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A case of superior vesical fissure is presented to discuss the embryologic origin of the anomaly. In view of the simplicity of the anomaly and the discrepancies between the characteristics of superior vesical fissure and bladder exstrophy, superior vesical fissure is suggested to be a distinct clinical entity with an embryological origin different from bladder exstrophy.

Although deteriorating effects of unilateral spermatic cord torsion are generally accepted, the mechanism remains controversial. An experimental study was performed to evaluate the necessity of testicular and spermatogenetic material for contralateral testicular deterioration following unilateral spermatic cord torsion in rats. The animals were allocated to four groups: control, spermatic cord torsion, subepididymal orchiectomy, and spermatic cord torsion 14 days after subepididymal orchiectomy. The testes were removed on the 14th days and mean seminiferous tubular diameters and mean testicular biopsy scores were determined. Although contralateral testicular deterioration was more pronounced in the presence of testicular tissue, the absence of testicular tissue and/or spermatogenetic material did not prevent its occurrence. This is highly suggestive that autoimmune mechanism does not play a role in contralateral testicular damage following unilateral spermatic cord torsion.

The cases of an 8-year-old boy who had two separate gangrenous intestinal segements with perforations during the early course of polyarteritis nodosa is presented.

The seventh case of colonic atresia and Hirschsprung's disease association is presented. It is proposed that if vascular accident occurs before the eighth week of intrauterine life, it does not only result in atresia but also associates with Hirschsprung's disease.

Physical examination is stated to be inaccurate in detecting organ injury after blunt abdominal trauma (BAT) in children and the use of diagnostic peritoneal lavage (DPL) and computed tomography (CT) are suggested. However, assessments for the need of such diagnostic aids are quite subjective. The records of 109 patients initially evaluated by ultrasonography (US) for BAT were reviewed to determine whether an easily performed, quick method such as US could be used for selection. US showed free intraperitoneal fluid (FIF) in 30 patients (27.5%) and retroperitoneal injury in 5 patients (4.5%). Of the 30 patients with FIF, 23 patients (76.7%) were treated conservatively but 7 (23.3%) required laparotomy. The correlation between the amount of FIF and the requirement for operative treatment was statistically significant (P.01). Of the 74 patients (68%) without FIF, clinical outcome was uneventful in 72 (97.3%) while 2 patients (2.7%) required laparotomy for peritonitis and ileal perforations were encountered. The present study has showed that US is inaccurate in detecting solid intraabdominal injuries; however, it is reliable in detecting FIF produced as a result of intraabdominal organ injuries and retroperitoneal organ injuries. We suggest the use of US as the objective initial evaluation method of choice on a routine basis.

Twelve patients who had undergone diaphragmatic plication with the diagnosis of congenital diaphragmatic eventration between 1975 to 1989 were evaluated for the long-term results of plication. Assessment of the long-term functions of the plicated diaphragms 1.5 to 11 years postoperatively was achieved by fluoroscopic, ultrasonographic, and spirometric studies. The absence of paradoxical motion with normal localization of the diaphragms in all patients, and satisfactory motions of diaphragms in 9 patients were documented by fluoroscopy. Measurements of diaphragmatic thicknesses showed that plicated diaphragms of all patients maintained their growths in proportion to the contralateral sides. Additionally, normal values of pulmonary function tests in five of six patients of suitable age for spirometry were obtained. All the clinical studies demonstrated that diaphragmatic plication did not interfere with further development of diaphragms, and late functional results of the plication were acceptable. This supports the choice of surgery in the treatment of diaphragmatic eventration.

A case of hepatic granuloma resembling a simple cystic lesion of the liver in computed tomography with clinical manifestation of erythema nodosum is presented. The causes of hepatic granulomas and the importance of liver biopsy or exploratory laparotomy in their diagnosis are discussed with a review of the literature.

