation, parasites are encountered in the lumen and appendectomy is performed to all cases. In 14 of the patients, other intestinal parasites encountered throughout the intestines. Histopathological examination of the specimens showed 13 Enterobius vermicularis and 8 Ascaris lumbricoides as the main obstructive ball.

Results: In appendicitis, which is frequently encountered in pediatric surgery, the causative agents may be different intestinal parasites which must be kept in mind because of the frequent encounter of these pathogens in our country.

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P33: Cooccurence of Spiegelian hernia and undescended testis: Spigelian-cryptoorchidism syndrome

U Ateş, G Küçük, G Göllü and A Yağmurlu

Department of Pediatric Surgery, Ankara University School of Medicine

Introduction: Lateral ventral hernia (Spiegelian hernia) is a rare surgical condition in children. Recently, a close relationship has been reported between cryptoorchidism and Spiegelian hernia in the literature. The aim is to present a case that had testis in Spiegelian hernia sac.

Cases: One month old boy who had left inguinal and left lower quadrant swelling, left nonpalpable testis was administered. He was diagnosed as left inguinal hernia, left spiegelian hernia and left nonpalpable testis. Left testis was found in Spiegelian hernia sac during diagnostic laparoscopy and both internal rings were open. The left testis in the Spiegelian hernia sac was descended to left scrotum and bilateral hernias were repaired. No complication occured during and after the operation. The patient has no problem since his operation.

Results: The risk of cryptoorchidism is higher in patients with Spiegelian hernia and testis can be found in the hernia sac. The cooccurence of Spiegelian hernia and undescended testis should be kept in mind in patients with either of them.

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P34: Fibroadenoma of the axillary ectopic breast: a case report

E Yilmaz, EE Ertan, N Arda, ÇE Afşarlar and D Erdoğan

Dr Sami Ulus Maternity and Children Training and Education Hospital

Introduction: Diagnosis of ectopic breast (EB) is important because EB shows similar pathologic changes that occur in naturally positioned breasts. We present a rare case of a 13-years-old adolescent girl with a subcutaneous tumour in right axilla that was histologically identical to the fibroadenoma seen in the breasts.

Cases: A 13 year-old adolescent girl patient was referred. She complained of mass in the right axillary region, which is associated with local pain and discomfort. On local examination we found a (3×4×3 cm) mass inthe right axilla. The mass was subcutaneous in position, firm, painless, freely mobile and completely isolated from theright breast. Nipple or areola were absent. Ultrasonography of the right axilla revealed multiple hypoechoic space occupying lesion's suggestive of multiple lymph nodes. The mass was completely excised under general anesthesia. The pathologic diagnosis was fibroadenoma of EB. The postoperative period was uneventful.

Conclusion: The clinical differential diagnosis for a solitary axillary mass is very broad. A few case of fibroadenoma in the axilla has beenreported in literature. Fibroadenoma in the EB tissue should be kept in mind in the differential diagnosis of axillary mass. It should be diagnosed with the same methods applied to normal breast tissue (mammography, ultrasonography, cytology and biopsy). When tumours or nodules are found along the mammary line, the presence of breast tissue should be considered during the investigation.

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P35: A case of duodenal web which is presented ingested foreign bodies

M Kaçar, İ Kiriştioğlu and H Doğruyol

Department of Pediatric Surgery, The Medical Faculty of Uludag University, Bursa, Turkey

Introduction: The foreign bodies (FB) that passed into the stomach from the esophagus leaves the gastrointestinal tract without any problems within 4–6 days. But if the FBs are not taken for longer than 4–6 weeks should be considered anatomical or pathological strictures. In this study, a case of duodenal web is reported which is presented ingested foreign bodies.

Cases: 2.5 year old boy with a disease not previously known, was admitted ingested coin. The patient ingested the coin 6 months ago. On retrospective history, the patient had also vomiting and could not ingested the solid food. The patient's physical examination was normal. Abdominal X-ray disclosed an opaque FB on the lower right quadrant. There was a FB at the same locations in previously abdominal X-rays. FB was thought to be attached to the ileocecal valve or Meckel's diverticulum. For this reason, endoscopy was not made and laparotomy was decided.

Intraoperative, there was a very large bladder (Megasistis). Intestines were explored until treitz ligament. However, there was no FB. The duodenum was mobilized by koher maneuver. there was megaduodenum. The coin and different FB were palpated in the lumen. Duodenotomy was performed the diagnosis of duodenal web. There was an annuler web. The various FB were removed out the duodenum. The web was excised and intestinal continuity was maintained by Heinecke-Mikulicz duodenoduodenostomy.

The patient was fed orally on postoperative 5 days. Urinary tests were normal. The patient was included on clean intermittent catheterisation programme and discharged on postoperative 7 days.

Conclusion: The FB that persisted for a long time can be considered anatomical (appendix vermiformis, ileocecal valve) or pathological (duodenal web, Meckel's diverticulum, previously anastomoses) strictures. Endoscopic or surgical treatment can be applied in these patients.

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P36: A rare hydatid cyst case: primary diaphragmatic hydatid cyst

M Yiğiter, A Oral, H Zeytun, T Dikmen, O Yalçin and AB Salman

Department of Pediatric Surgery, Ataturk Univercity, Faculty of Medicine, Erzurum, Turkey

Abstract: Hydatid disease may develop in almost any part of body. The liver is the most frequently involved organ, followed by the lung and the remainder of the body such as kidney and spleen. However primary diaphragmatic hydatic disease is very unusual presentation of the disease.

Patients: 9 years old boy patient applied to our clinic with chest pain complaint. Physical examination and laboratory tests were normal. Posteroanterior chest radiography demonstrated crenation on right diaphragm and minimal level blunting on costodiaphragmatic sinus. Subcapsular hydatid cyst compatible scene in liver segment 7 demonstrated on ultrasonography. 58×51×35 mm hydatid cyst compatible scene in liver segment 7 demonstrated on computed tomography. Cyst agglutination test was positive and liver was normal on operation. However a cystic structure confirmed which is diaphragma located, shows intraabdominal displacement and not related with peripherial tissues. Cystic structure was excised totally separated from diaphragma. Diaphragma orifice fixed primary. Histopathological research evaluated as hydatid cyst. Patient discharged 5 days postoperatively.

Results: Diaphragmatic localization is very rare in thoracic-located hydatid cyst cases. Most of these patients also have liver or lung cyst hydatid. This patient is a primary diaphragmatic hydatid cyst case without any liver or lung involvement.

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P37: A rare congenital anomaly of lung: lung aplasia

A Sayana, A Arikana, T Özdemira, H N Özera, H Turana and Ü Bayolb

aClinic of Pediatric Surgery and bPathology Laboratory, Tepecik Educational and Research Hospital, Yenisehir, Izmir

Aim: Lungaplasia is a rare congenital anomaly and other system anomalies associate with in the ratio of 50%. Although can be recognized in early ages, cases with no additional anomalies or mild anomalies are diagnosed in later/advanced ages and may lead confusion in diagnosis with other acquired diseases of lung. It's aimed to emphasize clinic and pathologic features of this rare anomaly by presenting the case with diagnosis of lung aplasia in our clinic.

Materials and methods: 7-year-old female patient's who was tried to be treated in another center with the diagnosis of bronchopneumonia but admitted to our clinic with pre-diagnoses of mass in left hemithorax or total lung atelectasis because of her complaints and no improvement in radiologic view direct graphy and computerized lung tomography results were evaluated. For advanced examination, CT angioraphy, virtual bronchoscopy, 3D (three dimensional) with CT and bronchoscopy were performed. Patient was taken into surgery for definite diagnosis.

Findings: Because of non-specific symptoms such as often recurrent lung infection, cough and view at direct graphy, patient had different diagnoses. During the bronchoscopy it was seen that the bronchoscope moved 5 cm in left main bronchus after carina, later no bronchus lumen were seen. During advanced examination it was seen that there is abnormally ventilated lung tissue at the region where left lung should be placed, left main bronchus was rudiment and there is 2–3 cm length lung tissue in abnormal morphological structure in left paravertebral region. Therefore it was determined that heartandthe esophagusremoved to left and there is elevation to left diaphragm. In left thorachotomy performed for definite diagnosis and treatment, left lung tissue detected in accordance with radiologic view were cut out completely with thymus. Thymus and lung tissue in abnormal morphological structure were detected in histopathological examination.

Result: Rare anomalies such as lung aplasia have similar symptoms with usual lung diseases so they always must be considered during diagnosing. So, we are of the opinion that loss of time for definite diagnosis and treatment can be avoided.

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P38: An unusual presentetion of cyst hydatid without any primary: five cases

M Çevika, ME Bolekena and ME Güldürb

Departments of aPediatric Surgery and bPathology, Harran University Medical Faculty

Background: Hydatid disease is a zoonosis caused by larval stage of the Echinococcus tapeworm. The location of the hydatid cysts is mostly hepatic and/or pulmonary, hydatid cysts of other organs are unusual such as, in the neck, soft tissue and axillar region without involvement of other sites is extremly rare, even in countries where echinococcus infestation in endemic. We reported our unusual 5 cases of primary hydatid cyst arising in the soft tissues of various part of body. The clinical presentation is non-specific. Therefore, diagnostic difficulties, and treatment are discussed.

Materials and methods: A retrospective study conducted where l was worked as pediatric surgeon in pediatric surgery departments 5 cases of primary hydatid cyst of the unusual region of the body treated between 2003–2010. There were 3 girls and 2 boys with a mean age of 6.4 years. Two patients having cyst in the axillar fossa, one patient having cyst in the neck, one in popliteal fossa and other one in the subcutaneous tissue on the right anterior thoracic wall. Symptomatology was nonspecific, who were admitted with a mass, which were previously diagnosed, lipoma, lenphadenit or sebaceous cyst. All patients were had previously different diagnose and diagnosed peroperative. The abdominal and Thoracal CT were normal in all cases. Histopathology revealed a hydatid cyst and postoperative albendazol was given for 3 months. No recurrence was observed during 1 year follow-up.

Conclusion: These unusual cases serves to demonstrate that echinococcosis, though rare, should be considered in the differential diagnosis of cystic lesions in every anatomic location, especially when patients have spent time in endemic areas. It should be kept in mind that hydatid cysts can cause swelling in the any region of body and clinician and radiologist need to be familiar with the diagnosis and managment of the hydatid disease.

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P39: Pediatric breast masses

M Korkmaza, S Fettahoglua, A Guvenb, M Caglara, A Bayara, Aİ Anadolulua, M Mutusa, C Ulukaya Durakbasaa and H Okura

Departments of aPediatric Surgery and bPediatric Endocrinology, S.B. Goztepe Training and Research Hospital, Istanbul

Aim: Breast masses are relatively rare in pediatric age group and most are benign. This study aims to evaluate a single center's experience in breast masses.

Materials and methods: A retrospective review of a 7-year period was done for all patients operated on for breast masses through files and operation logs.

Results: There were 12 patients aged between 4–18 years with a mean of 13 years. There were 8 (67%) girls and 4 (33%) males. All patients applied with the complaint of a ‘lump’ in the breast but one, who applied with nipple discharge. All were evaluated by ultrasonography and a decision for operation was undertaken if the mass persisted for more than 4–6 weeks or there is suspected malignancy. Total excision was done for all. Histopathology revealed the mass was fibroadenoma in 3, ductal ectasia in 3, simple cyst in 3, papilloma in 1, capillary hemangioendothelioma in 1 and low grade cystosarcoma phylloides in one.

Conclusion: Breast lesions in children are usually benign and therefore, conservative approaches can be encouraged in most cases. Cosmetic concerns can be considered as an operative indication especially for adolescent age group. Persistent masses, with a suspicion for malignancy in particular, should be totally excised.

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P40: Long gap esophageal atresia successfully treated by foker's elongation technique: experience with two cases

O Uzunlua, Ş Emrea, R Özcana, İ Adaletlib, E Erdoğana and G Topuzlu Tekanta

Departments of aPediatric Surgery and bRadiology, Istanbul University, Cerrahpaşa Medical Faculty, Istanbul, Turkey

Aim: Long gap esophageal atresias are very rare congenital malformations. The ideal surgical procedure for the long gap esophageal atresia remains unresolved. Here we reported two cases of children with long gap esophageal atresia treated by Foker's Elongation technique.

Case 1: A 2000 g boy born at 36 weeks gestation with esophageal atresia and anal atresia abdominal x-ray showed nasogastric tube is in the upper esophagus at the level of the thoracic inlet and a gasless bowel. The first step approach consisted stamm gastrostomy and sigmoid diverting colostomy a gastric contrast study showed 4.5 vertebral bodies with proximal and distal pouches. Serial examination showed that gap was still too wideat the sixth month the CT scan study (by filling the gastrik and upper esophageal segment with air) noted that the gap was 3 cm. We applied Foker's elongation technique by a right thoracotomy progressive stretching of both esophageal segments by traction sutures; was performed during seven days. Patient were ventilated throughout theprocess. On the eight day primary anastomosis was carried out by right thoracotomy incision. There was no complication occured.

Case 2: The second infant was born 2800 g at the 37 gestational week with pure long gap esophageal atresia (3.5 vertebrae gap) without fistula. The upper pouch was above the thoracic inlet. Stamm gastrostomy was performed. After sixth month same CT Scan technique was performed gap was 5.5 cm. As in the first case, same procedure was carried out. There was no complication occured.

Conclusion: In our two cases with long gap esophageal atresia treated uncomplicated with Foker's elongation technique. Before surgery defining both esophageal ends, CT scan study is more safer than the physical examination.

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P41: Sons of Aphrodite

C Aldirmaz Ağartan

Department of Pediatric Surgery, Çanakkale Onsekiz Mart University School of Medicine, Çanakkale

Introduction/objective: Hermaphroditus, the son of Aphrodite (the goddess of love, beauty and sexuality) and Hermes, and Priapus, the son of Aphrodite and Dionysus, were examined from paediatric surgery perspective.

Materials and methods: Various archaeological and mythological resources, collected works, expert opinions and assistances were used while studying the subject.

Findings: According to the mythological legend, 15-year old Hermaphroditus travelled to Halicarnassus region, where his body blended with the nymph's body (who could not seduce him and preyed the gods to never part them) into one form, ‘a creature of both sexes’. Priapus was the other son of Aphrodite. According to the legend, jealous and revengeful Hera put her hand on Aphrodite's belly when she was pregnant to Priapus and cursed him with impotence, ugliness and foul-mindedness.

Conclusion: Mythological resources mention about a hermaphroditus with grown breasts and male genitals at puberty. This may be either a physiological or pathological gynecomastia case or an intersex case classified into sub-group of pathological gynecomastia. Although only a limited number of newborn priapism cases have been reported, birth history of Priapus (known with his huge genital structure) suggests that the problem is not limited to genital organs and that it reminds some syndromes underlined by phallus and possibly accompanied by some other abnormalities. Mythological stories may serve as interesting sources in making paediatric surgery education more enjoyable.

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P42: An uncommon cause for recurrent ovarian torsion: dysgerminoma

M Çağlara, Ç Ulukaya Durakbaşaa, A Başa, S Fettahoğlua, IE Zemherib, FB Çakirc, T Zenginkinetb and H Okura

Departments of aPediatric Surgery, bPathology, and cPediatric Oncology, S.B. Goztepe Research and Training Hospital, Istanbul

Aim: Ovarian torsion is relatively a rare cause for acute abdomen. There is an increasing tendency for organ-preserving surgical approaches in such cases. However, the risk of associated malignancy in a preserved ovary is an unresolved problem.

Case report: A 14-year old girl presented with acute abdominal findings. She had been operated on for ‘isolated’ ovarian torsion a year ago in another city. The ovary had been detorsioned and left intact. Color Doppler ultrasound findings were consistent with a torsioned right ovary. Tumor markers were negative. An emergency operation was undertaken. The right ovary was found to be torsioned 7200, quite edematous, thickened and larger than the other. Palpation did not reveal a clear mass lesion. It was detorsioned again and fixed. A wedge biopsy was taken considering the previous history. Histopathology revelaed dysgerminoma. A tertiary operation was undertaken 2 weeks later and a right salphingoopherectomy was performed. Histopathological examination was consistent with the first one and there was no evidence of capsular invasion. Nevertheless, the patient was accepted as Stage II because of previous biopsy and a chemotherapy regimen was started.

Conclusion: Isolated ovarian torsion is rare and should always raise the suspicion of associated malignancy. Tumor markers may yield a positive result helping the decision on type of surgery but this is not always the case. It might be quite difficult to decide about the presence of malignancy in a torsioned ovary at surgery. Although conservative surgery is to be the surgical option in these cases, a biopsy should be performed in suspicious cases. Moreover, the vital importance of close postoperative follow up including various radiological investigations cannot be underestimated.

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P43: Anorectal-vestibular fistula with normal anus

A Çaya, M İmamoğluc, M Yurtsevenb and H Sarihanc

Departments of aPediatric Surgery Avicenna Hospital, and Department of aAnesthesiolgy and cPediatric Surgery Karadeniz Technical University Medical Faculty

Anorectal-vestibular fistula with normal anus is a rare entitiy in the spectrum of anorectal anomalies. However higher incidences have been reported in Asian countries. There is lack of consensus in the literature on how to treat yhis anomaly.

A three months-old girl presented symptoms after her parents noted presence of stool at the vestibulum. on the physical examination, anus was in normal location and size. A vestibular opening was seen in the midline just below of the hymen. With insersion of an 8 Fr catheter through the vestibuler opening, a fistulous communication was found between the vestibuler opening and the anorectum. The patient was operated for primary repair of the fistula. operative procedure of choice was the primary anterior perineal approach without colostomy, that is excision of the fistulous tract along with anal wall below the internal opening and then pull-through of the anterior anal wall. Perineal incision was not performed.

Various surgical techniques with or without protective colostomy have been described for Anorectal-vestibular fistula with normal anus repair. But there is no consensus regarding surgical management of Anorectal-vestibular fistula with normal anus.

In the management of Anorectal-vestibular fistula with normal anus, primary anterior perineal approach without colostomy, is a safe options.

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P44: Scrotal inflammation following appendicectomy

C Panteli, M Svirkos, T Feidantsis, E Rachmani and A Zavitsanakis

1st Department of Pediatric Surgery, Aristotle University of Thessaloniki, ‘G. Gennimatas’ Hospital, Thessaloniki, Greece

Aim: Intraabdominal infectious complications in the form of abscess formation following appendicectomy in children are well recognized. An acute scrotum occurring postoperatively in a patient with appendicitis is a rare complication.

Materials and methods: An unusual case of a twelve-year-old with scrotal suppuration on day 3 following appendicectomy is described and relevant cases reported in the literature are reviewed.

Results: A comprehensive literature review yielded eight studies reporting on twelve boys of 4 to 15 years of age with acute scrotum following appendicitis. At the time of appendicectomy eleven children were found to have a perforated appendix while two had acute appendicitis. Open and laparoscopic appendicectomies were carried out in eleven and two children respectively. Acute scrotal manifestations occurred between two and ten days postoperatively and involved the right hemiscrotum in nine children or the left hemiscrotum in four children. Exploration was performed via a groin incision in all patients. A patent proceccus vaginalis (PPV) or a hernial sac was identified in eight children while in the remaining four children a PPV was either not visualised or not present. One case of a three-year-old girl with inguinal and labial suppuration following appendicectomy has also been reported. The outcome was good in all cases except for one ten-year-old boy who had an orchiectomy due to a non viable testis at the time of groin exploration.

Conclusions: Scrotal inflammation complicating appendicitis should be considered in the differential diagnosis of acute scrotum presenting after appendicectomy in children. In cases of acute scrotal symptoms and signs patients should be explored early to avoid the risk of testicular loss.

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P45: Intraabdominal cystic lymphangiomatosis with severe intestinal bleeding in newborn: case report

DB Embleton, A Narci, N Okur, M Uğraş, GN Köken, AA Tuncer, Ç Tokyol and S Çetinkurşun

Departments of aPediatric Surgery, bRadiology, cPediatrics, dGynecology and Obstetrics and ePathology, Afyon Kocatepe University Medical Faculty, Afyonkarahisar, Turkey

Introduction: Generalized cystic lymphangiomatosis is a rare congenital malformation of the lymphatic system. Fetuses whose lymphangiomas are detected on ultrasound in the first trimester should undergo karyotyping. Between 30 to 70% of such fetuses have chromosomal aberrations, particularly Down or Turner syndrome, and the outcome is poor. We reported a newborn girl with prenatal ultrasound diagnosis of intestinal anomaly presented with abdominal distension and intestinal bleeding and diagnosed as having intestinal cystic lymphangiomatosis.

Case: 31 week girl baby whose first prenatal ultrasonography revealed dilatation and hypo-hyperechogenicity of the large bowel and small intestine at 15th week was referred to our clinic postnatally with the suspicion of intestinal abnormalities. On admittance, the patient had massive abdominal distension and subcostal retractions. Hemorrhagic fluid was aspirated with paracentesis. Abdominal ultrasound revealed disseminated tubulonodular cystic dilatations in various sizes in submucosal-and intramural sites of the intestines and primary intestinal lymphangiomatosis was suspected. Because her lymphocytes did not grow in culture, chromosomal analysis could not be performed. Presence of severe bleedingdiathesis and widespread disease led to conservative treatment. The patient died on postnatal 7th day and postmortem abdominal biopsies revealed cystic lymphangiomatosis.

Discussion: Detection of intestinal hyperechogenicity and/or dilatation in prenatal ultrasonography and persistence of these findings during pregnancy is suggestive for pathologies such as meconium ileus, meconium peritonitis and intestinal atresia. Although rare, intestinal lymphangiomatosis may give the same ultrasonographic findings and should be kept in mind in patients whose prenatal US findings persist until birth.

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P46: Sacrococcygeal teratoma? Human tail?

