Delayed Surgery for Perforated Appendicitis is Feasible in Children Without Compromising the Outcome in Selected Cases.

BACKGROUND AND AIM: The relationship between time to surgery and risk of postoperative complications and re-intervention has not been conclusively investigated in pediatric perforated appendicitis (PA). The aim of this study was to determine whether time to appendectomy (TTA) is a risk factor for postoperative complications and re-intervention in a cohort of children undergoing appendectomy for PA. METHODS: A total of 254 children (age: 8.7 ± 3.7 years) undergoing appendectomy for PA were retrospectively evaluated and stratified into Group I-III according to the Clavien-Dindo classification for postoperative complications (Group I n = 218, 86%; Group II n = 7, 3%; Group III n = 29, 11%). RESULTS: The TTA was comparable between all groups (group I: 8.8 ± 9.2 h; group II: 7.8 ± 5.3 h; group III: 9.5 ± 9.6 h; overall: 8.8 ± 9.1 h; p = 0.885). A C-reactive protein (CRP) value at admission of ≥128.6 mg/l indicated a higher risk for developing Grade II complications with no need for re-intervention (OR: 3.963; 95% CI: 1.810-8.678; p = 0.001) and Grade III complications with the need for re-intervention (OR: 3.346; 95% CI: 1.456-7.690; p = 0.004). This risk was independent of the TTA (OR: 1.007; 95% CI: 0.980-1.035; p = 0.613). CONCLUSIONS: Appendectomy can be delayed by an average time delay of about 9 h in children with PA without increasing the risk of postoperative complications and re-intervention, also in patients at high risk defined by the initial CRP level ≥ 128.6 mg/l. This data may support the correct risk-adjusted scheduling of surgical interventions in times of limited capacity.

Failed preoperative vacuum bell therapy does not affect outcomes following minimally invasive repair of pectus excavatum.

PURPOSE: It is unknown if failed preoperative vacuum bell (VB) treatment in patients undergoing minimally invasive repair of pectus excavatum (MIRPE), delays repair and/or affects postoperative outcomes. METHODS: A retrospective data analysis including all consecutive patients treated at one single institution undergoing MIRPE was performed between 2000 and 2016. Patients were stratified into preoperative VB therapy versus no previous VB therapy. RESULTS: In total, 127 patients were included. Twenty-seven (21.3%) patients had preoperative VB treatment for 17 months (median, IQR 8-34). All 27 patients stopped VB treatment due to the lack of treatment effect. Eight (47.1%) of 17 assessed VB patients showed signs of skin irritation or hematoma. VB treatment had no effect on length of hospital stay (p = 0.385), postoperative complications (p = 1.0), bar dislocations (p = 1.0), and duration of bar treatment (p = 0.174). Time spent in intensive care unit was shorter in patients with VB therapy (p = 0.007). Long-term perception of treatment including rating of primary operation (p = 0.113), pain during primary operation (p = 0.838), own perspective of look of chest (p = 0.545), satisfaction with the procedure (p = 0.409), and intention of doing surgery again (p = 1.0) were not different between groups. CONCLUSIONS: Failed preoperative VB therapy had no or minimal effect on short-term outcomes and long-term perceptions following MIRPE.

Predicting Postoperative Complications After Pediatric Perforated Appendicitis.

PURPOSE: Assessment of risk factors for postoperative complications following surgical treatment of pediatric perforated appendicitis (PA) is necessary to identify those patients in need of closer monitoring. In this study, we have investigated the impact of different risk factors on the occurrence of complications after an appendectomy in children with PA. MATERIAL AND METHODS: The study was a retrospective, single-centre analysis of all pediatric PA conducted over a 10-year period. Preoperative clinical and laboratory results, intraoperative findings, and postoperative complications were analyzed. Risk factors were defined and a risk score was determined for postoperative complications and reinterventions. RESULTS: Surgical treatment for appendicitis was performed in 840 pediatric patients during the observation period. 163 of the included patients were diagnosed with PA (mean age 8.9 ± 3.6 years). 19 (11.7%) patients developed postoperative complications, 17 (10.4%) of which required complication-related intervention. We identified five predictors of postoperative complications: the C-related protein value at admission, purulent peritonitis, open appendectomy (primary, secondary, or converted), placement of an abdominal drain, and administration of antibiotics not compliant to results from the subsequent antibiogram. The determined risk score was significantly higher in the complication group (p < .0001) and reintervention group (p < .001). CONCLUSIONS: Postoperative complications following pediatric PA can be predicted using specific preoperative, intraoperative, and postoperative risk factors. In the high-risk group, an active prevention, detection, and intervention of any occurring complication is necessary and we present a new specific pediatric risk score to define patients at risk for complications.

