Baruch Klin

Intussusception : A 9-year survey (1986-1995)

BACKGROUND Acute intussusception has different clinical features in various parts of the world. The goal of this study was to determine the clinical presentation in different ethnic groups in Israel. METHODS A retrospective chart review of a 9-year period (1985-1995) was carried out at a university medical center. Data extracted included age, sex, ethnic origin, presenting symptoms and signs, the type of enema (barium or air), and the success rate of non-surgical reduction of the intussusception. RESULTS Ninety patients suffering from intestinal obstruction due to acute intussusception were admitted. The triad of intermittent screaming attacks, lethargy, and vomiting was observed in 37.5% of study subjects. The majority of patients were admitted during the warmer months of the year. The average age of the patients was 7.8 +/- 3.7 months; 70% of them were between the ages of 4 and 9 months and 92.5% under 1 year of age. The female-to-male ratio was 1:2.1. Air enema was superior to the barium enema in achieving reduction (p < 0.01). The incidence in the Jewish population was similar to that observed in other surveys, and twice that found in the Arab population in our region (p < 0.05). CONCLUSIONS The overall clinical presentation of acute intussusception found in our study does not differ from other studies. The lower incidence of acute intussusception found in the Arab population can be explained by ethnic, genetic, or nutritional factors.

Unilateral Hydroureteronephrosis Caused by Abdominoscrotal Hydrocele

Abdominoscrotal hydrocele is extremely rare in children. A case is presented of an unusually large abdominoscrotal hydrocele in a child, with secondary right hydroureteronephrosis due to contiguous pressure and right cryptorchidism. This entity, although unusual, should be considered in the differential diagnosis of a lower abdominal mass in children, as well as a cause of hydroureteronephrosis. Diagnosis is made with ultrasound, computerized tomography and occasionally excretory urography. Complete surgical excision through a groin incision is recommended, but optional inguinoabdominal or abdominal incisions have been reported. After surgical removal, healing is usually complete, including regression of the hydroureteronephrosis.

Subcuticular Skin Closure as a Standard Approach to Emergency Appendectomy in Children: Prospective Clinical Trial

Abstract. We evaluated the morbidity associated with primary closure by interrupted subcuticular absorbable sutures following emergency appendectomy. In a prospective clinical trial over a 12-month period, 216 children who underwent emergency appendectomy had skin closure using subcuticular interrupted absorbable polyglactin 4-0 sutures. Preoperative prophylactic antibiotics consisting of metronidazole alone or in combination with gentamicin were used in patients with suspected phlegmonous appendicitis; a combination of metronidazole, gentamicin, and ampicillin was used when perforation of the appendix was suspected. Postoperatively, in patients with phlegmonous appendicitis metronidazole was given for 24 hours, whereas in those with peritonitis the triple antibiotics were continued for 7 to 10 days. All patients were assessed for complications resulting from the technique of wound closure. No intraabdominal abscesses or serious complications were recorded. The overall incidence of wound infection was 1.8%. Among children with a perforated appendix the rate of superficial wound infection was 5.7%. There was no difference in the rate of wound infection between patients who received metronidazole alone or metronidazole plus gentamicin preoperatively. All the patients and their families were satisfied with the cosmetic results and with the fact that removal of skin sutures was unnecessary. We conclude that the use of prophylactic antibiotics permits standard skin closure by interrupted absorbable subcuticular suture.

Postural stability by computerized posturography in minor head trauma

Mild head injuries are very common among young children. Often, these injuries are followed by a variety of subjective complaints termed posttraumatic syndrome. Posturography (balance test) was performed immediately after the trauma in 21 children who had sustained mild head injury. Significant difference in performance was observed in head-injured children in all subparts of the test as compared with a control group. We conclude that posturography may serve as a simple cost-effective method in qualifying the posttraumatic imbalance.

Blunt pancreatic trauma in children

PurposeTo report our experience with blunt pancreatic trauma in pediatric patients and evaluate several various management strategies.MethodsTen children admitted over the last 10 years with pancreatic blunt trauma were included in the present series.ResultsThe average time from injury to hospital admission was 2.4 days. All injuries resulted from accidents: bicycle handlebar injuries (5), being kicked by a horse (2), falls from a height (2), and injury sustained during closure of an electric gate (1). Additional systemic and abdominal injuries were recorded in 7 patients. The amylase levels at the time of patient admission were normal in 3 patients, mildly raised in 4 patients, and elevated in 3 patients. Abdominal computed tomography was performed in 10 patients, ultrasonography in 5, and endoscopic retrograde cholangiopancreatography (ERCP) in 4. Pancreatic injuries comprised 4 grade I, 3 grade II, and 3 grade III injuries. Grade I and II injuries were successfully managed by conservative treatment. The 3 children with grade III trauma and pancreatic ductal injury in the neck (1), body (1), and tail (1) of the gland were surgically treated, having an uneventful postoperative stay of 8–14 days and no complications during the 1-year follow-up period.ConclusionThe present study supports early ERCP as an essential part of the initial patient evaluation when pancreatic transection is highly suspected.