A Bayraktaroğlu, S Çetinkurşun, A Narci, DB Embleton, Ç Tokyol, EÖ Boyaci and A Erdoğan

Departments of Pediatric Surgery and Pathology, Afyon Kocatepe University Medical Faculty, Afyonkarahisar

Introduction: Human tail is a midline defect which consists of adipose tissue, muscle fibers, vascular tissue and no bone connection. Usually it doesn't contain bone and cartilage tissue but there is also a report of a patient with four vertebrae in the tail in the literature. Human tail disease is seen rarely. Association of spinal dysraphism, tethered cord, teratoma, meningocele, spina bifida, and lipoma was seen with human tail. It may be the first sign of these pathologies. There are 2 types: pseudo-tail and true tail. Treatment of the human tail disease is total excision of the mass.

Case: The patient was 11 years old. He presented with complaints of pain and there was a mass in the sacrococcygeal region. Approximately 6×5 cm in size, it was containing a few masses of hard consistency. With the initial diagnosis of human tail, an magnetic resonance imaging (MRI) was performed. The mass had cystic components and it was not associated with the spinal canal and rectum. Spinal canal and the dorsal nerve roots were normal. AFP and B-HCG was normal. Operation was performed with an eliptical incision around the mass under general anesthesia; the mass was excised totally and by taking a piece of coccyx. Pathological examination revealed a cyst lined with keratinizing squamous epithelium; and skin appendages, cartilage, respiratory epithelium, fat and smooth muscle tissue was observed around the cyst wall. The diagnosis was mature cystic teratoma with these findings. The patient was discharged on the postoperative fifth day. Postoperative early complications weren't observed. There was no recurrence during the three-month follow-up.

Discussion: In our case, because of presence of a midline mass and the patient's older age, the mass was thought to be human tail. But the pathology of the mass came out to be sacrococcygeal teratoma. Presence of benign germ cell pathology is surprising at this age.

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P47: Sort of a ‘Sword-Swallowing’ in a newborn

Ç Ulukaya Durakbaşa, A Baş, HM Mutuş, M Sert and H Okur

Department of Pediatric Surgery, S.B. Goztepe Research and Training Hospital, Istanbul

Aim: Foreign body (FB) ingestion is a recognized problem because of children's tendency to place objects in the mouth. However, neonatal FB ingestions are very uncommon. This report describes a neonate who ingested a sharp FB.

Case report: A-23-day old newborn was referred with a history of nail ingestion. The nail was placed into the baby's mouth by a 4-year old brother and the event was seen and reported to the parents by a 7-year-old sister. Upon admission, 4 h after the event, the physical examination of the neonate was normal. Direct radiography revealed the object on the gastric location. There were no clinical or radiological signs denoting disruption of esophageal continuity. Due to the age and size of the baby an emergent operation was undertaken via a laparatomy incision and a-6 cm nail was removed from stomach by way of gastrotomy. The postoperative course was uneventful and she was discharged on the 3rd postoperative day. The long term follow up at one year is normal.

Conclusion: Esophageal impaction of FBs in neonates is a rarely reported phenomenon. However, ingestion of a sharp object almost at the size of the stomach itself is so seldom that it has never been reported. Miraculously, the passage of nail through the esophagus did not cause esophageal rupture in the presented case. It probably found its way through the esophagus just like a sword swallowing process. The event can certainly be considered a form of child neglect.

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P48: A rare cause of acute abdomen in children: isolated torsion of fallopian tube

S Bilicia, M Göksua, M Meleka, C Akgünb, B Begera and V Avcia

Departments of aPediatric Surgery and bPediatrics, Yuzuncu Yil University School of Medicine, Van

Introduction: Adnexial torsion is frequently seen, but isolated fallopian tube torsion is rare. Although prompt diagnosis and timely surgical treatment are vital to salvage the organ, it is difficult to detect until the occurrence of tubal destruction. In this paper was presented a case admitted with sudden left pelvic pain and diagnosed with fallopian tube torsion.

Case report: A 14 year old single girl with sudden left pelvic pain has admitted to another clinic one day ago but undiagnosed. On her admission to our clinic, she had severe colicky pain without accompaniment of vomiting in left pelvic area. Physical examination revealed defence, rebound and susceptibility in left lower quadrant and suspect palpable mass in the same region. A mass with regular margins, containing cystic areas but not exactly identified its connection was reported in USG. A cystic mass lesion (10×13 cm) with smooth margins which adjacent to the left ovary were reported in abdominal computed tomography. On operation, very enlarged, necrosed with damaged perfusion and torsioned left tuba was determined. Distal partial salpingectomy was performed.

Conclusion: The diagnosis of fallopian tube torsion is difficult because it has not a specific clinical finding, imaging method and characteristic laboratory finding. Therefore, it should be taken into account in all adolescent admitting with sudden unilateral pelvic pain.

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P49: Invasive Aspergillus infection localized to the gastric wall

İ Karamana, A Karamana, E Cengiz Boduroğlub, D Erdoğana and G Tanirc

Departments of aPediatric Surgery, bPathology and cPediatric Infectious Diseases, Dr. Sami Ulus Children's Hospital, Ankara

Invasive aspergillosis is seen most commonly in patients with immune disorders and usually in the lung. Local invasive aspergillosis of the gastrointestinal system is quite rare. A 13-year-old female without immune deficiency presented with a clinical picture of acute abdomen due to full-thickness necrosis of the gastric fundus. The necrotic gastric wall was excised and the stomach repaired. The pathology revealed a gastric ulcer with invading Aspergillus hyphae and spores. Aspergillosis is an opportunistic infection and its spores cannot survive in normal gastric mucosa. We believe that the Aspergillus spores in our case grew on a background of gastric ulcer and caused wall necrosis and that the surgical treatment possibly provided a cure as it had stayed localized to the gastric wall.

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P50: Attention for liver abscess in premature newborns after umbilical vein catheterisation

O Bosnali, S Moralioğlu, O Pektaş and AC Celayir

Department of the Pediatric Surgery, Zeynep Kamil, Women and Child Deseases, Education and Research Hospital

Background/purpose: Liver abscesses are rare in neonates with the majority resulting from an ascending infection via the umbilical and portal veins, hematogenous spread, or via the biliary tree, or via direct contiguous spread from neighboring structures. The aim of this study was to draw attention to liver abscess caused by feeding umbilical catheter in newborns.

Materials and methods: Clinical records of the case were reviewed retrospectively.

Results: A premature newborn had been admitted to the NICU with the diagnosis of hydrops featalis and prematurity. Umbilical catheter had been placed to infuse TPN. When 9 days after, thrombocytopenia, leucocytosis, and abdominal distension has been developed, abdominal ultrasonography (US) was obtained. US revealed two cystic cavities (32×18 mm and 11.4×4.6 mm in size) which cannot be distinguished from liver abscess, hematoma, or cavernous hemangioma. Umbilical catheter had been withdrawn as it is supposed the possible site of infection. Since her clinic was detoriated, she was consulted by our clinic. On physical examination, there was abdominal distension, hepatomegaly, and liver tenderness. Second US revealed a compound cystic cavity which 45×35 mm in size. Abdominal computerized tomography (CT) with IV contrast confirmed the diagnosis of liver abscess. She had operated and abscess was drained. On the 18th postoperative day, with no leucocytosis, good oral feeding, and steady weight gain, she discharged without problem.

Conclusion: With the increasing number of hospitalized prematures in NICU, the number of this rare complication has been increasing. The exact position of umbilical infusion catheter should be verified by radiological before any hypertonic solution has been given to prevent from this rare complication.

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P51: An endocrin tumor mimicking acute apendicitis: report of a rare case

O Bosnali, S Moralioğlu, C Gül and AC Celayir

Department of the Pediatric Surgery, Zeynep Kamil Women and Child Deseases Education and Research Hospital

Purpose/background: Appendiceal endocrine tumors are separated into 2 main groups: classic endocrine tumors and goblet cell carcinoids. Treatment in goblet cell carcinoids is right hemicolectomy after the initial appendectomy. However, definite treatment in classical endocrine tumors in benign behavior is still controversial. The aim of this study was to discuss the surgical treatment of ‘well differentiated endocrine tumor with uncertain behavior’ (WDETmUB) in a child who operated with the diagnosis of acute abdomen/acute appendicitis at our institution.

Materials and methods: Clinical record of the case was reviewed retrospectively. Clinical history and physical examination findings, laboratory and radiological findings, per-operative macroscopic presentation, and pathological results were evaluated.

Results: 12-year-old girl was admitted to our clinic with abdominal pain lasting for four days. Physical examination revealed right lower abdominal tenderness and guarding, and no palpable abdominal mass. WBC count was 29 700; otherwise laboratory and radiologic findings were normal. Presumed diagnosis was acute abdomen/acute appendicitis. She was operated and an appendicecal mass covered with omentum was found. Mass was excised with its covering omentum just 0.5 cm above of the ceacal taenia. A solitary lymph node in ileal mesentery was excised. Postoperative laboratory analysis were revealed that CA-125 : 42.9 U/ml, sedimentation rate ½; 62%, and sedimentation rate 1; 83%. Pathological examination of specimen revealed no serosal infiltration by tumor, no tumor cells in surgical borders, omentum, and in lymph node. It has reported as WDETmUB of appendix.

Conclusion: In cases with total appendicecal tumoral involvement, even suggesting advanced malignancy by macroscopically, initial appendectomy with mesenteric lymph node sampling may sufficient to prevent from unnecessary right hemicolectomy.

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P52: Postoperative intussusception

M Tuşat, S Samut, Hİ Çakmak, D Başar, S Sağ, F Tandoğan, M İmamoğlu and H Sarihan

Department of Pediatric Surgery, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey

Background: Intussusception, which is one of the causes of early intestinal obstruction following a surgical procedure, occurs in the first two weeks in %90 of the cases. It is often lately diagnosed because the symptoms such as ileus, nausea and vomiting are thought to be related with the primary pathology. To find out the specific features that would allow early diagnosis and treatment, files of 9 patients who had intussusception after several surgical procedures between 1993 and 2010 are evaluated.

Materials and methods: The ages of the cases ranged from 6 months to 4 years. 6 were male and 3 were female. The procedures included 2 Nissen funduplications, 2 ladd operations for classic type malrotation, 1 ganglyoneuroblastoma resection, 1 bilateral inguinal hernioraphy. In 5 cases discomfort, abdominal pain was followed by an increase in the decreased NG drainage; and in 4 cases discomfort and abdominal pain attacks were followed by vomiting and the direct abdominal graphy showed the signs of small intestine obstruction. Six cases suspected to be intussusception underwent ultrasonography and the diagnosis was confirmed. The other 3 cases underwent operation with diagnosis of brid ileus, and intussusception was noted.

Results: The onset of the symptoms (discomfort, abdominal pain, vomiting or NG drainage increase) changed between 2–12 days (mean 4.7 days). None of the cases had bloody-mucous stools. In 3 cases the mass was palpable. The duration between the onset of the symptoms and the operation was 1–4 days (mean 25 days). The intussusception was ileoileal in 5, jejunojejunal in 2, jejunoileal in 1 and ileocolic in 1 case. Manual reduction was performed in all cases.

Conclusion: Palpation of the typical mass or bloody-mucous stool is rare. However discomfort and crying in infants and abdominal pain attacks in older children seem to be the first signs and they must be thought to be the clinical features in this type of intussusception. Ultrasonography would help us for the early diagnosis.

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P53: Gastric heterotopia as a polipoid mass in jejunum causing recurrent intussusception

B Çalişkan, A Güven, C Atabek, S Demirbağ and İ Sürer

Department of Pediatric Surgery, Gulhane Medical Military Academy

Introduction: Heterotopic gastric mucosa (HGM) is the gastric mucosa which is located outside the stomach inthe small intestine. It is rare and found incidentally when examining the reason of gastrointestinal bleeding, perforation, and intussusception.

Case report: A 14-year-old boy was admitted to the hospital with the history of episodes of colicky abdominal pain, nausea, and vomiting for 9 months. Physical examination revealed tenderness of both lower quadrants. Laboratory results were within normal limits. Abdominal ultrasound showed intussusception of bowel segments in the left lower quadrant. At laparotomy, jejunojejunal intussusception was found 20 cm distal to the ligament of Treitz. After manual reduction, an intraluminal polypoid lesion was palpated 15 cm distal to the ligament of Treitz. After performing enterotomy a polypoid mass with 5 cm diameter was detected. 7-cm segment of jejunum was resected together with polypoid lesion and primary jejunojejunal anastomosis was performed. On histopathological examination, there were well demarcated zones of gastric mucosa adjacent to jejunal mucosa.

Discussion: The common clinical picture is related to intermittent intussusception of the lesion at about 14 years age. The treatment of HGM is surgical resection of the involved segment. Although gastric heterotopy of the small intestine is a rare clinical condition, if there is unexplained gastrointestinal tract bleeding, perforation, and recurrent intussusception, the possibility of intestinal HGM should be kept in mind. In the long-term follow-up, the major problem is recurrence of HGM adjacent to the resection border or another segment of the small intestine.

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P54: Cystic liver mass does not always mean hydatid cyst in endemic areas

A Yildiz, M Akin, N Sever, A Canmemiş, ÇA Karadağ, H Barhoom and Aİ Dokucu

Department of Paediatric Surgery, Şişli Etfal Training and Research Hospital

Undifferentiated embryonal sarcoma (UES) of the liver is a very rare entity. This rare neoplasm accounts for approximately 9 to 13% of all hepatic tumors in paediatric ages. Less than 60 cases of paediatric UES have been reported in the literature. UES has no specific clinical or laboratory features. At computed tomography images, the tumour typically appears as a large, solitary, predominantly cystic mass with well defined borders.

This cystic appearance of UES can be cause a misdiagnosis with hydatid cyst very easily due to rarity of UES and more common seen hydatic cyst especially in endemic areas. We present a eight year old male case with cystic mass in liver, which was misdiagnosed and treated as hydatic cyst.

He was admitted with respiratory distress to our institution. Although initial diagnosis was hydatid cyst, radiologic imaging was suggestive of other possible pathologies. Percutaneous sample was obtained. Cytological examination did not confirm the hydatid cyst. Because of progressive respiratory deterioration, urgent abdominal operation was performed. Gross haemorrhagic cystic lesion was discovered and evacuated. Pathological examination revealed UES.

Because of pure cystic appearance of UEA in liver can be suggestive of benign similar pathologies, and cause delaying or misdiagnosis in such hydatic areas.

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P55: Isolated imperforate anus in newborn twins: a rare case report

S Bilicia, M Göksua, M N Acarc, O Tuncerb and B Begera

Departments of aPediatric Surgery, bPediatrics and cMaternal and Child Diseases Hospital, Yuzuncu Yil University School of Medicine, Department of Pediatrics, Van

Introduction: Anorectal malformation (ARM) is a congenital disease that seen of 1 in 2500–5000 live births and has familial occurrence. There is additional anomaly 50–60% of the cases with ARM. Isolated perforated anus in newborn twins is a rare situation. In this report, twin newborns with imperforated anus are presented.

Case: A 32 years old mother delivered a male twin at the third gestation normally by vaginal route and one of the male twins is 2200 g and the other is 2300 g. It was diagnosed pearl sign at the examination of the perineum of the twins referred to our clinics after noticed that they have no anus. However, it was not noticed fistula at the perineal area of the twins. It was not noticed additional anomalia at the end of the other systems and radiologic examinations. Anoplasti was applied to patients with low type (infralevator) ARM diagnosed in their invertograms after 18 h later from delivery. The patients without any complication were discharged after 3 days later after oparetion.

Conclusion: It was reported only 5 twin newborn with isolated ARM at the literature until now. All patients were monozygot that have anal stenosis in 3 twins, imperforated anus in 2 twins. It was not noted male twin babies with imperforated anus without fistulae such cases represented at the English literature. The incidence of ARM's is increasing among brothers except for twins. Many factors have been implicated from the etiology of the ARM until now. becouse incidence of diseases such as Down Syndrome in the family is much more, genetic factors in etyopathogenesis of this disease is thought to be effective. We thought that effective genetic factors at developing of ARM were better understood reporting twin babies with imperforated anus as this report.

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P56: An unusual presentation of labial fusion: urinary retantion and hematocolpos in a 20 year-old girl

HS Özcana and R Vargün Yildizb

Departments of aObstetrics and Gynecology and bPediatric Surgery, Ankara Güven Hospital, Ankara

Introduction: Labial fusion is most commonly seen in prepubertal girls. It can also presented with urinary incontinence and voiding problems at the postmenopausal age group. Very seldom, labial fusion can be seen in young females as menstrual and/or urinary problems.

Case report: A 20-year-old girl was admitted to emergency department with a complaint of severe abdominal pain and voiding-difficulty for two weeks. Her menstrual flow was prolonged and scanty for the last 3 months. She had no known history of trauma or sexual abuse. Pelvic examination revealed globus vesicalis and complete labial fusion. Ultrasonography showed hematocolpos and urinary retantion. Labial fusion was separated under general anesthesia. Postoperatively local estrogen ointment was used. After one month, she had recurrence of labial fusion and surgery was indicated. She had no recurrence on her 6 months follow-up.

Discussion: Labial fusion is extremely rare in pubertal girls. Genital trauma, sexual abuse, chronic inflamation due to vulvovaginitis are major causative factors. Labial fusion must be considered and a careful genital examination is indicated in pubertal girls who present with complaint of urinary retantion, voiding or menstrual flow difficulties.

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P57: Blunt laryngeal injury presenting with pneumotoraks and pneumomediastinum

A Narci, DB Embleton, A Ayçiçek, F Yücedağ and S Çetinkurşun

Departments of Pediatric Surgery and Otorhinolaryngology, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar/Turkey

Aim: Injuries due to traffic accidents are frequent in childhood and they have high mortality and morbidity. Laryngeal injury due to a traffic accident is a rare pathology and might be missed if not suspected. Here we present a laryngeal injury in a child after a blunt chest trauma during a traffic accident that presented with pneumomediastinum.

Case: Fourteen years old girl was referred for pneumomediastinum after a motor vehicle occupant injury. Her physical examination was normal except edema and tenderness on the cervical area and hoarseness. Chest tomography revealed pneumotorakx, pneumomediastinum and pneumomediastinum was increased during her hospital course. Direct laryngeal examination and cervical tomography revealed a laryngeal fracture. Fracture was repaired and tracheotomy was performed. She was discharged on postoperative 7th day. Tracheotomy tube was removed on postoperative 15th day. Her hoarseness, although decreased, still persists.

Conclusion: Pneumomediastinum is a rare result of a laryngeal fracture and if not suspected, fracture can be easily missed. It should be kept in mind after blunt cervical trauma with pneumomediastinum and/or pneumothorax. Although direct endoscopy is usually diagnostic, cervical tomography supports the diagnosis.

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P58: Pyogenic granuloma: a rare case of an infantile intraoral lesion

S Karacay, AID Ekincia, GÇ Erdağb, S Bilgenc, S Sözübir and A Vitrinelb

Departments of aPathology, bPediatrics and cAnesthesia, Yeditepe University, Faculty of Medicine, Pediatric Surgery, Istanbul

Introduction: Pyogenic granuloma (PG), is a non neoplastic inflammatory hyperplasia that results as a respond to various stimuli such as chronic local irritation, trauma, hormonal alterations, bone marrow transplant and graft reactions. In this presentation, the second youngest case of intraoral PG in literature is reported.

Case: A four month old male baby is referred to our clinic with the complaints of erythema and swelling at the gingival level which was first encountered two months ago before his admission by his mother. At physical examination, a soft, hyperemic mucosal lesion which protruded from the upper gingival floor was observed. Patient was prepared for excisional biopsy after the examination revealed no additional problems. Routine blood counts and other biochemical parameters were found to be normal. The histopathologic examination after the eventless full excision revealed, closely packed blood vessels of capillary size with open lumens within a collagen rich matrix beneath an intact mucosal layer. Granulomatous type PG was diagnosed. The excision site recovered and the post operative period was eventless.

Discussion: PG is a benign, acquired, vascular neoplasm of the skin and mucous membranes. Lesions are divided histologically into three groups: granulomatous, fibromatous and giant cell. Gingiva is the commonest intraoral site as in our case but this localization is specific for the older age group rather than infancy. As a conclusion, PG should also be kept in mind when hemangioma like lesions of oral cavity of infancy are encountered.

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P59: Community acquired methicillin-sensitive staphylococcus aureus invasive infection in a preschooler

C Panteli, E Rachmani, T Feidantsis, M Svirkos and A Zavitsanakis

1st Department of Pediatric Surgery, Aristotle University of Thessaloniki, ‘G. Gennimatas’ Hospital, Thessaloniki, Greece

Aim: Community acquired S. aureus infections are increasing worldwide. Community acquired Methicillin-sensitive S. aureus (CA-MSSA) is a rare cause of multifocal, severe disease in otherwise healthy children. An unusual case of CA-MSSA bacteraemia is described.

Case: A four-year-old girl presented with a swollen left thigh and a febrile illness of 24 h. On admission, she was pyrexial, tachycardic and tachypnoeic with a tender, erythematous left thigh and difference of girth of 4 cms. Laboratoty tests showed elevated WBC, ESR and CRP. Triplex US revealed femoral and popliteal vein thrombosis while US showed quadriceps pyomyositis. The patient was started on Ceftriaxone, Vancomycin and low molecular weight heparine. On diagnostic work up, hypercoagulation profile and abdominal CT was normal; chest CT findings were consistent with multiple septic emboli. Blood culture yielded Methicillin-sensitive S. aureus. Fever persisted for ten days and acute phase reactants remained elevated for forty days. The patient completed a four week course of intravenous Vancomycin and was discharged home on oral antibiotics for another three weeks. On follow up, she was clinically well; triplex US showed resolution of deep vein thrombosis and chest CT confirmed improvement of pulmonary involvement.

Conclusion: Deep vein thrombosis should be considered in children presenting with musculosceletal infections; the association with respiratory symptoms and abnormal pulmonary findings should raise suspicion of multifocal S. aureus disease. This condition is rare, but carries a high mortality; therefore, early recognition and initiation of aggressive treatment may be life saving.

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P60: A very rare pathology in childhood: adenomyoma of gallbladder

A Temiza, P Oğuzkurta, SS Ezera, E İncea, G. Erbayb, F Kayaselçukc and A Hiçsönmeza

Departments of aPediatric Surgery bRadiology and cPathology, Başkent Üniversitesi Faculty of Medicine, Ankara, Türkiye

Aim: Adenomyomatosis which is considered as a proliferative and degenerative disease of gallbladder commonly affects adult patients in fifth and sixth decades. It has been observed in 2–8% of cholecystectomy specimens of adults. In contrast it is very rare in children. There are only four cases previously described in children in English literature. Here we presented a case with the diagnosis of gallbladder adenomyomatosis (GBA).