A prospective, randomized clinical study was performed to compare the results of 1-day versus 7-day administration of the same prophylactic antibiotics to 30 consecutive patients undergoing colostomy closure. The antibiotics used were cotrimoxazole (8 mg/kg per day trimethoprim) and ornidazole (20 mg/kg per day), which were this department's standard prophylactic agents for colorectal surgery. Patients, in the first group received cotrimoxazole i. m. 1 h before the operation and ornidazole by i. v. infusion starting after induction of anesthesia. The same dosages of both drugs were repeated once 12 h after the initial dose. In the second group (7 days), both agents were started orally 48 h before the operation. The preoperative doses were given as in the short-course group and were continued in this fashion until the end of the 5th postoperative day. Mechanical cleansing of the bowel and the operative procedure were standardized for all patients. Intraluminal swab cultures were obtained during the operation; only aerobic cultures could be studied. Patients were closely monitored for septic complications during the post-operative period. Study groups were similar regarding age, sex, nutritional status, and micro-organisms isolated from the bowel. Wound infections confined to the subcutaneous tissue occurred in 2 patients, 1 in each group (6.6%). No intraperitoneal infection, anastomotic leakage/dehiscence, or wound dehiscence was encountered. While susceptibilities to antibiotics other than cotrimoxazole were similar in both groups, cotrimoxazole-resistant micro-organisms were found more often in the long-course group (P

The most common cause of esophageal stricture in children is the accidental ingestion of strong corrosive agents. During a 13-year period between 1976 and 1989, 202 patients were diagnosed as having caustic esophageal strictures at the Hacettepe University Children's Hospital Department of Pediatric Surgery. A retrospective clinical study was performed to find out the place and predictors of a successful outcome for conservative treatment in children who have caustic esophageal strictures. Two hundred two children, of whom 145 were male (71.7%) and 57 female (28.3%) with 168 (83.2%) being younger than 6 years of age, were evaluated retrospectively. Whereas only 49.3% of patients could be treated within a 12-month period, 50.7% needed more than 1 year, 32.9% needed more than 2 years, 26.7% needed more than 3 years, and 15.4% needed more than 4 years of periodic dilations in order to become swallowers through native esophaguses. The success of conservative treatment has been higher in patients younger than 8 years of age, and in strictures due to caustics other than lye involving upper third portion and less than five cm of an esophageal segment. Most caustic esophageal strictures could have been treated by conservative measures in children.

Caustic esophageal stricture is one of the most common indications for esophageal replacement in children. During a 13-year period between 1976 and 1989, colonic repacement was performed in 50 patients for the treatment of caustic esophageal strictures at the Department of Pediatric Surgery of Hacettepe University Children's Hospital. A retrospective clinical study was undertaken to discuss the indications and results of colonic replacement. The 50 children, 34 of whom were male (68%) and 16 of whom were female (32%) with 27 patients (54%) under 6 years of age, were evaluated retrospectively. Indications for operation included 21 (42%) who could not swallow saliva and had total or nearly total obliteration of lumen involving more than 3 cm of an esophageal segment at admittance, and 16 (32%) who had difficulty in swallowing within a 1-month period following the last dilation after completion of a 1-year dilation program. A further 13 (26%) had bleeding and difficulties during dilations, after experiencing an esophageal perforation. The right colon was used in 48 and the left in the remaining 2 patients. Patients were followed for at least 1 year following replacement. Growth was excellent in all but one patient who had redundant colon and showed growth retardation. There was one postoperative late death because of massive bleeding from ulceration of the transplanted colon. The other 49 patients were available for accurate follow-up. The results were good, 46 (92%) were able to eat everything, while occasional dysphagia in 3 (6%) required dilation after operation. Colon conduit provides an excellent substitute for esophagus in pediatric patients. The operation had a low rate of major complications, most of which could be corrected to give satisfactory long-term results.

A prospective, randomized, clinical study was done to evaluate the place of prophylactic antibiotics in uncomplicated childhood appendicitis. One hundred patients with uncomplicated appendicitis were randomly assigned to one of four groups, each consisting of 25 cases. Group 1 patients did not receive prophylactic antibiotic. Group 2, group 3, and group 4 patients received ornidazole, penicillin plus tobramycin, and piperacillin, respectively. The use of prophylactic antibiotics did not yield better results than the use of placebos. The rarity of infectious complications after uncomplicated appendicectomy may be unique for children. Although the need for antibiotic prophylaxis is well documented in adults, the rarity of infectious complications makes it highly questionable in the treatment of uncomplicated appendicitis in children.