Modified Spiral Intestinal Lengthening and Tailoring for Short Bowel Syndrome.

BACKGROUND: The spiral intestinal lengthening and tailoring (SILT) procedure is a new surgical technique for autologous intestinal reconstruction in patients with short bowel syndrome. The aim of this work is to present a first description of a modified SILT technique by which the mucosal layer is left intact to possibly reduce the severe postoperative complications of intestinal leakage and abdominal abscess formation. MATERIALS AND METHODS: The modified SILT technique was performed on a 10-cm-long intestinal segment in 2 pigs to determine the technical feasibility. Thereafter, the short-term clinical feasibility was monitored clinically in 2 dogs by gastrointestinal X-ray series at postoperative day 4 and by relaparotomy postoperative day 10. RESULTS: It was technically feasible to lengthen the intestinal segment from 10 cm to 20 cm and tailoring it from 3 cm to 1.7 cm in diameter, while leaving the intestinal mucosal layer intact. The postoperative course was uneventful for both dogs. The gastrointestinal X-ray series showed an inconspicuous intestinal transit time without any signs of stricture, perforation, or leakage. In the relaparotomy, the initially achieved lengthening and tailoring extents were preserved and the operated intestinal segment was well perfused with no early signs of necrosis, stenosis, or leakage. CONCLUSIONS: Leaving the mucosal layer intact during SILT is technically and clinically feasible in the short term in a large animal model. Further studies are needed to fully assess the impact of this technical modification on the long-term outcome of larger series.

Long-term outcome in displaced lateral humeral condyle fractures following internal screw fixation in children.

BACKGROUND: The aim of this study was to investigate the long-term clinical outcome following open reduction and internal screw fixation of displaced lateral condyle fractures (LCFs) of the distal humerus and compare the outcome of primary and secondary LCFs. METHODS: The clinical outcome in 31 children (mean age 5.8±2.4 years) operated for primary or secondary LCFs was retrospectively analyzed by standardized clinical examination and compared using the Mayo score, Morger score, and Patients Satisfaction score. RESULTS: The scores did not differ significantly between the primary and secondary displacement groups (Mayo score: 99.3±3.3 vs. 100±0, p=0.852; Morger score: 3.8±0.5 vs. 3.9±0.3, p=0.852; Patients Satisfaction score: 3.7±0.6 vs. 3.9±0.3, p=0.546). Deficits in range of motion and joint axis deviation were minor (< 10°) and no elbow instabilities were observed. CONCLUSIONS: Surgical treatment of a secondary displaced LCF with open reduction and internal screw fixation leads to a favorable long-term outcome. The long-term outcome is similar between primary and secondary displaced LCFs.

Long-term effects of fundoplication in children with chronic airway diseases.

BACKGROUND: Association between chronic airway diseases (CAD) and gastroesophageal reflux disease (GERD) is well described, but causality has not yet been conclusively established. This study evaluates the therapeutic significance of laparoscopic Thal fundoplication in children with CAD and diagnosed GERD. METHODS: We performed a retrospective analysis of 182 neurologically nonimpaired children, all with medically refractory CAD and GERD undergoing laparoscopic Thal fundoplication. The clinical response, ability to wean oral and inhaled medication and satisfaction with postoperative results were evaluated. RESULTS: Main symptoms disappeared completely in 68.7% of patients and were markedly improved in a further 22% of patients following surgery. Complete discontinuation of medication was achieved in 70.1-96.4% of cases and reduced in a further 1.8-23.5%. One intraoperative complication occurred (gastric perforation), however no conversion to laparotomy was necessary. Postoperative Dumping Syndrome occurred in 1% of cases and was managed dietetically. Prolonged postoperative dysphagia occurred in 4.3% of patients, but disappeared within 8 weeks in all but one case. CONCLUSIONS: Our study suggests that Thal fundoplication in neurologically nonimpaired children with CAD and documented GERD is effective and safe. Children unresponsive to preoperative medical management showed significant improvement in airway symptoms together with a marked reduction in the need for medication. We conclude that laparoscopic Thal fundoplication represents a significant treatment worthy of consideration in this group of patients.

Models of short bowel syndrome in pigs: a technical review.

