Is laparoscopic appendectomy in children associated with an uncommon postoperative complication?

BACKGROUND: Laparoscopic appendectomy (LA) is controversial due to the high rate of intraabdominal abscess (IAA). We report a postlaparoscopic appendectomy complication (PLAC) observed in pediatric patients discharged after an uneventful postoperative period. METHODS: In this case series, a review of the medical records of children who underwent LA or open appendectomy (OA) during a 5-year period was performed. The diagnosis of PLAC was based on three well-defined criteria: time of appearance, clinical and laboratory findings, and ultrasonographic characteristic features. RESULTS: A total of 374 patients underwent appendectomy (LA, 129 patients; OA, 245 patients). One patient with conversion of LA to OA and 35 patients with gangrenous or perforated appendicitis (seven from the LA group and 28 from the OA group) were excluded from the study. After LA, nine children developed intraabdominal complications during their hospitalization (six infiltrate in the right lower quadrant and three IAA); these were also excluded. Discharge from the department was done when three conditions were fulfilled: normal body temperature, normal leukocyte count, and passage of a stool. Among the 112 LA patients, PLAC was observed in 15 (13.4%), aged 12.5 +/- 2.9 years, who were discharged after LA in 2.7 +/- 0.9 days. Number of PLAC and time of its appearance were not significantly different in patients with normal or pathological appendix. Sonographic findings of PLAC at admission were fluid alone (n = 11), edematous mesenteric fat (n = 7), thickening of bowel wall (n = 9), and more than one sign (n = 9). At repeated sonography, these signs were present in all patients, and IAA developed in one of them. All children were successfully treated with antibiotics for 10.1 +/- 3.9 days, one of whom underwent a CT-guided percutaneous drainage for IAA. CONCLUSIONS: PLAC may be the result of a slow development of local interstitial infection in the ileocecal area due to mesothelial damage caused by CO2 pneumoperitoneum and local thermal effect produced by energized systems. This may explain its delayed appearance and the efficacy of the antibiotic treatment.

Pleuro-pulmonary involvement in children with blunt splenic trauma.

OBJECTIVE: Evaluation of the importance of pleuro-pulmonary involvement in paediatric patients with blunt splenic trauma. METHOD: A retrospective chart review of 27 patients, aged 2-16 years, treated for blunt splenic injury between 1992 and 1999 was performed. RESULTS: All patients except one were treated conservatively. In 12 patients (44.4%) left-sided pleuro-pulmonary involvement was diagnosed as primary traumatic injury or as a late complication. While Grade I and II splenic injuries were prevalent, pleuro-pulmonary involvement patients had a more severe degree of splenic injury. Chest pain, dyspnoea and diminished respiratory sounds were present on primary examination in patients with chest trauma. Body temperature during the first 5 post-trauma days was significantly higher among pleuro-pulmonary involvement patients. Specific pleuro-pulmonary involvement diagnoses on admission in six children with primary chest trauma were: lung contusion, pleural thickness, or haemo-pneumothorax. Three of them developed delayed pleural effusion. In the other six children with pleuro-pulmonary involvement, late complications appeared during 2-5 days post-trauma. CONCLUSIONS: Pleuro-pulmonary involvement was observed in almost half of patients with blunt splenic trauma. Pleuro-pulmonary involvement occurred either early as a result of direct chest trauma or was delayed. High suspicion, careful monitoring of body temperature and repeated chest X-ray studies are recommended for early diagnosis and treatment of delayed pleuro-pulmonary involvement.

Hiatal hernia in pediatric gastroesophageal reflux.

BACKGROUND: This study compares esophageal pH-monitoring parameters of children with gastroesophageal reflux (GER) with or without hiatal hernia (HH) and determines the outcome of those with GER and HH. METHODS: Among 718 children with GER, 45 children (6%) with associated HH were retrospectively studied. They were divided into those with neurologically normal development (NN, n = 35) and those with neurologic disorders (ND, n = 10). The pH-monitoring parameters of 27 of these (60%) were compared with pH-monitoring parameters of 27 control children who had GER without HH. RESULTS: Esophageal clearance was longer in patients with HH compared with those without HH (P < 0.05). All 35 NN patients underwent a trial of conservative treatment, which failed in 9 patients (25.7%). Surgery was the initial treatment in 8 ND patients. Follow-up was available in 20 NN and 10 ND patients. Nine of 11 conservatively treated NN patients improved. All NN (n = 9) and ND (n = 8) patients who underwent surgery improved. Conservative treatment failed in 2 NN and in 2 ND patients. CONCLUSIONS: Presence of HH in children with GER is associated with prolonged exposure of the esophagus to acid and a high failure rate of nonoperative treatment. However, medical treatment should be tried in NN children despite the significant failure rate.

[Laparoscopic cholecystectomy in elderly patients]. / Cholecystektomia laparoskopowa u pacjentów w wieku podeszlym.

The report presents results of the treatment of cholecystolithiasis in old patients (65 years). We compared two groups of the patients: first group treated using laparoscopic method, second group (control) where we performed classic cholecystectomy. Both of these groups were comparable according to age and sex.

Unilateral pulmonary edema during transesophageal echocardiography.

Transesophageal echocardiography is considered to be a relatively safe procedure, the complications of which are well known and include probe-related and procedure-related complications. Congestive heart failure rarely occurs. Unilateral pulmonary edema is relatively uncommon and to the best of our knowledge has never been reported in association with transesophageal echocardiography. Herein we describe an unusual case of unilateral pulmonary edema that developed during the course of transesophageal echocardiography.

Intussusception in children: reduction with repeated, delayed air enema.

PURPOSE: To evaluate the efficacy of pneumatic reduction of intussusception with an emphasis on repeated, delayed trials. MATERIALS AND METHODS: Seventy-one patients with intussusception were treated with air enemas. Before 1993, one trial of air reduction was performed; since 1993, up to three trials of air reduction were performed. The patients were categorized according to the duration of signs and symptoms: less than 12 hours (group A), 12-24 hours (group B), and longer than 24 hours (group C). RESULTS: The success rate for air reduction was 83% overall (59 of 71 patients), 89% in group A (25 of 28 patients), 83% in group B (20 of 24 patients), and 74% in group C (14 of 19 patients). The success rate was 70% (19 of 27 patients) before 1993 and 91% (40 of 44 patients) since 1993 (P < .05). When patients in whom air reduction was successful were compared with patients in whom it was unsuccessful, there was a statistically significant difference in radiographic signs of intestinal obstruction and duration of signs and symptoms but no important difference in age or rectal bleeding. There were no episodes of complications. CONCLUSION: Repeated, delayed pneumatic reduction of intussusception improves the outcome.

Gastrointestinal smooth muscle tumors and iron deficiency anemia in children.

Smooth muscle tumors are rarely seen in the pediatric population. We present a child with smooth muscle tumor of low malignant potential in the ileocecal valve region in whom iron deficiency anemia was the only presenting sign. Abdominal computed tomographic (CT) scan, barium enema, and colonoscopy revealed the mass. Following resection of the tumor the anemia was corrected and the child feels well.