Pneumoperitoneum in the Setting of Pneumatosis Intestinalis in Children: Is Surgery Always Indicated?

Aim Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled cysts form within the wall of the gastrointestinal tract in either the subserosa or submucosa. The presence of pneumoperitoneum in the presence of PI can present a therapeutic dilemma. The aim of our study was to review our experience and management of this condition. Methods A single-center retrospective study of consecutive children (> 1 year) presenting with a pneumoperitoneum and evidence of PI (2009-2015). Demographics, case notes, microbiology, and imaging were reviewed. Results Seven patients were identified (four males; age range 5-14 years). Four children had global developmental delay and were percutaneous endoscopic gastrostomy or jejunostomy fed, one was immunocompromised (acute lymphoblastic leukemia). The others had encephalitis and eosinophilic gastroenteritis. One patient proceeded to an exploratory laparotomy; no perforation was identified, pneumatosis of the colon was observed, and a loop ileostomy was formed. The remaining six were managed conservatively and made nil by mouth with intravenous antibiotics commenced. Five of the six had a computed tomography (CT) scan which revealed PI and free air with no other worrying signs. One died from nongastrointestinal causes, while the remaining five had feeds reintroduced uneventfully. Conclusion Free air in the setting of PI may represent rupture of the gas cysts and not always transmural perforation. Surgery may not always be indicated and conservative management may suffice. A CT scan can be useful for excluding other intra-abdominal pathological findings and continued clinical assessment is essential.

Comparison of intraabdominal abscess formation after laparoscopic and open appendicectomies in children.

AIM: Although laparoscopic appendicectomy (LA) is an accepted alternative to the open appendicectomy (OA) approach, it has been suggested that there is a higher incidence of intraabdominal abscesses (IAAs). Our aim was to determine the incidence of IAA in 3 pediatric surgical centers routinely practicing both techniques. METHODS: Data were collected retrospectively for pediatric patients undergoing LA or OA over an 8-year period. Analysis included IAA formation, appendicitis complexity, radiologic/histologic investigations, grade of surgeon, and wound infection. MAIN RESULTS: A total of 1267 appendicectomies were performed (514 LAs and 753 OAs). There was no difference between the incidences of IAA (LA, 3.9% [19/491] vs OA, 3.9% [28/714]; P = 1.0). The incidence of IAA was increased in those with complicated appendicitis (34/375 [9.1%] vs 13/830 [1.6%]; P ≤ .0001). There was an increased proportion of those with complicated appendicitis in the LA group (182/491 [37.1%] vs 193/714 [27.0%]; P = .0002). Surgical trainees were more likely to be the primary surgeon in the OA group (79% vs 63%; P = .0001), although the incidence of IAA did not correlate with grade of surgeon. There was no significant difference in incidence of wound infection between groups (LA, 4.6% [8/173] vs OA, 2.5% [18/377]; P = .93). CONCLUSION: This large retrospective study shows that the technique of appendicectomy does not appear to affect the incidence of IAAs. Patients with complicated appendicitis are more likely to develop an IAA regardless of technique.

[Stonefish stings: difficult analgesia and notable risk of complications]. / Piqûres par poisson-pierre: une antalgie difficile, un risque notable de complications.

INTRODUCTION: Marine activities and water sports in tropical countries entail some dangers. In our emergency department, stonefish (Synancae verrucosa) stings are second only to those by sea urchins among the 400 consultations a year for wounds by marine animals. METHOD: We retrospectively collected data for all emergency department visits for stonefish stings over a 5-year period from 2001 through 2005. RESULTS: The study included 57 patients (42 men; mean age 31.2+/-15.9 years, range 3-63 years) at 61 consultations. The reason for the emergency department visit was pain, often described as intense. Injuries occurred to the foot in 79% of cases and the hand in 21%. Local signs included a wound (100%), edema (74%), local inflammation (21%), bruising (23%), necrosis (19%), and, in one patient, cellulitis. Pain was reported in 95% of cases. Local care consisted of immersing the stung area in hot water (79%) or in situ lidocaine injection (16%). Analgesics were administered in 75% of the cases, including morphine (54%) and anti-inflammatory drugs in 47%. Other analgesic techniques included ketamine (3.5%), nitrous oxide (3.5%), and local or regional anesthesia (3.5%); 29% of patients received antibiotics. Patients requiring admission (46%) differed from those who did not by a need for more intense analgesia and by greater wound inflammation and necrosis. Three patients required surgery and three others, hyperbaric oxygen therapy. CONCLUSION: Stonefish stings present the risk of local complications. Analgesia is also a major concern for emergency physicians and prophylactic antibiotics must be considered.