1 Clinic of Pediatric surgery, Clinical Center University in Sarajevo, Patriotske lige 81, 71 000 Sarajevo, Bosnia and Herzegovina 2 Clinic for Anaesthesiology and Reanimation, Clinical Center University in Sarajevo, Bolnička 25, 71 000 Sarajevo, Bosnia and Herzegovina 3 Pediatric Intensive Care Department, Pediatric Clinic, Clinical Center University in Sarajevo, Patriotske lige 81, 71 000 Sarajevo, Bosnia and Herzegovina 4 Clinic of Neurosurgery, Clinical Center University in Sarajevo, Bolnička 25, 71 000 Sarajevo, Bosnia and Herzegovina Corresponding author: Asmir Jonuzi, PhD, Clinic of Pediatric surgery; Clinical Center University in Sarajevo; Patriotske lige 81, 71000 Sarajevo; Bosnia and Herzegovina e-mail: jonuziasmir@hotmail.com DOI: 10.5281/zenodo.5501485 ABSTRACT

Splenogonadal fusion (SGF) is a rare developmental anomaly in which an abnormal connection between the splenic tissue and gonads or mesonephric derivatives is present. This entity often presents with scrotal mass, inguinal hernia, or cryptorchidism. Less than 200 cases have been reported since it was first described in 1883. It can be of continuous and discontinuous type based on the presence of a band of connecting splenic tissue. Report a rare case of discontinuous type of SGF in an adolescent male presenting as nonpalpable testis. On evaluation, ultrasonography (USG) and magnetic resonance imaging of abdomen and pelvis, his left scrotal testis was atrophied and right intra-abdominal undescended testis. This is the first reported case of SGF from Bosnia and Herzegovina. Laparoscopy was demonstrated to be the only accurate exploratory procedure for the diagnosis and surgical treatment of SGF with non‐palpable testis.

Abstract Rationale: Circumcision like any other surgical procedure is not devoid of complications. Serious complications are rare and include iatrogenic hypospadias, glans ischemia/necrosis, and glans amputation, all of which require an emergent treatment. Patient concerns: We report here a case of 6 months-old-boy with a superficial glans ischemia following circumcision. Diagnosis: Physical examination revealed a severely cyanotic glans with the moderate edema of the dorsal penile skin. Plasma levels of D-dimer were 8.57 mg/L. Urine passage was unremarkable while color Doppler ultrasonography revealed a normal blood flow. Interventions: The patient was successfully treated with subcutaneous injection of enoxaparin (low-molecular-weight heparin) and topical 2.5% dihydrotestosterone. Outcomes: The appearance of the glans penis on the 5th day was close to normal while the control levels of D-dimer dropped to the reference range. The patient was discharged from the hospital on the 6th day. At 6-month follow-up, the appearance of the glans penis was normal. Lessons: Acute glans penis ischemia following circumcision is a rare complication. Its successful treatment with enoxaparin and topical dihydrotestosterone has not been previously reported in the literature.

A preterm female infant with a birthweight 1770 g was born via spontaneous vaginal delivery at 34 weeks’ gestation to a 21-yearold mother who received an adequate prenatal care. Routine prenatal ultrasound at 30 weeks revealed a proximal dilatation of the gut and polyhydramnios. At delivery, initial physical exam revealed a soft ‘scaphoid’ abdomen. Apgar score was 7 and 8 at 1st and 5th minute, respectively. A nasogastric tube (NGT) was placed for gastric decompression and bilious drain was observed. Post-natal erect X-ray of the abdomen showed dilated loops in the upper abdomen with the paucity of gas in the pelvis and confirmed proximal bowel obstruction (Fig. 1). After 24 h of stabilisation and care in the neonatal intensive care unit, the patient was taken to the operating room for surgical repair of her presumed jejunal atresia. Surgical exploration revealed a markedly distended atretic jejunum with a ‘type 3B’ intestinal atresia (apple-peel jejunal atresia) and a significant loss of intestinal length. The proximal end of the jejunal atresia was located 15 cm below the ligament of Treitz. On the distal end of ileal atresia, there were two multiple ileal atresias, each 7 cm of length. Approximately, 55 cm of the small bowel distal from the ileal atresias was found to be patent (Fig. 2a). In our case, the total length of small intestine was 70 cm (15 cm distal to the ligament of Treitz and 55 cm proximal to the ileocecal valve). All atretic segments were resected. The remaining segments were preserved (without tapering proximal jejunoplasty) and connected with the end-to-end jejunoileal anastomosis using 5/0 polyglactin sutures in the single extramucosal layer employing the Cheatle technique for size mismatch (Fig. 2b). Appendectomy was also performed. Post-operatively, the patient was placed on mechanical ventilation and extubated on the 6th post-operative day (POD). Total parenteral nutrition (TPN) via a central line along with enteral nutrition via NGT were administered and lasted until the 39th POD. After 2 weeks, enteral feeding gradually improved, so the baby started receiving peroral nutrition via bottle. The patient achieved her full enteral intake on POD 38. The baby was discharged from the hospital on POD 46 with highly improved body weight – 2485 g. At the follow-up of 9 months (Fig. 3), the baby was doing well with a body weight of 7500 g.