A diphosphonate, disodium etidronate, a compound known to inhibit microcrystal growth of hydroxyapatite was given to a 3.5-year-old girl with pulmonary alveolar microlithiasis (PAM) that was symptomatic. The drug was used for approximately 36 months in a single daily dose of 15 mg/kg. No significant side effects were encountered with somewhat clearing of lung bases in chest radiograms and subjective improvement in general condition. These findings suggest a role of diphosphonates in the treatment of PAM.

Testicular blood flows during unilateral testicular torsion were measured by Xenon-133 clearance technique. Xenon-133 was injected via the left carotid artery into the heart. Measurements were performed in control and left-sided testicular torsion groups, each consisting of ten rats. Left and right testicular blood flows, which were 29.157 +/- 2.272 ml/100 g/min and 29.773 +/- 2.934 ml/100 g/min in the controls, were 11.983 +/- 3.655 ml/100 g/min and 16.098 +/- 3.757 ml/100 g/min in the experimental group and differed significantly. The decrease in contralateral testicular blood flow may play an important role in the contralateral testicular damage encountered following unilateral testicular torsion.

An experimental study was designed to evaluate subsequent ipsilateral and contralateral testicular histologies, fertility, and fecundity of rats subjected to unilateral incarcerated inguinal hernia during the prepubertal period. Three study groups each containing 12 rats (28-day-old) were established. In group 1 the rats were only anesthetized. In group 2 the rats had undergone a sham operation. Left-sided incarcerated inguinal hernias were created in rats constituting group 3. After the rats had reached 4 months of age, each male rat was housed with two known fertile female rats for 3 weeks. Male rats were then castrated and the testes were evaluated histologically. Female rats were followed for 30 additional days, and the number of females impregnanted and the number of rats given birth to by each female rat were recorded. Left-sided incarcerated inguinal hernia has caused a lessened testicular/body weight ratio in the left testes, and histological deteriorations in both left and right testes that were expressed through diminished mean seminiferous tubular diameter and mean testicular biopsy scores. The fertility rate was not affected, but the number of rats produced by each male rat was lesser after having the incarcerated inguinal hernia. Unilateral incarcerated inguinal hernia during prepubertal period resulted in deteriorated ipsilateral and contralateral testicular histology and diminished the exocrine function of testes in rats.

Orthotopic liver transplantation is the most effective treatment for end-stage liver diseases in adults and children; however, the lack of convenient donors is the main restrictive factor existing in this particular area. The paucity of infant and child donors remains a worldwide problem, especially in developing countries where the number of adult cadavers is also very limited. The desperate search for organ sources has led surgeons to transplant a portion of the liver from an adult into a child, and this approach has been accepted by some centers [4, 6, 9].

Congenital "H type" urethroanal and urethroperineal fistulas are extremely rate anomalies. The treatment of these pathologies is very complex and there is no well established surgical approach. An urethroperineal fistula is presented and the treatment is discussed. Additionally the literature in English on the subject is reviewed.

Gastric teratoma is a very rare benign tumor. Fifty-three cases, only two of which were females, have previously been reported. This report concerns two cases of teratoma arising from stomach. One of them is the third female case described in the literature.

Summary— Primary realignment was used in the treatment of 12 children with complete rupture of the posterior urethra; 10 developed strictures but 7 of these responded to dilatation. Problems of continence were encountered only in patients who developed strictures. Since primary realignment results in dilatable strictures in most patients, it is suggested that this should be the treatment of choice in children.

Achalasia is infrequently reported in infants and children. It occurs exceedingly rarely in siblings. Only 33 cases of familial childhood achalasia were collected in the literature till 1987. Three definite cases and one suspicious additional case are presented and the aetiology is discussed.

Although rare, patients with Hirschsprung's disease (HD) may be admitted with colonic volvulus. Among 302 patients with HD two patients were admitted with colonic volvulus (0.66%). Involved segments were cecum and sigmoid colon. During the same period, 11 patients including those with HD were diagnosed with colonic volvulus. An aganglionic segment below sigmoid colon, and a freely mobile mesosigmoid seem to be the cause of sigmoid volvulus. However, extension of aganglionosis above the sigmoid colon in addition to anatomic tendency seems to result in volvulus of proximal segments. Because HD has been associated with colonic volvulus, children who present with colonic volvulus should be suspect for underlying HD.

