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Septate gallbladder associated with cholecystitis and pancreatitis in children
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INTERNATIONAL ABSTRACTS
tube. No data are given (as to) which temporary method (PTD, stent, tube) is combined with less risk of interventional placement and occasional tube displacement.—Peter Schmittenbecher Septate Gallbladder Associated With Cholecystitis and Pancreatitis in Children. I. Hunt, D. Palmer, A. Shirley et al. Aust N Z J Surg 72:920-921 (December), 2002. Two cases are reported of an 11-and 12-year-old boy presenting with recurrent episodes of right upper quadrant pain secondary to cholecystitis associated with cholelithiasis. In one child with a 6-week history the amylase was elevated to 703 U/L. Both children were treated satisfactorily with a laparoscopic cholecystectomy. Subsequent histopathology confirmed septation of the gallbladder, previously diagnosed on ultrasound examination in only one case. The authors cite an ultrasound study of 1,823 patients that suggested gallbladder septation occurs in 3.8% of hospitalized adults. This may predispose to cholelithiasis as a result of stasis, although this suggestion is speculative.— A.J.A. Holland Laparoscopic Exploration of the Contralateral Groin in Children With Unilateral Inguinal Hernia. E. Dluski, B. Zelawska, and Z. Dudkiewicz. Surg Child Intern 4:191-193, 2001 Contralateral inguinal exploration in children with unilateral hernia remains controversial. Between 1998 and 2001, 52 children (32 boys and 20 girls) aged 3 months to 7 years, underwent unilateral inguinal herniorrhaphy in the Institute of Mother and Child in Warsaw, Poland. Laparoscopic exploration of the contralateral groin during hernia repair was performed by passing a scope through the symptomatic hernia sac. Patent processus vaginalis (PPV) was found in 9 patients (17%). This percentage of identified PPV is significantly lower than reported by open explorations and is also closer to the reported rate of metachronous hernia presentation.—Jerzy K. Niedzielski Changeable Views on the Treatment of Gastroschisis. A. Chilarski, H. Bulhak-Guz and H. Grochulska-Cerska Surg Child Intern 10:18:22, (January), 2002. The authors report on 36 neonates (equal sex incidence) with gastroschisis treated in Polish Mother’s Health Institute in Lodz, Poland between 1994 and 2001. The mean birth weight was 2,150 g. The diagnosis was established by means of prenatal ultrasound in 27 instances (75%). In the beginning of this series, either primary fascial closure of the defect (9 of 36; 25%) or staged procedure with polyethylene silo construction (22 of 36; 61.1%) was performed. The decisionmaking criteria was monitoring of intraabdominal (bladder) pressure. Simple primary reduction, as advocated lately in selected cases of gastroschisis, was performed with good results in 5 children (13.9%). Four children died (11.1% mortality rate), and 3 (8.3%) had to undergo reoperation because of the massive adhesive ileus. The remaining 32 infants (88.9%) recovered uneventfully. Although the main goal in gastroschisis is always closure of the abdomen, the method should be individualised for each patient.—Jerzy K. Niedzielski
GENITOURINARY TRACT Retrospective Review of Pediatric Patients With Acute Scrotum. I. Mushtaq, M. Fung, and M.J. Glasson. Aust N Z J Surg 73:55-58, (January/February), 2003. The authors sought to investigate the reliability of history and clinical examination in the diagnosis of an acute scrotum. Of 268 boys that presented to a tertiary pediatric institution in Sydney between January 1994 and December 1998, 58 were excluded as a result of previous testicular fixation, intrauterine torsion, uncertain diagnosis, or incomplete medical records. Mean age of the remaining 204 boys was
9 years (range, 1 month to 15.5 years). One hundred ten had torsion of a testicular appendage, 40 testicular torsion, and 29 epididymo-orchitis. The only significant difference in clinical features between the 3 groups was in the duration of symptoms: boys with testicular torsion presented significantly earlier (P ⬍ .005; median, 9.5 hours v 48 hours). Surgical exploration was performed in 187 boys. History and physical examination together provided the correct diagnosis in 87.5% of boys with testicular torsion, 83% with torsion of an appendage, and 56% with epididymo-orchitis. Retrospective data collection and the variable seniority of the surgeon performing the initial assessment compromised this study. The proposal that a history of greater than 24 hours might be used as a suitable cut-off point for surgical exploration assumes that all torted testes remain torted. Further, the authors own data identified 2 patients with viable testes despite having symptoms for greater than 24 hours. Although routine exploration would not seem appropriate for all patients, for those in whom the diagnosis remains uncertain, exploration remains the safest course.