Complicated appendicitis wrongly diagnosed as nonspecific diarrhea: ways to decrease this continuous threat.

BACKGROUND: The diagnostic assessment of right lower quadrant pain in children and adolescents is still a challenge. The aim of this study was to analyze the cases of complicated appendicitis wrongly diagnosed as nonspecific diarrhea, and based on the information obtained suggest a clear and simple policy in order to decrease misdiagnosis in the future. METHODS: Three groups of patients were analyzed: children who underwent appendectomy (group 1); those with gastroenteritis (group 2), and those who underwent appendectomy following hospitalization under the wrong diagnosis of gastroenteritis (group 3). RESULTS: Group 3 presented a more prolonged and complicated clinical course, higher fever, diffuse abdominal pain, repeat vomiting, higher C-reactive protein values, longer surgery duration and recovery. CONCLUSIONS: When the etiology of right lower quadrant abdominal pain is not immediately evident and associated with atypical diarrhea, high fever, repeat vomiting, and significantly increased CRP values, early surgical consultation is required. If the clinical findings are unclear, an abdominal US should be performed as soon as possible. A limited abdominal computed tomography scan CT should follow those cases not resolved by history, physical examination, blood tests, and abdominal ultrasound.

Minimal Pilonidal Surgery vs. Common Wide Excision Operations: Better Well-Being and Comparable Recurrence Rates.

BACKGROUND: Pilonidal disease in the natal cleft is treated traditionally by a wide and deep excision of the affected area. There is growing awareness, however, to the advantages of minimally invasive surgeries. OBJECTIVES: To compare the efficacy of wide excision operations and minimal trephine surgery in patients with primary pilonidal disease. METHODS: In this retrospective study we examined surgical and inpatient records of 2039 patients who underwent surgery for primary pilonidal disease in five private hospitals between 2009 and 2012. Most procedures were of lay-open, primary midline closure, and minimal surgery types. Pilonidal recurrence rates were evaluated in a subset of 1260 patients operated by 53 surgeons each performing one type of surgery, regardless of patient characteristics or disease severity. RESULTS: With a mean follow-up of 7.2 years, 81.5%, 85%, and 88% of patients were disease-free after minimally invasive surgery, wide excision with primary closure, and lay-open surgery, respectively, with no statistically significant difference in recurrence rates. Minimal surgeries were usually performed under local anesthesia and involved lower pain levels, less need for analgesics, and shorter hospital stays than wide excision operations, which were normally performed under general anesthesia. The use of drainage, antibiotics, or methylene blue had no effect on recurrence of pilonidal disease. CONCLUSIONS: Minimally invasive surgeries have the advantage of reducing the extent of surgical injury and preserving patient's quality of life. They should be the treatment of choice for primary pilonidal disease.

To helmet or not to helmet: a global perspective on the bicycle compulsory protective helmet law.

Child injury from bike accidents is a significant component of morbidity, mortality and health expenditure in many countries. Universal use of bicycle helmets by children could prevent between 135 and 155 deaths, and between 39,000 and 45,000 head injuries annually. Surprisingly, epidemiologic data indicate a worldwide low prevalence of helmet use. A global view on the law on the compulsory use of safety helmets involving 58 different countries is provided in order to bring this critical debate back to the table. A broad search using "bicycle-related injuries," "bicycle helmet," "bicycle helmet legislation" and "compulsory bicycle helmet law by countries" was performed in order to identify and select the most pertinent information on the issue as well as all the information available on bicycle helmet law by countries. The papers identified permitted us to assess the main topics related to the use of bicycle helmets discussed over the years which are still relevant and without consensus even today, as well as alphabetically enlist the approach of 58 countries to the compulsory helmet law. Our review on the many faces of the bicycle helmet use (pros and cons), personal aspects, head injuries, legislation, promotion, socioeconomic influence, and finally a global view on the law on the compulsory use of safety helmets allowed us to bring here many suggestions and a few conclusions, mainly because "to helmet or not to helmet" should not be a question anymore. A universal consensus on their compulsory use has to be achieved in order to improve children's safety.

