Incidence and Management of Appendiceal Neuroendocrine Tumors in Pediatric Population: A Bicentric Experience with 6285 Appendectomies

BACKGROUND

Neuroendocrine tumors (NETs) are rare tumors that arise from neuroendocrine cells and are the most common tumors of the appendix. NETs of the appendix usually cause no symptoms and often go unnoticed until they cause acute appendicitis or are discovered during an accidental appendectomy. As the trend towards the conservative treatment of acute appendicitis increases in the pediatric population, the question arises as to whether the majority of NETs go undetected and are only discovered at an advanced stage. The purpose of the proposed study is to review the incidence and outcomes of treatment for NETs of the appendix in children and include the data presented in the data pool for further review.

METHODS

From 1 January 2009 to 1 November 2023, a total of 6285 appendectomies were performed in two large pediatric centers in Croatia. After a retrospective review of the case records and histopathologic findings, a total of 31 children (0.49%) were diagnosed with NET of the appendix and included in the further analysis. The primary outcome of this study was the incidence and treatment outcome of pediatric patients diagnosed with NET of the appendix. Secondary outcomes included the patients' demographic, clinical, and laboratory data and the histopathologic characteristics of tumor species.

RESULTS

The overall incidence of NETs of the appendix was stable over the study years, with minor fluctuations. The median age of patients was 14 (interquartile range-IQR: 12, 16) years, with a female predominance (64.5%). The majority of patients (96.8%) presented with acute abdominal pain and underwent appendectomy because acute appendicitis was suspected. Acute appendicitis was confirmed by histopathology in 18 (58%) cases. NETs of the appendix were not detected preoperatively in any of the patients. Among patients with confirmed acute appendicitis, most (n = 14; 77.8%) were found to have non-perforated acute appendicitis. In most children, the tumor was located at the tip of the appendix (n = 18; 58.1%), and the majority of tumors had a diameter of less than 1 cm (n = 21, 67.7%). The mitotic count (n = 25, 80.6%) and Ki-67 proliferation index (n = 23, 74.2%) were low in most patients, so most tumors were classified as NET G1 (n = 25, 80.6%), while NET G2 and NET G3 were found in four (12.9%) and two (6.5%) patients, respectively. All children were treated with appendectomy only. The median follow-up time was 54 (IQR: 24, 95) months.

CONCLUSIONS

The incidence of appendiceal NET among pediatric patients is very low. NET occurs most frequently in adolescents, with a female predominance. Most tumors are less than 1 cm in diameter, located at the tip, and associated with non-perforated appendicitis. Appendectomy is the treatment of choice, and major surgery was not necessary in our cohort.

Trends and Predictors of Pediatric Negative Appendectomy Rates: A Single-Centre Retrospective Study

BACKGROUND

Appendectomy is still the standard treatment for acute appendicitis in the majority of centers. Despite all available diagnostic tools, the rates of negative appendectomies are still relatively high. This study aimed to determine negative appendectomy rates and to analyze the demographic and clinical data of the patients whose histopathology report was negative.

METHODS

All patients younger than 18 years who underwent appendectomy for suspected acute appendicitis in the period from 1 January 2012 to 31 December 2021 were included in the single-center retrospective study. Electronic records and archives of histopathology reports were reviewed for patients with negative appendectomy. The primary outcome of this study was a negative appendectomy rate. Secondary outcomes comprehended the rate of appendectomies and the association of age, sex, body mass index (BMI), values of laboratory markers, scoring systems, and ultrasound reports with negative histopathology reports.

RESULTS

During the study period, a total of 1646 appendectomies for suspected acute appendicitis were performed. In 244 patients, negative appendectomy was reported regarding the patients' pathohistology. In 39 of 244 patients, other pathologies were found, of which ovarian pathology (torsion and cysts) torsion of greater omentum and Meckel's diverticulitis were the most frequent. Finally, the ten-year negative appendectomy rate was 12.4% (205/1646). The median age was 12 years (interquartile range, IQR 9, 15). A slight female predominance was noted (52.5%). A significantly higher incidence of negative appendectomies was noted in girls, with a peak incidence between the ages of 10 and 15 years (p < 0.0001). Male children whose appendectomy was negative had significantly higher BMI values compared to female patients (p = 0.0004). The median values of white blood cell count, neutrophil count, and CRP in the patients with negative appendectomy were 10.4 × 10⁹/L, 75.9%, and 11 mg/dL, respectively. The median of Alvarado's score was 6 (IQR 4; 7.5), while the median of the AIR score was 5 (IQR 4, 7). The rate of children with negative appendectomy who underwent ultrasound was 34.4% (84/244), among which 47 (55.95%) concluded negative reports. The rates of negative appendectomies were not homogenous in terms of distribution regarding the season. The incidence of negative appendectomies was more frequent during the cold period of the year (55.3% vs. 44.7%; p = 0.042).

CONCLUSIONS

The majority of negative appendectomies were performed in children older than 9 years and most frequently in female children aged 10 to 15 years. In addition, female children have significantly lower BMI values compared to male children with negative appendectomy. An increase in the utilization of auxiliary diagnostic methods such as computed tomography could affect the reduction in the pediatric negative appendectomy rate.