Case: A twelve-year-old boy who was evaluated for hypercholesterolemia at the department of pediatric gastroenterology was referred to our department because of pathologic ultrasonographic findings of the gall bladder. He had no compliants previously. Physical examination was normal. Thickened gallbladder wall, trabecular pattern and cystic formation were detected by ultrasonography (US). Laparoscopic cholecystectomy was performed with the preoperative diagnosis of chronic cholecytitis or gallbladder adenomyomatosis. Postoperative period was uneventful. He was discharged with full oral feeding on the first postoperative day. Pathological examination revealed thickened gallbladder wall with muscular hypertrophy and sinusoidal formation. Pathologic examination resulted as GBA.

Conclusion: GBA usually defined with pathologic examination of cholecystectomy specimens during postoperative period. GBA is rarely symptomatic but usually is detected incidentally. Ultrasonographic and magnetic resonance imaging features are specific. Although it is considered as a benign lesion, metaplastic, precancerous and cancerous changes associated with GBA have been reported. GBA is very rare in children, cholecystectomy should be performed when the imaging findings that indicate adenomyomatosis are present.

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P61: Cantrell's syndrome: report of a patient with atypical variant

G Karagüzel, S Demirezen, N Arslan and M Melikoğlu

Department of Pediatric Surgery, Akdeniz University School of Medicine, Antalya, Turkey

Background/aim: Cantrell's Syndrome is a rarely seen constellation of malformations having different variants and high risk for mortality. Herein, we aimed to present a hitherto variant of Cantrell's syndrome to discuss its clinical management.

Case: A male baby weighing 1040 g was born via cesarean section at 27 weeks' gestation because of pretem labor. Serial prenatal ultrasounds were interpreted as gastroschisis without other abnormality. Physical examination in the delivery room showed thoracoabdominal deformity, left diaphragmatic defect, a ventral midline abdominal wall defect of 9 cm from midsternum to suprapubic area. Left lung, heart, liver, stomach, small and large bowels, spleens (polysplenia) were all eviscerated. First, left diaphragmatic defect was repaired using PTFE greft after reduction of left lung into thoracic cavity. We planned staged repair for abdominal wall defect and eviscerated organs were inserted into a silo shaped greft. The patient died two hours after surgery because of severe cardiopulmonary failure.

Conclusion: It was suggested that, beside associated malformations, severe mesodermal defect located at ventral midline was responsible for fatal outcome. In antenatal period, careful and systematical obstetrical evaluation should be performed to establish both early and accurate diagnosis in such patients. Medical abortus should be considered as a reasonable alternative such patients because of high mortality.

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P62: The effectiveness of preoperative percutaneous drainage in giant mesenchymal hamartoma; case report

B Çalişkana, A Güvena, W Padshaha, B Altana, C Atabeka, B Ustunsozb and İ Sürer a

Departments of aPediatric Surgery and bRadiology, Gulhane Military Medical Academy

Introduction: Although mesenchymal hamartomas are the second most common benign tumor of the liver in the pediatric age group up to date only 200 cases reported in the literature. They are predominantly cystic, solitary or multifocal developmental anomaly. Approximately 85% of affected children are presenting before the age of 3 years.

Case: The patient was an asymptomatic 17-month-old male infant, in whom a large intra-abdominal mass was incidentally detected on physical examination at the time of accidental blunt injury. On palpation, the liver was firm, painless and hard which was extending down to the pelvis. Routine laboratory tests and alpha fetoprotein (AFP) levels were normal. Abdominal magnetic resonance scanning demonstrated a large solid and cystic mass with 14 cm diameter was located in 2, 5, 6, 7 and 8 segment of the liver.

Result: After clinical diagnosis, due to huge cystic mass which was compressing all vital vascular tree initially treated with percutaneous catheterization under ultrasonographic guidance 500 cc yellowish liquid was aspirated. The catheter was left in place for one week 50 ml of serous non biliary liquid discharged daily. Laparatomy with total mass excision was performed. The mass was well-circumscribed from the surrounding liver tissue but not encapsulated. On the cut surface, the central region of the mass was predominantly occupied by yellow-whitish, translucent liquid but the wall was very thick. The cystic mass was totally excised from liver with bovie. Ligasure, argon laser were not useful at the dissection due to very thin liver tissue around the cyst. The pathological result was mesenchymal hamartoma.

Conclusion: Preoperative percutaneous drainage may reduce the size of the mass and provide more exact borders so facilitate the total excision more easily.

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P63: A rare union: ileal duplication cyst and diverticulum with Meckel's diverticulum

A Sayana, A Arikana, T Özdemira, H N Özera, M Cana, F N Narlia and Ü Bayolb

aClinic of Pediatric Surgery and bPathology Laboratory, Tepecik Educational and Research Hospital, Yenisehir, Izmir

Aim: Gastrointestinal duplications, diverticulums and segmental intestinal dilatations are split notochord anomalies. However, the union of these anomalies with Meckel's diverticulum is seen rarely. It's aimed to emphasize the histopathological properties and embryological origins of these anomaliesby presenting a case treated in our clinic.

Materials and methods: Two-month intervals, the last two days the last 24 h of continuous abdominal pain, and becoming attached to 6-year-old male patient was admitted to our clinic with complaints of vomiting were hospitalized. Taken with the patient standing abdominal x-ray, abdominal ultrasonography (USG) and computed tomography (CT) as a result of the surgery patients were taken. Operative findings and histopathological features of the part extracted retrospectively analyzed.

Findings: The patients with abdominal x-ray of the right lower quadrant abdominal middle line and the shadows were of increased gas, USG and CT of the cystic mass was found. During the operation, 5 cm. far from ileocaecal valve proximally on the antimesenteric diverticulum 1 cm. in length, this approximately 20 cm. proximal from mezo cystic mass 3 cm in diameter and approximately 10 cm. proximal to the 1.5 cm. Meckel's diverticulum was found in length. Meckel's diverticulum far from ileocaecal valve to the proximal 2 cm segment of the bowel was removed and ileoileostomy. Postoperatively, patients are not the problem of an ileal segment from Meckel's diverticulum containing ectopic mucosa, ileal duplication cyst and diverticulum were.

Result: Split notokord abnormalities with the incidence of additional abnormalities is 25%. Rate of Meckel's diverticulum, although at least in addition to the anomalies that may lead to confusion and anomalies noted in diagnosis.

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P64: Subcutaneous central catheter away from eyes for 13 years

H Duran Çete and S Küpeli

Division of Pediatric Surgery and Pediatric Onkology, Children Disease Hospital, Diyarbakir, Turkey

Subcutaneous central port catheter is frequently used when long term intravenous treatment is necessary. Beside it is ease of use, port catheter shows some mechanical disfuncionalities (breaking, separation, tangling, switching and related embolus) and some complications, such as infection, plugging, which is related with thrombotic occlusions. For these reasons, catheter should be carefully used.

We present a 15-year-old boy who was under chemotherapy for Wilms tumor, had a subcutaneous port catheter around thirteen years ago. This patient was under remission, visited oncology policlinic for his check up and while his lung X-ray had been taken, the forgotton port catheter was seen.

The X-ray showed that parallel to the patient's growth, the catheter's tip got out off from the right atrium and end up under right clavicula, also the last three centimeter of catheter, toward the end, was broken. The catheter was taken off surgically without any complications.

Port catheters are commonly used patient with cancer and if it is not used properly, it can create serious morbidite.

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P65: A rare cause of intussusception in children: mucinous cystadenoma of the appendix

OZ Karakuşa, M Özçetinb, Ç Atilganc and A Müslehiddinoğlud

aDepartment of Pediatric Surgery, Maternity and Children's Hospital, bDepartment of Pediatrics, Gaziosmanpaşa University, Medical School, cDepartment of Anesthesiology, Maternity and Children's Hospital and dDepartment of Pathology, State Hospital, Tokat, Turkey

Although intussusception is a common cause of intestinal obstruction in children intussusception of mucinous cystadenoma (MCA) of the appendix characterized by distension of the lumen due to accumulation of the mucoid substance is rarely reported. Diagnosis of MCA usually is made in the operation. In these cases, as a general approach, appendectomy is performed for cystadenoma and right hemi-colectomy is recommended for cystadenocarsinoma. However, the type of surgical treatment is related to the dimensions and histology of the lesions. A 12-year-old boy admitted to our clinic with symptoms of mobile and painful mass in the right upper quadrant of the abdomen. Abdominal ultrasonography showed intussusception as well as a large, cystic and solid structure extending from cecum to transverse colon. Reduction of intussusception and right hemi-colectomy was performed subsequent to laparotomy. Pathologic diagnosis was reported as MCA. Although MCA extremely rare seen it always should be keep in mind in the differential diagnosis of intussusception and intra abdominal mass, especially in child patients with abdominal pain and distension.

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P66: A clinical review of nonpalpable testes

YA Baltrak, YH Çavuşoğlu, A Karaman, İ Karaman, D Erdoğan and İF Özgüner

Department of Pediatric Surgery, Dr.Sami Ulus Maternity and Children's Hospital, Altindağ, Ankara, Turkey

Abstract: With the routine usage of laparoscopic surgery, the approach to nonpalpable testes has significantly changed. In this study, we aim to evaluate the place of nonpalpable testes within our daily clinical practice and our approach.

Materials and methods: The records of patients admitted to the pediatric surgery unit between October 2008 and December 2010 with complaints of nonpalpable testes or undescended testes were retrospectively studied.

Results: Out of the 14 014 patients admitted to our clinic during the term of the study, 1231 (9%) had complaints of absence of testes from the scrotum. Of these patients, 502 (40.8%) were diagnosed with nonpalpable or undescended testes. Sixty-one (12.2%) out of the 502 patients had nonpalpable, and 441 (87.8%) had undescended testes. Fifty-three out of the 61 nonpalpable patients were screened; 42 were abdominal and scrotal USG imaging, seven lower abdominal MR imaging, two lower abdominal CT imaging, and two were testicular scintigraphy imaging. Ultrasound found testes in only seven of these examinations. Surgery was recommended to 61 patients with nonpalpable testes, but only 32 (52.5%) of them received surgery. Seventeen received laparoscopic surgery, and 15 of them underwent inguinal exploration. Ten of the 32 patients received orchiopexy (three patients had laparoscopy-aided orchiopexy, three received laparoscopy followed by open orchiopexy, and four patients received orchiopexy following inguinal exploration), ten received orchiectomy, and eight received excision of necrotic tissues. Four patients had no such tissues. USG had an accuracy rate of 11/12 (92%).

Conclusion: What is our protocol in reaction to these results? Open surgery will be planned if the testes are palpable in undescended testes. If the testes cannot be palpated, the testes will be sought by ultrasound because it allows quick, non-invasive access with a high rate of accuracy, and pre-op data can be obtained about inner genitalia and canalicular testes are detectable in obese patients. Explorative laparoscopy will be planned in the presence of intraabdominal testes or in the absence of testes. During laparoscopic surgery:

No inguinal exploration will be needed in case of blind-ending cords and veins.

Inguinal exploration will be performed in the presence of cord and/or vein structures extending into the internal canal.

Laparoscopic orchiectomy will be performed in the presence of atrophic intraabdominal testes.

Laparoscopy-aided orchiopexy or Fowler-Stephens orchiopexy will be performed in the presence of intraabdominal testes.

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P67: Presacral epidermoid cyst: report of a case

F Canpolat, D Erdoğan, YH Çavuşoğlu, İF Özgüner, HA Maden and E Cengiz Boduroğlu

Dr. Sami Ulus Maternity and Children's Training and Research Hospital, Ankara, Turkey

A 16 year old boy with known celiac disease was incidentally diagnosed to have presacral mass which was removed totally. Histopathologic examination revealed an epidermoid cyst. Epidermoid cysts are slow growing tumors derived from embriyological structures with desquamation of the epithelial cells. These are benign inclusion cysts of the skin usually seen on the face, scalp and neck. They are very rarely located in the presacral region and all the reported cases are adults. To best of our knowledge there is no reported pediatric case in the English literature. Here we present a case operated for presacral mass which was diagnosed as epidermoid cyst with the relevant literature.

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P68: Mean platelet volume in the diagnosis of acute appendicitis in children

S Bilicia, T Sekmenlib, M Göksua, M Meleka and V Avcia

aDepartment of Pediatric Surgery, Medical Faculty, Yuzuncu Yil University, Van and bDepartment of Pediatric Surgery, Hospital of Children, Diyarbakir

Introduction/purpose: The clinical diagnosis of acute appendicitis (AA) in children is still problematic and negattif explorasyon rates are still high. Many studies investigating the diagnostic value of laboratory inflammatory markers have been carried out in recent years. In this study, we aimed to investigate the diagnostic value of MPV in acute appendicitis at childhood

Materials and methods: Our study was carried out with 100 patients diagnosed as acute appendicitis chosen retrospectively 2009 and 2010, and 100 healthy individuals.

Results: While the acute appendicitis (AA) group included 44 girls and 56 boys, the control group included 46 girls and 54 boys. While MPV was found to be lower than normal in 48 cases in the AA group, it was normal or higher than normal in 52 cases. In the control group, while MPV was found to be lower than normal in 13 cases, it was normal or higher than normal in 87 cases. MPV was significantly lower in the AA group compared to the control group (P<0.001).

Conclusion: Our study indicated that MPV significantly decreased in paediatric AA patients. Hence, we believe that taking the MPV decrease into consideration along with the WBC elevation would be beneficial in patients with suspicion of AA. However, the fact that these studies should be carried out with higher patient numbers and prospectively should not be ignored.

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P69: Sirenomelia: a rare anomaly

A Karamana, M Doğanb and M Demircana

Departments of aPediatric Surgery and bRadiology, Inonu University, Faculty of Medicine

Sirenomelia is a very severe condition characterized by fusion of the lower limbs, single umbilical artery, and severe malformations of the urogenital and lower gastrointestinal tract. Sirenomelia is a rare anomalie, affecting approximately 1.5–4.2 cases per 100 000 births. We describe a newborn with clinical features of sirenomelia including one lower limb with medial position, absence of leg and foots, esophageal atresia/tracheoesophageal fistula, absence of genitalia, absence of anal orifice, myelomeningocele and single umbilical artery. In the laparotomy findings, duodenaland colonic atresia and absence of internal genitalia were observed. Bladder was filled with urine. At operation, dividing the fistula, end-to-end anastomosis between the esophageal segments, end-to-end anastomosis between the duodenal segments, end colostomy and vesicostomy were performed. The baby died 24 h after operation due to respiratory insufficiency. Prenatal diagnosis should focus efforts on discerning the extent of dysgenesis so that parental decisions can be made to continue the pregnancy and postnatal interventions to treat the congenital anomalies associated with sirenomelia can be planned.

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P70: Why laparoscopy? Omentum torsion, a rare cause of acute abdomen

G Küçük, G Göllü and A Yağmurlu

Department of Pediatric Surgery, Ankara University School of Medicine

Aim: The aim is to present a case with omentum torsion, a rare cause of acute abdomen.

Case: A nine-year old boy with abdominal pain and vomiting for two days was administered. Physical examination revealed obese abdomen with abdominal tenderness around and at the right side of umbilicus. Acute phase reactants were increased and ultrasonography revealed increased ecogenity in mesenteric fat tissue. Laparoscopic exploration revealed inflamated appendix vermiformis together with omentum torsion at right middle-upper quadrant. After laparoscopic appendectomy, necrotic omentum was removed from umbilicus by extending the incision by 2 cm and omentum was excised. The child was fed on sixth hour postoperatively and discharged on the next day. The patient has no problem since his operation.

Result: Explorative laparoscopy provides early treatment of accompanying intraabdominal pathologies in children with right lower quadrant pain with inflamated appendix vermiformis.

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P71: Persistent Müllerian duct syndrome with transverse testicular ectopia; two brothers

M Arpacika and T Yildizb

aDepartment of Pediatric Surgery, Sivas State Hospital, Sivas and bDepartman of Pediatric Surgery, Malatya State Hospital, Malatya

Persistent Mullerian duct syndrome is a rare form of internal male pseudohermaphroditism, in which mullerian duct derivatives uterus, fallopian tube and 1/3 upper part vagina. The presence of male phenotype and 46, XY karyotype. May be with transves testiculer ectopia.

Our cases two brothers. Physical examination demonstrated normal penis and empty scrotum. Gonads were not palpable. Rihgt hernia was detected. At operation, we found uterus, fallopian tube and 1/3 upper part vagina and transvers testiculer ectopia in both brothers. The uterus, fallopian tubes and upper part vaginawere excised, bilateral orchidopexy was performed.

Histological examination and cromosomal analisis showed normal testes and genotipical XY in both patients.

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P72: Laparoscopic cholecystectomy experience in our clinic: 9 cases

S Özkisacik, Ö Durmaz, H Gürsoy and M Yazici

Department of Pediatric Surgery, Adnan Menderes University Medical Faculty

Aim: Laparoscopic cholecystectomy has become the standard, in most pediatric surgery centers. In this study we aimed that to evaluate the role of laparoscopic cholecystectomy in the management of cholelithiasis in children.

Materials and methods: A retrospective review of our experience with laparoscopic cholecystectomy for cholelithiasis at our clinic, between 2005 to 2010. Data included patient demographics, clinical history, hematological investigations, imaging studies, operative technique, postoperative complications, postoperative recovery, and final histopathological diagnosis.

Results: Nine children with symptomatic cholelithiasis were treated by laparoscopic cholecystectomy (4 males and 5 females). The mean age was 8.5 years (range 4–13 years). The surgical indications were symptomatic cholelithiasis in all patients. There were no heamathologic disorders in all patients. All patients were discharged postoperative first day. No complications were noted during the operation and on follow-up.

Conclusion: We thougth that laparoscopic chloecystectomy is a safe and effective treatment for pediatric cholelithiasis.

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P73: Isolated fallopian tube torsion in adolescent girls

ME Bolekena, M Çevika and ME Güldürb

Departments of aPediatric Surgery and bPathology, Harran University Medical Faculty, Sanliurfa, Turkey

Isolated fallopian tube torsion is a rare gynecologic cause of acute low abdominal pain in adolescent girls and frequently misdiagnosed as acute appendicitis or ovarian torsion. Predisposing factors for torsion are hidrosalpinx, pelvic congestion, ovarian and paraovarian mass, prior tubal operation and trauma. Laparoscopy or laparotomy is often necessary to establish the diagnosis and salpingectomy is almost always necessary.

Herein, two cases of fallopian tube torsion in adolescent girls, one with hydrosalpinx, the other with paratubal cyst are presented and symptoms, diagnosis, predisposing factors and management are discussed.

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P74: Colon perforation due to foreign body in Hirschsprung disease

S Büyükbeşe, SC Karakuş, AU Erdem and R Akpinar

Department of Pediatric Surgery, Gaziantep Children Hospital

Accidental ingestion of foreign bodies and its management is a common problem seen more in the pediatric population than in adults. Foreign bodies passed into the stomach can usually be observed, because more than 80% of them would be spontaneusly passed. Obstructive congenital anomalies may cause the retention of foreign bodies within the intestine. This is the first case report of a Hirschsprung disease associated with radio-opaque foreign body lodged at the site of perforated sigmoid colon in the literature.

A 11-month-old boy presented with a history of abdominal distension, non-bilious vomiting and irritability for two days. Physical examination revealed left iliac fossa tenderness with rebound tenderness. The plain radiograph of his abdomen showed dilatation of intestine and a coin in the left lower quadrant. Parents were not aware that the child ingested the coin. At surgery dilatation of transvers colon with narrow sigmoid colon were detected and the coin was found to be lodged in the perforated sigmoid colon. Colostomy was performed. Rectal biopsy were taken and the diagnosis of Hirschsprung disease was proven histopathologically by the absence of ganglion cells. Soave procedure was performed.

This case highlights the fact that in case of the impacted radioopaque foreign body in a child, obstructive congenital anomaly should be considered in the differential diagnosis.

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P75: Unexplained and a sudden onset of diarrhea after percutaneous endoscopic gastrostomy

ME Memetoğlua, O Demirtaşb, Ö Kukula and V Bozkurta

aPediatric Surgery, Aydin State Hospital and bÇine State Hospital, Pediatric Surgery

Percutaneous endoscopic gastrostomy in children who cannot be fed via oral route, effective, practical, and is a commonly used method to enteral nutrition in intensive care units. Diarrhea occurs in 10–20% patients after PEG placement. Dietary changes, infection, malnutrition, and medications are potential causes. Here, we offer a 5- year-old boy with a mechanical ventilator support. The patient's swallowing reflex was lost due to severe hypoxic encephalopathy and then tracheostomy and PEG were applied. Parenteral nutrition was given to child for feeding difficulties, a sudden onset of diarrhea and high fever due to unexplained reasons in intensive care. Gastrocolic fistula was found, fistula repair and re-gastrostomy was performed. In the early postoperative period, the boy without any complications and was discharged with home ventilatory support.

Eventually, gastrocolic fistula should be suspected in children with a sudden onset of diarrhea due to unexplained reasons after PEG. Therefore, in those patients, radiological examination with water-soluble contrast material should be performed as soos as possible.

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P76: Wandering spleen with Niemann-Pick disease

Ö Balcia, YH Çavuşoğlua, D Erdoğana, S Apaydinb, İ Karamana, ÇE Afşarlara and İF Özgünera

Departments of aPediatric Surgery and bPathology, Dr Sami Ulus Maternity and Children's Hospital

Wandering spleen is a rare entity which develops as a result of splenic hypermobility caused by congenital absence or acquired laxity of splenic suspensory ligaments that hold the spleen in its normal position. It accounts for only 0.25% of all splenectomies and spleen usually migrates to the lower abdomen or pelvis. It is usually described in women of childbearing age and rare in children. Symptoms include acute or chronic intermittent abdominal pain due to the torsion of the pedicle. It may also be asymptomatic and discovered incidentally on clinical or radiological examination done for other reasons.

