Applying an explainable machine learning model might reduce the number of negative appendectomies in pediatric patients with a high probability of acute appendicitis.

The diagnosis of acute appendicitis and concurrent surgery referral is primarily based on clinical presentation, laboratory and radiological imaging. However, utilizing such an approach results in as much as 10-15% of negative appendectomies. Hence, in the present study, we aimed to develop a machine learning (ML) model designed to reduce the number of negative appendectomies in pediatric patients with a high clinical probability of acute appendicitis. The model was developed and validated on a registry of 551 pediatric patients with suspected acute appendicitis that underwent surgical treatment. Clinical, anthropometric, and laboratory features were included for model training and analysis. Three machine learning algorithms were tested (random forest, eXtreme Gradient Boosting, logistic regression) and model explainability was obtained. Random forest model provided the best predictions achieving mean specificity and sensitivity of 0.17 ± 0.01 and 0.997 ± 0.001 for detection of acute appendicitis, respectively. Furthermore, the model outperformed the appendicitis inflammatory response (AIR) score across most sensitivity-specificity combinations. Finally, the random forest model again provided the best predictions for discrimination between complicated appendicitis, and either uncomplicated acute appendicitis or no appendicitis at all, with a joint mean sensitivity of 0.994 ± 0.002 and specificity of 0.129 ± 0.009. In conclusion, the developed ML model might save as much as 17% of patients with a high clinical probability of acute appendicitis from unnecessary surgery, while missing the needed surgery in only 0.3% of cases. Additionally, it showed better diagnostic accuracy than the AIR score, as well as good accuracy in predicting complicated acute appendicitis over uncomplicated and negative cases bundled together. This may be useful in centers that advocate for the conservative treatment of uncomplicated appendicitis. Nevertheless, external validation is needed to support these findings.

Enhancement of Vascularization and Ovarian Follicle Survival Using Stem Cells in Cryopreserved Ovarian Tissue Transplantation-A Systematic Review.

The increase in cancer survival rates has put a focus on ensuring fertility preservation procedures for cancer patients. Ovarian tissue cryopreservation presents the only option for prepubertal girls and patients who require immediate start of treatment and, therefore, cannot undergo controlled ovarian stimulation. We aimed to provide an assessment of stem cells' impact on cryopreserved ovarian tissue grafts in regard to the expression of growth factors, angiogenesis promotion, tissue oxygenation, ovarian follicle survival and restoration of endocrine function. For this systematic review, we searched the Scopus and PubMed databases and included reports of trials using murine and/or human cryopreserved ovarian tissue for transplantation or in vitro culture in combination with mesenchymal stem cell administration to the grafting site. Of the 1201 articles identified, 10 met the criteria. The application of stem cells to the grafting site has been proven to support vascular promotion and thereby shorten the period of tissue hypoxia, which is reflected in the increased number of remaining viable follicles and faster recovery of ovarian endocrine function. Further research is needed before implementing the use of stem cells in OT cryopreservation and transplantation procedures in clinical practice. Complex ethical dilemmas make this process more difficult.

The Intrarenal Reflux Diagnosed by Contrast-Enhanced Voiding Urosonography (ceVUS): A Reason for the Reclassification of Vesicoureteral Reflux and New Therapeutic Approach?

Vesicoureteral reflux (VUR) is defined as the urine backflow from the urinary bladder to the pyelo-caliceal system. In contrast, intrarenal reflux (IRR) is the backflow of urine from the renal calyces into the tubulointerstitial space. VURs, particularly those associated with IRR can result in reflux nephropathy when accompanied by urinary tract infection (UTI). The prevalence of IRR in patients with diagnosed VUR is 1-11% when using voiding cystourethrography (VCUG), while 11.9-61% when applying the contrast-enhanced voiding urosonography (ceVUS). The presence of IRR diagnosed by VCUG often correlates with parenchymal scars, when diagnosed by a 99mTc dimercaptosuccinic acid scan (DMSA scan), mostly in kidneys with high-grade VURs, and when diagnosed by ceVUS, it correlates with the wide spectrum of parenchymal changes on DMSA scan. The study performed by both ceVUS and DMSA scans showed IRRs associated with non-dilated VURs in 21% of all detected VURs. A significant difference regarding the existence of parenchymal damage was disclosed between the IRR-associated and IRR-non-associated VURs. A higher portion of parenchymal changes existed in the IRR-associated VURs, regardless of the VUR grade. That means that kidneys with IRR-associated VURs represent the high-risk group of VURs, which must be considered in the future classification of VURs. When using ceVUS, 62% of places where IRR was found were still unaffected by parenchymal changes. That was the basis for our recommendation of preventive use of long-term antibiotic prophylaxis until the IRR disappearance, regardless of the VUR grade. We propose a new classification of VURs using the ceVUS method, in which each VUR grade is subdivided based on the presence of an IRR.