Clinical Outcomes of Daytime Versus Nighttime Laparoscopic Appendectomy in Children

Aim of the study: To evaluate the clinical outcomes and complication rate of laparoscopic appendectomy in children operated on during the daytime versus nighttime. Methods: A total of 303 children who underwent laparoscopic appendectomy for acute appendicitis between 1 January 2020 and 31 December 2022 were enrolled in this retrospective study. The patients were divided into two study groups. The first group consisted of the patients who underwent laparoscopic appendectomy during the day shift from 07:00-21:00 (n = 171), while the patients in the second group underwent laparoscopic appendectomy during the night shift from 21:00-07:00 (n = 132). The groups were compared for baseline clinical and laboratory data, treatment outcomes, and complications. The Mann-Whitney U test was used to compare continuous variables, while the Chi-square test was used to compare categorical variables. A two-sided Fisher's exact test was used when the frequency of events in a certain cell was low. All p values less than 0.05 were considered significant. Results: The proportion of complicated appendicitis was almost the same in both patient groups (n = 63, 36.8% vs. n = 49, 37.1%, p = 0.960). Out of the total number of patients presenting during the daytime and nighttime, 11 (6.4%) and 10 (7.6%) developed a postoperative complication, respectively (p = 0.697). Additionally, rates of readmission (n = 5 (2.9%) vs. n = 2 (1.5%); p = 0.703), redo-surgery (n = 3 (1.7%) vs. n = 0; p = 0.260), conversion to open surgery (n = 0 vs. n = 1 (0.8%); p = 0.435) and length of hospital stay (n = 3 (IQR 1, 5) vs. n = 3 (IQR 2, 5); p = 0.368) did not differ significantly between daytime and nighttime appendectomies. The duration of the surgery was significantly shorter in patients presenting during the day than in those presenting at night (26 min (IQR 22, 40) vs. 37 min (31, 46); p < 0.001). Conclusions: Different shift times did not affect the treatment outcomes or complication rates for children receiving laparoscopic appendectomy.

Diagnostic Accuracy of Leucine-Rich α-2-Glycoprotein 1 as a Non-Invasive Salivary Biomarker in Pediatric Appendicitis

The aim of this study is to evaluate the diagnostic accuracy of leucine-rich α-2-glycoprotein 1 (LRG1) in saliva as a novel biomarker for acute appendicitis in the pediatric population. From October 2021 to June 2022, 92 children aged 5 to 17 years who presented with acute abdomen and suspected acute appendicitis were enrolled in this prospective study. The parameters documented included demographic and clinical information, as well as operative and postoperative data. Patients were divided into two groups: those with acute appendicitis who underwent laparoscopic appendectomy (n = 46) and those without appendicitis (n = 46). The total white blood cell (WBC) count, percent of neutrophils, C-reactive protein (CRP) level, and salivary LRG1 were compared between groups. A commercially available enzyme-linked immunosorbent assay (ELISA) LRG kit was used to measure the LRG levels. The median salivary LRG1 level was significantly higher in the group of children with pathohistologically confirmed acute appendicitis compared to the control group: 233.45 ng/mL (IQR 114.9, 531.2) vs. 55.95 ng/mL (IQR 51.5, 117.9), p < 0.001. LRG1 had an overall good receiver-operator characteristic area under the curve of 0.85 (95% CI 0.76-0.92; p < 0.001). The optimal LRG1 cutoff with best separation between acute appendicitis and the controls was >352.6 ng/mL (95% CI from >270.7 to >352.6). Although the specificity was 100% at this cutoff, the sensitivity for identifying appendicitis was 36%. In addition, a significant difference was found between groups in the laboratory values of all inflammatory markers tested: WBC, absolute neutrophil count, and CRP (p < 0.001 for all). Although LRG1 in saliva showed a good AUC parameter and significantly higher values in patients with acute appendicitis compared to the controls, its usefulness in the patient population who present at emergency departments with abdominal pain is debatable. Future studies should focus on investigating its diagnostic potential.

Diagnostic Utility of Serum Leucine-Rich α-2-Glycoprotein 1 for Acute Appendicitis in Children

PURPOSE

The aim of this study is to assess the diagnostic utility of serum leucine-rich α-2-glycoprotein 1 (LRG1) in pediatric patients with acute abdominal pain, admitted to the emergency surgical unit, in order to make a prompt and accurate diagnosis of acute appendicitis.

PATIENTS AND METHODS

Pediatric patients older than 5 years of age who presented to the emergency department from 15 October 2021 to 30 June 2022 with acute abdominal pain and suspected acute appendicitis were prospectively recruited in the study. Demographic and clinical data, as well as operative and postoperative data, were recorded. A total of 92 patients were equally distributed into two groups: children with acute appendicitis who underwent laparoscopic appendectomy and non-appendicitis patients, presenting with non-specific abdominal pain. LRG1 levels were determined using a commercially available LRG1 enzyme-linked immunosorbent assay (ELISA) kit. Serum LRG1 levels, as well as other inflammatory markers (white blood cell count (WBC), C-reactive protein (CRP) and absolute neutrophil count) were compared between groups.

RESULTS

The median level of LRG1 in serum was significantly higher in the group of children with pathohistologically confirmed acute appendicitis than in the control group, at 350.3 µg/mL (interquartile range (IQR) 165.2-560.3) and 25.7 µg/mL (IQR 14.7-36.8) (p < 0.001), respectively. Receiver operating characteristic area under the curve for LRG1 from serum was 1.0 (95% CI 0.96-1.00; p < 0.001) and the value of >69.1 µg/mL was found to perfectly separate acute appendicitis cases from controls. Additionally, as expected, each of the examined laboratory inflammatory markers provided a significantly higher values in the acute appendicitis group compared to the control group: WBC 14.6 × 10⁹/L (IQR 12.7, 18.7) vs. 7.0 × 10⁹/L (IQR 5.4, 9.0) (p < 0.001), CRP 16.3 mg/dL (IQR 6.9, 50.4) vs. 2.2 mg/dL (IQR 2, 2) (p < 0.001) and absolute neutrophil count 84.6% (IQR 79.5, 89.0) vs. 59.5% (IQR 51.5, 68.6) (p < 0.001).

