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Objective – Massive gastrointestinal bleeding in children is rare. A Dieulafoy lesion is an uncommon condition which may lead to massive and repeated upper gastrointestinal bleeding. We report a pediatric case of gastric Dieulafoy lesion which was successfully treated surgically, after repeated unsuccessful endoscopic treatment. Case Report – A previously healthy 13-year-old boy presented with hematemesis upon admission to the hospital. He had tachycardia and mild anemia. A gastroscopy revealed erosive gastritis. During the following days, hematemesis continued to reoccur and consequently led to the development of hemorrhagic shock requiring endoscopic treatment with hemoclipping and adrenalin injection. Despite that, hematemesis continued, and it was decided to perform surgical treatment. During open surgery, a tortuous blood vessel was found, suggesting a Dieulafoy lesion. Conclusion – Although rare, a Dieulafoy lesion should be suspected when treating repeating hematemesis in children. Endoscopic treatment is recommended as first-line management, but rarely, in unclear cases, surgery proves to be a better diagnostic and therapeutic option for massive gastrointestinal bleeding.

Summary Introduction Endoscopic laser-puncture or electrosurgical incision are the most commonly used minimaly invasive approaches for the treatment of the ureterocele. Both techniques are mainly successful in decompressing of ureteroceles, but the consequence of such treatment may be formation of de novo vesicoureteral reflux and febrile urinary tract infection which could impact the final results. Objective To compare outcomes of treatment of two endoscopic techniques used in management of neonatal patients with intravesical ureterocele. Study design A case records of 64 neonates who underwent endoscopic procedures for intravesical ureterocele, performed at our institution from January 2005 to January 2021, were retrospectively reviewed. The patients were divided in two groups depending on used endoscopic procedure. The first group (n = 41) consisted of patients who underwent electrosurgical incision of the ureterocele, while the second group (n = 23) consisted of patients in whom 6 to 8 laser-punctures of the ureterocele were performed. The groups were compared in regards to outcomes of treatment, with special emphasis on de novo vesicoureteral reflux and the need for further treatment and surgery. Results Median follow-up was 7.5 (IQR 3, 11.5) and 3.5 (IQR 1.5, 5) years in the electroincision and laser-puncture groups, respectively (P = 0.017). No significant differences between the groups in regards to medians of duration of surgery (12 min vs. 11 min, P = 0.670), length of hospital stay (2 days in both groups, P = 0.988) or postoperative obstruction (n = 1 vs. n = 0, P > 0.999) were recorded. Ureterocele decompression was achieved after endoscopic treatment in 87.9% and 100% of the patients in electrosurgery and laser-puncture groups, respectively (P = 0.150). Five patients (12.1%) from electrosurgery group required endoscopic retreatment. The laser-puncture group had a significantly decreased rate of de novo vesicoureteral reflux (8.7% vs. 58.5%; P = 0.0001) and lower incidence of subsequent surgery due to de novo vesicoureteral reflux (50% vs. 62.5%; P = 0.727). Conclusion Both electrosurgical incision and laser-puncture endoscopic techniques are safe and effective in relieving the obstruction. Laser-puncture technique is associated with significantly lower incidence of de novo vesicoureteral reflux and accordingly fewer invasive procedures for neonatal patients. Summary Table 1 . Treatment outcomes between the investigated groups. Group I Group II P Electroincision (n=41) Laser-puncture (n=23) Complications, n (%) 3 (7.2) 0 0.547 a Intraoperative 1 (2.4) 0 Postoperative 2 (4.8) 0 Endoscopic retreatment, n (%) 5 (12.1) 0 0.150 a De novo VUR, n (%) 24 (58.5 2 (8.7) Grade I 0 0 0.0001 a Grade II 0 1 Grade III 31 1 Grade IV 15 0 Grade V 6 0 a Fisher exact test.

