Arlet G. Kurkchubasche

Open and laparoscopic appendectomy are equally safe and acceptable in children

Background: The aim of this study was to evaluate prospectively whether laparoscopic (LA) and open appendectomy (OA) are equally safe and feasible in the treatment of pediatric appendicitis. Methods: A total of 517 children with acute appendicitis were randomly assigned to undergo LA or OA appendectomy, based on the schedule of the attending surgeon on call. Patient age, sex, postoperative diagnosis, operating time, level of training of surgical resident, length of postoperative hospitalization, and minor and major postoperative complications were recorded. Chi-square analysis and the Student t-test were used for statistical analysis. Results: In all, 376 OA and 141 LA were performed. The two groups were comparable in terms of patient demographics and the incidence of perforated appendicitis. The operative time was also similar (47.3 ± 19.7 vs 49.9 ± 12.9 min). The overall incidence of minor or major complications was 11.2% in the OA group and 9.9% in the LA group. Conclusion: Pediatric patients with appendicitis can safely be offered laparoscopic appendectomy without incurring a greater risk for complications. Nevertheless, a higher (but not significantly higher) abscess rate was found in patients with perforated appendicitis who underwent laparoscopy.

Adaptation in short-bowel syndrome: Reassessing old limits☆☆☆

The improving survival of patients with severe short-bowel syndrome along with the advent of successful intestinal transplantation have accentuated the need to answer two questions. (1) Is there an intestinal length below which adaptation to full enteral nutrition can not be expected to occur? (2) How much time is necessary to complete intestinal adaptation? We reviewed the outcome of 21 infants with less than 50 cm of small intestine to answer these questions. Patients were divided into three groups based on intestinal length, regardless of ileocecal valve status: group I, < 10 cm (n = 3); group II, 10 to 30 cm (n = 11); and group III, 30 to 50 cm (n = 7). Data were collected to assess survival, incidence of adaptation, time to adaptation, and causes of mortality. Infants in group I did not achieve intestinal adaptation to full enteral nutrition. One survived and 2 died, one from varicella pneumonia and the other after intestinal transplantation. Eight of the 11 (73%) patients in group II survived and 5 of 8 (63%) survivors achieved full intestinal adaptation after a mean interval of 320 days (range, 148 to 506 days) on parenteral nutrition. Six of the seven patients (86%) in group III survived and all survivors (100%) achieved complete enteral adaptation after an average of 376 days (range, 58 to 727 days). The overall survival was 71% (15/21), but survival in patients with > 10 cm was 78%.(ABSTRACT TRUNCATED AT 250 WORDS)

Benefits of term delivery in infants with antenatally diagnosed gastroschisis

Abstract OBJECTIVE: To test the hypothesis that term gestation offers the best outcome. The relationship between gestational age and the extent of bowel injury in fetuses with gastroschisis is a matter of debate. Early delivery and cesarean delivery have been recommended to limit intestinal damage, but their benefits are unclear. METHODS: Data on all patients with gastroschisis seen at our institution from 1991 through 2001 were included. Patients were compared based on gestational age: less than 35 weeks, 35–37 weeks, and term (more than 37 weeks) with regard to age at definitive closure, age at first and full feedings, and hospital stay. Statistical significance (P RESULTS: Of the 57 patients, 19.3%, 43.8%, and 36.9% were born at less than 35 weeks, 35–37 weeks, and more than 37 weeks, respectively. Age at definitive closure was significantly higher at 35–37 weeks (5.9 ± 4.6 days) than at more than 37 weeks (1.5 ± 2.3 days) and less than 35 weeks (2.6 ± 2.5 days) (P CONCLUSION: Based on a homogeneous cohort of patients in whom gastroschisis was diagnosed antenatally, term delivery results in earlier closure of the defect and shorter time to full feedings. The benefit of early delivery postulated by others cannot be substantiated.

Nonoperative treatment of acute appendicitis in children: A feasibility study

PURPOSE Nonoperative treatment of acute appendicitis appears to be feasible in adults. It is unclear whether the same is true for children. METHODS Children 5-18 years with <48 h symptoms of acute appendicitis were offered nonoperative treatment: 2 doses of piperacillin IV, then ampicillin/clavulanate ×1 week. Treatment failure (worsening on therapy) and recurrence (after completion of therapy) were noted. Patients who declined enrollment were asked to participate as controls. Cost-utility analysis was performed using Pediatric Quality of Life Scale (PedsQL®) to calculate quality-adjusted life month (QALM) for study and control patients. RESULTS Twenty-four patients agreed to undergo nonoperative management, and 50 acted as controls. At a mean follow-up of 14 months, three of the 24 failed on therapy, and 2/21 returned with recurrent appendicitis at 43 and 52 days, respectively. Two patients elected to undergo an interval appendectomy despite absence of symptoms. Appendectomy-free rate at one year was therefore 71% (C.I. 50-87%). No patient developed perforation or other complications. Cost-utility analysis shows a 0.007-0.03 QALM increase and a

Transmucosal passage of bacteria across rat intestinal epithelium in the Ussing chamber: effect of nutritional factors and bacterial virulence.

1359 savings from

Rollover injuries in residential driveways: age-related patterns of injury.