CONCLUSIONS

LRG1 in the serum was found to be a promising novel biomarker, with excellent differentiation of acute appendicitis from non-appendicitis cases in children presenting with non-specific abdominal pain.

Incidence and causes of 30-day readmission rate from discharge as an indicator of quality care in pediatric surgery

AIM

Evaluation and comparison 30-day readmission rate (ReAd) from discharge within three year period and to note could it be a quality-of-care indicator in pediatric surgery.

METHODS

The case records of the patients that were readmitted within 30 days of primary surgery from January 1^st2017 to December 31^st2019 were identified retrospectively, for each year separately. Demographic data, diagnosis and the treatment on primary admission, length of hospital stay, and diagnosis with treatment on readmission, were collected. For each year readmissions were identified and divided into two groups (emergency and elective) based on the nature of the primary surgery. Outcomes were compared between two groups.

RESULTS

A total of 5392 admissions were identified among three years (2017, n = 1821; 2018, n = 1806; 2019, n = 1765). There was 1014(55.6%) elective admissions in 2017, 953(52.8%) in 2018 and 950(53.8%) in 2019. The overall ReAd rate was 0.82%, 0.99% and 0.57% for years 2017, 2018 and 2019, respectively (p = 0.348). The most common cause for readmission was appendicitis related followed by surgical site infection in different subfields. The share of the number of readmissions during the three-year period is 3.2 times higher for emergency admissions than for elective admissions (p < 0.001). The majority(>75%) of all readmission in all three years occurred in children above age of eight. Male gender was significantly more frequently associated with readmission(74.4%)(p < 0.001).

CONCLUSION

ReAd is a reproducible and good quality-of-care indicator in pediatric surgery. An incidence of ReAd is significantly higher in emergency admissions and an appendectomy is the most common procedure associated with ReAd.

The Laparoscopic Cholecystectomy and Common Bile Duct Exploration: A Single-Step Treatment of Pediatric Cholelithiasis and Choledocholithiasis

BACKGROUND

In recent years, complicated biliary tract diseases are increasingly diagnosed in children. Laparoscopic exploration of the common bile duct (LCBDE) followed by laparoscopic cholecystectomy has gained popularity in children. The aim of this study was to investigate the outcomes of LCBDE in children and compare them with the treatment outcomes of previously used endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

From January 2000 to January 2022, a total of 84 children (78.5% female) underwent laparoscopic cholecystectomy with a median follow-up of 11.4 (IQR 8, 14) years. Of these, 6 children underwent laparoscopic cholecystectomy (LC) + ERCP and 14 children underwent LCBDE for choledochiothiasis. The primary end point of the study was the success of treatment in terms of the incidence of complications, recurrence rate, and rate of reoperation. Secondary endpoints were stone characteristics, presenting symptoms, duration of surgery, and length of hospital stay.

RESULTS

The majority of patients were female in both groups (83.5% vs. 85.7%), mostly overweight with a median BMI of 27.9 kg/m² and 27.4 kg/m², respectively. Obstructive jaundice, colicky pain, acute pancreatitis, and obstruction of the papilla were the most common symptoms in both groups. The majority of patients (68%) had one stone, whereas two or more stones were found in 32% of patients. The median diameter of the common bile duct was 9 mm in both groups. The procedure was successfully completed in all patients in the ERCP group. In the group of patients treated with LCBDE, endoscopic extraction of the stone with a Dormia basket was successfully performed in ten patients (71.4%), while in the remaining four patients (28.6%) the stones were fragmented with a laser because extraction with the Dormia basket was not possible. The median operative time was 79 min in the LCBDE group (IQR 68, 98), while it was slightly longer in the ERCP group, 85 min (IQR 74, 105) (p = 0.125). The length of hospital stay was significantly shorter in the LCBDE group (2 vs. 4 days, p = 0.011). No complications occurred in the LCBDE group, while two (40%) complications occurred in the ERCP group: pancreatitis and cholangitis (p = 0.078). During the follow-up period, no conversions, papillotomies, or recurrences were recorded in either group.

CONCLUSIONS

Exploration of the common bile duct and removal of stones by LCBDE is safe and feasible in pediatric patients for the treatment of choledocholithiasis. Through this procedure, choledocholithiasis and cholelithiasis can be treated in a single procedure without papillotomy or fluoroscopy. Compared with LC + ERCP, LCBDE is associated with a shorter hospital stay. The incidence of complications was rather low but not statistically significant.

Barbed Versus Non-Barbed Suture for Pyeloplasty via the Minimally Invasive Approach: A Systematic Review and Meta-Analysis

Background: There is no agreed protocol on usage of proper and best suturing material in minimally invasive pyeloplasty. The aim of this meta-analysis was to summarize and analyze current evidence on suturing materials for laparoscopic pyeloplasty. Materials and Methods: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Scientific databases (PubMed, Scopus, Web of Science, and EMBASE) were systematically searched for relevant comparative studies on barbed suture (BS) and non-barbed suture (NBS) in minimally invasive pyeloplasty. Results: Five comparative studies met the inclusion criteria and were included in the meta-analysis. Pooling the data demonstrated a significantly shorter operative duration in patients belonging to the BS group versus the NBS group (95% confidence interval [CI] -81.63 to -10.41, P = .01), with statistically significant estimated heterogeneity among the included studies (P < .0001). Although the incidence of redo-pyeloplasty was higher in the BS group, the pooled risk ratio (RR) for the need for redo-pyeloplasty in subjects belonging to the BS group versus the NBS group was 6.00 (95% CI 0.78-46.14), demonstrating no statistically significant difference (P = .09). A total of 5 patients developed postoperative complications. The pooled RR for the occurrence of these complication showed no significant difference among the patients belonging to both the groups (95% CI 0.22-6.05, P = .88). Conclusions: Minimally invasive pyeloplasty using BS is associated with significantly shorter operative time. The incidence of postoperative complications and requirement of redo-pyeloplasty showed no significant difference among both the treatment groups. Further randomized controlled trials need to be conducted before any definite conclusions are drawn.