The role of dexamethasone in decreasing early recurrence of acute intussusception in children: A retrospective study.

BACKGROUND: Early recurrent intussusception (RI) is a concern after a successful pneumatic reduction. Steroids have been suggested as a treatment that decreases early RI. The purpose of this study was to examine the role of dexamethasone in decreasing early RI. METHODS: A retrospective review of 174 pediatric patients that underwent successful pneumatic reduction was conducted. Two groups were identified: group 1 that received intravenous dexamethasone (0.5mg/kg/dose) on diagnosis or immediately after the reduction maneuver, and group 2 that were not given dexamethasone. RESULTS: There were 113 boys and 61 girls ranging in age from 2 to 36months. There were no statistical differences between the groups except for younger age in the dexamethasone group (P=0.03). There was no significant difference (p=0.08) in the rate of early RI between the non-steroid group (5.4%, 4/74) and the steroid group 14% (14/100). Mean admission length was 30h. The majority of RIs occurred in the first 8h of admission. CONCLUSIONS: We found that premedication of children with idiopathic intussusception with dexamethasone did not decrease early RI. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Anal fissure in children: a 10-year clinical experience with nifedipine gel with lidocaine.

BACKGROUND: We aimed to evaluate efficacy and safety of the use of nifedipine gel with lidocaine in the treatment of acute anal fissures in children by reviewing the cases of 106 children with acute anal fissure treated conservatively by nifedipine gel with lidocaine between the years 2003-2012. METHODS: The patients included in this study were 48 males and 58 females. Their clinical presentation consisted of constipation, rectal bleeding, anal pain, perianal itching, abdominal pain, irritability and rectal prolapse. Posterior, anterior, both anterior and posterior, multiple, both posterior and lateral locations were the main physical findings in 65, 23, 10, 7, and 1 cases. RESULTS: Ninety-nine patients completed the 4-week treatment course of nifedipine gel with lidocaine successfully (93.40%), with complete healing of the fissure. The recurrence rate observed was very low (6.60%). CONCLUSIONS: Topical 0.2% nifedipine with lidocaine appears an efficient mode of treatment for anal fissures in children, with a significant healing rate and no side effects.

Abdominal injuries following bicycle-related blunt abdominal trauma in children.

BACKGROUND: The aim of this study was to confirm our clinical impression that intra-abdominal handlebar injuries are progressively increasing in number and severity in the latest years. METHODS: A retrospective analysis of data concerning 132 patients admitted to our department of pediatric surgery during a 10-year period (between 2003 and 2012), following bicycle-related blunt abdominal trauma, was performed. Patients were divided into two groups: those who fall from their bicycle (N.=43) and those who sustained direct impact from the handlebars (N.=89) and compared. RESULTS: Number of admitted patients due to bike related injury was increased during a 10-year period. The bikes used by 91.6% of the participants were the high quality BMX, with rigid and strong handlebars. The average age for both groups was 10.3 years (4-16 years). Boys were injured more than girls. Thirty patients from both groups sustained severe abdominal visceral injuries, 25 from the handlebar group and 6 from the fall group (P=0.018). The overall average length of hospital stay was 3.04 days, with 36 cases (27.36%) requiring pediatric intensive care unit (PICU) admission (N.=26 of the handlebar group and N.=10 of the fall group, P=0.024). Eight children sustaining handlebar injuries required abdominal surgery compared to only one case for the fall group (P=0.018), when excluding extra-abdominal procedures. CONCLUSIONS: Number of pediatric patients admitted due to bike related injury has been gradually increasing. Children who suffer from direct impact of the handlebars are more likely to require abdominal operative intervention and PICU admission than those who fall. Preventive measures are urgently needed in order to defeat this trend.

Blunt pancreatic trauma in children.

