Updates on bacterial resistance and empirical antibiotics treatment of complicated acute appendicitis in children.

OBJECTIVE: Through historical comparison with our previous study published 10 years ago, this paper aims to provide latest analysis of local bacteriology of acute complicated appendicitis and evaluate the effects of early escalation of potent antibiotics on course of postoperative recovery. METHODS: A 5-year retrospective review of all children receiving emergency laparoscopic appendicectomies for acute appendicitis from December 2014 to November 2019 was conducted. RESULTS: 257 cases of acute appendicitis were included, 126 were complicated appendicitis (38 gangrenous, 88 ruptured). 96 had positive peritoneal swab culture, 53 (42.1%) grew resistant bacterial strains, including extended spectrum beta-lactamase producing E. coli (ESBL E. coli), Pseudomonas aeruginosa, against traditional empirical triple antibiotics. The prevalence had significantly increased over the past decade (p = 0.008). In our patients, piperacillin/tazobactam, ertapenem, gentamicin provided coverage of 69.8%, 45.3% and 45.3% respectively. For patients with early escalation of postoperative antibiotics, no statistical significance was identified in terms of postoperative complications (p = 0.883), or duration of antibiotics (p = 0.0615). CONCLUSION: Growing prevalence of resistant strains were observed over the decade. Piperacillin/tazobactam provided the best coverage (69.8%) against resistant bacterial strains in our patients. Early escalation of antibiotics failed to reduce postoperative complications and antibiotics duration. TYPE OF STUDY: Clinical Research, Retrospective Historical Comparative Study Level of Evidence: Level III.

Impact of Age of Patient and Experience of Surgeon on the Outcome after Kasai Portoenterostomy: Can We Delay the Surgery?

INTRODUCTION: Age of patient and experience of biliary atresia (BA) center are well-known factors associated with early jaundice clearance (EJC) after Kasai portoenterostomy (KPE) in infants with BA. This study focused on the impact of age and surgeon factor on the short-term outcome after KPE within a single center. MATERIALS AND METHODS: Fifty-four consecutive infants (18 boys and 36 girls) who underwent KPE from January 2010 to January 2020 were reviewed. KPE was performed in the earliest available operative session once the initial work-up was completed. In group A (n = 41), KPE was performed by surgeon A. In group B (n = 13), KPE was performed by specialists under the supervision of surgeon B (who is the mentor of surgeon A) when surgeon A was not available for operation. The demographics of patients, the EJC (total bilirubin <20 µmol/L within 6 months of KPE), and 2-year native liver survival (NLS) between the two groups were studied. RESULTS: The median age at operation was 52 days (range 26-135 days). The overall EJC rate and 2-year NLS were 85.2 and 89.4%, respectively. Group A (p = 0.015) and male gender (p = 0.029) were statistically associated with EJC but not the age at operation (p = 0.101). Group A was also statistically associated with superior 2-year NLS (p = 0.047). CONCLUSION: Balancing between the impact of age at operation and the experience of surgeon on the outcome after KPE, our result suggested that KPE may be deferred until a more experienced surgeon to operate.

Long-Term Results of One-Stage Laparoscopic-Assisted Endorectal Pull-Through for Rectosigmoid Hirschsprung's Disease in Patients Aged Above 5 Years.

Purpose: Despite the fact that the laparoscopic-assisted endorectal pull-through (LAEPT) for Hirschsprung's disease (HD) was introduced over 20 years ago, published outcomes in older children and adolescent are lacking. To address this, we studied the long-term results of LATEP for rectosigmoid HD in patients above 5 years of age. Materials and Methods: A retrospective review was conducted on all nonsyndromic patients above 5 years of age and who underwent one-stage LAEPT for rectosigmoid HD between January 2002 and December 2017. Late Hirschsprung-associated enterocolitis (HAEC) was defined as HAEC occurring 1 year after the pull-through operation. Postoperative bowel function was assessed using the Krickenbeck classification. Results: Forty-one patients (37 males and 4 females) were included in this study with a median follow-up of 9.0 years. The median age at surgery was 55 days. Two patients had anastomotic leakage. No patient had late HAEC, rectal prolapse, anastomotic stricture, or intestinal obstruction. According to the Krickenbeck classification, all patients had voluntary bowel movements without constipation. Overall, 65.8% of patients had no soiling. However, on subgroup analysis, only 45.4% of patients younger than 11 years of age had no soiling compared with 89.5% in patients at or older than 11 years of age (P = .003). Conclusions: Our results showed that LAEPT for rectosigmoid HD was a safe procedure. Nearly 90% of patients had normal bowel function by puberty. Further studies are needed to address the problem of soiling in patients younger than 11 years of age.