Risk Factors Leading to Overnight Stays in Pediatric Surgical Outpatients.

BACKGROUND: Same-day surgery implies patient discharge on the same day after the surgery. The main aim of the research was to determine which predisposing factors lead to children treated with same-day surgery not being able to be discharged on the same day. METHODS: For the purposes of this research, the electronic records of patients in the hospital information system were reviewed retrospectively. The search included patients who were surgically treated through the Day Surgery Unit at the Children's Hospital Zagreb with various diagnoses from 1 January 2021 to 31 December 2023. The target group consisted of patients who could not be discharged on the same day (n = 68), while for the purposes of the control group (n = 68), patients were randomly selected, comparable by age and gender, who were discharged from the hospital on the same day in accordance with the principles of same-day surgery. RESULTS: In relation to the parameters of interest between the groups, statistically significant differences were observed in the type of general anesthesia (p = 0.027), the use of analgesics (p = 0.016), the time of entering the operating room (p = 0.000), the time of leaving the operating room (p < 0.0001) and the duration of surgery (76.81 ± 37.21 min vs. 46.51 ± 22.46 min, p < 0.0001). When explanatory variables were included in the regression model, they explained 38% of the variability in the dependent variable. Only the variable "duration of surgery" provided significant information to explain the variability in the dependent variable (p = 0.004). CONCLUSIONS: Although the duration of surgery was imposed as the main predictor of hospitalization after same-day surgery, and considering the extremely small number of studies on the mentioned topic, especially in the pediatric population, further, preferably multicenter research on the mentioned topic is needed.

Comparison of Percutaneous Internal Ring Suturing (PIRS) versus Open Ligation of the Patent Processus Vaginalis for the Treatment of Communicating Pediatric Hydrocele.

BACKGROUND: Although the laparoscopic approach become standard for the treatment of many surgical conditions many studies still debating whether laparoscopic surgery has significant advantages over open surgery in regards to hernia or hydrocele treatment. This study aimed to evaluate the outcomes of treatment of treatment of communicating hydrocele in pediatric patients between laparoscopic percutaneous internal ring suturing (PIRS) and open ligation of the patent processus vaginalis (PPV). METHODS: The medical records of pediatric patients who underwent surgery for communicating hydrocele between 1 January 2019 and 1 January 2024 were retrospectively reviewed. The primary objective of the study is to investigate the outcomes of treatment (complications and recurrence rates) of communicating hydrocele in children between laparoscopic and open surgical approaches. Secondary outcomes of the study are the duration of surgery and anesthesia, length of hospital stay (LOS), frequency of hospital readmissions (ReAd) and unplanned return to the operating room (uROR). RESULTS: A total of 198 children underwent surgery for a communicating hydrocele (205 repairs, as 7 cases were bilateral) and were included in the study. Of these, 87 children underwent a PIRS, while the remaining 111 cases underwent open ligation of the PPV. No recurrence of the hydrocele was observed in any of the study groups. Intraoperative complication (epigastric vein injury) was noted in two cases in both groups (2.3% vs. 1.8%, p > 0.999). A slightly higher number of postoperative complications was observed in the open group (n = 7, 6.3%) compared to the PIRS group (n = 2, 2.3%) (p = 0.190). The median duration of surgery (15 min (IQR 10, 17) vs. 21 min (IQR 15, 25); p < 0.001) and anesthesia (30 min (IQR 25, 40) vs. 40 min (IQR 35, 40); p < 0.001) were significantly lower in the PIRS group compared to open ligation of the PPV. In addition, a significantly shorter median of LOS was observed in the PIRS group compared to the open PPV group (9 h (IQR 8, 12) vs. 24 h (IQR 12, 24; p < 0.001). No cases of ReAd and uROR were observed in any of the study groups. CONCLUSIONS: PIRS is a safe and effective laparoscopic technique that can be used in the treatment of communicating hydrocele in children. PIRS showed excellent outcomes and a low incidence of complications and recurrences, comparable to traditional open surgery.

Safety and Effectiveness of Meatal Mobilization (MEMO) Technique for Glandular, Coronal, and Subcoronal Hypospadias Repair in Children: A 5-Year Single-Center Study with 105 Hypospadias.