PURPOSE: To report our experience with blunt pancreatic trauma in pediatric patients and evaluate several various management strategies. METHODS: Ten children admitted over the last 10 years with pancreatic blunt trauma were included in the present series. RESULTS: The average time from injury to hospital admission was 2.4 days. All injuries resulted from accidents: bicycle handlebar injuries (5), being kicked by a horse (2), falls from a height (2), and injury sustained during closure of an electric gate (1). Additional systemic and abdominal injuries were recorded in 7 patients. The amylase levels at the time of patient admission were normal in 3 patients, mildly raised in 4 patients, and elevated in 3 patients. Abdominal computed tomography was performed in 10 patients, ultrasonography in 5, and endoscopic retrograde cholangiopancreatography (ERCP) in 4. Pancreatic injuries comprised 4 grade I, 3 grade II, and 3 grade III injuries. Grade I and II injuries were successfully managed by conservative treatment. The 3 children with grade III trauma and pancreatic ductal injury in the neck (1), body (1), and tail (1) of the gland were surgically treated, having an uneventful postoperative stay of 8-14 days and no complications during the 1-year follow-up period. CONCLUSION: The present study supports early ERCP as an essential part of the initial patient evaluation when pancreatic transection is highly suspected.

The contribution of intraoperative transinguinal laparoscopic examination of the contralateral side to the repair of inguinal hernias in children.

BACKGROUND: Bilateral inguinal hernias are relatively common in children. This fact has led to a controversy of more than 50 years concerning the necessity of bilateral surgical exploration during the repair of unilateral inguinal hernias in children. The advent of transinguinal laparoscopic visualization of the contralateral side is a turning point and a major contribution to the subject, offering the opportunity to reassess the systematic bilateral exploration and the "wait and see" policies currently in use at most services of pediatric surgery. DATA SOURCES: The current information concerning intraoperative transinguinal laparoscopic evaluation of inguinal hernias in children was summarized in a didactic way. A MEDLINE search (PubMed) from 1995 to the present days was conducted. RESULTS: A patent processus vaginalis (PPV) is not equal to a future symptomatic hernia. There is still no definitive evidence on which PPVs will become a hernia (5.8% to 11.6%) and which remain clinically insignificant. Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side is today the most simple and accurate way to reduce the incidence of negative explorations. CONCLUSION: Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side during pediatric inguinal hernia repair is a simple, accurate, fast, and effective method to assess the contralateral processus vaginalis, improving decision-making, reducing the number of negative explorations, and sparing the surgeon the embarrassment associated with the appearance of a metachronous hernia at a later date. It is easily learned and should be part of every pediatric surgeon's practice.

An experimental study of the effect of two distinct surgical techniques of orchiopexy on spermatogenesis and testicular damage in cryptorchid testes.

OBJECTIVE: To compare the effect of two different techniques of testicular fixation on testicular function. DESIGN: Experimental study. SETTING: Surgical animal laboratory at an academic medical center. PATIENT(S): Sixteen mature golden hamsters underwent classic transfixation orchiopexy and true dartos pouch orchiopexy. INTERVENTION(S): Classic transfixation orchiopexy (CTO) involved transfixation of the testicular wall at two different points and fixation of the dartos fascia. True dartos pouch orchiopexy (TDPO) involved creating a window in the dartos fascia, passage of the testicle, and closure of the window from both sides of the testicle. MAIN OUTCOME MEASURE(S): Flow cytometric separation of testicular cells into haploid, diploid, and tetraploid fractions for histogram analysis. RESULT(S): A significant decrease in testicular weight was observed in 6 out of 16 animals undergoing CTO. Diploid cells comprised the main cell fraction, and almost no haploid or tetraploid cells were observed, while in the 16 animals undergoing TDPO no change from the control pattern was observed. CONCLUSION(S): This experimental work supports our clinical impression that TDPO should replace CTO as the method of choice for the treatment of an undescended testicle in children.

Transinguinal laparoscopic examination: an end to the controversy on repair of inguinal hernia in children.