Comparison of Characteristics and Outcomes in Antenatally and Postnatally Detected Choledochal Cyst in Infants and Young Children in a Laparoscopic Surgery Center.

Purpose: The aim of this study was to compare the characteristics and the outcome between infants and young children with antenatally (AN) and postnatally (PN) detected choledochal cyst (CC) in a laparoscopic surgery center. Methods: A retrospective review was conducted for all children who underwent excision of CC and hepaticojejunostomy (HJ) before 36 months of age between October 2004 and October 2019. Results: Thirty-nine children (28 girls and 11 boys) were included in this study. Twenty-one children had AN detected CC and 18 had PN detected CC. The median age at operation (AN vs. PN; 3 months vs. 15.5 months, P < .001) and body weight (AN vs. PN; 5.6 kg vs. 10.5 kg, P < .001) were significantly different between the two groups. Children in PN group has an increased risk of being symptomatic (AN vs. PN; 6 vs. 18, P < .001) and having intervention before operation (AN vs. PN; 0 vs. 4, P = .037). Laparoscopic excision was performed in all children in AN group and in 12 children (66.7%) in PN group (P = .006). Conversion to open HJ was performed in 4 children in AN group but none in PN group (P = .146). There was no statistical differences in success in laparoscopic operation (P = .257), median operative time (P = .094), postoperative complication (P = .576), and median length of hospital stay (P = .749). Conclusions: Despite younger age at operation, the outcome of laparoscopic excision of AN detected CC was comparable with PN detected CC. Earlier detection and operation decreased the risk of preoperative intervention.

Ten-Year Native Liver Survival Rate After Laparoscopic and Open Kasai Portoenterostomy for Biliary Atresia.

PURPOSE: Laparoscopic Kasai portoenterostomy (LKP) remains controversial in the management of infants with biliary atresia (BA). There are no data reporting the 10-year native liver survival rate after LKP. The study aims to present the 10-year native liver survival rate after LKP and complications in native liver survivors after Kasai portoenterostomy (KP). METHODS: A retrospective review was conducted for 31 consecutive infants with BA who underwent KP by day 75 of life in our institute from January 1993 to December 2007. The demographics and outcomes of patients after LKP and open KP (OKP) were compared. RESULTS: Eleven patients underwent LKP and 20 patients underwent OKP. No statistical difference was observed in the age at operation and the preoperative bilirubin level. The operative time for LKP was significantly longer than that for OKP (mean 314.5 minutes versus 271.5 minutes, P = .03). The 10-year native liver survival rate was 45% (5/11) after LKP and was 85% (17/20) after OKP (P = .03). Forty percent (2/5) of the native liver survivors in the LKP and 71% (12/17) in the OKP developed complications within 10 years after KP (P = .23). CONCLUSIONS: The 10-year native liver survival rate in patients who underwent LKP by 75 days of life was 45%. With superior 10-year liver survival rate and comparable complication rate after OKP, OKP is still the treatment of choice for BA in our institute.

Cystic meconium peritonitis with jejunoileal atresia: Is it associated with unfavorable outcome?

AIM: To compare the outcome between patients with jejunoileal atresia (JIA) associated with cystic meconium peritonitis (CMP) and patients with isolated JIA (JIA without CMP). METHODS: A retrospective study was conducted for all neonates with JIA operated in our institute from January 2005 to January 2016. Demographics including the gestation age, sex, birth weight, age at operation, the presence of associated syndrome was recorded. Clinical outcome including the type of operation performed, operative time, the need for reoperation and mortality were studied. The demographics and the outcome between the 2 groups were compared. RESULTS: During the study period, 53 neonates had JIA underwent operation in our institute. Seventeen neonates (32%) were associated with CMP. There was no statistical difference on the demographics in the two groups. Patients with CMP had earlier operation than patients with isolated JIA (mean 1.4 d vs 3 d, P = 0.038). Primary anastomosis was performed in 16 patients (94%) with CMP and 30 patients (83%) with isolated JIA (P = 0.269). Patients with CMP had longer operation (mean 190 min vs 154 min, P = 0.004). There were no statistical difference the need for reoperation (3 vs 6, P = 0.606) and mortality (2 vs 1, P = 0.269) between the two groups. CONCLUSION: Primary intestinal anastomosis can be performed in 94% of patients with JIA associated with CMP. Although patients with CMP had longer operative time, the mortality and reoperation rates were low and were comparable to patients with isolated JIA.