Percutaneous Internal Ring Suturing is a Safe and Effective Method for Inguinal Hernia Repair in Young Adolescents

Background: Percutaneous internal ring suturing (PIRS) is a laparoscopic procedure that has demonstrated its safety and efficacy as a method of hernia repair in younger children but without evidence among the adolescent population. The aim of this study was to determine the success of PIRS outcomes for hernia repair in the adolescent population. Methods: All adolescents who were operated on using the PIRS method for inguinal repair during the 5-year study period in a single center were included in a prospective cohort study. The main outcome of the study included treatment outcomes in a term of recurrence rate. The secondary outcomes include other treatment outcomes such as complications, conversion to an open procedure, and reoperation rates, as well as duration of anesthesia and surgery, duration of hospital admission, and the level of carbon dioxide pneumoperitoneum. Results: In 51 adolescents (72.5% males) with a median age of 13 years and median follow-up of 44 months, a total of 57 PIRS procedures were performed. There were 30 (58.8%) right hernia repairs, 15 (29.4%) left hernia repairs, and 6 (11.8%) bilateral hernia repairs. The median surgical time was 10 minutes for unilateral and 18 minutes for bilateral hernia repair. The median length of hospital stay was 24 hours. Only one (1.95%) intraoperative complication occurred during surgery, an inferior epigastric vein injury. No complications or recurrences were observed during the follow-up period. Conclusions: PIRS has proven to be simple, safe, and effective method for groin hernia repair in adolescent population. This method provides excellent overall and cosmetic outcomes. There is a low incidence of complications and recurrences. According to our results, PIRS could be considered to become a possible approach for groin hernia repair in adolescents.

The Effect of Single and Triple Testicular Biopsy Using Biopty Gun on Spermatogenesis in Pubertal Rats

Simple Summary

Nowadays, a punch biopsy is a simple, reliable and inexpensive method for different types of tissue sampling. Equally, it is the method of choice for obtaining testicular tissue samples for pathohistological analysis and sperm for intracytoplasmic sperm injection. The results of this study clearly showed that a single biopsy has little effect on the biopsied testis, especially on total fertility. Triple biopsy showed by the same parameters that histological and immunohistochemical consequences were more significant compared to single but without a significant effect on overall fertility. Sperm analysis showed that single and triple biopsies did not have a significant effect on sperm count, motility and morphology. In addition, both single and triple punch biopsies of one testicle did not significantly affect the overall fertility potential of pubertal rats.

Abstract

Background: The aim of this study was to compare consequences in single and triple testicular biopsy by biopty gun in pubertal rats using histological and immunohistochemical analysis. Methods: Thirty-two Sprague-Dawley male rats were used as the experimental model. The rats were randomly divided into three study groups. The rats from the first group (n = 12) received a single-biopsy of upper pole of the left testis, while the rats from the second group (n = 10) received triple-biopsy of upper and lower poles and lateral surface of left testis. The third group (n = 10) was a control group. On the eightieth day after the biopsy in all rats bilateral orchiectomy and funiculectomy were performed to obtain testicular tissue and sperm for analysis. The consequences of the puncture were observed by pathohistology, immunohistochemistry and semen analysis. Results: The results of the study showed lower percentage of sperm count (14.5 mill/mL vs. 16 mill/mL, p = 0.130), sperm motility (24.6% vs. 32.7%, p > 0.05), abnormal sperm (30% vs. 27%, p > 0.05), atrophic tubules (21% vs. 6%, p < 0.001), volume (1.7 mL vs. 2.28 mL, p < 0.01) and apoptotic index (1.56 vs. 1.19, p = 0.650) in the testes with a triple-biopsy compared to the testes with a single-biopsy. Semen analysis showed a borderline significant difference between the group with triple-biopsy where sperm count was lower than it in the control group (14.5 mill/mL vs. 17.5 mill/mL, p = 0.05). A single-biopsy has little effect on the testis, especially on overall fertility. A triple-biopsy showed higher degree of the testicular damage but without a significant impact on overall fertility. Semen analysis showed that single- and triple-biopsies did not have a significant effect on sperm count, motility and morphology. Conclusion: Biopty gun procedure is a cheap, simple and reliable method for testicular biopsy in rats without a significant effect on sperm count, motility and morphology.

Flexible intramedullary nailing for radial neck fractures in children

OBJECTIVE

The aim of this study was to analyze the outcomes of treatment and the rate of complications in children treated with flexible intramedullary nailing (FIN) for radial neck fractures.

METHODS

The study included 26 children (11 males and 15 females) with a median age of 9.5 years, treated with FIN for the radial neck fractures between May 2011 and May 2018. Immobilization after the surgery was not used. The median follow-up was 41 months. According to the Judet classification, 15 fractures were classified as type III and 11 as Type IV. For each patient, clinical, radiological, and disability of the arm, shoulder, and hand (DASH) scores were calculated.

RESULTS

All patients achieved complete radiographic healing at a median of 5 weeks. The nails were removed at a median of 4 months. The rate of complications was 11.5%, including 1 radial head necrosis, 1 angulation of 15°, and 1 displacement of the radial head. Twenty patients (76.9%) achieved a perfect clinical healing, while 23 patients (88.5%) achieved a perfect radiological healing. The median DASH score was 1.25. No cases of delayed healing were recorded. After removing of the nails, all patients returned to full function of the extremity and all complications were resolved.