Malacoplakia is a specific chronic inflammatory disease. In the English-language literature, there are a few reports of gastrointestinal malacoplakia occurring in childhood. The authors present the first case of gastrointestinal malacoplakia involving a surgical wound and preventing healing, with persistent drainage; the patient was a 4-year-old boy. The clinicopathologic features of this rare entity are discussed, with emphasis on diagnosis and treatment.

Although complete duplication of the bladder and urethra (CBDU) has been considered to be an isolated anomaly, the present report involves an infant who had CBDU and associated anomalies of the gastrointestinal and central nervous systems. Clarification of the upper-tract renal anatomy is mandatory in planning a staged approach to reconstruction, especially in the presence of associated anomalies.

Summary— The histological effects of unilateral incarcerated inguinal hernia on the ipsilateral and contralateral testes were examined in adult rats. Three groups were established. In the first group the left testis and caecum were exposed and replaced. In group 2 a left-sided incarcerated inguinal hernia was created with bilateral orchiectomy 24 h later. In group 3 a left-sided incarcerated inguinal hernia was created with reduction after 24 h. The testes of animals in groups 1 and 3 were removed after 15 days. The mean seminiferous tubular diameter (MSTD) and mean testicular biopsy score (MTBS) were determined for ipsilateral and contralateral testes in each of the 3 groups. A decreased MSTD and depressed MTBS, were pronounced in the ipsilateral testes, were found in the testes of group 3 animals. While unilateral incarcerated inguinal hernias caused more pronounced histological changes in the ipsilateral testes, they also affected the contralateral testes, but a time interval was required for the changes to become manifest.

The cardiopulmonary effects of CPAP under conditions of increased intra-abdominal pressure were studied using the rabbit as an experimental model. Central venous pressure and cardiac output were reduced when the intra-abdominal pressure was increased. Addition of CPAP caused a further reduction in C.V.P. and C.O. Despite these reductions CPAP significantly improved arterial PaO2 without significant effects on pH and PaCO2. The use of CPAP in conditions associated with pulmonary dysfunction secondary to increased intraabdominal pressure may be a definite therapeutic modality.

We report 10 cases of rupture of the urinary bladder in children. Only one patient was a girl. The rupture was caused by a road accident in 6 cases and occurred "spontaneously" in 4. Rupture of the bladder may be difficult to diagnose. In many patients the vesical rupture is not the only abnormality in the urinary tract and a thorough investigation is necessary. The majority of the bladder ruptures in these children were intraperitoneal, which contrasts with the reported experience in adults.

Since the first successful kidney transplant reported by Murray and his colleagues (1) and due to the development of the highly sophisticated field of immunosuppression, many centres throughout the world including the Middle East are now performing successful organ transplantation (2, 3, 4).

Cystosarcoma phylloides is an exceedingly rare breast lesion in adolescent females. The tumour contains both stromal and epithelial elements. Benign, malignant and intermediate forms have been described. Complete simple excision is adequate for therapy in all variants. An additional case treated by wide local excision is presented and treatment is discussed.

Summary— Changes in contralateral testicular blood flow during unilateral testicular torsion were evaluated using an electromagnetic flowmeter in 13 adult male New Zealand White rabbits. There was an immediate and then a progressive decrease during torsion and a gradual increase following detorsion. A decrease in testicular blood flow over a critical period of time may be associated with contralateral testicular damage following unilateral testicular torsion.

Retrograde dilatation performed with Tucker dilators is the safest known method of treating severe caustic strictures of the esophagus. Placing the string guide is sometimes difficult however, and the string taped to the cheek between dilatations causes cosmetic and psychological problems. The stringing method described by Andrassy et al [1] for dilatation of anastomotic esophageal strictures has been adapated by us for the treatment of caustic strictures. The success rate of the method has been 93,7%. Using this method, it is possible to prevent the placement difficulties and string complications in Tucker retrograde esophageal dilatation.