BACKGROUND: This study aims to compare outcomes of treatment, in terms of early and late complications, between the Snodgrass and meatal mobilization (MEMO) techniques in children operated on because of distal hypospadias. METHODS: The medical records of 127 children who underwent glandular, coronal, or subcoronal hypospadias repair between 1 January 2019 and 31 December 2023 were retrospectively reviewed. A total of 105 children met the inclusion criteria and were included in further analysis. The inclusion criteria were pediatric patients who underwent glandular, coronal, or subcoronal hypospadias repair using MEMO (n = 49) or the Snodgrass technique (n = 56) as a comparative group. The primary outcome of this study was the incidence of early and late complications with two different surgical techniques. Secondary outcomes were the duration of surgery, the length of hospital stay, the number of readmissions or unplanned returns to the operating room, and repeat surgeries between groups. RESULTS: The median age of all patients was 17 (interquartile range, IQR 13, 29) months, with a median follow-up of 26 (IQR 17, 34) months. Regarding the type of hypospadias, the majority of patients in both groups were categorized as coronal and subroronal hypospadias. Regarding the incidence of postoperative complications, a significantly lower incidence of postoperative complications was found in the MEMO group compared to the Snodgrass group (n = 4; 8.2% vs. n = 14; 25%; p = 0.037). An urethrocutaneous fistula was the most common complication in the Snodgrass group (n = 8; 14.3%), while in the MEMO group, only one patient (2%) developed a fistula (p = 0.034). The incidence of meatal stenosis (p = 0.621) and wound infections (p > 0.999) was low in both groups. No further complications were recorded during the follow-up period. Duration of surgery (41 min (IQR 38, 47) vs. 51 min (IQR 45.5, 61); p < 0.001), duration of hospitalization (1 day (IQR 1, 2) vs. 3 days (IQR 2, 6); p < 0.001), and time to catheter removal (3 days (IQR 2.5, 5) vs. 6 days (IQR 6, 8); p < 0.001) were significantly lower in patients operated on with MEMO compared to the Snodgrass technique. Only one case of readmission due to severe wound infection which led to suturing line dehiscence was recorded in the Snodgrass group. The incidence of redo surgery was significantly lower in the MEMO group than in the Snodgrass group (n = 3; 6.1% vs. n = 11; 19.6%; p = 0.048). CONCLUSIONS: MEMO is a safe and effective technique that can be used for the treatment of distal hypospadias. It showed excellent outcomes, cosmetic results, and a low incidence of complications as well as a significantly shorter duration of surgery compared to the Snodgrass technique.

The Safety and Effectiveness of Single-Stage, Vessel-Preserving, Laparoscopic Orchiopexy for Intra-Abdominal Testes in Pediatric Patients: A 10-Year Single-Center Experience.

Objectives: Intra-abdominal testes are located in a variety of intra-abdominal positions, most less than 2 cm from the internal ring. Various surgical techniques of laparoscopic orchiopexy have been described to date. The aim of this study was to evaluate the safety and long-term efficacy of a single-stage, vessel-preserving, laparoscopic orchiopexy for intra-abdominal testes in pediatric patients. Methods: A retrospective search of the medical records of 32 children (34 testes) who underwent single-stage, vessel preserving, laparoscopic orchiopexy for intra-abdominal testes between 1 January 2014 and 31 December 2023 was performed. Single-stage laparoscopic orchiopexies were performed in all patients for whom sufficient length of the spermatic cord was achieved during the procedure. The volume of each patient's testes was measured using ultrasound before and 6 months after laparoscopic orchiopexy. The main outcome of this study was testicular volume before and after the procedure. The secondary outcomes were the occurrence of early and late complications, the duration of surgery, and the length of hospital stay. Results: The median age at the time of surgery was 10 months (interquartile range-IQR 9, 13). The majority of the children (n = 24; 75%) were less than 12 months old at the time of surgery. A normal testis was found in 24 patients (70.6%), while a hypotrophic testis was visible in 10 cases (29.4%). The majority of the testes were located near the internal ring (n = 19; 55.9%), while in the remaining cases, the testes were located near the iliac blood vessels. The median duration of the surgical procedure was 37.5 min (IQR 33, 42.5). The duration of hospitalization was one day for all the children. No intraoperative complications were observed. One child had a wound infection at the site of the umbilical trocar, which was treated conservatively. In two cases (5.5%), testicular atrophy was detected during long-term follow-up. In three cases, the testis was found in a higher position in the scrotum during the follow-up period, but in two cases, the position was normal during the follow-up period, while in one case, the position in the scrotum remained unchanged. At long-term follow-up with a median of 35 months (IQR 19, 60.5), the overall success rate was 94.5%. The median testicular volume at 6-month follow-up increased from 0.31 mL (IQR 0.28, 0.43) to 0.40 mL (IQR 0.33, 0.53) (p = 0.017). Conclusions: Single-stage, vessel-preserving, laparoscopic orchiopexies for intra-abdominal testes are safe and effective in pediatric patients in whom adequate spermatic cord length can be achieved during the procedure.