CONCLUSION

The use of FIN for treating fractures of the radial neck in children shows very good functional and cosmetic results. It allows mobilization with rapid pain reduction. It is a minimally invasive, simple, and reproducible technique with a low rate of complication. Owing to excellent results, surgical stabilization of radial head and neck fractures using FIN is recommended in children and adolescents.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

ARTHROSCOPIC MANAGEMENT OF MENISCAL INJURIES IN ADOLESCENTS: OUTSIDE-IN SUTURING VERSUS MENISCAL DART TECHNIQUE

The aim of this study was to evaluate clinical and subjective outcomes of the meniscal dart technique in patients having undergone arthroscopic meniscal repair by comparing it with the outside-in suturing technique. From January 2006 until June 2017, case records of 37 patients having undergone arthroscopic meniscal repair were retrospectively reviewed. The patients were divided into two groups based on the technique used for meniscal repair, as follows: 18 patients in suture technique group and 19 patients in meniscal dart group. Each patient was analyzed for the following parameters: age, gender, mechanism of injury, side of injury and injured meniscus, injury localization regarding anatomic position, injury type and associated injuries. The patients that underwent meniscal repair were analyzed for type of repair technique, operating results and results of follow-up (Lysholm and International Knee Documentation Committee (IKDC) score). There were no statistically significant differences between the groups according to clinical outcomes except for anatomic injury localization (p=0.035). Median of operation time was 62.5 min in suture technique group and 70 min in meniscal dart group (p=0.184); median of hospital stay was 2 days for both groups (p=0.951); median of Lysholm score was 86.5 and 84.5 (p=0.651); and median of IKDC score was 81.05 and 81.6, respectively (p=0.986). Understanding the harmful impact of meniscectomy, arthroscopic meniscal repair should be attempted whenever possible. Our data support arthroscopic repair of meniscal tears, since both the suture technique and the meniscal dart technique are safe and successful in meniscal repair in children, with good long-term results and without important complications.

Elastic stable intramedullary nailing for treatment of pediatric forearm fractures: A 15-year single centre retrospective study of 173 cases

OBJECTIVE

The aim of this study was to analyze the outcomes and complications in children treated with elastic stable intramedullary nailing (ESIN) for forearm fracture.

METHODS

The study included 173 patients (126 men and 47 women; median age: 11 years (range: 3-17 years) treated with ESIN for forearm fracture between May 2002 and May 2018. Immobilization was not performed after the surgery. The median follow-up was 68 months (range: 3-161 months). The etiology, healing time, and complications were recorded.

RESULTS

All patients achieved complete radiographic healing at a median of 6.8 weeks (range: 4-11 weeks). The most common injuries were sport related (n=65) and by falling from standing height (n=57), followed by injuries from bicycle riding, motorbike accidents, road traffic accidents, and fights. Fifteen (8.76%) postoperative complications were recorded: eight entry-site skin irritations, two cases of skin infection, two refractures, and one case each of nail migration, injury of ulnar nerve, and pseudoarthrosis. All complications, except cases of refractures and pseudoarthrosis, were treated conservatively, with no long-term consequences for the patients. Patients with refractures and pseudoarthrosis were reoperated, and complete function of the extremities was fully restored.

CONCLUSION

ESIN for treatment of forearm fractures in children shows good functional and cosmetic results. This is a minimally invasive, cast-free, simple, and reproducible technique, with a low complication rate. Owing to these excellent objective and subjective results, surgical stabilization of the forearm fracture using ESIN is recommended in children and adolescents.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Video-Assisted Thoracic Surgery in Early Stage of Pediatric Pleural Empyema Improves Outcome

OBJECTIVES

 The aim of this study was to observe outcomes of early decortication in a treatment of pleural empyema using video-assisted thoracoscopic surgery (VATS).

METHODS

 The case records of 21 pediatric patients who underwent VATS for empyema between 2009 and 2019 were retrospectively reviewed. Patients were observed based on demographic, laboratory, and clinical data, as well as treatment outcomes.

RESULTS

 Out of a total of 59 patients treated for pleural empyema, 21 (10 male and 11 female) children with a median age of 5 years (interquartile range [IQR] 2.8; 6.0) received VATS. The empyema was classified as stage I in 2 patients (9.5%), stage II in 4 patients (19%), and stage III in 15 patients (71.5%). Median surgical time was 60 minutes (IQR 50; 90). There were 2 (9.5%) postoperative complications and 1 recurrence (4.8%). Children treated in stages I and II showed significantly better postoperative results compared with the children treated in stage III. Length of hospital stay (8 vs. 10 days; p = 0.01), length of intensive care unit stay (1 vs. 5 days; p < 0.001), duration of chest tube drainage (4 vs. 6 days; p = 0.043), duration of postoperative fever (1.5 vs. 4 days; p = 0.001), and surgical time (40 vs. 70 minutes; p < 0.001) were significantly shorter in children operated in stages I and II than in stage III.

CONCLUSION

 Early decortication using a VATS is a successful, effective, and easily performed surgical method in the treatment of pediatric pleural empyema, as well as a method that significantly improves recovery time and shortens the hospital stay.