BACKGROUND: Short bowel syndrome (SBS) is still a life-threatening disease in both children and adults. Although the therapeutic options are improving, challenges still remain, and to overcome these challenges is a major focus of SBS research today. In order to simulate anatomical and physiological conditions similar to those in humans for research, porcine models of SBS are often used. Various approaches for generating SBS models have been described in the literature. METHODS/RESULTS: In this work, we present a review of different types of porcine models of SBS and outline the differences between those models regarding types of animals, surgical procedures, monitoring, and methods of assessment. CONCLUSION: The aim of this study was to select the most suitable SBS model regarding the purpose of the research.

[Elbow dislocation in childhood. Long-term observational study]. / Ellenbogenluxationen im Kindesalter. Eine Langzeitbeobachtung.

Traumatic dislocation of the elbow is rare in children with an incidence of 3-6% of all elbow injuries. In the literature the outcome after elbow dislocation in childhood is rarely discussed. In the present study 33 children treated in our clinic from 2001 to 2008 with an acute traumatic dislocation of the elbow were retrospectively included. All events were unilateral whereby 1 child (3%) showed a recurrence of elbow dislocation after 9 weeks, 30% had a pure dislocation, 70% had a concomitant fracture, 55% showed a fracture of the medial epicondyle, 6% a fracture of the lateral epicondyle and 9% a further fracture. Of the fractures 83% required open reduction with osteosynthesis. After an average of 4.5 years 20 children (61%) were clinically examined. There were no instabilities of the joint and only minor clinical limitations of the range of motion. The established Mayo elbow performance score showed good to excellent results for all children. Despite severe joint trauma with frequently accompanying fractures, post-traumatic functional deficits are rarely limiting, independent of the accompanying fracture. The frequency of recurrence is low and instabilities were not seen.

Prospective, randomized, controlled trial comparing a tissue adhesive (Dermabond™) with adhesive strips (Steri-Strips™) for the closure of laparoscopic trocar wounds in children.

BACKGROUND: 4 methods are used in pediatric laparoscopic surgery to close trocar wounds. While tissue adhesives or adhesive strips have been shown to produce fewer wound complications and a better cosmetic result compared to trans- or only subcutaneous sutures, the choice of technique is still often based on the surgeon's personal experience. Thus, the objective of this trial was to assess the impact of tissue adhesives (Dermabond™) compared to adhesive strips (Steri-Strip™) on potential complications of wound healing, wound pain, cosmetic outcome, and patient satisfaction after laparoscopic appendectomy in children. METHODS: 49 patients undergoing laparoscopic appendectomy were enrolled in this prospective randomized trial. In every patient, two 5-mm and one 10-mm port-site incision was closed either with Dermabond™ or Steri-Strip™ after placing subcuticular absorbable sutures (4-0 Vicryl™). Postoperative complications, pain, and patient satisfaction with scars were evaluated at follow-up on day 10 and day 90 after the operation using a questionnaire and a visual analogue scale (VAS). Photographs of scars taken on day 90 were evaluated on a VAS by 2 pediatric surgeons blinded to the closure method used. RESULTS: According to the surgeons' evaluation of the cosmetic outcome, a significant difference between the 2 groups with regard to the cosmetic score was found on day 90 of follow-up, favoring Steri-Strip™ wound closure (p < 0.05). On day 10 and 90 there were no statistical differences between the 2 methods as regards the result of patient evaluations (p > 0.05). Only one wound infection (4%) was observed in the Steri-Strip™ group (n = 25) on day 10. At follow-up on day 90 two patients (9.1%) in the Dermabond™ group and one (4.8%) in the Steri-strip™ group complained of wound pain (p = 0.52). CONCLUSIONS: Both tissue adhesives and adhesive strips are excellent "no needle" alternatives for the closure of laparoscopic port-site incisions in children. As regards cosmetic outcome, Steri-Strip™ wound closure seems to be the most suitable and is also the less expensive technique.

Computerized axiography in TMD patients before and after therapy with 'function generating bites'.

The study evaluates the temporomandibular joint (TMJ) movements of patients with signs and symptoms of temporomandibular disorders (TMD) before and after therapy with the functional appliances of the 'function generating bite' (FGB) type. Thirty subjects suffering from TMD were selected and divided into two groups: group A (young patients: four males, nine females, mean age +/- standard deviation: 13.3+/-1.5 years); group B (adults: three males, 14 females, mean age +/- standard deviation: 23.2+/-4.4 years). A control group comprised 13 healthy subjects with perfect normal occlusion, TMD-free, was matched for age and sex with patient groups and was examined at T0 and after 12 months (T1). Computerized axiography was performed before and after therapy (average 13 months) with FGBs to evaluate any difference in condyle border movements. Results showed a statistically significant improvement after treatment, for groups A and B, in length, clicks, tracings with normal morphology, superimposition, deviations, regularity and return to starting position and speed (statistical analysis: chi-squared test) except for the symmetry of tracings which was significantly improved only for the young patient group. No statistically significant differences at time T0/T1 were found in the control group. In conclusion, the study shows that the TMJ tracings of TMD patients before and after therapy with 'FGB' significantly improve especially in young patients. FGB may be a useful appliance to improve TMJ function in young and adult TMD patients requiring orthodontic treatment.

