Diagnostic Ultrasound for Acute Appendicitis: The Gold Standard.

BACKGROUND: Acute appendicitis may present a diagnostic dilemma. The aim of this study was to review the accuracy of ultrasound in the diagnosis of paediatric acute appendicitis. METHOD: Ultrasound studies performed for investigation of appendicitis during 2015-2021 were retrieved from a tertiary paediatric hospital database and reviewed. Medical records were reviewed to determine operative intervention, further imaging, and final diagnosis. Diagnostic accuracy was assessed by sensitivity, specificity, predictivity, and overall accuracy. All appendicectomy specimens underwent histopathological confirmation. This study was approved by the local Human Research Ethics Committee. RESULTS: A total of 8555 consecutive ultrasound examinations were performed during the study period. Mean patient age was 10.8 years ( ± 3.7). Overall diagnostic accuracy was 96.1% (8221/8555) with a visualisation rate of 91.0%. Sensitivity and specificity were 96.2% (CI 95.3-97.0%) and 96.1% (CI 95.6-96.5%), respectively. When limited to positive/negative scans, sensitivity was 99.6% (CI 99.2-99.8%) and specificity 99.0% (CI 98.7-99.3%). Positive and negative predictive values were 96.9% and 99.9%, respectively. Repeat ultrasound following a non-diagnostic scan led to a definitive diagnosis in 76.1%. Negative appendicectomy rate was 5.5% overall in children who had undergone pre-operative ultrasound (107/1938), and 4.4% when other surgical pathologies were excluded. CONCLUSION: Ultrasound examination provides gold-standard accuracy in the diagnosis of paediatric appendicitis and reduces rates of negative appendicectomy. Given the disadvantages of computed tomography and magnetic resonance imaging, ultrasound should be considered the first-line investigation of choice in the diagnosis of acute appendicitis in children. LEVEL OF EVIDENCE: III.

Ultrasound guided hydrostatic enema reduction of ileocolic intussusception: a safe and effective technique.

BACKGROUND: Currently, the primary management of ileocolic intussusception in children is usually by non-operative image-guided enema reduction. In most centres around the world especially in Australasia the predominant technique is the pneumatic reduction under fluoroscopic guidance. At our institution, we have been performing ultrasound-guided hydrostatic reduction since 2012.This is an audit to determine the efficacy and safety of ultrasound-guided hydrostatic reduction for intussusception. METHODS: Following ethics approval, a retrospective review of all patients presenting to our institution with intussusception and subsequently undergoing hydrostatic reduction over a period of 9 years (2012 to-2020) was performed. The parameters studied included (i) successful reduction, (ii) recurrence, (iii) need for surgery and (iv) lead point at surgery. RESULTS: The mean age at presentation was 12 months. One hundred and eight children were diagnosed to have ileocolic intussusception. One hundred and six underwent ultrasound-guided hydrostatic reduction with successful reduction in 96 (90.5%) patients. Reduction was unsuccessful in 10 patients (9.5%). Of these eight were noted to have a pathological lead point (four-Meckel's diverticulum and four-Lymphoma) at the time of the surgery. The intussusception recurred in six patients (6.25%) within 24 h. No reduction related perforation occurred during the study period. CONCLUSION: Ultrasound-guided hydrostatic reduction is a safe and effective technique for managing intussusception as it allows continuous monitoring of the reduction of the intussusception without exposing the children to ionizing radiation.

Ultrasound diagnosis of hypertrophic pyloric stenosis - Time to change the criteria.

Introduction: Ultrasound is the examination of choice for the diagnosis of hypertrophic pyloric stenosis (HPS). A correct diagnosis is dependent on the technique and measurement accuracy. However, in the world literature there is a wide range of values suggested for the diagnosis of this condition. The current minimum measurements used to diagnose HPS seem excessively large, and therefore, we set out to redefine these values. Methods: A retrospective study was performed on 607 patients (615 scans) being investigated for HPS. The length and transverse diameter of the pyloric canal, and thickness of the pyloric muscle were measured. All results were correlated with clinical and surgical findings. Results: In this study, the muscle thickness in the normal group was <2.0 mm than in HPS infants having a muscle thickness of 2.0-5.0 mm. All the pyloric canal lengths in the normal group were <5.0 mm than in those with HPS having a length of 10.0-24.0 mm. The transverse diameters ranged from 6.0 to 11.0 mm in the normal group compared with those with HPS having a diameter between 8.0 and 16.0 mm. Conclusions: The current criteria for sonographic diagnosis of HPS should be redefined. The canal length is the single most important discriminator, with a clear separation between normal and abnormal. The commonly used 16.0-mm measurement is too long and should be reduced to 10.0 mm (without the risk of false positives). In many cases, the muscle thickness in those with HPS is as low as 2.0 mm, considerably less than the 3.0 mm that is currently used. The transverse diameter is not a useful discriminator for HPS. The use of current values will delay the diagnosis and timely treatment of this condition.