BACKGROUND: Contralateral exploration of the groin has been common practice among pediatric surgeons for nearly 50 years, based on the high incidence of patent processus vaginalis on the contralateral side with the potential for the subsequent development of a hernia. OBJECTIVES: To evaluate transinguinal laparoscopic examination of the contralateral side during repair of inguinal hernia in children in order to reach a decision regarding exploration of the contralateral side. METHODS: Over a 21 month period 124 children with unilateral inguinal hernia underwent laparoscopic evaluation of the contralateral groin. The operations were performed under general anesthesia as ambulatory procedures. RESULTS: Transinguinal contralateral laparoscopic exploration was positive (patent processus vaginalis) in 26 children (21%) and negative (closed processus vaginalis) in 88 (71%). Failure to introduce the telescope occurred in 10 patients (8%) due to a friable or narrow hernia sac. Twenty-five children below 2 years of age were spared exploration of the contralateral side as a result of the negative laparoscopic examination. On the other hand, 15 children aged 2-17 had their contralateral groin explored because of a positive finding at laparoscopy. CONCLUSIONS: Transinguinal laparoscopic examination of the contralateral side during repair of inguinal hernia in children is a simple, safe and quick method to avoid systematic bilateral explorations and should be part of every pediatric surgeon's experience.

Neonatal periappendicular abscess--updated treatment.

The authors present a case of periappendicular abscess in a 5-day-old full-term neonate. Prompt diagnosis enabled us to deliver conservative treatment followed by interval laparoscopic appendectomy, instead of a risky urgent laparotomy. This is the first description of an advanced imaging-guided drainage procedure, followed by minimal invasive surgery, for the treatment of periappendicular abscess at such a young age.

[Non-palpable testicle--the role of laparoscopy].

We report our experience with 133 children treated laparoscopically for non-palpable testis during the last eight years. Diagnostic laparoscopy eventually combined with orchiectomy, for atrophic testicle, was performed in 59 patients. An apparently normal-sized intra-abdominal testicle was found in 74 patients, ten of whom were bilaterally affected. In 21 children, whose testicle were located in the vicinity of the internal ring, immediate laparoscopic-assisted orchidopexy was carried out. All other 53 children underwent two-stage Fowler-Stephens laparoscopic orchidopexy, only four of whom developed testicular atrophy. New insight concerning germ cell maturation dictates a revised protocol of hormonal therapy followed by early surgical intervention. Hopefully, this will further improve the superior outcome reported herein, similar to that in most of the recent series, which have established the laparoscopic management of non-palpable testicles as "state of the art".

Acute idiopathic scrotal edema in children--revisited.

BACKGROUND: Acute idiopathic scrotal edema (AISE), a self-limiting acute scrotal edema and erythema that resolves without sequela, was first reported by Qvist in 1956. METHODS: Thirty eight patients with AISE seen in the authors' department over the last 10 years were reviewed, comprising 44 episodes, most occurring in children under 10 years of age. The average age at presentation was 6.2 years. No past history of allergy was elicited. RESULTS: Unilateral involvement predominated (90.1%). None of the patients was found to have a primary source of scrotal, perineal, or perianal infection. Scrotal discomfort; scrotal, perineal, and inguinal swelling; and erythema were the most common findings. Laboratory and ancillary examination findings were normal, except for the occasional eosinophilia. Characteristic ultrasonographic findings, such as marked thickening of the scrotal wall, with heterogeneous and edematous appearance, increased peritesticular blood flow, mild reactive hydrocele, and enlarged inguinal lymph nodes were found. Treatment was conservative in 92.1% of the patients. Resolution of all episodes occurred within 1 to 4 days. Recurrent episodes were observed in 4 patients (10 episodes), which were clinically more severe than the original episode. CONCLUSION: Clinical experience, good judgment, and color Doppler ultrasound scan can reliably identify those children with an acute scrotum who require exploration and spare those with AISE, where surgery is not indicated.

Double-ligature: a treatment for pedunculated umbilical granulomas in children.

Umbilical granulomas are common inflammatory reactions to the resolving umbilical stump. The double-ligature technique is simple to perform and provides good cosmetic and functional results with only minor complications. The granuloma becomes necrotic and drops off within seven to 14 days. The double-ligature is a preferable alternative to multiple topical applications of silver nitrate for the treatment of pedunculated umbilical granulomas in children.