To evaluate the management and outcomes of modified Marcy repair for inguinal hernia in a large series of children. We analyzed the case records of 6826 pediatric patients who underwent surgery for inguinal hernia between January, 1991 and January, 2015 at Split University Hospital in Croatia. The following parameters were examined: sex, age, location of the hernia, intraoperative or postoperative complications, recurrence, and surgical method. The 6826 patients included 4751 boys and 2075 girls operated on for inguinal hernia. The mean age was 3.5 years, and mean followup was 14 years. Right-side predominance was noted with 59.50 % right hernia repairs, 33.72 % left hernia repairs, and 6.78 % bilateral hernia repairs. There were 6410 (93.90 %) elective procedures and 416 (6.10 %) emergency procedures for incarceration. The mean duration of surgery was 26 min (14–90 min), and the mean hospital stay was 1 day. Marcy repair was the most commonly performed operation (95.76 %), whereas Ferguson’s technique was performed in only 3.98 % of the children. The overall recurrence rate was 0.43 %, with a recurrence rate of 0.36 % for Marcy repair and 1.83 % for Ferguson repair (p = 0.0003). Modified Marcy hernia repair is a safe and effective procedure for inguinal hernia in children with excellent outcomes and a low incidence of recurrence.

The aim of this study was to determine the efficacy and potential complications of double-J ureteric stents in the treatment of primary hydronephrosis in pediatric patients.A retrospective case-records review of 133 patients (45 girls and 88 boys) treated because of primary hydronephrosis with double-J ureteric stents, in Department of Pediatric Surgery, Split University Hospital, between December 1997 and December 2014, was performed. Success of treatment, results of follow up investigations and complications were recorded. Patients were followed up clinically and radiologically for a minimum of 2 years following stent insertion.In all, 133 endoscopic double-J ureteric stents insertions were performed. Of the total number of patients, left-sided hydronephrosis was found in 82 patients, right-sided in 38, and bilateral in 13 patients. The median age of children was 2 years (range 0-17 years). Mean hospital stay was 2 days (range 1-10 days). In primary hydronephrosis, double-J ureteric stenting alone was effective with resolution of hydronephrosis in 73% of cases (97/133 insertions). Regarding the age of the patients the highest success of 83.5% was achieved in age group 0-4 years. Success in groups 5-9 years; 10-14 years and 15-17 years were 47%; 33.5% and 0%, respectively. Several complications have been recorded: symptomatic infections, migration in the renal pelvis and bladder, progression of hydronephrosis, spontaneously prolapse of prosthesis, bleeding and perforation of the renal pelvis. A significant, decreasing trend in success rates by age of participants was observed (p0.001).Ureteric stenting is minimally invasive procedure that provides an alternative to open surgery in patients with primary hydronephrosis. Endoscopic placement of ureteric double-J stents should be considered as a first-line treatment in the management of primary hydronephrosis especially in children till 4 years of age, with success rate of 83.5% and without the need for conventional surgery. In a case of failure we are time-consuming to definitive surgery.

The objective of this study was to compare the clinical efficacy of two similar tissue bulking agents, Deflux and Vurdex, used for a treatment of vesicoureteral reflux (VUR) in our institution.The case records of 104 children, treated endoscopically for primary VUR from January 2010 to January 2015, were retrospectively reviewed. Most of the patients were treated with Deflux until 2012, when use of Vurdex was started. Exclusion criteria were patients with secondary reflux due to neurogenic bladder, duplicated refluxing ureters, primarily operated patients and patients operated after first or second injection.Endoscopic treatment of vesicoureteral reflux using Deflux was performed in 65 children (106 ureters). There were 24 patients with unilateral and 41 patients with bilateral VUR. After first injection of Deflux success was achieved in 74 ureters (69.8%), after second injection in 91 ureters (85.8%) and after third injection in 99 ureters (93.3%). The same procedure using Vurdex was performed in 39 children (58 ureters). There were 20 patients with unilateral and 19 patients with bilateral reflux. After first injection of Vurdex success was achieved in 43 ureters (74.1%), after second injection in 52 ureters (89.6%) and after third injection in 55 ureters (94.8%).Overall success rate for patients treated with Deflux was 93.3% and for patients treated with Vurdex 94.8%. No significant difference in success rates between two groups was found (p = 0.714). However, Vurdex has an advantage because of the significantly lower price, but with same treatment results as Deflux.