Subcutaneous nodules following vaccination.

Five patients presented to surgical clinics at our institution with subcutaneous nodules of the upper arm or thigh present for 6-18 months. Excisional or fine-needle biopsy was performed due to diagnostic uncertainty and parental concern. Histopathological examination revealed these to be cutaneous lymphoid hyperplasia in reaction to vaccine components. Nodular reactions with this histopathological pattern are well recognised within vaccine-related literature, but less commonly recognised in patients presenting to general paediatric or surgical clinics. This article reviews literature on delayed-onset nodule formation after vaccination and recommends observation and reassurance as mainstays of management of this largely benign entity.

Ultrasound imaging as the first line of investigation to diagnose intestinal malrotation in children: Safety and efficacy.

BACKGROUND: Upper gastrointestinal contrast study is considered the gold standard investigation to diagnose intestinal malrotation and midgut volvulus which is potentially devastating condition. Ultrasound imaging is an alternative but has been considered unreliable due to significant false negative results. At our institution we have been using ultrasound imaging as the first line investigation to diagnose malrotation since 2008 with a preliminary study of 139 patients published in 2014. This is an ongoing audit of a further much larger cohort of patients to determine the efficacy and safety of ultrasound imaging in the diagnosis of intestinal malrotation. MATERIALS AND METHODS: Following ethics approval, a retrospective analysis of a prospectively collected patient database undergoing ultrasound scans to exclude malrotation at our centre was performed from 2012 to 2019. RESULTS: 539 patients underwent ultrasound to assess for malrotation. The mean age of presentation was 365 days (median 30 days, mode 1 day). Malrotation was diagnosed in 17 with 5 having volvulus, with findings confirmed at surgery. 12 had equivocal findings and subsequent contrast studies ruled out malrotation. The remaining 510 patients with no evidence of malrotation were managed conservatively. CONCLUSION: We have shown ultrasound to be a safe and effective tool to assess intestinal malrotation without exposure to ionizing radiation. LEVEL OF EVIDENCE: Level IV.

Testicular Appendage Torsion-To Explore the Other Side or Not?

OBJECTIVE: To investigate and compare the risks vs benefits of synchronous contralateral scrotal compartment exploration when testicular appendage torsion is diagnosed intra-operatively. METHODS: Emergency scrotal explorations performed at the Women's and Children's Hospital between 2002 and 2017 were retrospectively analysed to identify patients with testicular appendage torsion. Primary outcome measures were metachronous acute scrotum re-presentations and returns to theatre. Outcomes were compared between groups that underwent unilateral and bilateral scrotal compartment exploration. RESULTS: Testicular appendage torsion was diagnosed intra-operatively in 575 patients and 90.4% underwent unilateral scrotal exploration. Re-presentations with metachronous acute scrotum on the non-index side occurred in 8.5% of unexplored and 3.6% of previously explored sides (P = .29). Non-index side returns to theatre occurred in 5.4% of unexplored and 0% previously explored sides (P = .097). Future metachronous contralateral testicular appendage torsion was diagnosed in 4.2%. Post-operative complications were comparably low in both groups. The number needed to treat to prevent a return to theatre for metachronous contralateral testicular appendage torsion is 24. CONCLUSION: The low morbidity of exploring the contralateral side is justifiable, but confers only limited benefit of preventing low likelihood future metachronous contralateral pathology. In balancing these risks, we recommend contralateral exploration as advisable but not a necessity.

Sutured point-fixation versus Jaboulay fixation for salvaged testicular torsion in children.

BACKGROUND: Surgical techniques for fixation of the testis are varied and subject to ongoing debate. Non-sutured techniques may avoid the theoretical morbidities of sutured fixation of the testis yet are criticized for insufficient prophylaxis against future torsion. This study aims to compare outcomes between sutured (point-fixation) versus Jaboulay fixation. METHODS: Emergency scrotal explorations performed at a tertiary hospital in the state of South Australia between February 2002 and December 2017 were analyzed to identify cases of testicular torsion. Primary outcome measures included future testicular torsions and return to theater episodes following initial testicular fixation. Secondary outcome measures included re-presentations and post-operative complications. RESULTS: A total of 482 scrotal compartments were explored in 244 boys with acute testicular torsion. Testis fixation was performed using sutured point-fixation in 58.4% and Jaboulay tunica plication in 41.6%. No future testicular torsion occurred regardless of fixation technique. There were no significant differences in returns to theater (0.4% versus 1.2%, p = 0.12), re-presentations (6.9% versus 6.0%, p = 0.83), and post-operative complications (1.7% versus 1.8%, p = 1.0) in testes that previously underwent sutured or Jaboulay fixation, respectively. CONCLUSION: Jaboulay testicular fixation techniques are comparable with sutured point-fixation techniques in effectiveness and morbidity. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.