Reference values of interrupter respiratory resistance in healthy preschool white children.

BACKGROUND: Interrupter respiratory resistance (Rint) is reported to be useful in evaluating lung function in poorly collaborating patients. However, no reference values are available from large samples of preschool children using the standard interrupter method. The aim of this study was to define reference Rint values in a population of healthy preschool children. METHODS: Rint was assessed without supporting the cheeks in children with no history of wheeze from six kindergartens. To evaluate the effects of upper airway compliance on Rint in healthy children, an additional group of preschool children with either no history of wheeze or no respiratory symptoms at the time of testing underwent Rint measurements in our lung function laboratory with and without supporting the cheeks. Short term (about 1 minute apart) and long term (mean 2.5 months apart) repeatability of Rint measurements (2 SDs of the mean paired difference between measurements) was also assessed in children referred for cough or wheeze. RESULTS: A total of 284 healthy white children (age range 3.0-6.4 years) were evaluated. Mean inspiratory and expiratory Rint (RintI and RintE) did not differ significantly in boys and girls. Age, height, and weight showed a significant inverse correlation with both RintI and RintE in the univariate analysis with linear regression. Multiple regression with age, height, and weight as the independent variables showed that all three variables were significantly and independently correlated with RintI, whereas only height was significantly and independently correlated with RintE. Supporting the cheeks had no significant effect on RintI (n=29, median 0.673 v 0.660 kPa/l.s, p=0.098) or RintE (n=39, median 0.702 v 0.713 kPa/l.s, p=0.126). Short term repeatability was 0.202 kPa/l.s for RintI (n=50) and 0.242 kPa/l.s for RintE (n=69). Long term repeatability was 0.208 kPa/l.s for RintE (n=26). CONCLUSIONS: We have reported reference Rint values in preschool white children and have demonstrated the usefulness of this technique in assessing lung function in this age group.

Airway resistance and spirometry in children with perinatally acquired human immunodeficiency virus-type 1 infection.

Airway resistance was measured by the interrupter technique in 54 children [aged 63.8 months (range: 9.1-131.6 months)], with perinatal human immunodeficiency virus-type 1 (HIV-1) infection and in a control group of 315 gender, height, and race-matched healthy children. In addition, 14 HIV-infected children, aged 75-131 months, had spirometry performed. Resistance was significantly higher in infected children than in controls (0.84 +/- 0.3 vs 0.64 +/- 0.08 kPa x l(-1) x s; t = 9.991; P < 0.0001). Resistance decreased with age in controls (r = -0.95; P < 0.001), but not in infected children (r= -0.22; P = 0.105). Resistance did not correlate with mothers' intravenous drug addiction, perinatal data, T-cell subset numbers, treatment, clinical course, or presence of respiratory complications. Resistance was higher (t = 3.103; P < 0.003) in p24 antigen-positive than in negative children. Thirty-nine children underwent a second evaluation 12.3 months (range 11.1-14 months) after the first. Resistance was higher (t = 3.960; P < 0.0001) at the second evaluation compared to the first. Eight of 14 children had abnormal spirometric measurements. We conclude that perinatal HIV-1 infection is associated with increased airway resistance and often abnormal spirometry. The degree of abnormalities in resistance depends on the duration of the infection rather than on HIV-1-related respiratory complications.

The preventive effect and duration of action of two doses of inhaled furosemide on exercise-induced asthma in children.

BACKGROUND: Exercise-induced asthma can be prevented by treatment with inhaled furosemide. OBJECTIVE: In this study we evaluated the effect and duration of action of two doses (15 and 30 mg) of inhaled furosemide in prevention of exercise-induced asthma in children. METHODS: Ten children with exercise-induced asthma (8 boys and 2 girls, aged 6 to 13 years) were included in the study. Each patient was tested with three treatment regimens (placebo, 15 mg of furosemide, and 30 mg of furosemide) in random order on 3 separate days. Patients performed exercise challenges on a treadmill at 20 minutes and 1, 2, 3, and 6 hours after each treatment. Pulmonary function, urinary output, and fluid intake were monitored. RESULTS: Both doses of furosemide had a significantly greater protective effect than placebo, but there was no significant difference between the two doses of furosemide. The higher dose of furosemide was associated with increased urinary output and had a longer duration of action. CONCLUSION: A 30 mg dose of furosemide is more effective for treatment of exercise-induced asthma in terms of duration but has a significant diuretic effect.

