Abstract Rationale: Pheochromocytoma (PHEO) is a rare neuroendocrine tumor arising from chromaffin cells of the adrenal medulla. Most pediatric PHEOs are functional tumors, and clinical manifestations are related to catecholamine hypersecretion and/or tumor mass effects. Patient concerns: We report here a case of a 10-year-old boy with a highly functional adrenal PHEO detected after the evaluation of a generalized tonic-clonic seizure in the patient. His vital signs at admission were: blood pressure up to 220/135 mm Hg; pulse, 112 beats/min; temperature, 37.4°C; respiratory rate, 22 breaths/min. Diagnosis: A 24-hour urine collection for catecholamines test showed a marked increase in Vanillylmandelic acid levels (338.9 μmol/L). An abdominal magnetic resonance imaging revealed a well-defined left adrenal gland mass measuring ∼5 cm in its largest dimension. Interventions: The mass was surgically removed, and histopathological examination revealed PHEO with low malignant potential (Adrenal Gland Scaled Score/PASS/ < 4). Outcomes: The patient was discharged on the 10th postoperative day in good condition. At 24-month follow-up, the patient was doing well without complications such as tumor recurrence, elevated blood pressure, and seizure. Lessons: PHEO should be considered in the differential diagnosis of children with seizures presenting in the emergency department. A multidisciplinary approach to the evaluation and treatment of PHEO is also crucial for a successful outcome.

INTRODUCTION Gastric acidity plays an important role in the protection of infants against various pathogens from the environment. The histamine-2 receptor blockers (H2-blockers) are off-labeled drugs that are frequently prescribed in preterm neonates to prevent stress ulcers. The impact of the H2-blockers on the development of the necrotizing enterocolitis (NEC) in preterm infants is still controversial, particularly in the developing world. MATERIALS AND METHODS One hundred twenty-two preterm infants were enrolled in the study. The multivariate logistic regression model was used to identify potential postnatal risk factors associated with NEC. RESULTS Preterm infants (n = 51) with total NEC, medical NEC, and surgical NEC had the highest rate of receiving ranitidine compared with controls (n = 71) (39.2%, 19.6%, and 47.6%, p < 0.05). Logistic regression analysis revealed that ranitidine use and nosocomial infections were significantly associated with NEC development (odds ratios 1.55 and 3.3). CONCLUSIONS We confirm that ranitidine administration was associated with an increased risk of NEC in preterm infants. H2-blockers use should be only administered in very strictly selected cases after careful consideration of the risk-benefit ratio.

Clinic of Pediatric surgery, Clinical Center University in Sarajevo, Patriotske lige 81, 71 000 Sarajevo, Bosnia and Herzegovina Clinic of Radiology, Clinical Center University in Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina Clinic for Gastroenterology, Clinical Center University in Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina Clinic of Pediatrics, Clinical Center University in Sarajevo, Patriotske lige 81, 71 000 Sarajevo, Bosnia and Herzegovina Clinic for Anaesthesiology and Reanimation, Clinical Center University in Sarajevo, Bolnička 25, 71 000 Sarajevo, Bosnia and Herzegovina Pediatric Intensive Care Department, Pediatric Clinic, Clinical Center University in Sarajevo, Patriotske lige 81, 71 000 Sarajevo, Bosnia and Herzegovina

Objective – We present herein a new case and survey comprehensively literature on this rare condition. Case report – A 9-yearold girl with a medical history of surgical correction of clubfoot three months earlier presented to our department with an incidentally detected abdominal mass during diagnostic workup for orthopedic surgery. A CT scan revealed a solid right extra-adrenal mass measuring 7×6 cm. It was compressing/involving the infrahepatic part of inferior vena cava, right renal vein and artery with an incomplete encasing of the abdominal aorta. The surgery was successfully performed. The histopathological analysis confirmed GN. Conclusions – Although pediatric extra-adrenal retroperitoneal ganglioneuroma (GN) are rare, their propensity for enveloping major blood vessels is not. GNs should be considered in the differential diagnosis of any circumscribed retroperitoneal mass. These tumors can be successfully treated with surgery that leads to an excellent outcome, even in case of incomplete resections with tumor residuals <2 cm.

Objectives To evaluate the clinical outcome and complications in the pediatric population who had splenectomy at our institution, emphasizing the incidence of postplenectomy reactive thrombocytosis (RT) and its clinical significance in children without underlying hematological malignancies. Materials and methods The medical records of pediatric patients undergoing splenectomy were retrospectively reviewed for the period 1999–2018. The following variables were analyzed: Demographic parameters (age, sex), indications for surgery, operative procedures, preoperative and postoperative platelet count (postplenectomy RT), the use of anticoagulant therapy, and postoperative complications. The patients were divided into two groups according to indications for splenectomy: The non-neoplastic hematology group and the non-hematology group (splenectomy for trauma or other spleen non-hematological pathology). Results Fifty-two pediatric (37 male and 15 female) patients who underwent splenectomy at our institution were reviewed. Thirty-four patients (65%) were in the non-hematological group (splenic rupture, cysts, and abscess) and 18 patients (35%) in the non-neoplastic hematological group (hereditary spherocytosis and immune thrombocytopenia). The two groups did not differ significantly in regards to the patients’ age, sex, and preoperative platelet count (P>0.05 for all variables). Forty-nine patients (94.2%) developed postplenectomy RT. The percentages of mild, moderate and extreme thrombocytosis were 48.9%, 30.7%, and 20.4%, respectively. The comparisons of RT patients between the non-neoplastic hematology and the non-hematology group revealed no significant differences in regards to the patients’ age, sex, preoperative and postoperative platelet counts, preoperative and postoperative leukocyte counts, and the average length of hospital stay (P>0.05 for all variables). None of the patients from the cohort was affected by any thrombotic or hemorrhagic complications. Conclusions We confirm that RT is a very common event following splenectomy, but in this study it was not associated with clinically evident thrombotic or hemorrhagic complications in children undergoing splenectomy for trauma, structural lesions or non-neoplastic hematological disorders.

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.