Spontaneous Intestinal Perforation: The Long-Term Outcome.

Background/Purpose Evaluating the long-term outcome of spontaneous intestinal perforation (SIP). Methods We studied all patients treated for SIP at our institution between January 1, 2005 and December 31, 2014. Results Twenty-three infants (13 males) with a median gestational age of 26 (range: 23-32) weeks and a median weight of 825 (range: 560-1,965) g composed this cohort. Seventeen (74%) infants had an extremely low birth weight (ELBW); nine (39%) infants were the result of multiple pregnancies.Patent ductus arteriosus (PDA) was present in 16 (70%) infants. Cyclooxygenase inhibitors were administered in 12 (52%) infants.Ten infants (seven males, 44%) were diagnosed with intraventricular hemorrhage (IVH), which was identified in the majority (8/10) at a median of 9 (range: 1-11) days prior to the perforation.All patients presented with pneumoperitoneum and underwent a laparotomy at a median age of 9 (range: 2-16) days. Twenty-one patients had an ileal perforation. A temporary stoma was placed in 21 patients, whereas two got primary anastomosis. Two (8.7%) male infants died. During the long-term follow-up period (median 6 years), six (five males) (26%) infants developed moderate to severe disabilities in combination with cerebral palsy. No surgical complications were observed. Conclusion The most important risk factor for SIP is ELBW (75%). The distal ileum is the most frequent site of perforation (88%). Approximately 40% develop IVH most often prior to the SIP. Moderate to severe neurologic disabilities are seen in more than a quarter of the children. Disability and mortality affect mostly the male sex. Long-term risks of surgical complications are very low.

Management of Intestinal Strictures Post Conservative Treatment of Necrotizing Enterocolitis: The Long Term Outcome.

OBJECTIVES: Evaluating the long-term outcome of the surgical management for intestinal strictures developing after necrotizing enterocolitis (NEC). PATIENTS AND METHODS: This is a retrospective study of all patients with an intestinal stricture after completion of conservative management for NEC. They were treated during the eight years period from 1st January 2008 to 31st December 2015. RESULTS: During the study period 67 infants had an operation for NEC, of which 55 had emergency surgery. The remaining twelve infants (6 males) had a stricture and were included in the study group. Their median gestational age was 35 (range 27-40) weeks and the median weight was 2180 (range 770 - 3290) g. The onset of NEC was seen at a median of 2 (range 1- 47) days. The median peak C-reactive protein (CRP) level was 73.1 (range 25.2 - 232) mg/dl. Isolated strictures were seen in 9 (75%) patients. Two-third of all strictures (n=15) were located in the colon. Surgery was done at a median of 5 (range 3 - 13) weeks after diagnosing NEC. Primary anastomosis was the procedure of choice; only one needed a temporary colostomy. This cohort had no mortality during a median follow up of 6.25 (range 0.5 - 7.6) years, whilst the overall death rate for NEC was 15 (22 %). Two fifth of the group developed a neurological / sensory impairment. CONCLUSION: One fifth of the surgical workload for NEC is related to post-NEC strictures. Most strictures are located in the colonic region. In the long-term no mortality and no surgical co-morbidities were observed.

Laparoscopic management of antenatally detected choledochal cyst: a 10-year review.

BACKGROUND: The aim of this review was to study the characteristics and the outcome of children who underwent laparoscopic management of the antenatally detected choledochal cyst. METHODS: A retrospective review was conducted for all children who underwent excision of antenatally detected choledochal cyst and hepaticojejunostomy from 2005 to 2015. RESULTS: Fourteen patients (11 females and 3 males) were included in this study. The mean diameter of the cyst was 5.0 cm (range 2-12 cm). The mean age at operation was 3.5 months (range 11 days to 9 months). The mean body weight was 6.0 kg (range 3.9-10.0 kg). Five patients were symptomatic before operation. Laparoscopic excision of choledochal cyst was successful in all cases. The distal end of common bile duct (CBD) was cauterized in all but two cases. Conversion to open hepaticojejunostomy was required in two children. There was no intraoperative complication. Two patients had postoperative fever. One patient had minor bile leak that resolved on conservative management. The mean operative time was 286 min (range 200-390 min). The median hospital stay was 8 days (range 6-25 days). At a median follow-up of 46 months (range 6-118 months), all patients were freed from cholangitis or intestinal obstruction. Symptomatic patients had earlier operation (mean, 1.7 vs. 4.5 months p = 0.012) and were associated with postnatal increase in cyst size (p = 0.023) but were not associated with increased risk of complication or conversion (p = 1.000). CONCLUSIONS: Laparoscopic excision of choledochal cyst and hepaticojejunostomy could be safety performed in patients with the cyst detected antenatally. The distal CBD was usually small and stenotic. Symptomatic patients had earlier operation with no increase in morbidity.

