Hannu Lintula

A diagnostic score for children with suspected appendicitis

Background/purposeAppendicectomy is an operation that is often performed without certainty of diagnosis. This study aimed to construct and to validate a prognostic score for the diagnosis of acute appendicitis in children.MethodsData for 35 symptoms and signs were prospectively recorded for 131 consecutive children with suspected appendicitis. Logistic regression analysis of the variables yielded a diagnostic score: gender (male 2 points, female 0) + intensity of abdominal pain (severe 2, mild or moderate 0) + relocation of pain (yes 4, no 0) + vomiting (yes 2, no 0) + pain in the right lower abdominal quadrant (yes 4, no 0) + fever (yes 3, no 0) + guarding (yes 4, no 0) + bowel sounds (abnormal 4, normal 0) + rebound tenderness (yes 7, no 0). The cut-off level for recommendation of appendicectomy was ≥21, and the cut-off level for non-appendicitis was ≤15. The score was prospectively validated on 109 children.ResultsIn the validation sample, based on clinical judgment, unnecessary appendicectomy was performed in ten (27%) children, and one (4%) child was misdiagnosed as not having appendicitis. By application of the score, unnecessary appendicectomies would have been reduced to four (13%), and three children (11%) with appendicitis would have been discharged.ConclusionThe use of a predictive mathematical model may facilitate the diagnosis of appendicitis to avoid unnecessary operations.

Diagnostic score in acute appendicitis. Validation of a diagnostic score (Lintula score) for adults with suspected appendicitis

PurposeWe have previously constructed and validated a diagnostic score to reduce the negative appendicectomy rate in children with suspected appendicitis. The purpose of this prospective study was to validate the diagnostic score (Lintula score) in adults with suspected appendicitis.MethodsA total of 177 patients with suspected appendicitis were randomly assigned to either the appendicitis-score-group (n = 96) or the no-score-group (n = 81). The management decision was based on the use of the diagnostic scoring system in the appendicitis-score-group and on a sole clinical assessment in the no-score-group. The main diagnostic performance parameters were the diagnostic accuracy, specificity and sensitivity, the positive and negative predictive values, and the rate of negative appendicectomies.ResultsThere was no difference between the appendicitis-score-group and the no-score-group in the diagnostic accuracy (92% vs. 91%; P = NS) and the negative appendicectomy rate (13% vs. 16%). Following repeated clinical examination, the diagnostic accuracy improved in both groups, 74% vs. 92% in the appendicitis-score-group (P = 0.01), and 84% vs. 91% in the no-score-group (P = 0.01). The application of the Lintula score yielded a higher positive predictive value (98% vs. 84%; P = 0.02) and specificity (98% vs. 84%; P = 0.028), but a lower negative predictive value (86% vs. 100%; P = 0.016) and sensitivity (87% vs. 100%; P = 0.022) than unaided clinical examination in the no-score-group. There were no differences in terms of the length of hospital stay, rate of complications and appendiceal histology between the two groups.ConclusionThe use of the acute appendicitis score developed for paediatric patients seems to provide some benefits compared to an unaided clinical diagnosis and may, thus, be a useful diagnostic tool for general surgeons.

Laparoscopic Versus Open Orchidopexy in Children with Intra-abdominal Testes

BACKGROUND/PURPOSE The management of intra-abdominal testis has been controversial but has changed significantly since the introduction of the laparoscopic technique. The aim of our study was to evaluate the success rate of laparoscopic orchidopexy (LO) compared with that of open orchidopexy (OO). MATERIALS AND METHODS In Kuopio University Hospital, 35 of 357 children with undescended testes treated between January 1992 and December 2004 had intra-abdominal testes. A retrospective review was performed to compare the outcomes of children having LO with those who had undergone OO. RESULTS Sixteen children with 19 intra-abdominal testes underwent LO and 18 children with 18 intra-abdominal testes underwent OO. Primary LO was performed in 14 children with 17 testes and staged Fowler-Stephens LO in 2 children. One LO was converted to OO. The mean (+/- standard deviation) operating time was 62 (+/- 30) minutes in the LO group and 43 (+/- 12) minutes in the OO-group (mean difference of 19 minutes, 95% confidence interval of the difference of 2 to 34 minutes; P = 0.025). There were no differences in the length of hospital stay between the two groups. Two major intra-abdominal complications occurred: 1 child in the LO-group had spermatic vessels torn, which led to a one-stage Fowler-Stephens orchidopexy, and the other child, one who had undergone a conversion from LO to OO, had a transection of the vas. One child in both groups was lost to follow-up. The overall success rate (acceptable scrotal position of the testis without testicular atrophy) was 88% in the LO group and 82% in the OO group. CONCLUSIONS Although marginally longer in duration, primary LO appears to be a feasible, safe technique for the management of the low intra-abdominal testes, whereas the staged Fowler-Stephens LO may be more safe than primary LO in cases with high intra-abdominal testes.

Laparoscopic Fundoplication in Children with a Preexisting Gastrostomy

BACKGROUND Children with a gastrostomy may require laparoscopic fundoplication (LF). METHODS Children with a gastrostomy who underwent LF between 1998 and 2002 were reviewed. The outcomes of children undergoing LF were compared with a group of children without a gastrostomy who had the same operation during the same period. RESULTS Ten children with a gastrostomy in place and eight children without a gastrostomy underwent LF. The median operating time was 198 minutes (range, 115-300 minutes) in the gastrostomy group and 110 minutes (range, 80-130 minutes) in the non-gastrostomy group (P =.002). In the gastrostomy group, two children had ventriculoperitoneal shunts and two had extensive intra-abdominal adhesions due to peritonitis. One laparoscopic procedure in each group was converted to an open approach. A successful LF was performed in nine of the ten children without taking down the gastrostomy. One child with a gastrostomy experienced recurrent vomiting that was managed with a gastrojejunal tube. One child in the non-gastrostomy group required reoperation due to an esophageal stricture. CONCLUSION It seems that LF can be performed safely and effectively in children with a preexisting gastrostomy. LF in children with a gastrostomy seems to be as efficacious as LF in children without a gastrostomy.

Laparoscopic dismembered pyeloplasty in a child with a relatively inaccessible intrarenal pelvis.

Laparoscopic pyeloplasty is an accepted way of dealing with pelviureteric junction obstruction in children with extrarenal pelvis. However, intrarenal pelvis has been considered a relative contraindication for laparoscopic pyeloplasty. Here, we describe the technique of laparoscopic dismembered pyeloplasty in a child with intrarenal pelvis. The key when one embraces laparoscopic dismembered pyeloplasty is to ensure that outcomes are not compromised. A successful outcome requires a widely patent, well-vascularised anastomosis performed free of tension.