Management of Primary Spontaneous Pneumothorax in Children

Objective. To examine the role of CT scans and early surgical intervention in the management of pediatric patients with primary spontaneous pneumothorax (PSP). Methods . Retrospective cohort study. Results. The authors identified 46 cases with 70 episodes of pneumothorax. The recurrence rate among conservatively treated patients was 50% both after the first and the subsequent episode. Recurrence rate in cases with and without blebs on CT was comparable. Initial episodes were treated with supplemental oxygen (n = 18) and chest tube drainage (n = 18), and 10 patients underwent video-assisted thoracoscopic surgery (VATS). The recurrence rate was significantly lower following surgical intervention compared with other therapy, and morbidity was comparable with that in patients who needed chest tube drainage. Conclusions. Recurrence after the first episode of PSP in children is frequent and is difficult to predict by CT findings. VATS is safe and effective in preventing recurrences. Surgical intervention may be an attractive alternative in patients who require chest tube drainage for the first episode of PSP.

Incidence of recurrent intussusception following barium versus air enema

The aim of this study was to determine whether using air enema for acute intussusception is related to a higher rate of recurrence than other methods of treatment. A 10‐y (1986‐95) retrospective study was performed in a university‐affiliated paediatric division. The overall recurrence rate for 97 patients with acute intussusception was 7.8% (10% of whom were treated non‐surgically). There were no recurrences following the surgical treatment. In matched groups of patients, no risk factors were found for recurrence following air vs barium enema.

Bicycle-related injuries in children: Disturbing profile of a growing problem

CONTEXT We observed a changing pattern of bicycle-related injuries in children, with the focus changing from head trauma to thoracic and abdominal injuries, and a trend to increasingly severe injuries. OBJECTIVE To assess the changing injury pattern, and investigate the development of preventive measures to improve safety. DESIGN, SETTING, AND PARTICIPANTS Retrospective record review of 142 paediatric patients admitted to our Department of Paediatric Surgery between 1996 and 2005 following bicycle-related injuries. Clinical, laboratory, diagnostic, and therapeutic aspects were analysed. Additional information concerning childrens bicycle-related injuries in Israel was obtained from the Gertner Institute (Israel National Center for Trauma and Emergency Medicine Research) and from Beterem (The National Center for Childrens Safety & Health, the Safe Kids Israeli Chapter) National Report on Child Injuries in Israel 2006. MAIN OUTCOME MEASURES The nature and severity of injuries were reviewed, and two 5-year periods compared-from 1996 to 2000 (53 children-Group 1), and from 2001 to 2005 (89 children-Group 2). RESULTS Head trauma was more common in the Group 1 patients (52.6% vs. 45.2%), but skull fractures and intracranial haemorrhage occurred more frequently in Group 2 (28.5% vs. 16.7%; 21.3% vs. 8.3%, respectively). Injury to the stomach or duodenum, kidneys and liver were all more common in Group 2. Splenic injury occurred with equal frequency in both groups, but more severe injuries were seen in Group 2. More children in Group 2 required intensive care (31% vs. 19.3%). CONCLUSIONS There is a changing pattern of bicycle-related injuries in children, with chest and abdominal injuries dominating, and an increasing incidence of more severe injury. These findings are important in decision-making regarding preventive measures.

Computed tomography is not justified in every pediatric blunt trauma patient with a suspicious mechanism of injury.

OBJECTIVE Computed tomography (CT) has become an important tool for the diagnosis of intra-abdominal and chest injuries in patients with blunt trauma. The role of CT in conscious asymptomatic patients with a suspicious mechanism of injury remains controversial. This controversy intensifies in the management of pediatric blunt trauma patients, who are much more susceptible to radiation exposure. The objective of this study was to evaluate the role of abdominal and chest CT imaging in asymptomatic pediatric patients with a suspicious mechanism of injury. METHODS Forty-two pediatric patients up to 15 years old were prospectively enrolled. All patients presented with a suspicious mechanism of blunt trauma and multisystem injury. They were neurologically intact and had no signs of injury to the abdomen or chest. Patients underwent CT imaging of the chest and abdomen as part of the initial evaluation. RESULTS Thirty-one patients (74%) had a normal CT scan. Two patients of 11 with an abnormal CT scan required a change in management and were referred for observation in the Intensive Care Unit. None of the patients required surgical intervention. CONCLUSION The routine use of CT in asymptomatic pediatric patients with a suspicious mechanism of blunt trauma injury is not justified.

The contribution of intraoperative transinguinal laparoscopic examination of the contralateral side to the repair of inguinal hernias in children

BackgroundBilateral inguinal hernias are relatively common in children. This fact has led to a controversy of more than 50 years concerning the necessity of bilateral surgical exploration during the repair of unilateral inguinal hernias in children. The advent of transinguinal laparoscopic visualization of the contralateral side is a turning point and a major contribution to the subject, offering the opportunity to reassess the systematic bilateral exploration and the “wait and see” policies currently in use at most services of pediatric surgery.Data sourcesThe current information concerning intraoperative transinguinal laparoscopic evaluation of inguinal hernias in children was summarized in a didactic way. A MEDLINE search (PubMed) from 1995 to the present days was conducted.ResultsA patent processus vaginalis (PPV) is not equal to a future symptomatic hernia. There is still no definitive evidence on which PPVs will become a hernia (5.8% to 11.6%) and which remain clinically insignificant. Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side is today the most simple and accurate way to reduce the incidence of negative explorations.ConclusionDiagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side during pediatric inguinal hernia repair is a simple, accurate, fast, and effective method to assess the contralateral processus vaginalis, improving decision-making, reducing the number of negative explorations, and sparing the surgeon the embarrassment associated with the appearance of a metachronous hernia at a later date. It is easily learned and should be part of every pediatric surgeon’s practice.