4130 to

Unique Characteristics of the Neonatal Intestinal Mucosal Barrier

2771 per nonoperatively treated patient. CONCLUSION Despite occasional late recurrences, antibiotic-only treatment of early appendicitis in children is feasible, safe, cost-effective and is experienced more favorably by patients and parents.

Unusual Sertoli Cell Tumor Associated With Sex Cord Tumor With Annular Tubules in Peutz-Jeghers Syndrome Report of a Case and Review of the Literature on Ovarian Tumors in Peutz-Jeghers Syndrome

Transmucosal passage of bacteria across the intestine, the essential and prerequisite step for bacterial translocation, cannot be effectively studied using in vivo models of translocation. We have adapted the Ussing chamber into a fresh, sterile organ culture system that can facilitate the study of bacterial-epithelial interactions. Intestinal membranes were mounted in the Ussing chamber and perfused with a solution rich in putative mucosal micronutrients. The transmembrane potential difference was constantly monitored as a marker of intestinal integrity. Transmucosal passage of various bacteria across the normal intestinal epithelium was quantitated, and the mucosal membrane was examined by light and transmission electron microscopy. The addition of potassium cyanide to the mucosal perfusate resulted in an irreversible loss of potential difference. Oxygen deprivation also led to a precipitous drop in potential difference, but it was reversible with prompt reoxygenation. In contrast, intestinal membranes perfused with a solution consisting of Dulbeccos modified Eagles medium + 20 mM glutamine maintained their potential difference for a sustained period (<180 min). Both the viability and structural integrity of the ileal intestinal membrane were maintained in culture ex vivo using this perfusate. Qualitative differences were observed in the mechanism of transmucosal passage of mild to moderately virulent bacteria such as Escherichia coli C-25 and Proteus mirabilis M-13, which pass through the intestinal epithelium without causing overt damage to the mucosa, and more virulent organisms such as Salmonella typhimurium, which cause extensive mucosal damage by light and transmission electron microscopy. The Ussing system should provide a useful model of intact organ culture for the study of the mechanisms of bacterial translocation and the pathogenesis of enteric infections.

Perioperative management of Parkinson’s disease

Background. The major objective of the present study was to determine the severity of nonfatal injuries sustained by children (<16 years old) when a motor vehicle rolls over them. We also sought to determine whether younger children (<24 months old) demonstrated different patterns of injury and/or a worse outcome, compared with older children (>24 months old). Methods. We reviewed the medical records of 3971 consecutive admissions to a single trauma service at an urban childrens hospital between March 1990 and October 1994. During this time period, 26 (0.7%) children presented with rollover injuries incurred by motor vehicles in residential driveways. Outcome was measured by length of both intensive care unit admission and hospitalization. Results. Two children died shortly after admission and were excluded from the remainder of the study. Younger children (<24 months old) had significantly higher injury severity scores and lower pediatric trauma scale scores. Both the duration in the intensive care unit and the length of hospitalization were significantly longer in younger children, compared with children >24 months old. One explanation for these observations was that younger children had a significantly higher incidence of both head and neck and extremity injury but a similar incidence and severity of chest and abdominal trauma, compared with older children. Injuries requiring operative intervention were rare. Conclusion. Younger patients sustaining rollover injuries in the residential driveway have a worse outcome, in part, because of the head and neck or extremity injures that they incur. The majority of rollover injuries can be managed conservatively. pediatric trauma, driveway, pedestrian events, rollover injuries, injury severity score, pediatric trauma scale.

Parenteral nutrition in intestinal failure

The purpose of this study was to compare the newborn and weanling intestinal mucosa to determine differences in: (1) the electrophysiologic characteristics of the mucosal barrier; (2) the effects of glutamine supplementation on these physiological characteristics; and (3) transmucosal bacterial passage. The Ussing chamber was used to study ileal mucosa from newborn (1 to 4 days old) and weanling (21 days old) piglets. After the seromuscularis was stripped off the bowel wall, the mucosa was mounted in the chamber and perfused with Hanks Balanced Salt Solution (HBSS) or HBSS + 20 mmol/L of glutamine. Following initial stabilization, potential difference (PD) and resistance (R) were measured at 30-minute intervals for 2 hours. Transmucosal bacterial passage was measured by quantitative cultures of the mucosal and serosal reservoirs obtained 2 hours after adding 10(8) E coli C-25 to the mucosal reservoir. Six groups of membranes were studied: (1) newborn and HBSS; (2) weanling and HBSS; (3) newborn and HBSS + glutamine; (4) weanling and HBSS + glutamine; (5) newborn - HBSS + glutamine + E coli; and (6) weanling - HBSS + glutamine + E coli. Newborn ileal mucosa had significantly lower PD and R compared with weanling at all time points. Glutamine led to a significant increase in PD in both newborn and weanling. Newborn mucosa had a significantly increased incidence of transmucosal bacterial passage (4/7) compared with weanling (0/10). These findings suggest that: (1) newborn mucosal barrier has uniquely different electrophysiologic characteristics; (2) glutamine improves the metabolic activity as measured by PD in both newborn and weanling; and (3) the newborn mucosal barrier allows increased transmucosal passage of bacteria.