Niemann-Pick disease is a lipid storage disorder. It is characterized by sphingomyelin and cholesterol accumulation in many organs predominantly liver and spleen. Hepatosplenomegaly may develop.

A 16 year-old girl with Niemann-Pick disease has admitted to our hospital with complaint of amenorea. A 10 cm pelvic mass possibly related to the right ovary was detected with abdominal ultrasound. Abdominal CT scan showed that the mass was wandering spleen with a 5 cm hypodense, heterogenous solid mass at the medial side. Laparotomy was performed and 12 cm wandering spleen was discovered at the left lower quadrant of abdomen. And 5 cm faint, solid mass was found to be fused with the spleen at hilus. Splenectomy was performed. Histopathological examination revealed ceroid histiocytosis throughout spleen. The hilar mass was found to be a necrotic and sclerotic tissue. The postoperative course was uneventful.

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P77: An anusual case report: total colonic duplication presenting as intestinal perforation in a neonate

Ö Balcia, D Erdoğana, YH Çavuşoğlua, S Apaydinb, A Karamana, İ Karamana and İF Özgünera

Department of aPediatric Surgery and bPathology, Dr Sami Ulus Maternity and Children's Hospital

Gastrointestinal tract duplications are rare congenital anomalies which occur anywhere from mouth to anus, most commonly in the ileum. Colonic duplications are even less frequent and account for only 15% of all gastrointestinal duplications. They may present with intestinal obstruction secondary to compression, asymptomatic abdominal mass, volvulus or intussusception. Usually colonic duplications contain intestinal mucosa and it is rare to present with intestinal perforation.

A three day-old male was admitted to our hospital with complaints of abdominal distention and bilious vomiting. Plain abdomen X-ray revealed free air in abdomen. Urgent laparotomy was performed and meconium was observed in the abdominal cavity. Three cystic and one tubular duplications were detected starting from cecum to the peritoneal reflection. There was 5 cm normal colon segment distal to the cecum. The cystic duplication at the splenic flexure was perforated at the antimesenteric site. Duplications were completely resected and a colostomy was performed on 5 cm distal part of cecum. Distal colon was left as a Hartman pouch nearly above the peritoneal reflection. Histopathological examination confirmed the duplications without any ectopic mucosa. The postoperative course was uneventful.

Although gastrointestinal tract duplications are rare congenital lesions, they should be kept in mind because they can be associated with life-threatening complications, the clinical presentation can manifest a variety of symptoms, and differential diagnosis is complicated.

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P78: Cystic duplication of esophagus: a pitfall diagnosis in endemic hydatidosis areas

M Akin, A Yildiz, A Canmemiş, ÇA Karadağ, N Sever, M Kaba, T Kamaci and Aİ Dokucu

Şişli Etfal Education and Research Hospital

Intrathoracic cystic lesions have broad spectrum as congenital lung anomalies, foregut duplications, hydatic cyst, and cystic malign tumors. Hydatic cyst (HC) is still an important health problem throughout the world, particularly in Latin America, Africa and Mediterranean area. Hematogenous and lymphatic spread of the disease can involve unusual sites in the body and lung is one of the most frequent tissue. On the other hand, duplications of the alimentary tract are well-known, but rare congenital malformations and can occur anywhere in the gastrointestinal tract. Cystic esophageal duplication (CED) is commonly found in the lower third part and on the right side. The duplication can be discovered incidentally in children, and confused with other cystic lesions.

Here, we describe a 7 years old female with a large intrathoracic cyst on left side. She was first diagnosed as HC and treated medically with albendazole. Indirect hemagglutination test was negative. Since no regression in the cyst was present after 9 months of medical treatment, surgical treatment was decided. During operation, aspiration of bloody and brown cyst fluid was not evaluated to be in favor of HC. Exploration of the mass showed a tiny attachment to the lower third portion of esophagus. It was totally extracted and pathological evaluation was cystic esophageal duplication.

In summary, differential diagnosis of intrathoracic cystic lesions may be problematic in endemic areas.

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P79: The role of intraoperative microbiolody culture in the postoperative management of acute scrotum

E Rachmani, C Panteli, T Feidantsis and A Zavitsanakis

1st Department of Pediatric Surgery, Aristotle University of Thessaloniki, ‘G. Gennimatas’ Hospital, Thessaloniki, Greece

Aim: Acute scrotum is a common paediatric emergency. Most frequent causes are torsion of the testicular appendages (TA), torsion of the spermatic cord (TSC) and epididymoorchitis (EO). Common practice is to explore any case of tender scrotum based on history and clinical findings. In the vast majority of cases a degree of reactive hydrocele is encountered at exploration regardless of cause. The aim of this work was to examine whether microbiology culture of the hyrocele fluid would modify postoperative management.

Methods: The case notes of all boys who underwent scrotal exploration for acute scrotum at a single institution between 2005 and 2009 were reviewed retrospectively and demographics, clinical assessment, intraoperative findings, fluid culture results, postoperative course and outcomes were recorded.

Main results: One hundred and eighty five boys of mean age of 9.1 years (range 6 months - 15 years) were identified. Exploration revealed TA in 104 boys, TSC in 26 and EO in 49; 6 boys had normal findings. One hundred and fifty seven boys in total had a fluid sample sent for microbiology culture and sensitivities intraoperatively. None of the patients had a pyocele at operation. Microbiology results were negative in all cases. Patients with EO received a course of antibiotics postoperatively.

Conclusions: Microbiology culture and sensitivities of the hydrocele fluid in cases of acute scrotum does not appear to have a role in postoperative management. However, it seems reasonable in patients with purulent fluid at scrotal exploration. Prompt diagnosis and surgical intervention remains the mainstay of management.

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P80: Isolated splenic hydatidosis in children

G Ekingen, L Elemen and M Tan

Department of Pediatric Surgery, Medical Faculty, University of Kocaeli

Hydatidosis, caused by Echinococcus granulosus is still an important problem in endemic areas Hydatid disease affects more common liver and lung. Isolated splenic hydatidoses are quite rare in the medical literature.

In this report, we present our experience two cases with isolated splenic hydatid cyst.

Case 1: A-5-year old boy presented our clinic with complaints abdominal pain. Physical examination and blood analyses were normal. Abdominal ultrasound and MR scan showed a thin-walled, multiple septations cystic mass (15×14 mm) in spleen at the inferior pole. Another abdominal organs, lungs and brain were normal. Based on clinical and laboratory findings and imaging techniques we suspected a hydatid cyst. And albendozel treatment was given Therefore, small and uncomplicated cysts surgical procedure was not done.

Case 2: A-9-year old girl patient was presented with abdominal pain. On physical examination, there was no pathological signs. The laboratory findings, only eosinophilia was present (7%). Suspect positive serum IgG Echinococcus antibodies (9.8 DU). Thorax ve cranial radiological examination was normal. Principally Albendazole threapy was performed. We will planing surgical intervation after play day.

Splenic hydatid cyst is an uncommon entity even in endemic areas for echinococcosis, with a reported frequency of 0.5–6% within abdominal hydatidosis.

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P81: A prenatally detected left adrenal cyst treated by adrenal-sparing surgery and review of the literature

V Erikçi, B Uçan, O Arslan, C Öztürk, N Aksoy, A Dursun and M Hoşgör

Department II of Pediatric Surgery, Dr. Behcet Uz Children's Hospital

Purpose: We present a case of left adrenal cyst detected in utero and treated by adrenal-sparing surgery.

Case: A 2500 g full-term boy was born by vaginal delivery. Antenatally an abdominal mass was diagnosed at 24 weeks of gestational age. Postnatal sonography demonstrated a 38×29 mm cystic mass localized between the tail of the pancreas and the upper part of the left kidney. Physical examination showed an immobile mass in the left lower abdomen of the newborn. All laboratory investigations were normal except a slight increase in ferritin level. A computed tomography scan study revealed normal sized kidneys and an ovoid shaped hypodense lesion between spleen and the upper pole of the left kidney with an unidentified solid echogenity medially located to the mass At operation, a well-encapsulated cystic mass arising from the left adrenal gland, measuring 30×35 mm, was excised totally without adrenalectomy. Pathology showed a uniloculated cyst consisted of hemorrhagic fluid with walls composed of dense, fibrous connective tissue, devoid of a recognizable endothelial layer was reported as pseudocyst. After surgery, the patient was discharged 4 days postoperatively in good condition.

Conclusion: If the currently available radiological modalities are unreliable for differential dignosis of benign and malignant adrenal conditions, early primary surgical excision is recommended for either diagnosis or treatment.

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P82: A pancreatic neuroendocrine tumor diagnosed during the management of an acute appendicitis

V Erikçi, O Arslan, B Uçan, C Öztürk, A Dursun, N Aksoy and M Hoşgör

Department II of Pediatric Surgery, Dr. Behcet Uz Children's Hospital

Purpose: In recent years, pancreatic neuroendocrine tumors (PNET) are increasingly being discovered by chance on imaging studies being performed for various nonspecific abdominal symptoms. A case of PNET diagnosed and treated during the management of acute appendicitis is presented and discussed.

Case: An 11-year-old boy had appendectomy because of acute gangreneous appendicitis and localized peritonitis. Before appendectomy, all laboratory parameters were normal except an increase in WBC and a suspicious solid pancreatic mass in ultrasound (US). Biochemical parameters including tumor markers were found to be normal after appendectomy. US and magnetic resonance imaging confirmed a solid pancreatic mass 22 mm in diameter with an iso- and hipoechoic pattern. Intraoperatively, an encapsulated tumor with a diameter of 20 mm located between the head and body of the pancreas, was found and enucleated totally. Histopathologically the tumor was interpreted as a well differentiated PNET with no capsular or vascular invasion. Immunohistochemically the tumor showed positivity for synaptophysine and chromogranine. The patient showed an uneventful postoperative course. Presently, he is being followed-up by both the departments of pediatric surgery and pediatric oncology and has no evidence of disease for 10 months.

Conclusion: Radiological imaging studies may reveal a pancreatic mass other than findings consistent with acute appendicitis. The importance of imaging modalities in doubtful patients with acute abdominal pain is emphasized in this report and if a pancreatic mass is found it should be surgically excised.

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P83: Acute appendicitis in two children with Henoch-Schönlein Purpura

S Bilicia, C Akgünb, M Melekb, E Pekera, S Akbayramb, G Bulutc and M Doğanb

Department of aPediatric Surgery bPediatrics, Yuzuncu Yil University School of Medicine, Van and cDepartment of Pathology, Yuksek Ihtisas Research Hospital, Van

Introduction: The involvement of ileum and ascending colon with vasculitides may mimic appendicitis and can cause unnecessary appendectomy. In this study, we reported two cases of acute appendicitis with Henoch Schönlein Purpura(HSP) because simultaneous occurrence of these two conditions is rarely observed in the literature.

Case report: Case 1: A 13-year-old male patient who was treated with the diagnosis of HSP in the pediatrics clinic for a weekwas consulted. He had a 10-day history of a non-blanching purpuric rash on his lower extremities and abdominal pain which was intensified in the last 8–9 h. He also had nausea and vomiting at the same period. Abdominal ultrasound evaluation showed distended appendix with a diameter of 8 mm. The patient underwent appendectomy. Pathologic examination of the appendix showed acute suppurative appendicitis with vasculitic changes.

Case 2: A 12-year-old girl was seen in pediatric emergency room with the complaints of severe diffuse abdominal pain, vomiting, bloody diarrhea and purpura skin lesion of the lower legs and arms. Abdominal ultrasound evaluation was performed to rule out an intussusception and showed distended appendix which was not compressed and free fluid in the abdominal space. The patient underwent appendectomy. Pathologic examination of the appendix showed acute suppurative appendicitis with vasculitic changes.

Conclusion: Although vasculitic involvement of the ileum or ascending colon may produce signs that mimic acute appendicitis and lead to an unnecessary appendectomy, acute appendicitis should be considered in the differential diagnosis. Frequent physical examination and serial ultrasonography should be done in patients with HSP who have abdominal pain.

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P84: A rare tumour of the newborn: congenital epulis

L Elemena, K Karaoğlua and Y Gürbüzb

Departments of aPediatric Surgery and bPathology, Kocaeli University Medical Faculty

Introduction: Congenital epulis of the newborn is a rare tumour which is usually benign. Epulis is located on the maxillary ridge more often as on the mandible. The histogenesis of the tumour is unknown. Female babies are affected more often than males.

Patient: A two-day-old female baby admitted with difficulty in oral feedings due to a oral mass. Her physical examination revealed a 1×2 cm pedunculated mass originating from the anterior maxillary surface. Her blood work-up and cranio-facial graphy showed no abnormality. The patient was taken to operation and total excision of the tumour was performed. Oral feedings were started the day after and the patient was discharged on the post-operative 2nd day. She still remains well without complications for 5 months follow-up. The histopathological examination was consistent with a congenital epulis.

Result: The first description of congenital epulis is attributed to Neumann in 1871. To best our knowledge, only 240 cases were reported in the literature to date. The symptoms vary from feeding difficulty to severe dyspnea due to the size and localization of the tumour. It is a benign lesion and excision is adequate and neither recurrence nor malignancy has been reported, even after incomplete excision. Congenital epulis should be kept in mind in discrimination of oral masses in the new-born period.

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P85: Chronic abdominal pain with polysplenia syndrome and associated anomalies: a girl

L Cankorkmaza, MH Atalarb, C Gümüşb, G Köylüoğlua and C Güneya

Deparments of aPediatric Surgery and bRadiology, Cumhuriyet University, School of Medicine, Sivas, Turkey

Background: Polysplenia syndrome is a rare congenital anomaly characterized by multiple individual splenules, cardiopulmonary, vascular and abdominal disorders. The diagnosis is mostly made in the childhood with radiological examinations. We report here an 11 year old girl patient with polysplenia syndrome associated with abdominal, thoracic, and vascular anomalies.

Case report: We report here an 11-year-old girl patient presented for evaluation of left upper quadrant chronic pain. In abdominal ultrasound examination was portal vein aneurysm and polysplenia. Thoracic and abdominal (multi-detector computed axial tomography) MDCT was also performed. MDCT examination revealed situs solitus (normal position) of the liver and spleen; however, multiple splenules were present. An abnormal portal vein traversed the abdomen in a posteroanterior direction, suggesting an intraperitoneal location, and entered into the left hepatic lobe, continuing as a tubular structure and finally reaching the porta hepatis. The normal (right) inferior vena cava (IVC) was absent. The hemiazygous continuation of the IVC was noted in the left paraaortic region. The hepatic veins drained independently to the right atrium via a common channel. A congenitally ‘short’ pancreas with a small head and absence of the body and the tail was evident. CT of the thorax was within normal limits, except for prominence of the azygous vein in the right paratracheal region.

Conclusion: We believe that MDCT examination can provide useful information about polysplenia syndrome associated with abdominal, thoracic, and vascular anomalies in children.

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P86: A rare cause of acute abdomen in children: axial torsion of Meckel's diverticulum and internal hernia due to fibrous band

S Bilicia, M Meleka, M Göksua, N Ceylanb and M Şimşeka

aDepartment of Pediatric Surgery, Yuzuncu Yil University School of Medicine and bDepartment of Pediatrics, Medisina Private Hospital, Van

Introduction: Although Meckel's diverticulum is the one of most common congenital abnormality of the gastrointestinal tract, it is generally asymptomatic. Intestinal bleeding and obstruction is a common clinical situation in symptomatic patients. Axial torsion that a rare complication of Meckel's diverticulum and internal hernia due to the fibrous band were reported in a child.

Case: A 5-year-old male patient was admitted to our hospital with complaints of abdominal distension, abdominal pain and vomiting which started two days ago and inability to stool for one day. On examination there were tenderness in all regions of abdomen, defence, and rebount which was particularly on suprapubic region. There was air-fluid levels on umblical region at direct radiography of the abdomen. Additional information was not noted with Usg except ileus. At emergency laparatomy, a torsion of a Meckel's diverticulum at the end partof 1/3 which wasadheredto the abdominal posterior wall with a fibrous cord forming a bridge and consequently ileal segment herniation were seen. The fibrous band was excised and diverticulectomy was performed.

Conclusion: Although operation results are good, the diagnosisof complications du to Meckel's diverticulum is difficult because it has not a specific clinical finding, imaging method and characteristic laboratory finding. Meckel'sdiverticulum and its complications should not be forgotten in the differential diagnosis of acute abdomen patients who undergo surgical intervention and in particular, it should be investigated in patients whom clinical signs could not be explained with a detectable pathology.

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P87: Laparoscopic appendectomy without ligature of the stump

A Aslan

Department of Pediatric Surgery, Akdeniz University School of Medicine

Aim: The technique of laparoscopic appendectomy without using clip or ligature is rarely used in the children. In this report, we evaluated the efficacy of the technique by using bipolar cautery in a case.

Materials and methods: A 7-year-old boy was admitted with diagnosis of the acute appendicitis. The patient underwent laparoscopic appendectomy. A 0° degree, 3-mm telescope was used through the port on the left lower quadrant. Two 5-mm working ports were inserted, one through umbilical incision and the other on the suprapubic area. Inflamed appendix anteroinferior to the cecum was identified. Mesoappendix adjacent to the cecum was coagulated by bipolar cautery. The appendix could not be separated from the cecal wall in the antegrade route because of the adhesion. Appendeceal stump was coagulated approximately 5 mm away from the cecum by bipolar cautery (Power Blade, Lina Tripol 5, Denmark). The coagulation of 50 milliamper took until no bubbles appeared at the cautery site. The stump was divided with scissor, and checked to ensure for complete occlusion. Appendix was then separated from the cecum and mesoappendix in the retrograde route, and removed by through the umbilical incision.

Results: The intraoperative and postoperative course was uneventful. Bipolar coagulation for stump took two min. The duration of surgery was 40 min, postoperative hospital stay was 2 days, and time to oral feeding was 12 h.

Conclusion: In this case, the closure of the stump with using only bipolar coagulation seems to be safe and a feasible method.

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P88: Early post operative laparoscopic adhesiolysis

İ Sürer, B Çalişkan, A Güven, W Padshah and S Demirbağ

Department of Pediatric Surgery, Gulhane Military Medical Academy

Introduction: Abdominal adhesions may cause infertility, bowel obstruction, difficult reoperation, and chronic abdominal pain. Chronic abdominal pain can be caused by postoperative abdominal adhesions, whether by the nerve fibers in the adhesions themselves, by traction to the peritoneum or organs.

Case: Twelve years old girl presented with abdominal pain. She was treated for enteritis for one week in pediatrics. Physical examination revealed rigid tenderness and positive rebound. On blood account WBC was 16.7×109/l and hemoglobin was 11.7 g/dl. With the diagnosis of perforated appendicitis, appendectomy, partial omentectomy were performed. A drain is placed to right paracolic region. One week later she reevaluated for abdominal pain and fewer and 5×7 cm abscess found in Douglas pouch and drained percutaneously under US guidance. Three weeks later she was disappointed with colicky abdominal pain in left lower quadrant. Computerized tomography and US not revealed any significant data about the nature of the recurrent pain. Plain graphies showed ileal sentinel loops and laparoscopic intervention was planned. One port from umbilicus and other from right lower quadrant inserted. An atraumatic grasper and scissor is used to isolate and dissect band adhesions between intestine and anterior wall and dense adhesion between ileum and peritoneum at the left lower abdomen.

Result: Intra-abdominal adhesions are often well-vascularized and innervated. In laparoscopic adhesiolysis, the first trocar needs to be placed using Hasson's technique for open laparoscopy in order to avoid accidental bowel perforations. Electric energy should not be brought in proximity to the bowel, and the entire jaw of each instrument should be visible at all times. Initial contraindications to laparoscopy such as previous abdominal surgery have since disappeared with increased experience and technical advances in surgical instrumentation. Early post operative adhesiolysis to filmy bands prevents dense severe fibrotic adhesions in symptomatic cases.

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P89: Ectopic pancreas tissue at gastric anterior wall: a rare localization

C Parlakgümüş, S Türker, İ Cesur, G Güler and S İskit

Department of Pediatric Surgery, Çukurova University Medical Faculty, Adana, Turkey

Aim: Ectopic pancreas is a rare condition in any part of the body and gastric wall is even more rare. in this study, we present 2 cases with ectopic pancreas tissue of the gastric anterior wall that is found incidentally.

Case: In our clinic, in the last 6 months, we have operated 2 children because of gastroesophageal reflux and lower esophageal stenosis. During their operations, we have seen masses at the anterior surface of the stomach in the size of 0.7 and 1 cm. Masses were excised with an ectopic tissue prediagnosis. After histopathologic examination both tissues are reported as ectopic pancreas tissue and there have been no complaint at the postoperative follow up.

Conclusion: Ectopic pancreas is a rare problem even it is symptomatic and must be remembered at the differential diagnosis of gastric wall masses.

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P90: Chemical peritonitis due to gluteraldehyde after laparoscopy

T Özdemir, A Arikan, N Narli, A Sayan and HN Özer

Department of Pediatric Surgery, Tepecik Training and Research Hospital, Izmir

Aim: Gluteraldehyde (GA) spillage to the intraabdominal cavity caused chemical peritonitis in a 3 yeras old boy who undergone diagnostic laparoscopy because of nonpalpable testis. The case is presented to draw attention to prevent this complication.

Case report: A small amount of GA mixed with lavage saline was spillaged to intraabdominal cavity inadvertently via the insufflation tube during diagnostic laparoscopy. Subsequent chemical peritonitis and its treatment is discussed. Abdominal distention, bilious vomiting and serous discharge from trochar placement points were observed at postoperative first day. During laparotomy, no pathologies other than serous peritonitis and large amount of serous fluid were present. A rubber tube was placed. Peritoneal fluid was sterile microbiologically. Peritoenal drainage was ceased at day 22 and the tube was removed.

Conclusion: GA, which is widely used as a disinfectant for the medical equipment is a potential sensitizer. Lack of adequate rinsing of the instruments or tubes causes inadvertent introduction of GA to the body cavities and yields inflammation and serositis. Special attention should be given during instrument cleaning to ensure that the GA is completely rinsed off the surface and irrigated through the channels and tubes of the devices.