The preventive effect of nedocromil or furosemide alone or in combination on exercise-induced asthma in children.

BACKGROUND: Recent evidence suggests that inhaled nedocromil and furosemide are effective in preventing asthma by ultrasonically nebulized distilled water, allergen, and exercise. There are, however, no studies that compare the effects of these two drugs. The aim of this study was to investigate the effect of inhaled furosemide (30 mg), nedocromil (4 mg), the combination of these two drugs, and placebo aerosol in preventing exercise-induced asthma. METHODS: Twenty-four children with exercise-induced asthma, aged 6 to 16 years, performed a treadmill test before and 20 minutes after a single dose of drug(s) in a double-blind trial. Lung function measurements were taken before drug administration, before the exercise test (20 minutes after drug administration), and then 2, 4, 6, 8, 10, 15, 20, and 30 minutes after the exercise test. RESULTS: Both active drugs performed significantly better than placebo. In fact, the exercise challenge resulted in a mean maximum fall in forced expiratory volume in 1 second of 28.46% +/- 13.84% after administration of placebo, but of only 15.42% +/- 8.35% after administration of nedocromil (p < 0.001) and of 11.37% +/- 9.14% after administration of furosemide (p < 0.001). When the two drugs were given together, there was a statistically significant additive effect because the mean maximum fall in forced expiratory volume in 1 second was 5.75% +/- 3.57% (nedocromil vs nedocromil + fluorsemide: p < 0.001; furosemide vs nedocromil + furosemide: p < 0.01). CONCLUSION: This study suggests that nedocromil and furosemide provide a comparable effect in preventing exercise-induced asthma in children. The combined administration of the two drugs significantly increases the protective effects, suggesting a potential therapeutic use.

Inhibition of exercise-induced-asthma (EIA) by nedocromil sodium and sodium cromoglycate in children.

Nedocromil sodium (Ned) 4 mg, sodium cromoglycate (SCG) 10 mg, and placebo were compared for their efficacy in preventing exercise-induced asthma. Nineteen asthmatic children aged six to 15 years performed a treadmill exercise test before and 20' after a single dose of drug in a double-blind trial. Both active drugs performed significantly better than placebo; in fact the exercise challenge resulted in a mean maximum fall in FEV1 of 26.1 +/- 14.9% after placebo, but only of 14.6 +/- 11.5% after SCG (P < 0.05), and 11.0 +/- 12.4% after Ned (p < 0.01). Measurements of PEFR gave similar results, while the effect of treatment on FEF 25-75 was significant for Ned alone (p < 0.05). Direct comparison between Ned and SCG at different time points demonstrated significant differences in FEV1 at 1 min (p < 0.05) with a better overall performance of Ned. In individual patients, complete protection was provided in 9 patients with SCG, in 14 patients with Ned and in 2 with placebo. No side effects were observed. This study suggests that at the dosages used there are only slight differences between SCG and Ned activity in the prevention of exercise-induced asthma.

Surgical correction of ptosis in ocular fibrosis syndrome.

The surgical management of ptosis is reported in seven patients suffering from the ocular fibrosis syndrome. Satisfactory results were obtained with bilateral Crawford type brow suspension with autologous fascia lata in six patients and bilateral Fox type brow suspension with stored fascia lata in a young child. As patients with ocular fibrosis syndrome usually exhibit little or no Bell's phenomenon, corneal exposure can become a problem after brow suspension. It was recommended that the lids are left just closed on the operating table at the end of the operation. None of the patients required a subsequent procedure to lower an overcorrection of the ptosis. The routine prescription of ocular lubricants for 2 months after ptosis correction is advocated. Urgent brow suspension in young children using non-autologous materials should only be considered if there is a risk of amblyopia.

Bilateral Acanthamoeba keratitis in a gas-permeable contact lens wearer.

Acanthamoeba keratitis is an uncommon but potentially devastating complication of contact lens wear that has been reported with increasing frequency since its first description in 1974. We describe a case of bilateral Acanthamoeba keratitis, which occurred in a 24-year-old man, wearing gas-permeable contact lenses. This is to our knowledge the first case of Acanthamoeba keratitis reported in Italy, and the fourth bilateral case reported in the literature. Medical therapy (carried out after the first week by a different institution, due to the absence of essential antiamebic drugs on the Italian market) was effective in stopping the progression of the disease.