Carlos Reck

Comprehensive Evaluation of 11 Cytokines in Premature Infants with Surgical Necrotizing Enterocolitis

Objective A prospective study to investigate the pattern of pro- and anti-inflammatory cytokine responses in neonates with surgical necrotizing enterocolitis (NEC) and identify those cytokines being the most promising for future research. Methods A panel of 11 different cytokines were measured in 9 infants with proven NEC and compared with 18 age-matched healthy neonates. Results The serum concentrations of the interleukins (IL)-6, IL-8, and IL-10 were significantly (32–fold to 56-fold) higher in NEC infants compared with controls. In contrast, IL-5, IFN gamma, IL-4 and IL-2 showed slightly (1.4-fold to 5.9-fold) lower levels in the NEC samples. However, these cytokines showed a very low absolute concentration in infants with NEC and in controls. The sum of the serum concentrations of IL-6, IL-8 and IL-10 was able to clearly separate infants with NEC from control samples. IL-1 beta and TNF-alpha showed no statistically different levels. The serum levels of TNF-beta and IL-12p70 were below the detection limit in more than 50% of all samples per group. Conclusion In spite of strong local inflammation only three out of eleven cytokines (IL-6, IL-8, and IL-10) showed strongly increased serum levels indicating an important role of them in the pathogenesis of NEC. At least two of these three cytokines were elevated in every single NEC patient. Thus, longitudinal monitoring of combined IL-8, IL-6, and IL-10 levels could reveal their potency in being clinical relevant markers in NEC.

Interleukin 8 correlates with intestinal involvement in surgically treated infants with necrotizing enterocolitis

PURPOSE The aim of this study was to test the predictive value of interleukin (IL) 8 in the assessment of intestinal involvement in necrotizing enterocolitis (NEC). METHODS Forty infants with surgically treated NEC were classified into 3 groups based on intestinal involvement during laparotomy: focal (n = 11), multifocal (n = 16), and panintestinal (n = 13). Preoperatively obtained serum levels of IL-8, C-reactive protein, white blood cell count, and platelet count were correlated with intestinal involvement using logistic regression models. RESULTS Interleukin 8 correlated significantly with intestinal involvement in infants with surgically treated NEC (odds ratio, 1.74; confidence interval, 1.27-2.39; P < .001). An exploratory IL-8 cutoff value of 449 pg/mL provided a specificity of 81.8% and sensitivity of 82.8% to discriminate focal from multifocal and panintestinal disease. An IL-8 cutoff value of 1388 pg/mL provided a specificity of 77.8% and a sensitivity of 76.9% to discriminate panintestinal disease from focal and multifocal disease. CONCLUSIONS To our knowledge, this is the first study to demonstrate a significant correlation of IL-8 with intestinal involvement in advanced NEC in a large patient population. Our results indicate that IL-8 may be a promising biomarker for assessing intestinal involvement in infants with advanced NEC.

Interleukin-8 predicts 60-day mortality in premature infants with necrotizing enterocolitis

OBJECTIVE The purpose of this study was to evaluate the predictiveness of circulating interleukin (IL)-8 for 60-day mortality in premature infants with necrotizing enterocolitis (NEC). BACKGROUND NEC affects up to 5% of premature infants and remains a leading cause of mortality among neonates. METHODS A total of 113 infants with surgically (n=50) or medically (n=63) treated NEC were retrospectively analyzed. Laboratory parameters including serum IL-8 were assessed at the diagnosis of NEC and during the preoperative workup. RESULTS The 60-day mortality was 19% (22/113), 10% (6/63) in medical and 33% (16/50) in surgical NEC. IL-8 levels significantly correlated with 60-day mortality (odds ratio: 1.38; CI 1.14-1.67; p=0.001). Median IL-8 levels at diagnosis were significantly higher in neonates who were later treated surgically (median=2625 pg/ml; range: 27-7500) compared with those treated medically (median=156 pg/ml; range: 5-7500; p<0.001). The AUC to discriminate between medical and surgical NEC was 0.82 (CI, 0.74-0.90), and an exploratory IL-8 cutoff point could be established at 1783 pg/ml (sensitivity of 90.5%; specificity of 59.2%). CONCLUSIONS Our findings that serum IL-8 (i) correlates directly with 60-day mortality and (ii) differs significantly between medically and surgically treated infants may change the process of therapeutic decision making in NEC.

Neuroendocrine tumor of the common hepatic duct, mimicking a choledochal cyst in a 6-year-old child

We report a rare case of a neuroendocrine tumor of the extrahepatic biliary tree in a child. A 6-year-old girl who presented with jaundice and pruritus was found to have elevated liver enzymes along with a cystic dilatation of the common hepatic duct. After further diagnostic testing, a working diagnosis of a type I choledochal cyst was established. Laparotomy revealed hydrops of the gall bladder, an elongated and dilated cystic duct and a cystic dilatation of the common hepatic duct. An unusually thickened common bile duct was also noted at the time. Follow-up histology revealed an invasive neuroendocrine tumor which lead to a second look operation in which extended resection and lymphadenectomy was performed. No histological or gross pathological evidence of lymph node metastasis was found. Postoperatively the patient continues doing well 2 years after the original diagnosis was established. Neuroendocrine tumors of the extrahepatic bile duct are extremely rare with only 4 pediatric cases of a total of 51 cases published in the literature. To our knowledge, this is the youngest patient reported so far. The rarity of this entity made it challenging to diagnose a case of a neuroendocrine tumor in an atypical location that radiologically mimicked a choledochal cyst.