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P91: Management of conjoined twins during neonatal period

Kamal Abd EL-Elah Aly

Department of Surgery, Pediatric Surgery Unit, Mansoura University Hospital, Mansoura, Egypt

Background/purpose: Conjoined twins (CT) are rare and complex anomalies of the newborn. It is reported in 1/50 000 to 1/100 000 live births. The aim of the study was to summarize the experiences gained during separation of 5 sets of conjoined twins with presentation of literature review.

Materials and methods: During the period from January 2003 to June 2009, 5 sets of Conjoined twins had been separated during the first month of life. Two sets were symmetrical (male thoraco – omphalopagus CT, female pygopagus CT) while the other 3 sets were asymmetrical (male epigastric heteropagus CT, parasitic teratopagus CT, fetus in fetu).

Results: Urgent separation of 3 sets of conjoined twins had been performed due to respiratory embarrassment. Elective surgery was performed for the case presented as fetus in fetu and the case of thoraco- omphalopagus twins in which the shared liver was divided between both babies. The short term postoperative follow up revealed uneventful course of 6 children resulting from separation of 5 sets of conjoined twins.

Conclusion: Parasitic twins and twins with sever anomalies incompatible with life in one of them are considered to be one person. Timing of separation and separation plan should be individualized according to the need of urgent separation and the degree of organ fusion.

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P92: A rare cause of abdominal pain in children: sporadic gastrinoma

H Taşkinlara, İ Killia, Ç Çitakb, EC Günayc, G Gündoğdua, D Avlana and A Naycia

Departments of aPediatric Surgery, bPediatric Oncology and cNuclear Medicine, Mersin University Faculty of Medicine

Introduction: Gastrinoma is a rare neuroendocrine tumor of childhood with recurrent abdominal pain and accompaying diarrhea due to gastric acid hypersecretion.

Case: A 11-year-old boy is presented with, nightly increasing abdominal pain, nocturnal sweating, loss of appetite and weight of 7 kg without diarrhea during the last 3 months. The ultrasonograhy demonstrated a solid hypoecoic nodular lesion with the dimension of 28×18 mm in the prepancreatic-suprapancreatic region. Abdominal tomography was compatible with the sonography. Somatostatin receptor scintigraphy (SRS) detected another mass on the pancreas. Neither in the hypophysis nor in the parathyroids adenoma was not detected in the further imaging studies. Serum gastrin level (538 pg/dl) was high in the biochemical analysis. Solid masses with the dimension of 3×2 cm protruding to the lesser sac and of 0.5×1 cm between the neck and head of pancreas which was found with palpation during operation were excised. Pathological studies confirmed the diagnosis of neuroendocrine tumor. The gastrin levels of patient who is followed-up wihout complications is monitored within normal levels.

Conclusion: The completely removal of the tumor is important in the treatment of gastrinoma that cause frequent abdominal pain, gastrointestinal bleeding and diarrhea during childhood. Through abdominal ultrasonograhy and tomograhy, tumors that are smaller than 1 cm are often missed. Searching additional lesions and metastases with SRS and with palpation during surgery is important in regards to patient's complete recovery.

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P93: A case of epigastric heteropagus with omphalocel

MH Okur, İ Uygun, S Otçu* and M Siğa

Department of Pediatric surgery, Dicle University School of Medicine

Heteropagus Twin (Parazitic twin) which is a special type of conjoined twins is exceptionally rare (1 in 1–2 million live birth)**. Despite some theories, exact etiopathogenesis of HT have remained enigmatic. In this study, we reported a case of parasitic omphalopagus with complicated by omphalocele.

Case: A male baby with a birth weight of 3000 g (conjoined twin, one of them is parasitic) was delivered by cesarean sectionto a 23-year-old G2, P2 mother at 38th weeks' of gestation. At the physical examination, parasitic twin was connected from the abdominal region of the autosite. Parasitic twin was acephallic and acardiac. He had rudimentary thorax, developed external genitalia and imperforated anus. Urinary drainage was seen from the urethral orifice. There was an omphalocele sac with a diameter of 5–6 cm under the connection site of the autosite. Radiologic studies, ultrasonography, and Magnetic resonanceimaging (MRI), scan of the autosite showed no significant anomaly. After the preparations completed, parasitic twin was surgically separated from the autosite baby. During the operation, it was observed that parasitic twin was vascularly supplied with a pedicle sourcing from the falciform ligament and sternal region. Parasitic twin had kidney, ureter, bladder, small and large bowels. There were multiple atresias in the small bowel. After completion of the separation procedure, omphalocele of the autosite baby was primarily closed. Postoperative course was uneventfull, he was discharged from the hospital on the day 6 after the operation.

Till date, only 37 cases have been reported in the literature (8). In the current case, imaging tests were performed during the postnatal period. The combined utilization of ultrasonography fallowed by MRI evaluating conjoined twins is an important measurement sequence that allows physicians to predict the chances of survival of one or both twins. These findings permit the development of an exact surgical approach for the separation of conjoined twins thus can be separated and treated successfully in the majority of cases.

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P94: The surgical management of congenital hyperinsulinaemia: reports of three cases

Aİ Dokucu, T Akçay, ÇA Karadağ, N Hatipoğlu, A Yildiz, A Bülbül and Ö Özbağriaçik

Department of Paediatric Surgery, Şişli Etfal Training and Research Hospital

Aim: Nesidioblastosis is a controversial medical term for hyperinsulinemic hypoglycemia attributed to excessive function ofpancreatic beta cells with an abnormal microscopic appearance. it was used as a synonym for what is now referred to as congenital hyperinsulinism. It can cause severe brain damage.

Materials and methods: Three patients operated for nesidioblastosis between june 2008 and February 2011 were reviewed retrospectively. Age, sex, operative results and methods of management were evaluated.

Results: Three patients were included. All cases were found male. All infants were born at term. Only one case had associated cardiac anomaly. Age of operation time was 55, 40, 50 days. Complaints of patients were respiratory distress, hypotonisity in first 24 h. High concentration of glucose infusion was applied in all cases with a dose of 18, 20 and 18 mg/kg/min respectively and underwent frequent oral feeding. Diazoxide and octreotid therapy were used in all cases. We performed 85, 95, 85% pancreatectomy respectively. Preoperative examination revealed diffuse in 1.2 and focal in third cases but no focal nodule could not found preoperatively. The firstpatientcould not be evaluated with a genetic analysis, and accepted as diffuse. In second case genetic analysis revealed homozygous mutation in ABCC8 gene. Parents had also this mutation. In third case heterozygous mutation in ABCC8 gene was found. Partial pancreatectomy was the treatment of choice due to possibility a focal adenoma in the light of literature survey. In the operation an adenoma at the tail of the pancreas was found and confirmed with frozen biopsy. In this situation patient underwent a 85% pancreatectomy. No complication was observed. Pathological examination revealed nesidioblastosis. We lost first case after surgery because of sepsis, of two living cases, second one has no complication and medication free. Last case is still in post operative follow-up period without any support of glucose infusion.

Conclusion: This disease has the potential to make a severe neurological damage. Therefore, early diagnosis and treatment of patients is important. It is is essential close cooperation with endocrinologists to achieve the best outcome

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P95: Clinical outcome of aortopexy in ventilator-dependent infants with severe tracheo-bronchomalacia

A Naycia, H Taşkinlara, D Yiğita, AE Arslanköylüb, Y Çelikc, G Gündoğdua and D Avlana

Departments of aPediatric Surgery, bPediatric Intensive Care Unit and cNewborn Intensive Care Unit, Mersin University School of Medicine

Aim: Management of ventilator-dependent infants with severe tracheo-bronchomalacia is challenging. Although aortopexy is recommended, it remains a dilemma. We report three patients unable to be extubated due to severe tracheo-bronchomalasia, benefited from aortopexy.

Materials and methods: Ventilator-dependent infants with severe tracheobronchomalasia were included. Patients were typically ventilated at the edge of the weaning process. However, every extubation attempt failed. Diagnosis of tracheobronchomalacia was made by rigid bronchoscopy, with the patient spontaneously breathing. Aortopexy was accomplished through a left anterior thoracotomy and suture fixation of the aorta and innominate artery to the posterior sternum.

Results: Patients data are shown in table. All were extubated following aortopexy. Aortopexy was less effective in the neonate with perinatal asphyxia, and needed tracheostomy in addition. There was no morbidity or mortality associated with the procedure.

Conclusions: Our data suggest that aortopexy should be considered even in cases of severe, ventilator-dependent tracheo-bronchomalacia. It is possible to weaning from the ventilator.

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P96: Ciliated hepatic foregut cyst: case report

E Sevima, Ç Akyildiza, D Nartb and O Ergüna

Departments of aPediatric Surgery and bPatology, Ege University, Faculty of Medicine

Purpose: Ciliated hepatic foregut cyst (CHFC) is a rare foregut developmental malformation usually diagnosed in adulthood; however, rare cases have been reported in the pediatric population. Patients are usually asymptomatic. CHFC may transform into a squamous cell carcinoma. We hereby present a 9-year- old girl with CHFC.

Case: 9-year old female patient was referred to our clinic due to a cystic mass in the 4th segment of the liver incidentally detected on ultrasound while being investigated for recurrent abdominal pain. Serology for echinococcal cystic disease of the liver was negative. MR cholangiographyfor differential diagnosis of a choledocal cyst was indeterminate. Hepatic cyst 30×30×33 mm in diameterwas located in the segments 4A and 4B of the left hepatic lobe, and was compressing to the portal vascular system and bile duct. Ultrasound - guided fine needle aspiration biopsy revealed cellular plates of cuboid epithelium with organized chromaffin pattern, and was non-diagnostic. She was considered for surgery with initial diagnosis of hepatobiliary cystadenoma. The mass was cystic and had a mucoid content, and was completely excised. Histopathological examination of the specimen revealed a ciliated pseudostratified columnar epithelium, and was consistent with hepatic foregut duplication cyst.

Conclusion: The ciliated hepatic foregut cyst is an extremely rare entity which is difficult to diagnose clinically before pathologic examination. Although rare, the diagnosis should be considered in the differential diagnosis of cystic masses of the liver.

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P97: Notice tracheal atrezia that can not be tracheal intubation in newborns

C Gül, K Pelin and AC Celayir

Department of the Pediatric Surgery, Zeynep Kamil Women and Child Deseases Education and Research Hospital, Istanbul, Turkiye

Introduction and aim: Tracheal atresia is a rare congenital anomaly. Clinically, the finding in the newborn, respiratory distress and unable to cry that the biggest problem in these patients can not be intubated. Presented a patient that born in our hospital with the diagnosis of tracheal atresia after the tracheostomy and esophagoscopy.

Case report: A male infant weighing 2200 g that prenatally not follow was delivered after 40 weeks of gestation by vaginal delivery at our hospital. The baby was interned at neonatal intensive care unit due to respiratory distress and cyanosis. After the failure of the many attempts to tracheal intubation, consultation with pediatric surgery; at the level of cricoid cartilage of the larynx was obstructed full are seen by laryngoscope and an emergency tracheostomy was performed. There was no tracheal cartilage in the neck dissection, during bag-mask ventilation expanding esophagus was intubated by esophagostomy. Blood saturation of the patient improved and inspiration of the the lungs were better. A chest X-ray both of lungs are expanded. There was no tracheal opening at the emergency esophagoscopy. Only 2.7 mm 0 degrees telescope were advanced to fistula is a tiny mouth on the front at the level of middle esophagus, after the trachea carina begins about 1.5 cm. Tracheal atresia is thought to be Type II Floyd (or E-type tracheal atresia of Faro) intubated patient with also nasogastric decompression taken into intensive care. After the progression of respiratory distress, he died at postnatal 12thhour. Autopsy did not accepted by the family.

Conclusion: When the rise in saturation by bag-mask ventilation cases, tracheal atresia should be considered that postpartum sudden onset of respiratory distress, cyanosis, and no audible cry. Despite esophageal intubation and gastric decompression remains a deadly disease. Although survival can not be reported in the literature by surgical operations, the development of tissue engineering in reconstructive operations after the production of cartilage tissue suggest that long-term survival could be achieved.

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P98: Successful treatment of post circumcision glanular ischemia-necrosis with hyperbaric oxygen and intravenous pentoxifylline

L Elemena, K Topçuc, N İnan Gürcanb and A Akaya

Departments of aPediatric Surgery, bRadiology, Kocaeli University Medical Faculty, Kocaeli and cDepartment of Pediatric Surgery, Turkish Ministry of Health, Gebze Farabi Research and Education Hospital, Kocaeli

Introduction: Although circumcision is a minor procedure, the incidence of complications ranges from 1.5 to 5%. Ischemic complications after circumcision are rare and commonly due to intravascular administration of vasoconstrictive local anesthetics. Herein, we report a child with severe glanular ischemia who was treated with hyperbaric oxygen treatment (HBOT) and intravenous pentoxifylline.

Patient: A 5 year old boy was admitted with dark coloration of the glans penis. The patient had undergone a circumcision with an adrenaline containing local anesthesia 4 days before. His former medical history was unremarkable. Physical examination revealed brownish coloration of the glans penis and superficial necrosis of the glanular epithelium. Hematological and coagulation parameters were all in normal ranges. Penile color Doppler ultrasound examination revealed lack of arterial signals in the cavernous arteries and glans penis. Dorsal penile artery and venous blood flow was normal. The patient was hospitalized. Intravenous pentoxifylline (10 mg/kg) divided in four doses daily was started and the patient was taken to HBOT with 2.5 atmosphere pressure for 90 min-long sessions. On the 2nd day the color of the glans began to lighten and on the 5th day the glans appeared absolutely normal. Pentoxifylline treatment was stopped. Penile Doppler ultrasonography revealed that all the arterial blood flow-including cavernous arteries were normal. HBOT was continued for 1 day longer. The patient was discharged on the 7th day and remains well for a follow-up of 6 months.

Discussion: HBOT together with intravenous administration of pentoxifylline seems to be adequate for treatment of glanular ischemia, even in the lack of cavernous arterial blood flow. However, definite procedures for relieving glanular ischemia and necrosis following a circumcision should be developed rather than sporadic interventions.

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P99: A rare mass on chest wall: Infantil Fibromatozis

A Oral, M Yiğiter, T Dikmen, O Yalçin and AB Salman

Department of Pediatric Surgery, School of Medicine, Ataturk University, Erzurum, Turkey

Case presentation: An eight-month-old baby girl, who was previously healthy, was accepted to our clinic with a mass which appeared under her left breast and had grown very fast. During ultrasound analysis, a 25×16 cm solid mass, which had a smooth border and encapsulated single rib about 300 degree, was determined. An appearance compatible with hematoma was determined in soft tissue density on the surface of left 7th ribs anterior in thorax BT. Since the mass has grown in a short time the patient was consulted with pediatric oncology clinic. The patient was operated for biopsy and the mass was excised over the rib by preserving thorax wall. Infantil Fibromatozis (IF) which shows mitotic activity and has high recurrence possibility was reported in histopathological analysis. Existence of tumor structure and hypermetabolic residual invading neighboring costal structures was reported during Positron Emission Tomography performed to determine residual tumor tissue and to plan the next operation. Extensive mass excision was planned for the patient.

Discussion: Proliferative diseases of fibrous tissue can be in various forms such as histological and morphological. These are; Dupuytren's fibromatosis, fibromatosis colli, myofibroma, aggressive fibromatosis, juvenile hyaline fibromatosis, juvenile aponeurotic fibroma, juvenile angiofibroma, fibrous hamartoma of infancy, infantile digital fibromatosis andinfantile fibromatosis. IF is a rare case and located in benign part of fibrous tumors. While soft tissue localization was mostly reported on sternocleidomastoid muscle, plantar localization on bone tissue and mandibula localization are also known. Extensive resection is necessary in treatment due to high recurrence possibility and invasion feature.

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P100: The umblical mass in the neonate: presentation of two rare cases umblico-appendicular fistula

M Çevik, ME Boleken, A Aydinoğlu, S Öcal and E Balcioğlu

Department of Pediatric Surgery, Harran University Medical Faculty

Background: The normal umbilicus is a simple structure but intrauterine development of the umbilicus is highly complex. Neonatal umbilical mass anomalies usually represent failure of obliteration of the vitelline or the allantios duct which results in persistence of remnants, which can lead to a wide variety of disorderse. Here are presented presented differences between the cases.

Case 1: A full term 20- day- old female baby with referred our clinic for evaluation of umbilical discharge and a small redness mass. On physical examination, a small mass with a fistulous opening on the top and intestinal discharge. A fistulogram that was done through the fistulous opening revealed an irregular track extending to right iliac fossa. The patient was operated with the diagnosis of umbilical mass. The mass was evaluated as appendix and there was also a mobile cecum. After ligation of the mesenteric wessels, appendectomy and mass were performed. The clinical course of the patient was uneventfully.

Case 2: A full term 2-day-old male referred to our clinic for evaluation of an umbilical mass. On physical examination, umbilical cord was normal and on the edge of its there was a mass which was 3 cm in diameter, fixed and erythematous with a fistulous opening on the top of it. A fistulogram that was done through the fistulous opening showed an irregular track extending right iliac fossa. The mass was connected with 1/3 proksimo-lateral appendix and cecum was mobile. After ligation of the mesenteric vessels, appendectomy along with the fistula tract and mass were performed. Final pathologic analysis revealed a normal appendix and mesoappendix. The clinical course of the patient was uneventfully.

Conclusion: The umbilical appendix was a rare conganital abnormally. This neonatal anomally usually mixed failure of obliteration of the vitelline or the allantios duct of remnants, The definite diagnosis is usually during operation. Fistulogram is the gold standard for diagnosis. In our two cases, one of them was directed prolapsed in the umbilicus, other one prolapsed by fistula

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P101: Management of bronchopleural fistula in extremely preterm newborns

H Taşkinlara, C Erdoğana, S Gülaşib, G Gündoğdua, D Avlana, A Aticib and A Naycia

Departments of Pediatric Surgery, and Newborn Intensive Care Unit, Mersin University School of Medicine

The management of bronchopleural fistula remains a major therapeutic challenge. Bronchopleural fistula is associated with significant morbidity and mortality, especially in extremely preterm newborns, We report two extremely preterm newborns, presented with persistent pneumothorax during ventilator therapy. First patient's gestation age and birth weight were 29 week and 1090 gram, second's were 24 week and 1115 g. The patients did not respond to the ventilatory support strategies including high frequency oscillatory ventilation; medical treatments such as nitric oxide, surfactant therapy; tube thoracostomy, even insertion of multiple chest tubes, and negative chest tube aspiration. Following bronchopleural fistula, first patient underwent thoracotomy on day 5 and second patient on day 11. In both, thoracotomy revealed a major rupture of the intermediate bronchus, probably related to suction catheter trauma. The bronchus was primarily repaired. In the first patient, the bronchopleural fistula recurred two days later, and died postoperatively on day 7. In the second patient, there were no complications and was discharged home postoperatively on day 35. We suggest that early thoracotomy may be a life-saving procedure in extremely preterm newborns when medical therapy and chest tube insertion have failed.

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P102: Two cases followed with diagnosis of the chronic intestinal obstruction

T Acer, E Fakioğlu, İ Ötgün and A Hiçsönmez

Department of Pediatric Surgery, Baskent University Faculty of Medicine, Ankara, Türkiye

Introduction: The Chronic Intestinal Pseudo-Obstruction (CIPO), is a rare anomaly characterized with a clinic presentation mimicking mechanical obstruction although there was no lesion obstructing intestine, due to failure of intestine to transmit the its contents. It has high mortality and morbidity rates. Only 5% of the causes can be identified.

Case 1: A 16-year-old boy, had a liver cystectomy due to cyst hydatic at 6 month prior to his administration to our clinic. After the cystectomy, biliary fistula encountered and managed by placing a stent to coledoc. Afterwards gastric perforation diagnosed and managed by primary repair. Two months after his discharge, the patient admitted our center with abdominal pain and vomiting. He was very cachectic and mentally retarded. Examinations indicated intestinal obstruction. Adhesiolysis was done. During postoperative course, the clinic of intestinal obstruction remained. Adhesiolysis and ileostomy was done. As the clinic remained unchanged after the second operation, diagnosis of CIPO was made and prokinetic medications started. A temporary well being was observed. Electrolyte imbalance occurred due to massive discharge from ileostomy, so that ileostomy was closed. During the follow up period, there was always a finding of intestinal obstruction at supine direct abdominal graphies, while the patient could tolerate oral feeding. After 7 months of hospitalization, the patient discharged. It was learned that the patient died 2 months after his discharge.

Case 2: A 15-year-old boy referred to our hospital with complains of abdominal pain ongoing for 1 months and vomiting ongoing for 1 day. During his stay abdominal exploration was done two times. At the first operation, there was diffuse intestinal thickening beginning from second part of the duodenum, the biopsy taken revealed no pathological finding. After his discharge, he was hospitalized three times and he was discharged as he could tolerate oral feeding, although there was air-fluid levels at supine direct abdominal graphies, he is now followed at as out-patient.

Results: There are many needless operations at the history of the CIPO patients as this entity mimics mechanical obstruction of the intestine. So, because of the history of operations it is nearly impossible to define the obstruction is whether functional or mechanical. As the diagnosis is difficult most of e patients could not be diagnosed correctly or the patients diagnosed lately. We want to draw attention to this entity.

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P103: Intra-thoracic kidney with Bochdalek hernia

SC Karakuş, N Koku, S Büyükbeşe, A Yilmaz and E Parmaksiz

Department of Pediatric Surgery, Gaziantep Children Hospital

Bochdalek hernia is a congenital posterior lateral diaphragmatic defect that allows abdominal viscera to herniate into the thorax. Intra-thoracic kidney is a very rare congenital anomaly representing less than 5% of all renal ectopias. The incidence of intra-thoracic kidney with congenital diaphragmatic hernia was reported to be less than 0.25%.