Prognostic Value of "Basal-like" Morphology, Tumor-Infiltrating Lymphocytes and Multi-MAGE-A Expression in Triple-Negative Breast Cancer.

"Basal-like" (BL) morphology and the expression of cancer testis antigens (CTA) in breast cancer still have unclear prognostic significance. The aim of our research was to explore correlations of the morphological characteristics and tumor microenvironment in triple-negative breast carcinomas (TNBCs) with multi-MAGE-A CTA expression and to determine their prognostic significance. Clinical records of breast cancer patients who underwent surgery between January 2017 and December 2018 in four major Croatian clinical centers were analyzed. A total of 97 non-metastatic TNBCs with available tissue samples and treatment information were identified. Cancer tissue sections were additionally stained with programmed death-ligand 1 (PD-L1) Ventana (SP142) and multi-MAGE-A (mAb 57B). BL morphology was detected in 47 (49%) TNBCs and was associated with a higher Ki-67 proliferation index and histologic grade. Expression of multi-MAGE-A was observed in 77 (79%) TNBCs and was significantly associated with BL morphology. Lymphocyte-predominant breast cancer (LPBC) status was detected in 11 cases (11.3%) and significantly correlated with the Ki-67 proliferation index, increased number of intratumoral lymphocytes (itTIL), and PD-L1 expression. No impact of BL morphology, multi-MAGE-A expression, histologic type, or LPBC status on disease-free survival was observed. Our data suggest that tumor morphology could help identify patients with potential benefits from CTA-targeting immunotherapy.

Safety and Effectiveness of Triclosan-Coated Polydioxanone (PDS Plus) versus Uncoated Polydioxanone (PDS II) Sutures for Prevention of Surgical Site Infection after Hypospadias Repair in Children: A 10-Year Single Center Experience with 550 Hypospadias.

AIM: Triclosan is an antiseptic substance that has been shown in preclinical studies to reduce bacterial load in the wound and slow bacterial growth by inhibiting fatty acid synthesis. It is claimed that the coating protects against colonization of the tissue around the suture. This study aimed to compare the safety and efficacy of triclosan-coated polydioxanone versus uncoated polydioxanone sutures for the prevention of surgical site infections (SSIs) following hypospadias repair in children. METHODS: The medical records of 550 children who underwent hypospadias repair between 1 January 2014 and 31 December 2023 were retrospectively analyzed. The patients included in the study were divided into two groups. The first group consisted of the patients in whom polydioxanone (PDS II) was used (n = 262), while in the patients of the second group (n = 288), triclosan-coated polydioxanone (PDS Plus) was used for hypospadias repair. Secondary outcomes were defined as the occurrence of early and late complications, the number of readmissions within 30 days after surgery (ReAd), unplanned return to the operating room (uROR), and repeat operations. RESULTS: The median age of all children enrolled in the study was 16 (IQR 14, 20) months. The patients in whom PDS Plus was used for hypospadias repair had a significantly lower number of SSIs than the patients in whom PDS II was used (n = 18 (6.9%) vs. n = 4 (1.4%), p < 0.001). Wound infection led to wound dehiscence in 10 of 18 patients from the PDS II group, while all four wound infections from the PDS Plus group led to wound dehiscence (p = 0.07). The number of postoperative urethrocutaneous fistulas was significantly lower in the patients in whom PDS Plus was used (13.7% vs. 8.3%, p = 0.042). The incidence of late complications did not differ between the study groups: meatal stenosis (p = 0.944), residual chordee (p = 0.107), urethral stricture (p = 0.196), scarring (p = 0.351) and urinary discomfort (p = 0.713). There were no cases of uROR in either group. The ReAd rate was low in both groups (n = 5 (1.9%) vs. n = 2 (0.6%), p = 0.266). The frequency of reoperations was lower in the group of patients treated with PDS Plus than in the group of patients treated with PDS II (11.1% vs. 20.6%; p = 0.03). CONCLUSION: The use of PDS Plus in hypospadias surgery significantly reduces the incidence of SSI, postoperative fistulas, and reoperation rates compared to PDS II.