—A.J.A. Holland The Role of Nitric Oxide in Reflux Nephropathy. B. Chertin, U. Rolle, A. Farkas, et al. Pediatr Surg Int 18:630-634, (October), 2002. Reflux nephropathy accounts for about 25% of cases of end-stage renal failure, but the mechanism by which reflux produces renal scars is still not clear. The authors examined nitric oxide (NO), which regulates arteriolar tone, mesangial cell proliferation, and extracellular matrix production by staining of NOS, an important enzyme in the synthese of NO. They differentiated the isoforms inducing NOS (iNOS), endothelial NOS (eNOS), and neuronal NOS (nNOS), the first a proinflammatory agent secreted by macrophages and mediating apoptosis, the others thought to have beneficial effects in relaxing vascular tone and ameliorating tubulointerstitial fibrosis. Kidney specimen from children with severe reflux nephropathy (RN) obtained at nephrectomy were compared with normal kidney tissue from adults undergoing surgery for small kidney tumors. Staining for NOS and iNOS in the proximal tubules of control kidneys was weak compared with RN specimen. nNOS and eNOS were lacking in control tissue, but were strongly visible in the tubulointerstitial spaces and in the glomeruli in RN kidneys. The authors correlated the markedly increased iNOS activity with the impressive histologic increase in proximal tubule apoptosis and atrophy, interpreting this as an effect of a macrophagestimulated proinflammatory cytokine overproduction. eNOS may buffer iNOS effects on fibrosis by an increase of regional blood flow and relaxation of mesangial vessels. nNOS, probably stimulated by angiotensin II receptors, may reduce interstitial fibrosis by leading to an increased cyclic GMP level. Therefore, blockage of iNOS and induction of eNOS and nNOS may be helpful in preventing parenchymal injuries in RN.—Peter Schmittenbecher Primary Megaureter: Results of Surgical Treatment. G. Aksnes, R. Imaji, and P.A. Dewan. Aust N Z J Surg 72:877-880, (December), 2002. A retrospective analysis was performed of clinical and radiologic outcomes in 16 patients with 17 isolated primary megaureters presenting to one institution between January 1997 and April 2001. The median age at surgery was 11 months, and there were 13 boys. Presenting features were a urinary tract infection in 8, wetting in one, and failure to thrive in one, with the remainder identified after an antenatal diagnosis of hydronephrosis. Patients were treated with a Cohen reimplantation with variable imbrication of the distal ureter. Median review after surgery was 17 months, during which, 6 of 8 patients had no further urinary infections; a patient’s wetting improved, and the infant with failure to thrive ceased vomiting. Those asymp-
INTERNATIONAL ABSTRACTS
tube. No data are given (as to) which temporary method (PTD, stent, tube) is combined with less risk of interventional placement and occasional tube displacement.—Peter Schmittenbecher Septate Gallbladder Associated With Cholecystitis and Pancreatitis in Children. I. Hunt, D. Palmer, A. Shirley et al. Aust N Z J Surg 72:920-921 (December), 2002. Two cases are reported of an 11-and 12-year-old boy presenting with recurrent episodes of right upper quadrant pain secondary to cholecystitis associated with cholelithiasis. In one child with a 6-week history the amylase was elevated to 703 U/L. Both children were treated satisfactorily with a laparoscopic cholecystectomy. Subsequent histopathology confirmed septation of the gallbladder, previously diagnosed on ultrasound examination in only one case. The authors cite an ultrasound study of 1,823 patients that suggested gallbladder septation occurs in 3.8% of hospitalized adults. This may predispose to cholelithiasis as a result of stasis, although this suggestion is speculative.— A.J.A. Holland Laparoscopic Exploration of the Contralateral Groin in Children With Unilateral Inguinal Hernia. E. Dluski, B. Zelawska, and Z. Dudkiewicz. Surg Child Intern 4:191-193, 2001 Contralateral inguinal exploration in children with unilateral hernia remains controversial. Between 1998 and 2001, 52 children (32 boys and 20 girls) aged 3 months to 7 years, underwent unilateral inguinal herniorrhaphy in the Institute of Mother and Child in Warsaw, Poland. Laparoscopic exploration of the contralateral groin during hernia repair was performed by passing a scope through the symptomatic hernia sac. Patent processus vaginalis (PPV) was found in 9 patients (17%). This percentage of identified PPV is significantly lower than reported by open explorations and is also closer to the reported rate of metachronous hernia presentation.—Jerzy K. Niedzielski Changeable Views on the Treatment of Gastroschisis. A. Chilarski, H. Bulhak-Guz and H. Grochulska-Cerska Surg Child Intern 10:18:22, (January), 2002. The authors report on 36 neonates (equal sex incidence) with gastroschisis treated in Polish Mother’s Health Institute in Lodz, Poland between 1994 and 2001. The mean birth weight was 2,150 g. The diagnosis was established by means of prenatal ultrasound in 27 instances (75%). In the beginning of this series, either primary fascial closure of the defect (9 of 36; 25%) or staged procedure with polyethylene silo construction (22 of 36; 61.1%) was performed. The decisionmaking criteria was monitoring of intraabdominal (bladder) pressure. Simple primary reduction, as advocated lately in selected cases of gastroschisis, was performed with good results in 5 children (13.9%). Four children died (11.1% mortality rate), and 3 (8.3%) had to undergo reoperation because of the massive adhesive ileus. The remaining 32 infants (88.9%) recovered uneventfully. Although the main goal in gastroschisis is always closure of the abdomen, the method should be individualised for each patient.—Jerzy K. Niedzielski