Use of laparoscopy as the initial surgical approach of impalpable testes: 10-year experience.

AIM: To review the experience in the management of impalpable testes using laparoscopy as the initial approach and the need for inguinal exploration. METHODS: From January 2004 to June 2014, 339 patients with undescended testes underwent operation in our institute. Fifty patients (15%) had impalpable testes. All children with impalpable testes underwent initial laparoscopy. A retrospective review was conducted on this group of patients and the outcome was analyzed. RESULTS: Forty children had unilateral impalpable testis. Ten children had bilateral impalpable testes. Thirty-one children (78%) in the unilateral group underwent subsequent inguinal exploration while 4 children (40%) in the bilateral group underwent inguinal exploration (P < 0.05). Orchidopexy was performed in 16 children (40%) in the unilateral group and 9 children (90%) in the bilateral group (P < 0.05). Regarding the 24 children with unilateral impalpable testis and underwent orchidectomy for testicular nubbin (n = 19) or atrophic testes (n = 2) or has vanishing testes (n = 3); contralateral testicular hypertrophy was noticed in 10 (41%). No intra-operative complication was encountered. Two children after staged Fowler-Stephens procedure and 1 child after inguinal orchidopexy had atrophic testes. CONCLUSION: The use of laparoscopy in children with impalpable testes is a safe procedure and can guide the need for subsequent inguinal exploration. Children with unilateral impalpable testis were associated with an increased need for inguinal exploration after laparoscopy. Orchidopexies could be performed successfully in 90% of children with bilateral impalpable testes.

Irreducible inguinal hernia in children: how serious is it?

BACKGROUND/PURPOSE: We evaluated the experience with irreducible inguinal hernias at our institution. METHODS: We reviewed patients with an inguinal hernia operation at our institution between 1st January 2004 and 31st December 2013. Individuals with a failed manual reduction of an incarcerated hernia under sedation by the attending surgeon were included into the study group as irreducible hernia. RESULTS: Overall 2184 individuals (426 females) had an inguinal herniotomy with the following distribution: right 1116 (51.1%), left 795 (36.4%) and bilateral 273 (12.5%) cases. A laparoscopic herniotomy was done in 1882 (86.4%). 34 patients (3 females) - just 1.6% of the total - presented at a median age (corrected for gestation) of 12 months (range 2 weeks to 16 years) with an irreducible hernia, of which 24 individuals (70%) were right sided. A laparoscopic approach was attempted in 21 (62%), two required a conversion. The open technique was chosen in 13 (38%) individuals. The content of the hernia sac was distal small bowel in 21 (62%), omentum in four (12%) and an ovary in three (9%) cases. Four patients (12%) required laparoscopic assisted bowel resection and two partial omentectomy (6%). Two gonads (6%) were lost: one intraoperative necrotic ovary and one testis atrophied over time. There was no recurrent hernia. CONCLUSION: Irreducible inguinal hernias constitute 1.6% of the workload on inguinal hernia repair. The hernia sac contains in males most frequently small bowel and in females exclusively a prolapsed ovary. Significant comorbidity is present in 18%. Laparoscopic and open techniques complement each other in addressing the issue.

Laparoscopic excision of Meckel's diverticulum in children: what is the current evidence?

Complications aroused from Meckel's diverticulum tend to developed in children. Children presented with abdominal pain, intestinal obstruction, intussusception or gastrointestinal bleeding may actually suffered from complicated Meckel's diverticulum. With the advancement of minimally invasive surgery (MIS) in children, the use of laparoscopy in the diagnosis and subsequent laparoscopic excision of Meckel's diverticulum has gained popularity. Recently, single incision laparoscopic surgery (SILS) has emerged as a new technique in minimally invasive surgery. This review offers the overview in the development of MIS in the management of children suffered from Meckel's diverticulum. The current evidence in different laparoscopic techniques, including conventional laparoscopy, SILS, the use of special laparoscopic instruments, intracorporeal diverticulectomy and extracorporeal diverticulectomy in the management of Meckel's diverticulum in children were revealed.

