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    A Prospective Study: Can physical examination identify palpable undescended testes more accurately than ultrasonography?
    (Logos Medical Publishing, 2022) Akman, Mustafa
    Introduction: The cremasteric reflex, which makes the testicle mobile, and excessive scrotal adipose tissue may mimic scrotal emptiness, leading to the evaluation of cases as undescended testes. Although it has been suggested that the location of the testes cannot be determined by imaging tests, suspicious localization may lead the physician to imaging tests. This study reveals the needlessness of ultrasonography (USG), especially in palpable cases. Methods: In our study, patients who had their initial evaluation and USG performed by a pediatrician were targeted. Finally, a pediatric surgical evaluation was performed by a single pediatric surgeon, and the findings were compared. The cases were divided into two groups, normal and abnormal testicles, based on the pediatrician's distinction. According to this distinction, all cases were evaluated as a whole. Testes that could not maintain their position within the scrotum were considered abnormal. Consistency was sought in intergroup relations with Cohen's Kappa. Results: The study was conducted with 75 patients who met the criteria. In the group with normal localization in the pediatrician examination, pediatric surgical evaluation was compatible in one (2.6%) of the cases reported as abnormal on USG and 38 (100%) of the cases reported as normal on USG. In the group with abnormal localization in the pediatricians’ examination, pediatric surgical evaluation was compatible with 32 (40%) of the cases reported as abnormal on USG and four (100%) of the cases reported as normal on USG. Discussion: Radiologic examination of testicles, the localization of which cannot be ascertained by USG, began in the 1970s and is still being practiced. Some institutional bodies and independent researchers express opposing views, and some authors suggest that USG should be used. Conclusion: The popularity of USG does not seem to be ending. In our study, the findings showed that the number of patients referred to surgery by USG was significantly higher. The findings obtained in this study suggest that imaging should be confined to non-palpable cases and USG only, and diagnostic laparotomy should be accepted as the gold standard. Relying on normal pediatric exams and being skeptical of abnormal reports revealed by USG will mean staying on the safe side.
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    Is it reliable to make a decision based on visual changes in the patient's diaper in the evaluation of post circumcision bleeding?
    (NLM (Medline), 2023) Akman, Mustafa
    Background: The most common complication of circumcision is bleeding. Monitoring bleeding by visual assessment of the diaper can cause errors due to the high absorbency of diapers. The patient may have had significant problems before the visible changes. The amount of liquid that wets the cloth does not necessarily lead to a visual change consistent with the amount, and the nature of the liquid contaminating the diaper may cause difficulties in terms of visual evaluation. Making a decision based on the visual changes in the patient's diaper cannot be considered as reliable. Methods: We planned to evaluate the visual changes that are caused by liquids of various volumes and contents that wet the diaper, according to measurable criteria. We aimed to emphasise the importance of the subject in circumcision practices of diapered children. Wetting of diapers with different volumes and variable blood load was performed utilising blood with different haematocrits and fluids. One hundred and sixty different diapers in four groups were moistened utilising the drip method. Visual changes in the soaked diapers were evaluated with the colorimetric method and five different colour criteria. The saturation and lightness values, which indicate the colour value, were obtained by using the numerical equivalents of the three main components, red, green and blue. Analysis was carried out by subjecting statistical evaluation within and between groups. Results: There was a significant difference between the control group and the study group. It was observed that visual changes caused by the moistened cloths with linear increase did not make the same linear interaction. There was not a significant difference between Group II and Group IV, which were soaked with the same amount of blood and different volume of fluid. In Group III, colour saturation changes were found to have a parabolic effect instead of a linear change. In two different analyses of moistened diapers in terms of volume and blood load; it was not determined that the expected linear changes between the groups were not observed. Conclusion: Visual changes in diapers related to volume or blood load effects of fluids may not be compatible with the amount of bleeding. Mistakes may occur when super absorbent wipes are used when determining the amount of bleeding from the use of colour changes in the diaper. Visual changes should not be relied on in bleeding due to circumcision. Rather, vital signs follow-up and measurable laboratory tests should be used as a basis.