Diagnosis and management of omental infarction in children: Our 10 year experience with ultrasound.

AIM: To review children with Omental Infarction (OI) and the role of Ultrasound Scan (US) in its diagnosis and management. METHODS: Cases of OI were identified retrospectively from 2004 to 2014 through screening of admission coding, pathology databases and radiology records. Demographic, clinical and pathological data were extracted from case records. MAIN RESULTS: 30 cases were identified (17 male, 13 female). Mean age was 10.7years (range 3.5-17.2). The majority of the patients were grossly overweight, with 83.3% of patients weighing greater than the mean for their age. All patients underwent at least one US, 4 had a repeat US and 1 patient also had a CT to rule out appendicitis after a US demonstrating OI. OI was demonstrated in 26 initial USs; in 4 cases initial USs were negative but repeat USs correctly detected OI. In 34 USs the appendix was identified on 20 occasions (15 normal, equivocal in 5). 13 patients underwent surgery, while 17 were managed nonoperatively; 7 underwent omentectomy only, 5 had omentectomy plus appendicectomy and 1 underwent appendicectomy only. All 12 omentectomy specimens were confirmed as OI histologically while none of the 6 appendices showed inflammation histologically. There were no postoperative complications. CONCLUSION: In a large series we have demonstrated the efficacy of US in the diagnosis and management of OI in children. To our knowledge this is the largest series of its kind to date. No patient with OI was incorrectly diagnosed with acute appendicitis or vice versa. LEVEL OF EVIDENCE: Level IV. TYPE OF STUDY: Retrospective Case Series.

Beware the Looping Vas Deferens in Orchidopexy.

A looping vas deferens may be present in up to 20% of undescended testes located within or proximal to the inguinal canal. This associated abnormality is vulnerable to transection during orchidopexy. We present an example of a very long looping vas to emphasize the importance of inspection for this anomaly, and demonstrate the extreme extent that a looping vas may extend. Identification of the vas among cord structures may provide false reassurance of normal ductal anatomy. Examination for a looping vas by inspecting structures caudal to the testis should occur at an early opportunity during orchidopexy to avoid inadvertent transection.

Benchmarking the value of ultrasound for acute appendicitis in children.

BACKGROUND: This study appraises the diagnostic quality of ultrasound for acute appendicitis in children and consequently challenges the perception of inferior accuracy and suitability compared to computed tomography (CT). METHODS: Radiologist reports for consecutive "query appendicitis" ultrasound studies were retrieved from a hospital database for the study period 2009-2014. Children who subsequently underwent appendicectomy were identified. Corresponding operative and histopathology findings were evaluated. Diagnostic accuracy of ultrasound was determined by analyzing overall accuracy, sensitivity, specificity, predictivity, and likelihood ratios. RESULTS: A total of 3799 ultrasound examinations were evaluated. Mean age was 11.5±3.8years. The proportion of patients investigated with preoperative ultrasound was 59.9% (1103/1840). Appendix visualization rate was 91.7%. Overall diagnostic accuracy was 95.5%. Sensitivity and specificity values were 97.1% (95.9-98.1; 95% CI) and 94.8% (93.9-95.6; 95% CI), respectively. Separate analysis of only ultrasound positive and negative examinations (i.e., excluding nondiagnostic examinations) confirmed sensitivity and specificity values of 98.8% and 98.3%. CONCLUSION: In this largest reported single institution series of ultrasound examinations for appendicitis, we report benchmark standard quality of diagnostic accuracy and visualization rates. Given the radiation and cost implications of CT, there is a strong argument to recommend ultrasound as the primary imaging modality. Diagnostic Study-Level II.

Bilateral perinatal testicular torsion: successful salvage supports emergency surgery.