Outcome of patients after single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification.

PURPOSE: The aim of the study is to assess the characteristics and outcome of anorectal malformation (ARM) patients who underwent single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification. METHODS: From 2002 to 2013, twenty-eight males and four females with perineal fistula who underwent single-stage repair without colostomy in our institute were included in this study. Patients with perineal fistula who underwent staged repair were excluded. Demographics, associated anomalies, and operative complications were recorded. The type of surgical procedures and functional outcome were assessed using the Krickenbeck classification. RESULTS: Six patients had associated anomalies, including two patients with renal, two with cardiac, one with vertebral, and one with limb abnormalities. Thirteen patients underwent perineal operation, and fourteen patients underwent anterior sagittal approach in the neonatal period. One patient underwent anterior sagittal approach, and four patients underwent PSARP beyond the neonatal period. One patient had an intra-operative urethral injury and one a vaginal injury. Complications were not associated with the type of surgical procedure (p=0.345). All perineal wounds healed without infection. By using the Krickenbeck assessment score, all sixteen children older than five years of age had voluntary control. One patient had grade 1 soiling, and no patient had constipation. CONCLUSIONS: Single-stage operation without colostomy was safe with good outcomes in patients with perineal fistula. The use of Krickenbeck classification allows standardization in assessment on the surgical approach and on functional outcome in ARM patients.

Bowel perforation in newborn with anorectal malformation and no fistula at presentation.

PURPOSE: Anorectal malformation (ARM) in newborns with no fistula at presentation resembles intestinal obstruction. The aim of this study is to study the factors associated with bowel perforation in this group of patients. METHODS: From 2000 to 2012, 106 newborns with ARM were managed in our hospital. Thirty neonates without fistula at presentation were included in this study. Demographic data and the incidence of bowel perforation were studied. RESULTS: Twenty-nine male and 1 female were included in the study. Five patients were born premature and six patients had low birth weight. Six patients had Down's syndrome and 12 patients had associated anomalies. Cross-table lateral x-ray in prone position was performed from 20 to 24 hours after birth. All operations were performed within 48 hours after birth. One neonate underwent primary anoplasty. Twenty-nine neonates underwent colostomy. Two males developed bowel perforation before surgery (at 33 and 36 hours after birth). Perforation was associated with low birth weight (p=0.034) and was not associated with prematurity (p=0.31), Down's syndrome (p=0.634) or the presence of other associated anomalies (p=0.687). CONCLUSIONS: In newborns with ARM, bowel perforation can occur within 36 hours after birth. Forty-eight hours of waiting is too long as it risks perforation. In this study, a neonate with low birth weight was trended toward bowel perforation.

Early experience in robotic-assisted laparoscopic bilateral intravesical ureteral reimplantation for vesicoureteral reflux in children.

A high success rate has been reported for laparoscopic intravesical ureteral reimplantation in the management of high-grade vesicoureteral reflux in children. With the introduction of the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA), robotic-assisted laparoscopic intravesical ureteral reimplantation may provide additional benefits, particularly in intravesical suturing. We present here our experience in three children, all with high-grade bilateral vesicoureteral reflux, who underwent robotic-assisted laparoscopic intravesical bilateral ureteral reimplantation. The procedure was successfully performed in all cases. There were no intra-operative or post-operative complications. Operative times were 430, 240 and 220 min. Hospital stay was 7, 6 and 2 days. Postoperative voiding cystourethrogram confirmed resolution of vesicoureteral refluxes in all cases and all three children were free from urinary tract infections on follow-up. Our initial experience with robotic-assisted laparoscopic intravesical ureteral reimplantation has shown this to be a technically safe and feasible option in the management of children with bilateral high-grade vesicoureteric reflux.

Laparoscopic inguinal hernia repair by the hook method in emergency setting in children presenting with incarcerated inguinal hernia.