Vesicoureteral reflux (VUR) is an abnormal movement of urine from the bladder into ureters or kidneys. It may present before birth as prenatal ureterohydronephrosis, an abnormal widening of the ureter, or with a urinary tract infection (UTI) or acute pyelonephritis. The International Reflux Grading system classifies VUR into 5 grades depending on the degree of retrograde filling and dilatation of the renal collecting system.1 Vesicoureteral reflux is estimated to occur in 1%–3% of children.1 Younger children are more prone to VUR because of the relative shortness of the submucosal ureters. In children with UTIs, the incidence of VUR is 29% in boys and 14% in girls.2 Although VUR is more common in boys antenatally, in later life there is a definite female preponderance with 85% of patients being female.1,2 Traditionally, if medical management with low-dose antibiotic prophylaxis failed, the only alternative was open surgery.3 In recent years, endoscopic subureteral transurethral injection (STING) has become a first-line therapy for children with VUR because of its high success rates and a very low incidence of complications.1,3–5 Since Matouschek’s initial description of the subureteral injection technique in 19816 and the first clinical series reported by O’Donnell and Puri in 1984,7 it has evolved into a therapeutic alternative to open surgery. Injectable agents, such as Teflon, bovine collagen and Macroplastique, have all been used; however, concerns about efficacy and safety have limited their use.1,3,8 Since the approval of dextranomer/hyaluronic acid copolymer (Deflux), endoscopic management of VUR has become an established alternative treatment in children.1,9 Both dextranomer and hyaluronic acid are biocompatible, which means that they do not cause clinically important reactions within the body. In fact, hyaluronic acid is produced and found naturally within the body.1,9 We present our results of endoscopic treatment using the subureteral Deflux injection (SDIN) for VUR in children at our institution.

PURPOSE: Testicular rupture is a very rare entity in children and adolescents. The aim of this study was to evaluate the outcomes of surgical repair after testicular rupture in children. METHODS: Between January 2000 and January 2010 seven patients were operated on because of testicular rupture. Mean age at the time of the accident was 15 years. In all patients, an emergency scrotal ultrasonography showed a rupture of the testicular capsule with a surrounding hematocele. Surgical exploration was performed to evacuate the hematocele and repair the ruptured testis. RESULTS: Mean follow-up was 4.9 years. Average hospital stay was 2 days. Mean time between surgery and the initial trauma was 35 h. There were no major complications. Control ultrasound imaging showed that the tunica was repaired and Doppler signal confirmed vascularity in all patients. There were no significant differences in size between the right and left testes. There were no recorded cases of testicular atrophy. Semen analysis showed normospermia 6 months after surgery and anti-sperm antibodies count was within normal limits in all patients. CONCLUSION: Prompt surgical intervention is crucial. Ruptured testis can be salvaged, with a high success rate, if surgical repair is performed within 72 h of testicular injury.

A 14.5-year-old girl with Fraley's syndrome, which caused left flank pain and massive haematuria with anaemia underwent left renal surgery. The infundibulum for the left upper calyx group was entrapped between the lower segmental renal artery and one branch of the renal vein. Despite other known surgical procedures, the surgeon explored the area around the entrapped infundibulum and resected the vein. Impression of the infundibulum disappeared, the dilatation of the upper calyces diminished, the pain was immediately relieved, and the haematuria stopped. In the two-year follow-up period the patient remained healthy, without haematuria or a subjective feeling of illness. The surgical treatment performed was successful, and it is also one of the most nephron-sparing procedures available.

The case of an infant, aged 2 months and 23 days, with chylous ascites after nephrectomy is reported. Nephrectomy was performed because of a large hydronephrosis. Chylous ascites was treated with medium-chain triglycerides, diet and cholestyramine. After 3 days the volume of the abdomen was reduced and on day 8 chylous ascites was not visible clinically or ultrasonographically. D Cholestyramine, chylous ascites, infant, medium-chain triglycerides. D Mladini-Vulic, Sukoianska 37, 58000 Split, Croatia

Snake venom poisoning is a medical emergency that requires urgent therapeutic procedures. The treatment of venomous snakebites is still controversial because of unclear therapeutic modalities. Choice of treatment is dictated in part by regional characteristics with regard to patient population and types of venomous snakes. The purpose of the study presented here was to report regional experience with venomous snakebites and to describe first-aid, pre- hospital, and hospital therapeutic procedures for horned viper bite. During a 16-year period, from 1980 to 1996, at the Clinical Hospital Split (Croatia) we collected data on 389 victims of horned viper bite. Incidence of the local and general complications is presented. We also reviewed therapeutic modalities and outcome with special attention to compartment syndromes and the indications for fasciotomy.