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    Penile skin length can be predicted before frenuloplasty during routine circumcision
    (NLM (Medline), 2022) Akman, Mustafa
    Background: One of the restricting factors for surgical treatment of congenital anatomical pathologies of the penis is the skin structure. Thanks to its structure, the penis is a flexible organ structure, and the treatment can be completed without the need for a free tissue graft. Length changes are obtained on the ventral side of the penis by frenuloplasty. Aims: Our study aims to attain an objective formula that could noninvasively predict these changes on the ventral side before the procedure. Patients and Methods: In our study, 52 patients who were admitted for routine religious circumcision were included, and penile ventral and dorsal skin and inner mucosa lengths were measured before and after frenuloplasty, which is a part of the normal routine circumcision procedure and performed via the "pull and burn" method. Stitches were done to prevent scar formation in the frenuloplasty area. The results were used to estimate the length changes to be obtained on the ventral side by performing a regression analysis of the patient's weight, height, ventral and dorsal inner mucosa, and outer skin lengths. Result: Following frenuloplasty, an increase was detected in the ventral surface ranging from 20% to 177%. This increase was found to be predictable with 62.5% precision (P < 0.01) using the formulation established by assessing the ventral inner mucosa length from pre-procedure values. No significant result was determined in the regression analysis of the patients' other measurements (P > 0.05). Conclusion: Penile length changes that would occur following frenuloplasty can be calculated using a noninvasive method. Frenuloplasty, which would be performed without any vascular change, could be helpful in the surgical planning of some penile surgeries. More studies should be conducted on older boys, in anatomic deviations, and moreover, to establish a reliable formulation.
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    Simplify long-term venous access via external jugular vein in children
    (Springer, 2021) Akman, Mustafa
    Background: Bone marrow transfer has begun to be widely used in complicated conditions, such as chemotherapy or hemodialysis, following the description of indwelling central venous catheters and demonstrating their suitability in pediatric patients. The widespread use of it has increased the incidence of complications as well. The use of external jugular vein catheterization, which is a safer route compared to the blind route of administration, has topographical difficulties. The findings obtained in this study showed that these difficulties could be overcome. Our study revealed that the catheterization was possible and described a facilitating technique. Of the pediatric patients involved in the bone marrow transfer programs, patients who were deemed eligible candidates for the use of external jugular vein, based on the preoperative assessment, were included in the present study. Results: No early complication was observed in this study. The central catheter was placed on all patients in the same session. Catheters were inserted using the external jugular vein in 98 patients and percutaneous internal jugular vein in 2 patients. A central catheter was inserted through 105 interventions and 103 incisions in 100 patients. External jugular vein use, which was planned before the procedure, was achieved in 98 patients. The internal jugular vein was selected as the second option in 2 patients. The success rate of external jugular vein use was 95.1%. Conclusions: The findings obtained in this study suggest that placement of a central catheter using an external jugular vein is an appropriate option. Application difficulties can be overcome. Mechanical and early complications are negligible compared to percutaneous blind techniques. The use of the external jugular vein route is easy, requires less equipment, has few complications, and the success of the procedure is a preoperatively predictable technique. External jugular vein catheterization is a better alternative compared to the Seldinger technique, in the absence of ultrasonography, which enhances the success of the percutaneous technique, and in cases where blind techniques, such as bleeding diathesis, may be unfavorable.