BACKGROUND: The development of laparoscopic hernia repair has provided an alternative approach to the management of incarcerated inguinal hernia in children. Different laparoscopic techniques for hernia repair have been described. However, we hereby review the role of laparoscopic hernia repair using the hook method in the emergency setting for incarcerated inguinal hernias in children. METHODS: A retrospective review was conducted of all children who presented with incarcerated inguinal hernia and underwent laparoscopic hernia repair using the hook method in emergency setting between 2004 and 2010. RESULTS: There were a total of 15 boys and 1 girl with a mean age of 30 ± 36 months (range, 4 months to 12 years). The hernia was successfully reduced after sedation in 7 children and after general anesthesia in 4 children. In 5 children, the hernia was reduced by a combined manual and laparoscopic-assisted approach. Emergency laparoscopic inguinal hernia repair using the hook method was performed after reduction of the hernia. The presence of preperitoneal fluid secondary to recent incarceration facilitated the dissection of the preperitoneal space by the hernia hook. All children underwent successful reduction and hernia repair. The median operative time was 37 minutes. There was no postoperative complication. The median hospital stay was 3 days. At a median follow-up of 40 months, there was no recurrence of the hernia or testicular atrophy. CONCLUSIONS: Emergency laparoscopic inguinal hernia repair by the hook method is safe and feasible. Easier preperitoneal dissection was experienced, and repair of the contralateral patent processus vaginalis can be performed in the same setting.

The outcome of laparoscopic portoenterostomy for biliary atresia in children.

AIM: There were only a few reports on laparoscopic portoenterostomy for biliary atresia in children. We report our experience on laparoscopic Kasai operation for biliary atresia. MATERIAL AND METHODS: A retrospective review of all children who had biliary atresia underwent laparoscopic portoenterostomy from January 2002 to September 2006 were included and analyzed. RESULTS: Sixteen children (five boys and eleven girls) with a mean age of 66 days (range 47-106 days) at operation were included in this study. All patients had type III biliary atresia. There was no conversion to open procedure. The operative time ranged from 193 to 435 min (mean 292 min). At a median follow-up of 72 months (range 33-89 months), eight patients were free of jaundice with bilirubin level <20 µmol/L and did not require liver transplantation. Seven patients underwent liver transplantation. One patient who had persistent elevated bilirubin defaulted follow-up. One patient complicated with volvulus of intestine post-operatively. All patients survived except one patient who had combined liver and intestine transplantation. CONCLUSION: Laparoscopic portoenterostomy in children with biliary atresia is technically feasible. 50% of children who had type III biliary atresia were free of jaundice and did not require liver transplantation. A longer follow-up is required to assess the long-term outcome.

Evidence-based adjustment of antibiotic in pediatric complicated appendicitis in the era of antibiotic resistance.

INTRODUCTION: Antibiotic resistance is a global issue especially in developed areas. With the emergence of antibiotic resistant-bacteria, the traditional choice of broad spectrum antibiotics may not be effective in complicated appendicitis. We herein report the bacteriology and antibiotic susceptibility of intra-operative peritoneal culture in children with acute appendicitis in Hong Kong. This may guide us to adjust the choice of antibiotics with evidence. METHODS: A retrospective review of all cases of children who underwent laparoscopic appendicectomy from 2003 to 2007 was performed. Data including histology of appendixes, the choice of antibiotics, bacteriology, and antibiotic susceptibility of the intra-operative peritoneal cultures were analyzed. RESULTS: Over a 5-year period, 250 children were included in this study. 41 children had gangrenous- and 77 had ruptured appendicitis, respectively. Peritoneal swab was taken in 158 children. Common bacteria isolated including E. coli, Streptococcus, and Bacteroides. Ampicillin, cefuroxime, and metronidazole were our choice of antibiotics. 26% of children with gangrenous and 25% with ruptured appendicitis were insensitive to the current regime. Using 3 antibiotics regime by switching cefuroxime to ceftazidime, it covered 77% resistant bacteria. Using 4 antibiotics regime by adding gentamycin, it covered 96% resistant bacteria. CONCLUSIONS: One-fourth of children with gangrenous or ruptured appendicitis were insensitive to the current regime. This study provides evidence-based information on the choice of antibiotics.

A rare case of primary omental neuroblastoma and resection of the recurrent tumor by laparoscopy.

Neuroblastoma is the most common extracranial solid tumor in children. Primary omental neuroblastoma has never been reported in the English literature. A 4-year-old girl presented with a mobile abdominal mass; primary omental neuroblastoma was diagnosed. There was tumor recurrence after complete tumor resection. She received chemotherapy and underwent laparoscopic resection of the recurrent tumor. There was no tumor recurrence after 1 year of follow-up.