Management of the Pediatric Spontaneous Pneumothorax: The Role of Video-Assisted Thoracoscopic Surgery

Purpose: Treatment of pneumothorax involves conservative treatment and surgery. The aim of this study was to assess the best approach of initial treatment and long-term outcomes of video-assisted thoracic surgery (VATS) for primary spontaneous pneumothorax in pediatric patients. Patients and Methods: From January 2009 until June 2019, 36 patients younger than the age of 18 who were treated for spontaneous pneumothorax were included into retrospective study. Patients were divided into 2 groups, non-VATS and VATS, depending on the way they were treated. The groups were compared regarding demographic and clinical data and outcomes of treatment (the length of hospitalization, the frequency of postoperative complications, and reoperations). Results: Out of 36 patients, there were 24 boys and 12 girls with median age of 16.5 years. Median duration of hospitalization was 8 days. Eight patients were treated by observation and 28 by chest tube insertion. In 14 patients with spontaneous pneumothorax, VATS was performed [indications were persistent air leak in 8 (57%) and recurrent pneumothorax in 6 (43%) children]. Patients who underwent surgery had significantly higher length of hospitalization (P < .001) and lower rate of recurrences (P = .003) than those who did not. In 12 (86%) patients, blebs were found intraoperative, and in all of them, pleurodesis was performed. Duration of chest tube insertion was significantly longer in patients who experienced recurrent pneumothorax (P < .001). Conclusions: VATS is successful, efficient, and safe method of treatment for spontaneous pneumothorax, due to its significantly lower rate of recurrence in comparison with chest tube insertion.

Acute Appendicitis in Children Younger than Five Years of Age: Diagnostic Challenge for Pediatric Surgeons

Background: The aim of this study is the evaluation of clinical signs and outcomes of treatment in children under five years of age who underwent appendectomy because of acute appendicitis. Patients and Methods: From January 2009 until December 2018, 90 patients (54 boys and 36 girls) younger than five years of age, treated with appendectomy because of acute appendicitis, were included in this study. Patients were divided into two groups, depending on the intra-operative finding of non-perforated (Group I; n = 32) or perforated (Group II; n = 58) appendicitis. The groups were compared regarding demographic, clinical, and laboratory data and outcomes of treatment. Results: Of 1687 appendectomies in this period, 90 (5.3%) of them were performed in patients aged five years or younger. There were 58 (64.4%) patients with perforated appendix. Positive correlation between the rate of perforation and the age of patients was found. Perforation rates were significantly higher in younger patients (100%, <1 year; 100%, 1-2 y; 83.3%, 2-3 y; 71.4%, 3-4 y; 78.6%, 4-5 y, and 47.3%, 5 y) (p = 0.037). Vomiting and diarrhea were found more commonly in the group of perforated appendix (p < 0.002, p < 0.001), while constipation was found more often in the patients whose appendix was not perforated (p < 0.001). The median duration of symptoms (48 h vs. 16 h; p < 0.001) and median duration of hospitalization (7.5 d vs. 5 d; p < 0.001) were notably longer for the group of patients with perforated than the group of patients with non-perforated appendix. All complications occurred in the group of perforated appendix with total incidence of 4.4%. Conclusion: The clinical presentation of acute appendicitis for children aged five years or younger is often unusual, and establishing the proper diagnosis is often delayed. Patient age is tied closely to the stage of acute appendicitis, so the youngest patients present with more advanced stages of disease and are at greater risk of perforation. Acute appendicitis should be considered in all cases where a child is having abdominal pain, fever, and diarrhea, which has been shown to be present significantly more often in children with perforated appendix.

Elastic Stable Intramedullary Nailing for Treatment of Pediatric Femoral Fractures; A 15-Year Single Centre Experience

Objective:

To analyze outcomes of treatment and complications in children treated with elastic stable intramedullary nailing (ESIN) due to femoral fracture.

Methods:

From May 2002 until May 2018 case records of 103 patients (76 male and 27 female), with median age of 9 (range, 3-17) and follow-up of 92 months, who underwent ESIN because of displaced femoral fracture were retrospectively reviewed. The patient’s information including age, sex, side involved, trauma mechanism, type of fracture, associated injuries, neurovascular status, complications, operation time, duration of hospital stay, time to implant removal were analyzed. The surgical procedure implied a reposition of bone fragments and osteosynthesis with titanium elastic nails introduced through an incision over the lateral and medial border of the distal femoral metaphysis.

Results:

All patients achieved complete radiographic healing at a mean of 8.5 (range, 5-15) weeks. Nine (8.49%) postoperative complications were recorded: three entry site skin irritation, two cases of valgus angulation and one case of nail protrusion, re-fracture, Varus angulation and delayed union. All complications, except case of re-fracture and one valgus angulation, were treated conservatively, with no long term consequences for the patients. Two patients were re-operated. After removal of nails all patients recovered complete function of the extremity, without long term consequences.

Conclusion:

The ESIN for treatment of femoral fractures shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction. Because of the excellent objective and subjective results, the operative stabilization of femoral fractures with ESIN should be recommended to all pediatrics patients

Gallbladder Disease in Children: A 20-year Single-center Experience

OBJECTIVE

Aim of this study was to examine the changes in incidence of pediatric cholecystectomies.

METHODS

Based on a review of hospital-records, children were divided into two groups regarding year of surgery (Group I: 1998-2007; Group II: 2008-2017) and their characteristics were compared.

RESULTS

Number of cholecystecomies increased from 11 to 34. Median age increased from 11 to 15.5 years and mean BMI increased from 19.2 cm/m2 to 23.0 cm/m2. Hereditary spherocytosis decreased from 63.6% to 11.8% (P=0.001) of indications for cholecystectomy, while proportion of cholesterol stones increased from 27.3% to 70.6% (P=0.006). Frequency of laparoscopic cholecystectomy increased from 36.4% to 85.3% (P=0.001). Duration of hospital stay shortened from 8 to 4 days (P=0.008).