Delayed Referral Despite Appropriate Knowledge in Cryptorchidism as a Cause of Delayed Orchidopexies in Austria

AIM Guidelines recommend early orchidopexy in cryptorchidism to decrease the risk of infertility and tumor formation. We aimed to asses if a delayed initial presentation for cryptorchidism was due to unawareness of these guidelines or for any other reasons. METHODS A short questionnaire exploring timing and referral habits when assessing children with cryptorchidism was sent by email to all registered pediatricians in Austria. Comparatively, a chart review of performed orchidopexies was performed at our institution. RESULTS Of 369 registered pediatricians, 102 (27.6%) returned valid questionnaires. The average maximum age at which pediatricians in Austria suggested treatment of cryptorchidism was the 21.2 (8.4 months standard deviation (SD)) month of life. Assessment of testicular descent was reported to be regularly performed until the 8.8 (3-18 years SD) year of life. In contrast, from 1997-2008, 730 boys were treated surgically for cryptorchidism at our department. The mean age at operation was 3.4 years (3.1 years SD). CONCLUSION The majority of pediatricians in Austria know the correct timing for treatment of cryptorchidism. Nevertheless, orchidopexies are still carried out to later than suggested by international guidelines. Further studies and analysis to evaluate the reasons for these suboptimal referring patterns coupled with further communication improvements between pediatricians and surgeons are needed.

Online hypospadias support group data analysis

BACKGROUND Although hypospadias is the most common malformation of the penis, this condition is virtually unknown to the general population. This lack of information may lead to psychological distress to both parents and patients. In this study the content of an Internet-based hypospadias support group is analyzed. MATERIALS AND METHODS All comments and postings made by members of an online support group between 2001 and 2008 were analyzed. No personalized data were used for evaluation. RESULTS At the end of 2008, the group consisted of 535 members. In the study period, 3050 postings were published. Major issues discussed in the group were (a) medical questions, exchange of medical knowledge, experience, and history; (b) psychological, ethical, and philosophical aspects; (c) practical questions and recommendations; (d) recommendations for surgeons; and (e) hypospadias in adults. CONCLUSIONS Online hypospadias support groups play an important role in how parents and patients cope with the condition. Surgeons dealing with hypospadias should be aware of the importance of Internet-based information in the field of hypospadias. They may benefit from the valuable feedback information from patients and parents to improve their practice and outcome.

Major complication after intrauterine vesico-amniotic shunting

Bilateral foetal uropathy is the leading cause of chronic renal failure in childhood. Vesico-amniotic shunting (VAS) is a simple, feasible, and widely used procedure for decompressing the foetal urinary system. We report a case of a boy with bilateral foetal uropathy who underwent VAS at a gestational age of 29 weeks. Vesico-abdominal shunt dislodgement occurred and led to urinary ascites and anhydramnios. Postpartal laparotomy showed a shunt perforation between the urinary bladder and the peritoneal cavity.

Submucosal hematoma presenting as small bowel obturator obstruction in a patient on low-molecular-weight heparin

Recent studies have shown the efficacy of low-molecular-weight heparin (LMWH) in the treatment of venous thromboembolic disease in children. Compared to unfractionated heparin and coumadin, LMWH has more predictable pharmacokinetics and a reported lower incidence of osteoporosis and heparin-induced thrombocytopenia in children. The overall incidence of severe hemorrhage on LMWH in children is low. To date, there is a single report of a small bowel obstruction in a child secondary to a hematoma while on LMWH. We report the second case of a child, on enoxaparin (Lovenox) therapy, who underwent bowel resection secondary to a completely obstructing small bowel wall hematoma.

Rectal atresia and anal stenosis: the difference in the operative technique for these two distinct congenital anorectal malformations

Rectal atresia and anal stenosis are rare forms of anorectal malformations. The aim of the definitive surgical repair in such cases is to preserve the anal canal, the dentate line, and the sphincter complex. We present a case of rectal atresia and anal stenosis to demonstrate the differences in the operative repair. The techniques described leave the anterior wall of the very distal anal canal untouched in both rectal stenosis and anal atresia; however, the dissection of the rectum differs. The atretic rectum in rectal atresia is mobilized and sutured to the anal canal circumferentially. In anal stenosis, the posterior rectum is mobilized in the form of rectal advancement, and the posterior 180° is anastomosed directly to the skin (as in a standard PSARP) with preservation of the anal canal as the anterior 180° of the final anoplasty. These patients have an excellent prognosis for bowel control and fecal continence, and therefore, complete mobilization and resection of the anal canal must be avoided.

Decision making among different treatment options for neurologically impaired boys with undescended testis: A multinational pediatric survey

OBJECTIVE To determine the attitude of referring pediatricians towards the decision of treatment modalities for undescended testis (UDT) in neurologic impaired boys (NIB). METHODS AND MATERIALS An online questionnaire was offered to registered pediatricians in Austria and Germany for online completion. RESULTS 221 male (61.6%) and 138 female (38.4%) pediatricians completed the survey; 326 (90.8%) believe that UDT should be treated according to national guidelines; 31 (8.6%) believe that UDT should be treated according to the parental wish, whereas only 2 (0.6%) tend to no treatment at all. Tumor prophylaxis, further sexual life, legal concerns, risks of anesthesia, and the choice of the parents have major impact on the perception of UDT. Moreover, fertility and limited life expectancy seem to be of minor importance only. In general, Pearson χ2 test could not identify age and sex of pediatricians as significant predictor of how the importance of the treatment of UDT is appraised. CONCLUSION From the pediatric point of view UDT in NIB is an important issue and should be treated according to guidelines. Nevertheless, this study indicates the problems in decision-making and choosing the best management for UDT in NIB. Undoubtedly, further ethical discussion is needed to optimize treatment of UDT in NIB.