GENITOURINARY TRACT Retrospective Review of Pediatric Patients With Acute Scrotum. I. Mushtaq, M. Fung, and M.J. Glasson. Aust N Z J Surg 73:55-58, (January/February), 2003. The authors sought to investigate the reliability of history and clinical examination in the diagnosis of an acute scrotum. Of 268 boys that presented to a tertiary pediatric institution in Sydney between January 1994 and December 1998, 58 were excluded as a result of previous testicular fixation, intrauterine torsion, uncertain diagnosis, or incomplete medical records. Mean age of the remaining 204 boys was
9 years (range, 1 month to 15.5 years). One hundred ten had torsion of a testicular appendage, 40 testicular torsion, and 29 epididymo-orchitis. The only significant difference in clinical features between the 3 groups was in the duration of symptoms: boys with testicular torsion presented significantly earlier (P ⬍ .005; median, 9.5 hours v 48 hours). Surgical exploration was performed in 187 boys. History and physical examination together provided the correct diagnosis in 87.5% of boys with testicular torsion, 83% with torsion of an appendage, and 56% with epididymo-orchitis. Retrospective data collection and the variable seniority of the surgeon performing the initial assessment compromised this study. The proposal that a history of greater than 24 hours might be used as a suitable cut-off point for surgical exploration assumes that all torted testes remain torted. Further, the authors own data identified 2 patients with viable testes despite having symptoms for greater than 24 hours. Although routine exploration would not seem appropriate for all patients, for those in whom the diagnosis remains uncertain, exploration remains the safest course.—A.J.A. Holland The Role of Nitric Oxide in Reflux Nephropathy. B. Chertin, U. Rolle, A. Farkas, et al. Pediatr Surg Int 18:630-634, (October), 2002. Reflux nephropathy accounts for about 25% of cases of end-stage renal failure, but the mechanism by which reflux produces renal scars is still not clear. The authors examined nitric oxide (NO), which regulates arteriolar tone, mesangial cell proliferation, and extracellular matrix production by staining of NOS, an important enzyme in the synthese of NO. They differentiated the isoforms inducing NOS (iNOS), endothelial NOS (eNOS), and neuronal NOS (nNOS), the first a proinflammatory agent secreted by macrophages and mediating apoptosis, the others thought to have beneficial effects in relaxing vascular tone and ameliorating tubulointerstitial fibrosis. Kidney specimen from children with severe reflux nephropathy (RN) obtained at nephrectomy were compared with normal kidney tissue from adults undergoing surgery for small kidney tumors. Staining for NOS and iNOS in the proximal tubules of control kidneys was weak compared with RN specimen. nNOS and eNOS were lacking in control tissue, but were strongly visible in the tubulointerstitial spaces and in the glomeruli in RN kidneys. The authors correlated the markedly increased iNOS activity with the impressive histologic increase in proximal tubule apoptosis and atrophy, interpreting this as an effect of a macrophagestimulated proinflammatory cytokine overproduction. eNOS may buffer iNOS effects on fibrosis by an increase of regional blood flow and relaxation of mesangial vessels. nNOS, probably stimulated by angiotensin II receptors, may reduce interstitial fibrosis by leading to an increased cyclic GMP level. Therefore, blockage of iNOS and induction of eNOS and nNOS may be helpful in preventing parenchymal injuries in RN.—Peter Schmittenbecher Primary Megaureter: Results of Surgical Treatment. G. Aksnes, R. Imaji, and P.A. Dewan. Aust N Z J Surg 72:877-880, (December), 2002. A retrospective analysis was performed of clinical and radiologic outcomes in 16 patients with 17 isolated primary megaureters presenting to one institution between January 1997 and April 2001. The median age at surgery was 11 months, and there were 13 boys. Presenting features were a urinary tract infection in 8, wetting in one, and failure to thrive in one, with the remainder identified after an antenatal diagnosis of hydronephrosis. Patients were treated with a Cohen reimplantation with variable imbrication of the distal ureter. Median review after surgery was 17 months, during which, 6 of 8 patients had no further urinary infections; a patient’s wetting improved, and the infant with failure to thrive ceased vomiting. Those asymp-