CONCLUSIONS

Number of pediatric cholecystectomies has significantly increased in the last 20 years, as well as average BMI of the observed population This probably signifies a correlation between rising obesity rates and increase in frequency of symptomatic cholelithiasis in children.

Bilateral Simultaneous Testicular Torsion in a Newborn: Report of a Case

INTRODUCTION

Testicular torsion is a urological emergency. If not recognized in time, this condition may result in ischaemic injury and loss of testis. Simultaneous bilateral neonatal testicular torsion is extremely rare and is usually misdiagnosed.

CASE REPORT

We report a case of a male newborn, who presented with bilateral scrotal swelling and redness of the scrotum. Doppler ultrasound supported the diagnosis of bilateral testicular torsion, with an absent blood flow signal on the right side and a weak signal on the left side. Testicular exploration through scrotal incision was performed and bilateral testicular torsion was found. Right testis was grossly gangrenous, and right orchiectomy was performed. Left testicle was dark but showed recovery after detorsion with some bleeding from incised tunica albugenia. Fixation of the left testicle was performed. At six month follow-up, the left testis showed signs of atrophy and hormonal assay showed very low testosterone and elevated LH and FSH, suggesting hypogonadism.

CONCLUSIONS

Management of neonatal testicular torsion is a matter of controversy. Testicular torsion results into acute ischemia and urgent surgical exploration is the key point of management. Although the possibility of salvaging the involved testicles is usually very low it is hard to justify a passive approach to a bilateral torsion resulting in such a devastating condition as anorchia.

Flexible intramedullary nailing for treatment of proximal humeral and humeral shaft fractures in children: A retrospective series of 118 cases

BACKGROUND

The aim of this study was to analyze outcomes of treatment and complications in children treated with flexible intramedullary nailing (FIN) due to humeral fracture.

HYPOTHESIS

The FIN for treatment of humeral fractures in children would allow an early functional and cast-free follow-up with a quick pain reduction and low complication rate.

PATIENTS AND METHODS

From May 2002 until May 2016 case records of all children who underwent fixation with titanium intramedullary nails because of humeral fracture were retrospectively reviewed. The study included 118 patients treated with FIN for proximal humeral or humeral shaft fracture. The average age at the time of trauma was 12 years. Mean follow-up was 77 months. Left hand was affected in 51% of patients. The most common mechanism of injury was fall (n=58), followed by sports injuries, road traffic accidents, pathological fractures, motorbike accidents and bicycle riding.

RESULTS

There were no residual valgus/varum deformities. All patients achieved complete radiographic healing at a mean of 7.5 weeks. Nine complications were recorded: 1 humeral shaft fracture in patient with osteogenesis imperfecta, 4 entry site skin irritations, 2 skin infections and 2 radial nerve injuries. There were no cases of delayed union, nonunion or mal-union. After removal of the nails, all patients regained full function and all complications resolved.

DISCUSSION

The FIN for humeral fractures is a minimally invasive, simple and well reproducible technique with very low complication rate.

CONCLUSION

The FIN for treatment of humeral fractures shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction.

LEVEL OF EVIDENCE

Level IV - retrospective study.

A Case of 2-Year-Old Child with Entero-Enteric Fistula Following Ingestion of 25 Magnets

INTRODUCTION

Magnet ingestion usually does not cause serious complications, but in case of multiple magnet ingestion or ingestion of magnet with other metal it could cause intestinal obstruction, fistula formation or even perforation.

CASE REPORT

We report case of intestinal obstruction and fistula formation following ingestion of 25 magnets in a 2-year-old girl. Intraoperatively omega shaped intestinal loop with fistula caused by two magnetic balls was found. Intestine trapped with magnetic balls was edematous and inflamed. Resection of intestinal segment was performed, followed by entero-enteric anastomosis. A total of 25 magnets were removed from resected intestine.

CONCLUSION

Single magnet ingestion is treated as non-magnetic foreign body. Multiple magnet ingestion should be closely monitored and surgical approach could be the best option to prevent or to cure its complications.

Myocardial bridging as one of the causes of atypical chest pain in young women

Introduction

Myocardial bridging is congenital anomaly which usually has benign prognosis but there are also reports suggesting that it can be associated with ischemic clinical syndromes presenting with chest pain. Coronary computed tomography angiography is a well-established method for detecting myocardial bridging. However, clinical significance of this anomaly still remains unclear.

Methods

We studied 977 patients who presented with recurrent typical or atypical chest pain in outpatient clinic. All patients have undergone detailed clinical examination, ECG stress testing and coronary computed tomography angiography.

Results

Highest positive prediction for having myocardial bridging was for patients presenting with atypical chest pain with negative ECG stress test and who were younger women.

Conclusion

Coronary computed tomography angiography may be preferable method for evaluation of chest pain in younger women presenting with atypical chest pain.

Lateral thermal damage of mesoappendix and appendiceal base during laparoscopic appendectomy in children: comparison of the harmonic scalpel (Ultracision), bipolar coagulation (LigaSure), and thermal fusion technology (MiSeal)

BACKGROUND

The aim of this study was to compare lateral thermal damage of mesoappendix and appendiceal base using three different instruments for sealing and cutting of mesoappendix.

MATERIALS AND METHODS

A total number of 99 patients (54 males and 45 females) who underwent laparoscopic appendectomy because of suspected appendicitis between December 2013 and May 2015 were enrolled in the study. The patients were divided in three groups based on instrument used for sealing of mesoappendix: group 1 (Ultracision; n = 36), group 2 (LigaSure; n = 32), and group 3 (MiSeal; n = 31). Lateral thermal damage, intraoperative and postoperative complications, duration of surgery, hospital stay, and economic value were compared within groups.