A 11-month-old boy presented to our hospital for abdominal pain with associated cough. Physical examination was unremarkable. Chest X-ray showed intestinal loops herniated into the left chest. Abdominal ultrasonography demonstrated absence of left kidney. Contrast enhanced computed tomography showed intestinal segments protruding through a left sided Bochdalek hernia and the left kidney adjacent to the heart. The patient underwent primary surgical correction through an abdominal approach and no intervention was performed to an asymptomatic thoracic kidney. Postoperative renal 99mTc- DMSA and 99mTc-DTPA scintigraphy were normal. He has no problem at the seventh month follow-up.

Intra-thoracic kidney should be considered in the differential diagnosis of a lower thoracic mass.

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P104: Double duodenal web: 2 cases

Ş Emre, R Özcan and E Erdoğan

Department of Pediatric Surgery, Istanbul University Cerrahpasa Medical Faculty

Aim: Presentation and discussion of our two duodenal web cases; a very rare condition.

Cases: Case 1: Duodenal obstruction was seen on the upper gastrointestinal tract passage graphy of an eight days old patient who applied with vomiting after nutrition started from the first day of postnatal period and laparotomy procedure was done. Duodenal distension was detected on exploration. Web was seen on the second part duodenotomy and excised. On the control with inflated Foley catheter balloon, a second web was detected 2 centimeters proximal to the former web and excised. The case is problem free since the ten years of the follow-up period.

Case 2: Partial obstruction of the second part of duodenum and extrahepatic biliary tract reflux of the contrast agent were seen on the upper gastrointestinal tract passage graphy of a 20 days old patient followed up for jaundice and septicemia since the second day of birth. On the duodenotomy of the dilated second part of the duodenum, duodenal web and opening of choledochus into the proximal part of the web were seen. On the control with Foley catheter, a second duodenal web close to the pylor was detected and excised. The case is on the sixth month of the follow-up period and free of any problem.

Conclusion: Intraluminal control is necessary on the cases operated with the diagnosis of duodenal obstruction in case of an accompanying second web or atresia. Extrahepatic biliary tract reflux on the upper gastrointestinal tract passage graphy of the case, diagnosed with duodenal obstruction should be considered to have double duodenal web. Mortality and morbidity increase in case of negligence of the second reason causing obstruction.

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P105: Double hand Ligasure technique may facilitate laparoscopic splenectomy

B Tander, Ü Bicakci, M Günaydin, R Rizalar, E Ariturk and F Bernay

Department of Pediatric Surgery, Ondokuz Mayis Üniversitesi, Samsun

Aim: Laparoscopic splenectomy may be challenging especially in patients with large spleens. Tissue sealing device (Ligasure) is a useful instrument for the dissection of the spleen and its attachments. It is widely used by most surgeons. We hypothesized Ligasure in both hands might be even more advantageous and it may ease the dissection of the spleen.

Materials and methods: Four patients with hereditary spherocytosis (Three males and one female, 3, 8, 13 and 16 years old) underwent laparoscopic splenectomy. Laparoscopy was performed with standart four trochar technique. We applied two Ligasure in right and left hands. We evaluated technical advantages of Ligasure in both hands in the laparoscopic splenectomy.

Results: We found that Ligasures in both hands provides cutting and sealing with both hands and this maneuver facilitates the dissection of the spleen. In all three cases the splenectomy has been performed more easily. The shotest time of surgery was 35 min. In one patient, a bleeding not realted to Ligasure occured and the case was converted to open. No complication has been experienced. In one patient, a cholecystectomy has also been carried out.

Conclusion: Tissue sealing devices (Ligasure) are very useful instrument in laparoscopic splenectomy. Two Ligasures in both hands eases the dissection of the spleen.

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P106: Borchardt triade: signs of acute gastric volvulus

S Bilicia, M Göksua, M Meleka, F Sayirb and M Şimşeka

Departments of aPediatric Surgery and bThoracic Surgery, Yuzuncu Yil University School of Medicine, Van

Introduction/aim: In acute gastric volvulus, there are findings of severe pain and distention in upper abdomen or lower thorax, not being able to vomit despite nouses and not being able to more forward the nasogastric catheter which may be identified as Borchardt triade. In this paper, left posterolateral diafragm hernia together with wandering spleen and mesenteroaxial gastric volvulus was found in a 3 year old girl who presented with signs of Borchardt triade.

Case: On physical examination of patient who admitted distention, severe pain and not being able to vomit despite nausea beginning abruptly 8 h ago, her general status was, there was a painful swelling at epigastric region on palpation. In addition, it was observed that the patient was not able to vomit despite severe nausea. The nasogastric tube was not able to move forward. Her radiological graph revealed wide gastric gas filling left upper quadrant of the abdomen and half of the thorax and nasogastric catheter was observed to be folded. At operation was found mesenteroaxial gastric volvulus, posterolateral diafragm hernia and untorsioned wandering spleen.

Conclusion: Acute gastric volvulus is a life- threatening condition. Because early diagnosis and treatment decreases mortality, in presence of abruptly beginning epigastric pain and swelling together with not to be able to vomit despite nausea in a child, acute volvulus should be considered and the situation should be diagnosed with taking a simple radiograph and moving forward a nasogastric catheter.

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P107: A rare vacterl association; prune belly syndrome, umbilical cord hernia, hydrocephalus and maple syrup urine disease

A Oral, M Yiğiter, O Yalçin, T Dikmen and AB Salman

Department of Pediatric Surgery, School of Medicine, Ataturk University, Erzurum, Turkey

Case presentation: A 2600 gram male baby born in the 38th week into the pregnancy from a marriage of the second degree was admitted to our hospital with a diagnosis of Prune Belly syndrome together with anal atresia and umbilical cord hernia. During a physical examination, it was detected that there was absence in the muscles of the abdominal wall, umbilical cord hernia (UCH) and high type anal atresia, besides, the patient had bifid scrotum and bilateral anorchia. In the abdomen USG test a left renal agenesis was detected. In the babygram there existed a lomber vertebrae arcus defect. In the ECHO a patent foramen ovale was detected. Because of the UKH and anal atresia an operation was performed and during the operation the detected rectovesical fistula was excised, urinary wall primer was repaired and the intestine inside the pouch was placed into the abdomen. A colostomy was performed. A cystoscopy, shortly after the operation, was performed on the patient, who did not have a spontaneous urine exit and a urethral stricture appeared. The voiding cystourethrogram, which was performed on the patient who was placed with a suprapubic cystostomy catheter, resulted in an irregular contour of the bladder and the dimension was found to be large. The blood screening test of the heel, which came back positive, was diagnosed with maple syrup urine disease (MSUD) as a result of a detailed enzyme examination. The patient, who was established with a rise in the diameter of the head, hydrocephalus was diagnosed with trans-fontanel ultrasonography. Grade III noncomminican hydrocephalus and a bilateral subarachnoid hemorrhage was determined in the 3rd and lateral ventricle with a brain MRI. A caryotype analysis was performed of the patient and a 46xy was reported.

Discussion: Prune belly syndrome together with anal atresia was rarely reported before. However, our current case VACTERL+prune belly syndrome+umbilical cordanal atresia with rectovesical fistula+hydrocephalus+MSUD combination is notified for the first time. MSUD also called branched-chain ketoaciduria, is an autosomal recessive metabolic disorder affecting branched-chain amino acids. While it can be fatal for untreated patients, it is possible for those with an arranged diet to lead normal lives. We think that the association of VACTERL and MSUD is an association which should be researched.

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P108: Our experience in two cases with Bart's syndrome

Y Yilmaza, HÖ Ulua, ŞS Oğuzb and U Dilmenb

Departments of aNeonatology Pediatric Surgeon and bNeonatology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey

Pyloric atresia is a rare autosomal recessively anomaly with a incidence of 0ne per million births. The hypothesis that the pyloric atresia follows intrauterine scarring of epidermolisis bullosa, result ing when mechanical and chemical irritation strip the pyloric mucosa and cause adhesions, which may in turn lead to cicatrization. This is a report of two neonates with Epidermolysis Bullosa associated with Congenital Pyloric Atresia.

Case 1, 32 weeks' gestasional age, cesarean section delivery with a birth of 1730 gram male baby. After the diagnosis, Pyloroplasti was performed on the second day of life. He developed respiratory failure and died at postoperative second day.

Case 2, 30 weeks' gestasyonel age, cesarian section delivery with birth of 1580 gram male baby. Pyloroplasti was performed second day of life. He developed sepsis and died postopertive 4th day.

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P109: An unusual cause for chylothorax: Gorham syndrome

R Özcana, A Alptekina, Ş Emrea, S Kuruoğlub, M İnanc and G Topuzlu Tekanta

Departments of aPediatric Surgery, bRadiology, cOrthopedy, Istanbul University, Cerrahpaşa Medical Faculty, Istanbul, Turkey

Aim: Gorham syndrome is a rare disease that goes with idiopathic osteolysis but the cause is unknown. Chylothorax is with Gorrham syndrome in 20% of cases. Chylothorax with Gorham syndrome has bad prognosis and very resistant to treatment. This is the case report of a child that admitted to our clinic with chylothorax and diagnosed as Gorham syndrome.

Case: A 7 years old child with coughing, fever and dispnea for 15 days admitted to clinic. Due to bilateral pleural effusion bilateral tube thoracostomy was performed. No cause could be found. He was fed by TPN and taking out the tubes, discharged with a diet that is full of MCT (middle chain triglycerids). After 2 months he was admitted to our clinic with dispnea and coughing. At X ray bilateral pleural effusion was there right side is worse. At thorax MRI there were bilateral pleural effusion and at thoracal vertebras pathcy type osteolyic changes. Thoracentesis was performed. He was consulted with radiology and orthopedics department and diagnosed as Gorham syndrome. For a month time somatostatin was used and a diet was given which depends mostly on MCT. But after recurrence of the effusion steroid 2 mg/kg/day was started. After 3 months of time the effusion was again recurred. After thoracentesis interpheron alpha 2b treatment started. It's 3rd month of treatment and the child has no symptom.

Conclusion: Chylothorax with Gorham syndromu is very resistant to medical treatment. Interpheron alpha 2b may be helpful for the treatment of the disease.

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P110: The impact of 4D ultrasonography and fetal MRI imaging in the perinatal management of a temporofacial mass

Z Sahinoglua, AA Ertekina, A Cerrah Celayirb and B Gucluera

aDepartments of Obstetrics and Gyneaocology and bPediatric Surgery, Zeynep Kamil Women and Child Diseases Education and Research Hospital, Istanbul, Türkiye

Introduction/aim: Teratomas are the most frequent solid neoplasms in newborns, their prenatal diagnosis could be usually obtained by ultrasonography after the midpregnancy. Here, we describe the prenatal diagnosis of a fetal temporofacial teratoma located on the right.

Case report: A healthy, 24-year-old pregnant, Gravida 2, Para 1 was referred to our clinic for a suspicion of fetal face anomaly. After Doppler Ultrasound scan and 4D-dimention we found a spherical, exophytic, well-circumscribed, poorly vascularized temporofacial tumour (53×44 mm) with solid and cystic components located on the right fetal temple of the fetus, in 265/7 gestational weeks. The cerebral and other facial structures, and the left sagittal view were normal, there was no additional abnormality. The termination or follow-up of pregnancy and postnatal resection (with collaborate another branches specialists) were discussed with the family by the perinatologist and pediatric surgeon. Family opted for the continuation of pregnancy and refused invasive fetal karyotyping procedure. In follow-up scans, a remarkable increasing in size of tumour (up to 14×16 cm) and almost completely covered with the tumoural mass of fetal right hemiface were detected. A female baby, 2850 g, with Apgar scores 8 and 10 in first and 5th min was delivered with C/S section without any tumoural laceration in 35th week gestation. A huge, right temporofacial tumour (16×14 cm) was inspected. Newborn was ransferred to another center for multidisciplinary approaching of the tumour. Following the successful resection, the histopathology was consistent with mature teratoma.

Conclusion: Besides 4D ultrasound visualization, fetal magnetic resonance imaging seems to be a facilitating factor in predicting the perinatal outcomes, as well as promoting the perception of the fetal malformations by the family. The presence of an expeditious tumoural growth during follow-up and a remarkable displacement of the facial structures, and a good perinatal management and postsurgical outcome are interesting things of our case.

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P111: A case of malign gastric stromal tumor with local recurrence

T Acer, İ Ötgün and A Hiçsönmez

Department of Pediatric Surgery, Başkent University Faculty of Medicine, Ankara, Türkiye

Introduction: Gastrointestinal stromal tumors (GST) are rarely encountered neoplasms which have their origin from the connective tissue elements of the gastrointestinal tract. In this report, a very rare clinical presentation, a patient with GST taking it's origin from the stomach is presented.

Case: Six years old male patient who had been brought to a state hospital with the complaint of loss of apetite was referred to our hospital as the result of the histopathologic examination of his endoscopic biopsy performed because of the findings of diffuse thickening of the gastric wall and an antral wall thickness of 2.5 centimeters at abdominal ultrasonography (USG) and abdominal computerized tomography (CT) respectively. At USG performed in our hospital, a vascular, solid mass lesion with heterogenic, hypoechoic and malignant appearance and the dimensions of 53×40 milimeters located at the posterior antral wall and a mass lesion located at the anterior antral wall just at this level with a similar appearance and dimensions of 37×18 milimeters were visualized, however, an extension beyond the antral wall or to the duodenum was not observed. Antrectomy, pylorectomy and excision of the first portion of the duodenum was performed and the histopathologic findings of the tissue specimen was found to be in accordance with malignant mesenchymal tumor; but at which differentiation between leiomyosarcoma and GST could not be achieved by immunophenotyping. As a result of the finding of neoplastic tissue at the surgical margin, the proximal part of the second portion of the duodenum and anastomotic line was excised in order to take the residual tumor out totally. No neoplastic tissue was found at the frozen sections and at the regular histopathologic examination of the specimen obtained at the second operation. The patient received vincristin and actinomycin-D chemotherapy for a year. After two years have passed, recurrent mass at the stomach was observed. The polypoid mass were palpated two centimeters distally from the oesophagus at the minor curvature at the third operation and it was excised totally. The result of it's histopathologic evaluation was reported to be that the mass showed chaaracteristics that were in accordance with malignant mesenchymal tumor.

Result: Stomach masses larger than five centimeters, having exophytic component, polylobulated contour, heterogenous staining pattern, findings of mesenteric infiltration and ulceration are some of the criteria that suggest a more malignant character. It should be held in mind that GST's can metastatize or make local recurrences; even if with a small risk; so patients operated for GST should be followed up for metastases or local recurrences.

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P112: Pancreas injury due to bicycle accident: surgical treatment of two cases

G İnal, T Acer, İ Ötgün and A Hiçsönmez

Department of Pediatric Surgery, Baskent University Faculty of Medicine, Ankara, Türkiye

Introduction: Pancreatic injury comprises about %5 of all blunt abdominal traumas. Although it is possible to determine the extent of pancreatic injury by abdominal ultrasonography (USG) and computerized tomography (CT), endoscopic retrograde cholangiopacreaticography (ERCP) is superior to the mentioned radiographic techniques at the detection of ductal injuries. ERCP can be used as a guide at the visualization and grading of ductal injury and treatment and management of the complications of ductal injury. At this report two cases of pancreatic injury due to bliunt abdominal trauma is presented.

Case 1: Our first case is an eight years old boy, who was referred to our hospital with the history of a car crashing to him when he was driwing bicycle. His abdomen was tender at palpation. At the laboratory examination, markers of pancreatic injury were found to be high [LDH: 414 U/l (120–300), serum amylase: 1817 (30–110), lipase: 909 (13–60)]. Complete rupture between head and corpus segments of the pancreas were observed at CT. Surgical intervention was carried out because of the observation of contrast material leak from the duct at ERCP. A 5×5 centimeters area of hematoma and ductal injury between the head and corpus portions of pancreas were found out and DPE(?) was carried out. The patient was discharged at the ninth postoperative day.

Case 2: A Ten years old boy who was referred to our hospital with the diagnosis of pancreatic injury as a result of falling down from the bicycle. Tenderness, guarding and rebound phenomenon were observed at the physical eamination of the abdomen. Serum amylase and lipase levels were recorded as 565 and 1155 U/l respectively. Complete separation of the head portion of the pancreas from it's corpus portion was observed at the CT. The leak of opaque material from the head portion of the pancreas was seen at ERCP and the patient was operated. Complete separation of the head portion from corpus and presence of hematoma between them are observed peroperatively and DPE(?) is performed. The patient was discharged at the tenth post-operative day. Both of our patients are followed up without any major health problem.

Discussion: Pancreatic injury is associated with high mortality and morbidity. Complication rate due to pancreatic injury is between %20–35. The factors affecting morbidity and mortality are the concomitant injuries of the other organs, pancreatic duct, choledoc or duodenum injuries. USG an CT are widely used at the diagnosis. However, ERCP performed by experienced personal gives more reliable results at the diagnosis of ductal injury. We suggest that ERCP has positive effect on the morbidity and mortality of the cases with the diagnosis of pancreatic injury, according to DPE (?) results.

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P113: A rare esophageal atresia case: esophageal atresia with distal tracheoesophageal fistula+distal esophageal web+esophageal stenosis

A Oral, M Yiğiter, T Dikmen, O Yalçin and AB Salman

Department of Pediatric Surgery, School of Medicine, Ataturk University, Erzurum, Turkey

Case presentation: A one day old male baby born at 38 weeks weighing 2500 grams was transferred to our hospital from an external clinic with an anal artesia (AA) and esophagusartesia (EA) diagnosis. A highly settled EA with distal tracheoesophagealfistula was detected in the contrast esophagogram of the patient, who was detected with a high type AA during the physical examination. A lumbosacral vertebrae defect was present in the baby gram. An atrophic right kidney was detected by the urinary ultrasound. A distinctive VSD together with a left arcus aorta was reported. An emergency colostomy was carried out on the patient in order to decrease the current abdominal distention. A high settlement of the upper pouch in the cervical area and a distal fistula with a very wide diameter were determined by a formal right thoracotomy, which was carried out on the second day. A no.8 feeding catheter was threaded to the anastomosis tube used during the operation due to the width of the fistula; however, the stomach could not be reached by the distal esophagus. Thereupon, a contrasted t esophagogram, which was taken, showed a 1/3 narrowness in the distal esophagus. A longitudinal esophagus cut was made from the level of the blockage and aintraluminal mucosal webwas inserted. A stricture appeared during the insertion of the web. First esophagus was repaired on transverse plane. An contrast esophagogram taken 20 days after the operation showed that there was a transition to the stomach. The patient was discharged without a problem.

Discussion: A proximal EA along with a distal esophageal intraluminal mucosal webare very rare co-occurrence. EA+luminal web, EA+luminal stenosis cases were presented in the literature in previously, in the patient with VACTERL association, EA+web+distal stenosis was not notified at all. Because it was not possible to transmit the N/G catheter to the stomach through the anastomosis during the operation, the recognition of the fistula tracts with wider than usual while performing EA repair is the messenger of the existence of a stenosis or web in the distally esophagus.

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P114: A case of intestinal lymphangiectasis whom pancreas preserving total duodenectomy was performed

İ Ötgün, Ö Şenocak and T Acer

Department of Pediatric Surgery, Başkent University Faculty of Medicine, Ankara/Turkey

Introduction: Intestinal lymphangiectasis is a disease characterised by lympathic blockade in the intestines and their mesentery and a disease in which intestines are difusely affected. In the rare cases whom intestines are locally affected by the disease process, resection of the diseased segment may provide relief. Our case is a three years old patient with intestinal lymphangiectasis whom duodenectomy was performed.

Case: Three years old female patient who had been followed up with the diagnosis of intestinal lymphangiectasis for two years was consulted to our department regarding the necessary surgical intervention for her anasarca type oedema, massive ascites and refractory hypoalbuminemia. Partial intestinal resection was peformed two times before for intestinal lymphangiectasis. Duodenectomy was performed to our patient whose biopsies obtained by upper gastrointestinal tract endoscopy revealed duodenal involvement.

Conclusion: Treatment of intestinal lymphangiectasis consists of high protein, fat free diet and adding middle chain triglycerides to that diet. In the rare cases whom intestines are locally affected by the disease process, resection of the diseased segment may provide relief. As duodenectomy is a surgical technique which has not been reported to be performed in the children with intestinal lymphangiectasis, our patient was regarded worth to be discussed.

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P115: A different treatment approach on combination of caecal intramural duplication cyst and intussusception in an infant: a case report

İ Çiftcia and S Kayaçetinb

aUniversity of Selcuk, Selcuklu Medical Faculty Pediatric Surgery Department and bKonya Education and Resaerch Hospital

Duplication cysts are uncommon congenital abnormalities. They were first named as duplication cysts by Ladd. They may occur at all levels of the gastrointestinal tract from mouth to anus. Generally, they present with a tubular or cystic structure. They may demonstrate clinical signs of intussusception, obstruction, volvulus, malignity, hemorrhage, and rarely perforation. A 7-month-old female patient was operated on because of intussusception formation. We considered the case worthy of reporting due to usage of a different treatment approach.

Caecal intramural duplication cyst associated with intussusception is a rare case in the literature. Generally, total excision is recommended. During the excision, caecal and ileocaecal valves are removed, as well. However, in our case, both caecal and ileocaecal valves were preserved.

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P116: Pseudo-Meigs syndrome in a child with juvenile granulosa cell tumor associated with raised blood ca-125 levels

İ Çiftcia, M O Pirgonb and Y Ünlüb

aUniversity of Selcuk Selcuklu Medical Faculty Pediatric Surgery Department and bKonya Education and Research Hospital

Ovarian tumor and cysts are rarely seen in children. They constitute 1–2% of solid tumors among children. They are categorized in three main groups: epithelial, embrionic, and sex cord-stromal tumors. Sex cord-stromal tumors arise from primordial cell cords located in the center of the ovary undergoing embriological development. Juvenile granulosa cell tumor (JGCT) is the most common type of sex cord-stromal tumors. While this tumor may be formed only by granulosa cells, it may contain varying amounts of theca cells and fibroblasts. Due to estrogen release, patients may clinically demonstrate gynecomastia, vaginal hemorrhage, premature pubarche, irregular menstruation, and precocious puberty. Moreover, clinical symptoms may be accompanied by pelvic or abdominal mass, ascites, and pleural effusion. Unilateral oophrectomy or salpingooophorectomy is the treatment of choice. Our 2-year-old female patient was deemed as a remarkable case because of having a large mass in the abdomen, ascites, and a marked pleural effusion in the right hemithorax. The association of JGCT and pseudo-Meigs syndrome is a considerably rare event. Since we did not find any previous case reports involving concurrent JGCT and pseudo-Meigs syndrome in the literature, we decided to report the case.