Background: Stump appendicitis is an acute inflammation of the residual part of the appendix and a rare complication of incomplete appendectomy. This is a rare delayed complication after appendectomy with the reported incidence of 1 in 50,000 cases. Clinically it can be presented as acute abdomen and presents a diagnostic dilemma. Prompt recognition is important to lead to an early treatment, thus avoiding serious complications. Case study: We present a 14-year-old girl with diagnosis of stump appendicitis, who underwent surgical treatment (open appendectomy) after  having laparoscopic appendectomy a month before. Radiologically (UZV and CT scan) was diagnosed an inflammatory mass with abscess dimension 41 x 21 mm in the right iliac fossa. During operation a 1,5 cm-diameter appendiceal stump was noted in the anatomical region of the appendix. The appendiceal stump was resected and inverted into the cecal wall. Histopathology examination showed acute inflammation and patchy necrosis of the appendiceal stump. The post-operative course was uneventful. Patient was discharged on third post-operative day. Conclusion: Stump appendicitis is a rare but serious complication of appendectomy. The prevalence and incidence of stump appendicitis has been increasing in the recent years. Clinical presentation of stump appendicitis mimics symptoms and signs of acute appendicitis or acute abdomen and with a previous appendectomy. So it must be considered in the differential diagnosis of acute abdomen despite the patient’s open or especially laparoscopic appendectomy history.

Introduction: The most common congenital abnormality of the penis is hypospadias. Although the main treatment is surgical; hormone therapy with dihydrotestosterone is also used. Materials and Methods: This randomized clinical trial was carried out between January 2012 and December 2017 on 79 children with hypospadias (in the Clinic of Pediatric Surgery, Clinical Centre University of Sarajevo). Their mean age was 38.2±2.8 months. GroupI included 36 children whom were treated with 2.5% dihydrotestosterone gel which was applied twice a day to the penile shaft and glans for one month prior to surgery. GroupII included 43 children whom did not receive any treatment preoperatively. Results: Mean age of patients in group I was 37.3±6.3 months and in group II it was 39.1±5.9 months which were comparable. Complications occurring postoperatively were: urethrocutaneous fistula in 6 patients (13.9%) in group II, versus 1 patient (2.7%) in group I. There were 2 patients with meatalstenosis in group II (4.7%), and 3 (8.3%) in group I. Finally, there was a significant difference (p<0.05) between the overall reoperation rates between groups (p<0.05). Conclusion : Pretreatment with 2.5% dihydrotestosterone transdermal gel before hypospadias repair is beneficial in decreasing complication rates.

Disorders related to Bartholin’s duct and glands affect approximately 2% of young women, and are very rare in premenarchal girls. Bartholin’s gland cysts are usualy small, do not cause any symptoms and resolve spontaneously. However, symptomatic larger cysts require medical treatment. Although many treatment modalities have been applyed, the best approach has not yet been found. Treatment modalities of Bartholin’s cyst include application of silver nitrate to the abscess cavity, incision and drainage of the cyst, curettage of the abscess cavity, placement of “Word catheter”, marsupialization, needle aspiration and alcohol sclerotheraphy, carbon dioxide laser excision and surgical gland excision. Here, we report a case of a large, soft, regular contoured painless Bartholin’s cyst located in the left labia minora with a diameter of 8 x 5 cm in an 11-year-old premenarchal girl, treated by surgical gland excision after previous unsuccessful incision and aspiration of the cyst.

Aggressive fibromatosis, also known as desmoid tumor, is a locally invasive soft tissue lesion arising from connective tissues. Reports in children less than 10 years of age is rare. We report a case of a  desmoid tumor located at the middle and lower third of the left rectus abdominis, in a 2-year-old-boy. Partial resection of the muscle segment and simultaneous reconstruction of the abdominal wall by abdominal fascia was done. The patient had an uneventful recovery. At one year of follow-up neither recurrence nor functional or aesthetic complications were seen.

A seven-day old male infant (weight 3.5 kg) presented with abdominal distension and a mass in the abdomen since birth. There was no history of exposure to any drugs or radiation to the mother in the antenatal period. All the laboratory investigations including beta-human chorionic gonadotropin (hCG) and alpha-fetoprotein (AFP) were normal. X-ray abdomen showed a mass effect in the abdomen with calcifications in the left hypochondrium (Fig.1A).