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    The measurement of different diaper parameters for the evaluation of postcircumcision bleeding and their significance for the İnfant's health
    (NLM (Medline), 2022) Akman, Mustafa
    Background: Evaluation of circumcision bleeding cannot depend on the visual change in the diaper. Diapers have different product features and absorbency capacities. The apparent changes in the diapers may vary according to their absorbent capacity and may not be in parallel with the amount of bleeding. Before significant visual difference occurs, the patient's hemodynamics may be impaired. Aim: Aim of the study is to evaluate better circumcision bleeding. Patients and Methods: Patients were divided into groups according to 12 different brand diapers of the same size, containing super-absorbent material. The study started by 15/01/2022, and finished by end of 01/03/2022. Diapers with concealed brands were soaked with blood with equal hematocrit value in 100 ml with increments of 5 ml. 252 images were obtained by taking 21 images of each diaper with the same method. The diapers were evaluated colorimetrically, and numerical values were obtained showing the color differences in red, green, and blue and saturation and lightness. Working groups were formed according to 12 different brands of diapers of the same size, containing super-absorbent material. Standard statistical tests were performed using obtained values. Result: : Dry diapers had different weights, volumes, and specific gravities; the diapers with the lowest unit weight were ranked ninth in terms of volume; the diapers with the highest specific gravity were ranked third in terms of thinness. There were significant differences in the blood on the diaper, and significant differences between some groups (p < 0.005); on the other hand, there was not any difference between some other groups (p > 0.05). There was a significant relationship in terms of Analysis of Variance (ANOVA) (P < 0.05 and P < 0.01). Visual graphic examination showed that linear but non-parallel color changes occurred. As the blood load increased, the visual and statistical differences between the diapers became more pronounced, and the curves diverged. Conclusion: Visual evaluation of the color change of the diapers may not give accurate results for bleeding follow-up. If necessary to use diapers after circumcision, it is more appropriate to prefer those with low absorbency capacity. Using fabric or cotton products in cases with bleeding risk may be recommended. If bleeding is suspected, hemogram control is the most appropriate option. Diaper manufacturers should warn consumers of the risk. In conclusion, we should be on the safe side for mortality and morbidity.
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    Unexpected thoracic injury caused by a falling bullet in a metropolis
    (NLM (Medline), 2023) Akman, Mustafa
    The incident of being wounded by free-falling bullets is not usual in provinces where there is limited civilian armament in large metropolises. Cases that are wounded by falling bullet wounding apply to health-care institutions with major clinical manifestations. The patient was admitted with minor complaints, which manifested itself with mild back pain and spotting bleeding. An ovoid-style open wound was detected on the left scapula. Radiographic examination showed a semi-ovoid bullet-like radiodensity image inside the thoracic wall. In the evaluation performed under general anaesthesia, a bullet was found in the thoracic wall and was removed. In the standard follow-ups after the procedure, full recovery was achieved in the early period. Bullet wounds might be experienced outside of the battlefields without any direct fire, and these cases might not manifest the signs of gunshot injury. The cruciality of radiography in tackling diagnostic challenges was put forward.
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    What is world pediatric surgeons’ opinion on EMLA® cream induced local anaesthesia in circumcision?
    (Turkey Association of Pediatric Surgery, 2021) Akman, Mustafa
    Objective: Studies on neonatal pain are ongoing. Complications regarding the physiology ofneonates, low GFR rate, limited drug use, methemoglobinemia, which is not found in other agegroups lead to the search for safe drugs for painless operation. The idea that neonates do not feelpain has come to avoid pain caused by injection today. Therefore, EMLA® Cream, which is knownto be effective with topical application, has become popular. Our study aims to reveal how thecream, which its analgesic effect is still doubted, is used by pediatric surgeons and to determineits common usage principles. Methods: Many surgeons from every continent and many different countries were contacted viae-mail. The questionnaire, with few questions and limited choices, was completed by thephysicians. The participants were kept anonymous and interaction among them was prevented.Upon 10% returns from the e-mails sent, the questionnaire was terminated and subjected tobasic evaluation. Results: The survey was completed in 107 women and 238 men, 345 participants. The resultsshowed that 82 participants circumcised only using the cream and 91 surgeons who did not usethe cream could use it in the future. The results also showed that 74.78% of the participants whoavoided the cream had doubts about its pain prevention impact. The rate of avoidance of creamdue to fatal side effects was 3.76%. According to the accommodation area of the participants,36%-67% relied on the cream and performed neonatal circumcision. Conclusion: Pediatric surgeons consider that the idea of neonates to feel pain is important anddespite its positive effect on pain, the cream is not used by all pediatric surgeons around theworld. Despite its local anesthetic effect occurring without injection, side effects or usagedifficulties, the cream will still be popular.