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P117: Traumatic pulmonary pseudocyst: a case report

C Güney, M Çakar and G Köylüoğlu

Department of Pediatric Surgery, Cumhuriyet University Aculty of Medicine, Sivas

Purpose: Chesttrauma rarely cause filled with air, fluid or blood, non-paved withepithelium of inner face, well-limited traumatic pulmonary pseudocysts (TPP). This complication is usually occurs after blunt chest trauma. The diagnosis is placed by chest radiograph and computed tomography (CT). The treatmentis usually conservative and spontaneous resolution occurs approximately in 1–4 months. In here, in after blunt thorasic trauma, pneumothorax and hemothorax determined and in the follow-up, pseudocyst developed case, and the follow-up of one-year have been presented.

Case: 14 year-old female patient came to emergency because of the general body trauma. Bilateral tube thoracostomy was performed to patient that had bilateral pneumothorax and hemothorax. Thoracic CT scans were performed to patient because of that cystic images were detected on chest radiograph of post traumatic ninth day. In right hemithorax, 3×5 cm and 3.5×3.5 cm sizes and in left hemithorax 6×4 sizes cystic structures that was determined had air-fluid images. This structures was estimated as TPP. The patient was discharged with antibiotic treatment on prophylactic dose after 24 days from trauma. In thorax CT after three month, it was determined that radiological findings improved. Prophylaxis was ended.

Results: TPP oftendevelops in young people and it is characterized by lack of an apperant epithelial wall within cyst. Pulmonary hematoma and pseudocysts is usually benign as clinical and are resorbed spontaneously with supportive treatment without to need for any other treatment. If prophylaxis is not gave, pseudocyst may develop abscesses and require surgery.

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P118: Intermuscular hydatid cyst: a case report

MH Okura and C Akgünb

aDepartment of Pediatric Surgery, Dicle University School of Medicine and bDepartment of Pediatrics, Yuzuncu Yil University School of Medicine

Primary musculoskeletal and childhood Echinococcus infection without other organ involvement is a very rare condition. Here, we report a case of a 7-year-old boy with primary intermuscular hydatid cyst in the right thigh.

Case: A 7-year old boy who was living in rural area was admitted with a complaint of painful swelling in the right thigh with the increasing size for the last three months that caused difficulty in walking. There were no histories of trauma, surgery or illnesses. Laboratory studies showed eosinophilia (15.4%) and leucocytosis (15 300/mm3). Elisa test was positive for Echinococcus. Ultrasonography (USG) showed 27×44 mm cystic lesion with a thick capsule containing extensive internal septation localized anterio-medial position in the right thigh.

Magnetic resonance imaging (MRI) study revealed 28×44 mm cystic lesion (Hydatid cyst?) Preoperatively, 10 mg/kg albendazole was given for 10 days. The cyst was detected between adductor rectus femoris and iliopsoas muscles during operation with under general anesthesia. The cystic mass was totally removed without destroying the cyst wall and hypertonic saline was applied into the cavity.

After excision, mass was opened and germinative membrane and rock water was found in it. Any problem did not occur in the postoperative period. The patient was discharged with 10 mg/kg/dayalbendazolegiven for 3 months. On oneyearfollow-up, his clinical examination, laboratory and radiogical tests do not show any echinococcosis recurrence to date.

Result: In conclusion hydatidcystshould not beignored in the endemicareas in patients with cystic masses in any part of the body and with suspicion approach radiologicaland serologicalstudies for hydatidcystshould be done before biopsy. When the diagnosis of hydatid cyst was made the cystic masses should totally be removed without drainage.

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P119: A rare combination: appendicitis in the patient with trauma

A Oral, M Yiğiter, O Yalçin, T Dikmen and AB Salman

Department of Pediatric Surgery, School of Medicine, Ataturk University, Erzurum, Turkey

Case presentation: An 11 year old boy patient was evaluated in the emergency service due to a fall from high location. An extensive abdominal sensitivity and defense was observed in physical examination. In abdominal tomography, anteroposterior even laceration in liver, extensive contusio including hilum of the liver and free liquid in abdomen was determined. Since patient's hemoglobin level dropped down to 7.9 g/dl from 11.3 g/dl within 10 h in follow ups erytrocyte suspension replacement was provided for the patient. The patient was hemodynamically stabilized in progressive period follow-ups. In the 4th day of his follow-up, his N/G probe was removed and upon increase in his abdominal pain and bilious vomiting it was placed again. Since his abdominal pains increased and due to bilious N/G drainage abdominal USG was applied in the 6th day of his follow-up. Retrocecal localized perforated appendicitis was reported. There was seconder hemoragic extensive liquid in addition to trauma experienced in exploration. It was determined that retrocecal localized appendicitis was perforated and there was purulent liquid around. One fecaloma was extracted from inside. The patient was released from hospital in the 6th day following appendectomy with the advice of mandatory bed rest.

Discussion: Appendicitis after a trauma was a rare case. It is difficult for the doctors to notice the appendicitis developing simultaneously with the existence of abdominal sensitivity as a result of trauma. It can mostly be noticed with radiological analysis after it was perforated. It is unknown whether appendicitis is incidental or develops together with trauma or whether there exists obstruction picture within the abdominal trauma. It must be kept in mind that there is the possibility of simultaneous existence of appendicitis in the patients with abdominal trauma and it is very difficult to make a diagnosis with current examination findings.

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P120: Calcification and fat necrosis of transverse colon due to chronic pancreatitis: cause of uncontrolable massive ascites and high fever

T Acer and İ Ötgün

Department of Pediatric Surgery, Başkent University Faculty of Medicine, Ankara, Türkiye

Introduction: Parencyhmal calcifications can be seen 30–50% of chronic pancreatitis cases. In our case calcification was seen in transverse colon. Massive ascites and high fever deu to inflammation and fat necrosis, was controlled by transverse colectomy.

Case: Nine-year-old male patient has been receivig chemotherapy since 2005 with a diagnosis of ALL-L3. After chemotherapy, while meutropenic, the patient consulted with abdominal pain. Physical examination revealed mild distension and mild diffuse tenderness. Abdominal ultrasound and CT reported as nodular lesions at pancreas, leukemic infiltration like appearance throughout transverse colon, intraperitoneal minimal ascites and aortocaval LAP. As blood amylase and lipase levels were high, medical treatment for pancreatitis was started. The tru-cut biopsy from transverse colon was out off any living tissue. The peritoneal drainage catheter placed due to increased ascites during the follow up. The catheter drained 2000–3000 cc ascites per day. In spite of long course, wide-spectrum antibiotic treatment, there was uncontrollable fever as high as 39.9°C. As medical treatment was unsuccessful, transverse colectomy, proximal colostomy with Hartman pouch of distal colon was done and drainage catheters placed to the field. Pathologic examination repored as fat necrosis and granulation tissue. The amount of drained ascites decreased by the time and the drainage catheters were taken off. Fever did not reoccur. The patient is going well and is followed with medical treatment, receiving chemotherapy for ALL-L3. He is at 5th postoperative month.

Discussion: Chemotherapatic induced pancreatitis can be seen at patients with hematological or oncological pathologies. Inflammation, fat necrosis and calcification due to chronic pancreatitis can invade surrounding tissues and cause massive ascites and high fever. In our case, there was no response to medical treatment, the success was achieved by surgical resection.

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P121: The association of oropharingeal web with Pierre-Rubin Syndrome: a case report

İ Ötgüna, T Acera, S Uçkanb, A Piratc, L Özlüoğlud and A Hiçsönmeza

aDepartment of Pediatric Surgery, Baskent University Faculty of Medicine, bDepartment of Oral and Maxillofacial Surgery, Faculty of Dentistry, cDepartment of Anestezijoloji and dDepartments of Otolaryngology

Introduction: Pierre-Rubin Syndrome (PRS) is characterized with the triad of micrognathia, glossoptosis and cleft palate. In this report, a case with oropharyngeal web, hypoplasia of the mandibula and the tongue is presented.

Case: The female baby who was given term birth with a birth weight of 3.200 g as the first offspring of the seventeen years old mother from her first pregnancy was referred to our clinic because of the the observation of lingual hypoplasia and micrognathia at her physical examination. A tracheostomy was performed because of the impossibility of intubation of the patient who was begun to be followed with the diagnosis of PRS, who had an oropharyngeal web and who had severe retractions and respiratory distress. The oropharyngeal web was excised and gastrostomy was opened. Mandibular distractors were placed by the mandibular surgery staff and the gap between their arms were widened everyday after the fifth postoperative day. At her follow up, maxillofacial computerized tomography (CT) showed that mandibular development was normal. She had an adequate opening and her tracheostomy was closed nine months after it had been established.

Result: PRS is an autosomal recessive disorder which is characterised by micrognathia, glossoptosis and cleft or high arched palate. The chief problem that increases the severity of the clinical presentation is respiratory distress. Plenty of therapeutic maneuvers were performed to stabilize upper airways in these patients; the use of mandibular osteogenesis distractors to elongate the mandibular rami is the newest and mostly used of them. Our patient had an oropharyngeal web in addition to the routine clinical features of PRS. Our patient did not have cleft palate; but had micrognathia, lingual hypoplasia and oropharyngeal web. Mandibular retractors were used bilaterally in our patient and were followed up with maxillofacial CT. The use of mandibular osteogenesis distractors, which is claimed to be effective at the literature decrease the need for tracheostomy or even discard it totally in some patients.

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P122: Traumatic neuroma after torticollis surgery: a rare occurrence

R Özcana, M Eliçevika, E Mammadova, S Kuruoğlub, S Dervişoğluc and S Celayira

Departments of aPediatric Surgery, bRadiology and cPathology, Istanbul University, Cerrahpaşa Medical Faculty

Herein we report a 15 years old girl applied with signs of recurrent torticollis, complaining from local and consistent pain at the operation site. The patient was operated twice on 1 and 6 years of age and suffering from pain at the operation site while movements of the neck, since. At physical examination, the SCM was found very fibrotic and seemed like a band but not totally inhibiting the neck movements and the posture of the patient did not point to severe torticollis. The MRI of the neck showed only a fibrous SCM band and no additional neck pathology was observed. The surgical indication was based on the clinical complaint of pain and the presence of the fibrous band. During the surgery, two incisions were made, the SCM was found fully fibrotic and the SCM between the incision site was totally removed. The histopathological examination of the specimen demonstrated a traumatic neuroma, which consistently correlates with the symptoms. The patient was discharged on the second day of the PO and was taken into a neck physiotherapy program, thereafter. The patient is symptom free at early controls. This case demonstrates a rare occurrence of traumatic neuroma after torticollis surgery, which can manifest with pain.

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P123: A case of Langerhans Cell Histiocytosis who have come up to emergency service with sudden dyspnea (a 14 years old boy with langerhans cell histiocytosis who have come up to emergency service with sudden dyspnea)

İ Ötgün, Ö Şenocak and T Acer

Department of Pediatric Surgery, Başkent University Faculty of Medicine, Ankara, Turkey

Introduction: Langerhans Cell Histiocytosis is mostly seen between 20–40 years of age male patients who are smoking and with symptoms of cough, dyspnea, weight loss and fever. In this report, a case of Langerhans Cell Histiocytosis who was diagnosed with the only complaint of dyspnea caused by pneumothorax is presented.

Case: 14 years old male patient who was admitted to a local health center with the complaint of sudden dyspnea was found to have right sided massive pneumothorax and was referred to our hospital. Right sided tube thoracostomy was applied from fourth intercostal space at the anterior axillary line. The chest X-ray of the patient revealed reticulogranular pattern bilaterally at the lung parenchyma. Computerised tomography of the thorax was performed which showed multiple bullae distributed widely throughout the lung parenchyma bilaterally. Lung biopsy with minithoracotomy was performed with the forediagnoses of lLangerhans Cell Histiocytosis?, Lymphangioleiomyomatosis?, congenital cystic adenomatoid malformation?, pulmonary involvement of tuberous sclerosis? and histopathologic diagnosis turned out to be Langerhans Cell Histiocytosis. The patient than began to receive chemotherapy according to LCH-3 protocol. Later, left sided pneumothorax occured which was again drained by tube thoracostomy.

Discussion: The patient with Langerhans Cell Histiocytosis presented in this report is an unusual case who did not have complaints of weight loss, cough, fever, dyspnea before, who was not smoking cigarettes and who was diagnosed with the only complaint of suddenly developed dyspnea which was caused by right sided pneumothorax. Continuous medical support is of vital importance at this patient.

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P124: Gallbladder torsion: a rare cause of acute abdomen

C Güneya, M Çakara, G Köylüoğlua and H Özerb

Departments of aPediatric Surgery and bPathology, Cumhuriyet University, Medical School, Sivas

Purpose: Torsion of gallbladder is a rare cause of acute surgical abdomen. The incidence is higher in elderly patients, it is especially a rare pathology in pediatric patients. In english literatüre, more 20 cases were reported in child-age group. The diagnosis is usually placed in operation andthe treatment is emergent cholecystectomy. In here, ithas been purposed to present of a case that was operated with acute abdomen and was diagnosed gall-bladder in operation and underwent cholecystectomy.

Case: 9-year-old male patient was seen with complaints of abdominal pain of three-day and vomiting in the emergency service. In the physical examination, the right upper quadrant tenderness was presented. Laboratory tests was determined as WBC: 13100, ALT: 18, AST: 31, T. Bil: 1.0, D. Bil: 0.2, respectively. In ultrasonography, it was reported that ‘increased gallbladder volume, normal wall thickness, bile sludge within lumen, increasingof echogenicityof pericholecysticarea. ’Torsion of the gallbladder was determined during the operation after the patient was took to emergency operation, and cholecystectomy was performed. The patient was discharged on postoperative third day.

Conclucion: Gallbladder torsion is a rare disease in children. Thetreatment is emergent cholecystectomy. It is a surgical pathology that should be considered in exploration during surgery, despite laboratory does not support in patients that had right upper quadrant abdomen complaint and physical examination findings.

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P125: An uncommon occurrence in children: hydrogen peroxide ingestion

M Çağlar, A Gökgöz Bayar, Ç Ulukaya Durakbaşa, M Korkmaz, S Fettahoğlu, M Sert and H Okur

Department of Pediatric Surgery, S.B. Göztepe Training and Research Hospital, Istanbul

Introduction: Hydrogen peroxide (H2O2) is an oxidative agent which rarely ingested accidentally. It is used as a disinfectant and hair bleacher and also in paper and textile industries in different concentrations. This study presents two patients who ingested H2O2 in the form of hair bleacher and aims to draw attention to the probable dangers of the situation.

Case report: Case 1: A 2.5-year old female child applied to the emergency ward after ingesting perhydrole containg %20 H2O2. The physical examination was normal. A flexible endoscopic examination was done 24 h later and showed a grade 2 caustic injury in the gastric fundus, corpus and cardia. An antiacid treatment was initiated and she was discharged. A control endoscopy done 6 weeks later revealed purplish petechial healing areas in the cardia and was otherwise normal. She is at the 10 month of follow up and free of symptoms.

Case 2: A 1.5-year old female patient applied with perhydrole containing 7.5% H2O2 intake. She had pharyngeal hyperemia. She underwent a flexible endoscopic examination at the 24th hour which revealed edema and minimal fibrous reaction at the lower esophageal end as well as hyperemic and partially erosive patchy lesions in the mucosa of the corpus, antrum and cardia. She is at the 10th postoperative month and currently free of symptoms.

Conclusion: Perhydrole is used as a hair-dying agent and contains 20–30% H2O2. The mechanisms of injury formed by H2O2 intake are through corrosive injury, oxygen gas embolization and lipid peroxidation. The concentrations above 10% are more dangerous. Very high concentrations can cause mortality. The two patients presented here had caustic injuries only and healed without an adverse sequel.

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P126: Hepatic hydatid cyst and intra-peritoneal free hydatid cyst

İ Çiftcia, H Yilmazb and M Gündüzc

Departments of aPediatric Surgery, bGeneral Surgery, University of Selcuk, Selcuklu Medical Faculty and cDepartment of Pediatric Surgery, Konya Education Research Hospital

Introduction: Hydatid disease is relatively frequent in our country and non-invasive ultrasonic imaging techniques have made possible an earlier diagnosis prior to serious complications. Human hydatid disease usually occurs by infestation with Echinococcus granulosus and less frequently with Echinococcus multiocullaris. Humans receive the disease through enteral exposure and become accidental intermediate hosts. Hydatid disease is an endemic problem in Turkey as well as in sheep-breeding regions of the world. Hydatid disease may be located in any organ of the body. The most frequently involved organ is the liver (50 to 70%), while the lungs are the second most common site (20 to 30%). The cyst may be ruptured after trauma or spontaneously as a result of increased intracystic pressure. The most frequent complication is rupture of the cyst, either internally or externally, followed by secondary infection, anaphylactic shock, and liver displacement in decreasing frequency with the same order.

Our case: A twelve-year old girl fell from the swing 12 days ago. The patient was suspected of acute abdomen and was operated under emergency conditions. A cystic formation white in color and wall thickness approximately 15 cm was observed at the level of umbilicus near the midline. Debridement of the abdominal areas was made with blunt dissections and povidine iodine pads were used. The patient received post-operative Andazol treatment. Currently, the patient is still under follow-up at month 36. Recurrence was not detected at the time of writing this report.

Discussion: Exploration of the abdomen of our patient revealed a giant cystic lesion formation, and this development did not fit the development of hydatid cyst pathophysiology. Under normal conditions, such cysts grow 0.8–1 cm per year in 12-year-old children, therefore, reaching of the cyst to a size of 15 cm is not possible. In addition, we know that the cyst formation in tissues lead to the formation of pseudocapsules. But in this case, formation of pseudocapsule was not present. The mass was separated very easily from the mesentery and intestines, and adhesions were not present and the cystic lesion was removed as a whole. Vesicles were cleared This case does not conform to the pathophysiology of cyst development. We suggest that the development of this particular cystis an exception or review of the pathophysiology of development. Also agree with the opinion of surgical treatment, in addition to preventing recurrence of Albendazole Treatment.

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P127: A case with multiple intestinal atresia (anal, colonic and jejunoileal) and associated multiple anomalies

MH Okura, T Akçab, M Tutançc, E Ünverb and C Akgünd

aDepartment of Pediatric Surgery, Dicle University, School of Medicine Diyarbakir, Turkey, bVan Maternity and Children Hospital, Van, Turkey, cDepartment of Pediatrics, Mustafa Kemal University, School of Medicine and dDepartment of Pediatrics, Yuzuncu Yil University, School of Medicine

Colonic atresia is a very rare anomaly seen in 1/20 000 births. A 2000 gram female baby, who was born on the 37th gestational week as the fourth child of a 27 year-old healthy mother, was hospitalized due to multiple anomalies.

Physical examination revealed syndromic face, blepharophymosis on the lateral 1/3 part of the left eye, multiple synechia between the upper and lower eye lip of the right eye, low nasal bridge, enlarged nose tip, dysplasic eye lashes and bilateral upper eye lids, iris coloboma of the left eye, left preauricular pit, trigonocephaly of the head, accesory digit on the right hand and polysyndactily of the left foot.

A catheter could be inserted 2 cm from anus and not further. Rectal atresia and so atretic segment was established with radiopaque material injected to the rectum. On abdominal ultrasound, grade 2–3 hydronephrosis on the right and grade 1 hydronephrosis on the left kidney was diagnosed. During the operation, jejunoileal atresia type 4, malrotation, short colon, ceacal membrane, and type 1 colonic atresia were diagnosed. The intestinal segment at the proximal part of the ileostomy was 100 cm.

Such cases must be thoroughly evaluated for other probable systemic anomalies before the surgery; and during the surgery the whole intestinal tract should be evaluated for other probable intestinal atresias. In the light of our knowledge, this is the first case that reported in the literature with these associated anomalies.

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P128: A rare torsion case in children: paraovarian cyst torsion

Y Yilmaza, D Çalişkanb, İO Özenc and U Dilmend

aDepartment of Neonatology Pediatric Surgeon, Ministry of Health Zekai Tahir Burak Maternity and Teaching Hospital, Ankara, bMinistry of Health Diskapi Children's Hospital, Pediatric Surgery, Ankara, cGazi University Medical Faculty, Pediatric Surgery, Ankara and dDepartment of Neonatology, Ministry of Health Zekai Tahir Burak Maternity and Teaching Hospital Ankara

11 years old girl with acute abdominal pain (mostly in the lower quadrants), nausea and vomiting was seen in the outpatient clinic. An ovarian cyst of 6 cm in diameter was encauntered in ultrasound scan. Laparotomy was done via a lower transvers incision. The left broad ligament 7200 counterclockwise twisted due to a paraovarion cyst was seen. The left ovary was normal and was not involved in the torsion. After the correction of the torsion the cyst was removed.

Paraovarian cyst arises in the paraovarium of the broad ligament between the Follapian tube and ovary. It is more commonly seen in 30 and 40 years of age and very uncommon in children. When uncomplicated it is generally asymptomatic. It usually diagnosed incidentally during radiological investigation or pelvic surgery. When encountered during pelvic surgery, the cyst should be excised whenever possible, because of its ability to undergo torsion and rapid enlargement.

The incidence of torsion is very low in paraovarion cysts due to its unpedinculated structure. In children the incidence of paraovarian cysts is also very low. Therfore, there are very few case reports of paraovarian cyst torsion in children in the literature.

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P129: A case of intractable diarrhea: an unusual symptom of neuroblastoma

Ö Şenocak, T Acer, İ Ötgün, P Oğuzkurt and A Hiçsönmez

Department of Pediatric Surgery, Baskent University Faculty of Medicine, Ankara, Türkiye

Introduction: In %5–10 of the patients with neiuroblastoma, the disease presents itself with hipopotasemia and intractable diarrhea, the cause of which is a hormone named as vasoactive intestinal polypeptide (VIP) that is secreted from the tumor. In this report, a case of neuroblastoma with the complaint of intractable diarrhea is presented.