Perinatal testicular torsion (PTT) has poor rates of testicular salvage. Although rare, bilateral PTT carries the risk of anorchia. We present a case of a 2-day-old term infant with acute onset right-sided scrotal discolouration and tenderness. The infant was promptly taken to the operating theatre for emergency scrotal exploration. Bilateral extravaginal testicular torsion was identified, with the right testis appearing to have a more established ischaemic appearance compared to that on the left side. Intraoperative findings were representative of metachronous PTT with a short time period of only several hours separating the torsion events. Both testes were detorted and fixated in the scrotum. The infant made an uneventful recovery. Outpatient clinic review at 6 weeks and 6 months postoperatively confirmed no clinical evidence of testicular atrophy. Given the potential for contralateral torsion and the morbidity of anorchia, our experience supports the role for emergency scrotal exploration in suspected PTT.

Simplified technique for retrieval of large trichobezoars in children.

Trichobezoars are concentrations of indigestible hair or hair-like fibres within the proximal intestinal tract. In children, delayed presentation with large bezoar masses is not unusual as bezoar formation is an indolent process that takes many months or years before becoming symptomatic. Surgical management is challenging and becomes inevitable once a trichobezoar becomes more established. The standard approach involves a sizeable transverse or midline laparotomy. We describe a less invasive technique for extraction of large gastric trichobezoars via a mini-laparotomy. The key aspect to this technique involves insertion of an Alexis O Wound Protector/Retractor (Applied Medical, Rancho Santa Margarita, California, USA) into the stomach following creation of a secure temporary gastrostomy by hitching gastrotomy edges to the abdominal wall. This simplified approach has advantages of (1) secure and excellent direct intragastric access, (2) shorter operating time and (3) reliable protection of both the wound edges and peritoneal cavity from bezoar contamination.

Utility of sonographic assessment of the position of the third part of the duodenum using water instillation in intestinal malrotation: a single-center retrospective audit.

BACKGROUND: Intestinal malrotation and particularly volvulus are potentially devastating conditions. Upper gastrointestinal (UGI) contrast studies have been considered the gold standard for diagnosis. However the use of ultrasonography (US) has been increasingly described. We describe a method for delineating the duodenal anatomy with US as a means to exclude malrotation. OBJECTIVE: To report our experience using US to assess intestinal rotation. MATERIALS AND METHODS: We conducted a retrospective audit of US scans performed at a tertiary referral centre to exclude malrotation for paediatric surgery between 2008 and 2011. RESULTS: One hundred thirty-nine infants were included, of whom 114 had a normal US scan. Of the 114, nine had subsequent upper gastrointestinal contrast studies that confirmed the initial results; there were no false-negatives. There were abnormal US scans in four infants associated with midgut volvulus and malrotation; there were no false-positives. The other 21 US scans were equivocal, and 11 of these had a confirmatory UGI contrast study; only one required surgery to correct malrotation. CONCLUSION: US has been a safe and effective tool in the assessment of intestinal rotation at our institution. The main advantages of US imaging are its lack of ionising radiation and its rapid and accurate diagnosis of volvulus.

Testicular and paratesticular pathology in children: a 12-year histopathological review.

BACKGROUND: Our institution is the principal pediatric surgical referral center for a population of 1.6 million. The objective of this study was to determine the spectrum and incidence of pediatric testicular and paratesticular pathology in this population. METHODS: Pathology results of all testicular and paratesticular specimens between August 1995 to September 2007 were analyzed. Clinical details were retrieved retrospectively from the computerized database, recording age, mode of presentation, laterality, and associated inguinoscrotal pathology. RESULTS: Over 12 years 2 months, 474 patients (502 specimens) were identified. Testicular and paratesticular pathology was most frequent in patients aged 1-2 years (11%) and 11-12 years (10.5%). In all, 442 patients had non-neoplastic pathology, with 60.4% presenting acutely. The most common non-neoplastic pathologies were hydatid of Morgagni (42.6%) and "vanishing testis" (14.3%). Vanishing and atrophic testes were frequently explored between 1 and 2 years of age, with a left predominance. Most atrophic testes were undescended (54.8%). Testicular torsion occurred in 11.2%, with bimodal peak ages of <1 year and 13-14 years. Interestingly, testicular torsion also occurred more on the left side (68%). A total of 32 patients had neoplasms. Of 27 patients with testicular neoplasms, 55.6% were malignant (29.6% primary and 26% secondary), the principal primary malignancy was yolk sac tumor; the most common benign neoplasms were epidermoid cysts and teratomas. Five patients had paratesticular neoplasms, with rhabdomyosarcoma in 80%. CONCLUSIONS: The variety of scrotal and testicular pathology in children is considerable, with acute pathologic conditions comprising the bulk in the older (7-15 years) children, whereas impalpable testes and neoplasms comprise most of the lesions in infants. Interestingly testicular torsion, vanishing testes, and atrophic testes occur mainly on the left side. Benign testicular neoplasms occur more frequently than primary malignancies.