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.

Utility of Ischemia-Modified Albumin as a Biomarker for Acute Appendicitis: A Systematic Review and Meta-Analysis.

BACKGROUND: Acute appendicitis is a frequently encountered surgical emergency. Despite several scoring systems, the possibility of delayed diagnosis persists. In addition, a delayed diagnosis leads to an increased risk of complicated appendicitis. Hence, there is a need to identify biological markers to help clinicians rapidly and accurately diagnose and prognosticate acute appendicitis with a high sensitivity and specificity. Although several markers have been evaluated, the pressing concern is still the low specificity of these markers. One such marker is serum ischemia-modified albumin (IMA), which can be a novel biomarker for accurately diagnosing and prognosticating acute appendicitis. METHODS: The authors conducted a systematic search of the PubMed, EMBASE, Web of Science, and Scopus databases through February 2023 as per the PRISMA guidelines. The difference in the levels of IMA between patients with acute appendicitis vs. healthy controls, and the difference in the levels of IMA between patients with complicated vs. non-complicated acute appendicitis were taken as the outcome measures. Statistical analysis was performed using a random effects model and mean difference (MD) was calculated. The methodological quality of the studies was assessed by utilizing the Newcastle-Ottawa scale. RESULTS: A total of six prospective comparative studies were included in the meta-analysis. The analysis revealed that the mean level of serum IMA was significantly raised in the acute appendicitis group (MD 0.21, 95% CI 0.05 to 0.37, p = 0.01). Similarly, the mean serum IMA levels were also raised in the complicated appendicitis group compared to the non-complicated appendicitis group (MD 0.05, 95% CI 0.01 to 0.10, p = 0.02). Three of the studies included were, however, of poor methodological quality. CONCLUSIONS: Serum IMA is a viable potential marker for diagnosing and prognosticating acute appendicitis. However, due to the limited methodological quality of available studies, further prospectively designed and adequately powered studies are needed.

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.

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.

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.

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.

A Bizarre Cause of Acute Appendicitis in a Pediatric Patient: An Ingested Tooth.

(1) Background: Among all possible causes, foreign bodies are the rarest cause of appendicitis in the pediatric population. In the majority of cases, ingested foreign bodies pass through the gastrointestinal tract without causing symptoms. However, those foreign bodies that pass through the lumen of the vermiform appendix cannot re-enter the colon and may cause acute appendicitis. So far, various foreign bodies have been described to enter the appendix and cause acute appendicitis, such as seeds, needles, toothpicks, plant material, or even hair. Tooth or dental implants as a cause of acute appendicitis have been described in only a few cases. To our knowledge, this is the first described case of the tooth causing acute appendicitis in the pediatric population. (2) Case presentation: A 14-year-old male patient presented to the emergency department complaining of pain in the right lower quadrant of the abdomen and vomiting that persisted for approximately 24 h. Until then, the patient was healthy and had no concomitant diseases. Physical examination revealed guarding and tenderness in the right lower abdominal quadrant. The white blood cell count was 17.1 × 109/L with a neutrophil count of 91.1% and a C-reactive protein of 39.3 mg/dL. Ultrasonography of the abdomen revealed a thickened, inflamed appendix with a diameter of 11 mm and free periappendicular fluid. A 9 × 6 mm foreign body at the base of the appendix was visualized. The patient was diagnosed with acute appendicitis, and an emergency laparoscopic appendectomy was performed on the same day. Intraoperatively, gangrenous appendicitis was noted and removed without complications. Upon examination of the removed specimen, it was determined that the patient's appendicitis had been caused by an ingested tooth. As it later turned out, the patient had broken a lateral incisor while playing sports the day before admission without knowing that he had swallowed it. The patient recovered well and was discharged the day after surgery. (3) Conclusion: Although an extremely rare event, acute appendicitis can be caused by a swallowed tooth. This case highlights the importance of a thorough history in pediatric patients who present to the emergency department with suspected acute appendicitis to determine if there is a precipitating event that may have caused acute appendicitis.

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 1st2017 to December 31st2019 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.

Advances and Future Challenges of Minimally Invasive Surgery in Children.

Minimally invasive surgery is a relatively new field of surgery where the surgeons operate through small incisions using a variety of techniques to perform less damage to the patient's body than with conventional open surgery [...].

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.