RESULTS

The median age of patients was 14 y (range 3-17). A histopathologic analysis revealed a positive diagnosis of appendicitis in 84 patients (85%). The median lateral thermal damage on appendiceal base using Ultracision, LigaSure, and MiSeal was 0.10 mm, 0.16 mm, and 0.10 mm respectively, and on mesoappendix, 0.08 mm, 0.13 mm, and 0.08 mm, respectively. Significantly higher thermal damage was found on mesoappendix (P = 0.015) and appendiceal base (P = 0.012) in patients treated with LigaSure than in patients from other groups. There were no statistical differences among the groups regarding intraoperative and postoperative complications (P = 0.098). No significant difference in thermal damage between appendicitis and nonappendicitis group was found (P = 0.266).

CONCLUSIONS

Using of Ultracision, LigaSure, and MiSeal for sealing of mesoappendix in laparoscopic appendectomy in children is safe and useful. LigaSure produces significantly greater lateral thermal damage compared with other instruments.

Synthesis of 4-aryl-1,2,3-triazolyl appended natural coumarin-related compounds with antiproliferative and radical scavenging activities and intracellular ROS production modification

Diverse natural coumarin-based compounds linked to aryl via a 1,2,3-triazole spacer with antiproliferative activity against K562 cells, radical scavenging activity and a decrease of ROS production were provided.

Management of acute scrotum in children: a 25-year single center experience on 558 pediatric patients

INTRODUCTION

The aim of this study was to analyze management and outcomes of treatment in patients with acute scrotum.

MATERIAL AND METHODS

From January 1990 until January 2015 case records of 558 patients who underwent surgery for acute scrotum were retrospectively reviewed. Mean age was 12 years old. Each patient was analyzed for following parameters: history data, localization of pain, physical examination, operating results and the results of follow up, age, etiology, and the time from initial symptoms to surgery.

RESULTS

Scrotal explorations revealed 142 cases (25%) of spermatic cord torsion, 344 (62%) torsion of the testicular appendage, 54 (10%) epididymitis, 10 (2%) testicular trauma and 8 cases (1%) of other conditions. Two peaks of incidence of spermatic cord torsion were found, the first during first year of life and the second between 13 and 15 years of life. In patients with spermatic cord torsion, median duration of symptoms in the group of salvaged testes was 6 hours; while in the group of patients who underwent orchiectomy was 46 hours. Of the total number of patients with spermatic cord torsion 40 patients (28%) underwent orchiectomy while 102 testicles (72%) were saved. There were no major complications. Acute scrotum is significantly more common in the winter. Torsion of the testis has the highest incidence in January and August.

CONCLUSION

Early scrotal exploration based on careful physical examination decreases the risk of misdiagnosis of spermatic cord torsion. It is of great importance that the patient seeks immediate medical attention. If the patient arrived within 6 hours the testicle can be saved.

Comparison of dextranomer/hyaluronic acid based bulking agents in the treatment of vesicoureteral reflux in children: Deflux versus Vurdex

INTRODUCTION

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.

MATERIAL AND METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.

Pneumoperitoneum in in-vitro Conceived Quadruplet Neonate: Rare Manifestation of Hirschsprung's Disease--Report of a Case

INTRODUCTION

Hirschsprung's disease is a congenital colonic aganglionosis, usually presented as inability or difficulty in passing of meconium, chronic and persistent obstipation, maleficent feeding, vomiting, distension and lethargy.

CASE PRESENTATION

We presented a case of an in-vitro conceived quadruplet premature neonate who presented with pneumoperitoneum caused by transverse colon spontaneous perforation and microcolon appearance of distal bowel, treated by resection and temporary colostomy turns to be a rare manifestation of Hirschsprung's disease.

CONCLUSION

Assisted reproductive technologies increases chances for multiple pregnancies and may increase chance for major congenital anomalies. Rare manifestation of Hirschsprung's disease is spontaneous pneumoperitoneum which remains a surgical emergency. Delay in recognizing and treatment can significantly worsen prognosis. In neonate with intestinal perforation one should consider Hirschsprung's disease.

Primary malignant fibrous histiocytoma of the spleen: recurrence eight years after splenectomy--report of a case and literature review

Primary intraabdominal malignant mesenchymal tumors are very rare. There are just few cases of intraabdominal visceral malignant fibrous histiocytoma in the literature. We report a case of primary malignant fibrous histiocytoma of the spleen in a 57-year-old man, with a recurrence eight years after the splenectomy. After the initial surgery the patient was without complaints, and refused to receive chemotherapy or radiotherapy. Eight years after the surgery the patient reported due to general weakness and malaise when the diagnosis of disease relapse was established. Radical surgery was performed although the tumor involved large curvature of the stomach, left crus of the diaphragm, splenic flexure of the colon and tail of pancreas. Four months after the surgery patient died. To the best of our knowledge, to date, only 18 cases have been reported in the literature, describing malignant fibrous histiocytoma of the spleen.

[Determination of blood volume in pulmonary capillaries in patients with chronic obstructive lung disease]

The subjects were divided into four groups, three of which consisted of patients with various degrees of lung obstruction, while the fourth was the control group. The patients were divided according to the spirometric values: VC, FEV1, FEV1/VC%. The diffusing capacity was determined on the basis of the single breath method and graphical separation of the diffusion components was performed. It was found that the diffusing lung capacity was slightly lower in patients with mild to severe obstructive lung disease. The capillary blood volume was also slightly lower. Correlations between the degree of obstruction of the respiratory system and the diffusing lung capacity or the lung capillary blood volume was not statistically significant (p greater than 0.5). In studying patients with obstructive lung disease we were unable to establish which of the diffusion components significantly affected the value of the total diffusing lung capacity.