Case: The patient, a girl of one year of age, who had been brought to a regional state hospital with the complaint of frothy, mucous diarrhea, and bowel frequency of at least three times a day was referred to our hospital because of her long lasting diarrhea and high blood pressure level, reaching 150/80 mmHg. She was consulted to us because of her abdominal distention during her treatment at the pediatry ward for intractable diarrhea and hipokalemia. Her abdominal ultrasonography and colon graphy did no reveal any pathology; but the abdominal tomography, which was performed for the investigation of the cause of hypertension, revealed a mass of 6×5×5 centimeters, located at the left surrenal area. The mass was observed to contain calcific and cystic-necrotic areas and a pseudocapsule. With these findings, the mass was interpreted to be neuroblastoma and operated. The lesion was totally excised and at the histopatological study, it was found to be differentiated type neuroblastoma. The patient whose complaints have disappeared is followed up without chemotherapy as the tumor was totally excised and as it was of the differentiated type.

Conclusion: Opsomyoclonus, paraplegia or intractable diarrhea due to VIP secretion of the tumor are unusual symptoms of neuroblastoma. Intractable diarrhea and hipokalemia are observed at %5–10 of neuroblastoma cases. Because of this fact, our patient can be considered as a case of neuroblastoma with unusual presentation. It can also be stated that, in the presence of intractable diarrhea, the possibility of a malignant neoplasm being the cause should not be overlooked.

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P130: A rare retroperitoneal tumor in childhood: schwannoma

G İnala, İ Ötgüna, P Uyarb, F Sarialioğluc and A Hiçsönmeza

aDepartment of Pediatric Surgery, Baskent University Faculty of Medicine, bDepartment of Pathology and cDepartment of Pediatrics, Pediatric Oncology

Introduction: Schwannoma, which is a peripheral nerve sheath tumor, originates from the cells of schwann. It is a rare tumor of mid-ages. Retroperitoneal location of schwannoma is very rare in children.

Case: A 4-year-old male patient admitted with the diagnosis of a retroperitoneal mass. Physical examination revealed hepatosplenomegaly. Neurologic examination was normal. Abdominal ultrasonography and tomography showed a 43×40×32 mm solid mass neighbouring to the left kidney. The retroperitoneal mass was totally excised. It was diagnosed as cellular epitheloid type schwannoma with histologic examination. No chemotherapy was administered because of no invasion and no residual tumor of the mass. The patient is healthy and tumor free in his one-year follow up.

Discussion: Schwannoma is most commonly seen in skin, head, neck and extremities. The incidence is reported to be 0.001%. It is a tumor of second and fourth decades. One-half of the tumors accompany to neurofibromatosis. Relapse is rare in cases with total excision. Chemotheray and radiotherapy is administered in patients with invasive or residual tumor.

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P131: A case of cervical teratoma whose treatment was delayed because of erroneous diagnosis

İ Ötgüna, G İnala, M Coşkunb, F Sarialioğluc and A Hiçsönmeza

aDepartment of Pediatric Surgery, Baskent University Faculty of Medicine, bDepartments of Radiology and cPediatrics, Pediatric Oncology, Ankara, Türkiye

Introduction: Teratomas take their origin from the three germ layers. %8 of them are located at the cervical region. They can be diagnosed prenatally by ultrasonography (USG). Cervical teratomas are usually benign and are cured surgically. Whereas, cystic lymphangiomas which take their origin from yhe lympathic tissue may present with capillary, cavermous or cystic histology. They can be cured surgically or by sclerotherapy. USG or computerized tomography may be helpful in the diagnosis. In this report a case of cervical teratoma whose treatment was delayed as a result of erroneous diagnosis is presented and at whom a life threatening complication had occcured.

Case: The two and a half months old male patient, who had been followed with the diagnosis of cleft palate and cervical lymphangioma had received two doses of bleomycin injection to the mass, but regression had not been observed. The patient had to be intubated once because of loss of consciousness after having meal. After his referral to our hospital, at the physical examination, a heterogenic mass of irregular contours which was located under the mandibula at the left side of the neck and displacing the tongue to the right was observed. At the USG, a subcutaneous mass of 12×8 centimeters having lobulated contours and containing calcification areas which was located under left mandibular ramus was observed. It was also observed that the mass was having abundant blood supply and having multiple cystic components. The serum alphafetoprotein (AFP) level of the patient was found to be high according to the reference values of his age. The histopathologic examination of the mass after it's total excision revealed that it was mature cystic teratoma. After surgical treatment, serum AFP level of the patient declined to the normal value range.

Conclusion: The cystic masses of the neck may threaten life because of their location; thus they should be diagnosed promptly and appropriate treatment should be given immediately. Generally it is not difficult to differentiate cervical teratomas from cystic higroma, congenital goiter, foregut duplication cyst or branchial cleft remnants. The incidence of preventable morbidity and mortality can be reduced with appropriate treatment performed by a pediatric surgery team with adequate knowledge, experience and physical equipment.

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P132: Report of four cases with giant ovarian cyst

Y Yilmaza, G Kilinçb, HÖ Ulua, İH Çelikb, ŞS Oğuzb and U Dilmenb

Departments of aNeonatology Pediatric Surgeon and bNeonatology, Ministry of Health Zekai Tahir Burak Maternity and Teaching Hospital

Ovarian cysts compose most of the intraabdominal cysts in fetal period. Most of them regress spontaneously at intrauterine period or postnatally. Generally, the cysts that are complicated and do not regress are excised. Here we report a case serie that consists of four newborns having giant (≥10 cm) ovarian cysts. The patients had no additional anomalies and laboratory evaluation and tumor marker levels were within normal ranges. All of the patients were term infants and followed for ovarian cysts in intrauterine period. They were operated on 5, 11, 28, 47 th days respectively. Three patients had unilateral cysts (two right, one left), one had bilateral cysts. The cysts in one of the unilateral cases and right one of the bilateral case had torsion. The sizes of the cysts in the unilateral cases were 10 cm and the bilateral case were 10 and 5 cm. All of the patients were begun to feed enterally after 24 h of the operation and discharged at 4th day without any complication.

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P133: Tailgut cyst (retrorectal cystic hamartoma) misdiagnosed and treated as rectal prolapse

İ Akillioğlu, S Yücesan and A Hiçsönmez

Department of Pediatric Surgery, Başkent University Faculty of Medicine

Introduction: Tailgut cyst (TGC) is an extremely rare lesion of developmental origin usually located in the retrorectal area as a multilocular benign tumour. The rarity and nonspecific clinical presentations of TCGs, often lead to misdiagnose and inappropriate treatment. We report one such case misdiagnosed as rectal prolapse and discuss the management.

Case: A 1-year old boy was referred to our clinic with rectal prolaps and constipation. He had been taking lactulose for constipation during the last 6 months. On examination, the patient was healthy except a mass in the anorectum which was palpable. Magnetic resonance imaging (MRI) was carried out and showed the presence of a well demarcated cystic extrinsic mass of anorectal area and no communication with the rectum. There was no solid component and septations within the cystic mass. A semicircular mucosal incision made on the posterolateral inner wall of the rectum. As the cyst was large it was aspirated to decompress it and after a carefull dissection the patient underwent complete surgical excision without a protective colostomy. Pathologic finding showed a unilocular cyst lined by ciliated columnar epithelium. The postoperative period was uneventful, he was discharged on the seventh postoperative day. The patient has been doing well 3 years after operation.

Discussion: TGC is a rare cystic lesion originating from the embryonic tailgut that appear usually in the retrorectal area. The incidence is unknown because there have been few series published. It is predominant in females in a 3 : 1 ratio and the reason of this predilection is unknown. Despite their congenital origin they are usually diagnosed in adults. The clinical presentation of TGCs is often nonspecific and misleading. Described symptoms include discomfort or pain while sitting, urinary retention, constipation, recurrent perianal abscesses, rectal bleeding and dysuria. They are almost always benign, although malignancy including cases have been reported in the literature. Because of the location, they can usually be palpated by digital rectal examination, such in our case. Complete surgical excision is the treatment of choice for TGC.

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P134: Carcinoid tumor presentation at the appendectomy material: a case report

G İnal, T Acer, İ Ötgün and A Hiçsönmez

Department of Pediatric Surgery, Başkent University Faculty of Medicine, Ankara, Türkiye

Introduction: Carcinoid tumor is the most common neoplasm of the appendix. This tumor is rare in children. It is originated from the endocrine cells in the lamina propria and submucosal zone. The ones seen in appendix are not symptomatic and usually are coincidental.

Case: 13-years-old girl admitted to emergency room with right groin pain, fever and vomiting who had right lower quadrant tenderness and local muscle rigidity in her physical examination. Minimal peritoneal fluid in the Douglas area and mild dilatation in right kidney pelvicalyceal region was reported by the abdominal ultrasound examination. She was hospitalized 3 years ago with the same symptoms and was watched closely for the mild dilatation in right kidney pelvicalyceal region. The patient was taken under surgery with the prediagnosis of acute appendicitis. Appendix was inflamed; its position was retrocecal and subserosal. Histopathologic examination of the excised appendix was reported as monotone neoplastic cell proliferation at the tip of the appendix tissue, located between submucosa and muscle layers which was pancitoceratin (+), synaptophysin (+) and chromagranin-A (−). The histopathology was coherent with carcinoid tumor. The patient was discharged in 2 days with no additional treatment.

Result: Carcinoid tumors are usually diagnosed coincidentally with the histopathological examination of the appendectomy material. Right hemicolectomy must be done after appendectomy if the tumor is larger than 2 centimeters or near the cecum however no additional treatment must be added if the tumor smaller than 2 centimeters. The incidence of the coincidental diagnosis of this tumor must enhance the importance of the histopathological examination of the appendectomy material.

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P135: A rare soft tissue tumor: juvenile xanthogranuloma

HS Yalçina, İ Ötgüna, T Acera, F Sarialioğlub, N Usluc and A Hiçsönmeza

Departments of aPediatric Surgery, bPediatrics, Pediatric Oncology and cPathology, Baskent University Faculty of Medicine

Introduction: Juvenile xantogranuloma is a rare benign soft tissue tumor which is usually diagnosed in the first year of life. Here is presented a case of abdominal wall juvenile xantogranuloma.

Case: 13-month-old male baby admitted with a swelling which had been noticed by his parents 5 days before. Physical examination revealed; a palpable, mobile, smooth-surfaced, subcutaneous, 2-cm mass where left subcostal and midclavicular lines intersect. Ultrasonography defined lt as a hypoechoic solid mass with minimal vascularity, suggestive of lymphadenopathy or lipoma. The mass was excised totally. Histopathologic analysis was consistent with juvenile xanthogranuloma. He is free of problems on follow-up.

Results: Juvenile xanthogranulomas are soft tissue masses which are usually seen in the first year of life with a diameter around 3–4 cm. They are rarely seen in other tissues than soft tissue. They are benign and histopathologically considered as non-langerhans cells histiocytosis. Tuton type giant cells are diagnostic. They can be followed-up without any treatment as benign tumors with potential of spontaneous regression. As diagnosis is made histopathologically, surgical excision is the ideal management, including both the diagnosis and treatment -with exclusion of any other kind of soft tissue tumors. We aimed to remember juvenile xanthogranuloma, which is so rare, and its treatment alternatives with this case.

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P136: A rare cause of neonatal intestinal obstruction: neonatal small left colon syndrome

SC Karakuş, N Koku and A Yilmaz

Department of Pediatric Surgery, Gaziantep Children Hospital

Neonatal small left colon syndrome is considered a rare cause of neonatal intestinal obstruction, characterized by low colonic obstruction and a contracted distal colon from the anus to the splenic flexure. Maternal diabetes has been reported in approximately 50% of the published cases of neonatal small left colon syndrome. Long segment aganglionosis and cystic fibrosis should be considered in the differential diagnosis. The rectum may dilate in small left colon syndrome and a ratio of rectum to sigmoid colon diameter greater than 1 can help exclude long segment aganglionosis.

A 1-day-old, full-term male was admitted with bilious vomiting and abdominal distention. His birth weight was 2500 g. Antenatal ultrasound performed in week 8, 21 and 30 was normal. There was no history of maternal diabetes. He failed to pass meconium in the first 24 h of life. Abdominal X-ray revealed a low colonic obstruction. Following a subsequent contrast enema that showed a narrow descending and sigmoid colon, normal meconium passage was began. He had a normal sweat chloride value. Two months later he is well, with a normal bowel habit.

Early and true diagnosis is important in order to prevent perforation and differentiation from long segment aganglionosis.

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P137: Congenital diaphragmatic hernia (bochdalek) in twins, and literature rewiev

MT Gürbaz, A Kazez, Y Çolakoğlu and T Tartar

Department of Pediatric Surgery, Firat University Faculty of Medicine, Elaziğ, Turkey

Congenital diaphragmatic hernia (CDH, Bochdalek type) is a very rarely seen in both of newborns of identical twins.

CDH in both of babies of twins have been presented only 5 sets of twins who underwent succesfully surgical repair to present.

In this study, we present a 35 weeks' twins with CDH both survived, and rewiev of the literature.

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P138: A rare cause of partial intestinal obstruction: jejunal stenosis ladd band and malrotation

M Gündüza, İ Çiftçid, Z Gökmenb and Y Ünlüc

aDepartment of Pediatric Surgery, bDepartment of Neonatalogy, cDepartment of Pathology, Konya Training and Research Hospital and dDepartment of Pediatric Surgery, Selçuk University Selçuklu Medical Faculty

Introduction: Jejunal stenosis is defined as a localized narrowing of intestinal lumen without disruption in the intestinal wall or a defect in the mesentery.

Case: We describa a case of 90 day old triplet, premature boy that was treated for necrotizan enterokolitis. A day after being discharged he presented with yellow-green vomiting to our hospital. Physical examination findings showed right inguinal hernia, weight was 1600 g and a plain abdominal radiograph showed double-bouble sign but an upper gastrointestinal contrast study showed filling in distal intesinal sytem. Upon persistant bilious vomiting and air-fluid levels in plain abdominal radiograph exploration was done by supraumblical right transverse incision. Ladd bands, malrotation, Meckel diverticulum and jejunal stenosis was found approximately 15 cm distal to Treitz ligament. Cecum was right lateral to duodenum. Ladd bands were excised. We have not been able to catheterise the stenotic lumen with 6 Fr tube. Resection and end to end anastamosis and inguinal hernia repair was done. Primary repair was done to iatrojenic jejunal damage. Postoperative recovery was uneventful.

Conclusion: Jejunal stenosis is a rare cause of partial intestinal obstruction. In patients with persistant bilious vomiting intestinal stenosis should be considered.

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P139: A rare iatrogenic complication of an infant: bladder rupture

A Oral, M Yiğiter, O Yalçin, T Dikmen and AB Salman

Department of Pediatric Surgery, School of Medicine, Ataturk University, Erzurum, Turkey

Case presentation: A 2500 g male baby, born on 38th gestation week, was examined for complaints of icterus and feeding difficulties in the fifth day of his life. Hiperbilirubinemia was determined and he was admitted to newborn intensive care unit for phototherapy. Ultrasonography (USG) was reported as normal for the patient who had 100 000 E.coli in his full urine analysis. Voiding Cystourethrogram(VCUG) was applied to the patient, who antibiothearpy had been applied, in 31st day of his life by pediatric nephrolog for advance examination. The patient was transferred to our clinic due to bladder volume expansion and the fact that the bladder was seriously trabeculated in the VCUG taken. Urachal cyst was reported in urinary tract USG performed on the patient. In cystoscopy performed on the patient, it was determined that bladder volume was very small and there was a hemorrhagic tear through the middle line on the back wall. Perforation was found in retoperitonal region in bladder posterior. Perforation primer was repaired and foley prob and sistostomi prob was placed through uretral way. Bladder volume was measured as 5 cc. In 12th day of postop the patient was released from hospital without any problem. Urinary USG was performed on Postop 45th day. Bladder capacity was reported as insufficient. VCUG was planned in 3rd month.

Discussion: Insufficient bladder volume, not recognizing this problem during VCUG and incorrect application technique may cause serious complications to arise in urinary system examinations. Applying VCUG properly and not applying during VCUG are effective to prevent possible complications.

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P140: Management of neuroblastoma

A Temiza, P Oğuzkurta, SS Ezera, E İncea, N Yazicib, F Sarialioğlub, Ş Demirc and A Hiçsönmeza

Departments of aPediatric Surgery, bPediatric Oncology and cRadiology, Başkent University Faculty of Medicine, Ankara, Türkiye

Aim: Neuroblastoma is a malignant solid tumor of childhood which develops from sympathetic ganglions. In this study, weevaluated the outcome of the patients with neuroblastoma.

Materials and methods: The records of 13 patients who were treated with diagnosis of neuroblastoma between July 2007 and November 2010 were reviewed retrospectively.

Results: There were 8 boys and 5 girls with a mean-age of 20.3±9 months. Abdominal distention (n:4), abdominal pain (n:2), tremor (n:2), coughing (n:2), forehead and neck mass (n: 1), swelling of left leg (n:1), excessive water intake (n:1) were complaints. Abdominal mass (n:7), opsomyoclonus (n:2), raccoon eyes (n:2), peripheral lymphadenopathy (n:2) and normal findings were detected on examination. Tumoral involvement of bone marrow was detected in 3 of them. Masses were detected in the retroperitoneum (n:11), thorax (n:1) and pelvis (n:1). Metastatic lesions were observed in 5 patients on bone scintigraphy. Tru-cut biopsy was done in 10 patients. The diseases were classified as stage-1 in 1, stage-2A in 1, stage-2B in 1, stage-3 in 5 and stage-4 in 5 patients. Opsomyoclonus syndrome was defined in 2 patients. Neoadjuvant chemotherapy and primary surgery were applied in 10 and 3 patients respectively. Total excisions in 7 and gross total excisions in 6 patients were performed. Adjuvant chemotherapy was applied in 11 patients. 1 patient died during the follow-up. 2 patients still take adjuvant chemotherapy. The follow-up period is still uneventful in the remaining 8 patients.

Conclusion: Primary surgery is performed in patients with early stage. Surgery is necessary to reveal viable tumoral cells after chemotherapy in patients with advanced stage. Satisfactory results of treatment are obtained with multidisciplinary approaches.

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P141: Results after necrotizing enterocolitis (NEK) surgery

A Musayev

Department of Pediatrics İnstitute Named After K.Faradjov Newborn and Children Operation, Bakü, Azerbaijan

Aims: To study and therapy problems and complains appeared after NEK treatments and surgery.

Purpose: The medical history of 84 patients who underwent a surgery with NEK diaqnosis in Newborn Surgery Unit (Scientific Research Institute of Pediatrics) in the period from 2009 to 2010 were evaluated.

Method: 39 girls and 45 boys patients have been surveyed. On average the patients were 4.2–7.6/365 days. Patient complaints:abdominal distension, vomiting, abdominal pains, blood faeces, complication of general state, pathologic liquid in abdomen according Ultrasonography. Intraperitoneal gas (according ADGB), intestinal dilatation, intestinal pneumotomy, peristan. Laboratory examination showed following: leukopenia, thrombocytopenia, increase PZ, gas acidosis. At the practice we observed full recovery in 37 patients. Second stage therapy of stoma at 47 patiens. Patients with postop stoma have been undergone contrast X ray examination. Microcolon detected at 19 patients. Patients had clysterize. 3 patients with Hirchprung disease underwent surgery. One patients with stricture appearance had surgery in another clinic center. One patient had resectiononal anastomosis in our clinic.

Results: The aim of this work is to study NEK and postop complications which occur fairly often at term and prematurely born term infant. One of patient group with seconder NEK had seconder complications.51% of patients after stoma was need to survey postop at our practice. 6.3% patients - Hirchprung seconder NEK, 4.2% patients-stricture of NEK. So that after problems which observed in stoma closing stage we decided to examine patients again.

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P142: Role of endoscopic transillumination in the diagnosis and management of questionable cases of imperforate anus

S Khalid

Shreef Pediatric Surgery Unit, Surgery Department, Zagazig University, Egypt

Background/purpose: Ten to twenty percent of cases of imperforate anus are questionable with no clinical evidences support the diagnosis of the level of the anomaly. The diagnostic tests used to determine the level of defect are not accurate enough and the surgeon may subject the patient to an unneeded colostomy while the level of the anomaly was low. The aim of this study is test the feasibility of using antegrade endoscopic transillumination to give precise knowledge about the level of the anomaly in these questionable cases and thus help in the proper management.

Materials and methods: This is a prospective study comprising ten newborns boys with questionable level of imperforate anus admitted through the emergency unit of surgery department from May 2007 to April 2009. All Patients had sigmoidostomy 24–72 h after having failed to pass the meconium. A pediatric size flexible sigmoidoscope was introduced through the distal pouch of the sigmoid and the distal termination of the rectum was clearly identified. Bright transperineal transilluminationof the endoscopic light indicated a low malformation amenable to transanal anoplasty with closure of the sigmoidostomy. Poor or no transilluminationindicated a higher defect that needed staged posterior sagittal anorectoplasty.

Results: Ten boys were admitted, Six of them had low anomaly and showed bright transperineal transilluminationand were managed by endoscopic-assisted anoplasty. Four patients had high anomaly with no transperineal transilluminationand their operations were converted to staged posterior sagittal anorectoplasty. There were no operative complications. All patients with low anomaly (6 patients) were followed regularly in the outpatient clinic; the median follow up period was 6 months. All had a good anal size; four of them had mild to moderate constipation and respond well to medical treatment.

Conclusion: The use of antegrade endoscopic transilluminationin questionable cases of imperforate anus helps in reaching the proper diagnosis, safe identification and reconstruction of the new anus and avoidance of unneeded colostomy in cases with low anomaly.

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P143: Extremly rare congenital pulmonary anomaly: cystic pulmonary lymphangiectasia and cystic pulmonary lymphangioma

A Sayana, A Arikana, T Özdemira, H N Özera, M Cana, H Turana and Ü Bayolb

aClinic of P