Ilan Erez

A role for conservative antibiotic treatment in early appendicitis in children

PURPOSEnTo evaluate whether antibiotics without surgery is sufficient treatment for children with clinically and ultrasonographically suspected acute appendicitis (AA).nnnMETHODnChildren with clinical, laboratory and radiological findings suspicious for AA were evaluated prospectively. Patients with mild clinical signs, without peritonitis were considered for IV followed by oral antibiotics without surgery.nnnRESULTSnFrom 1 November 2013 through 30 June 2014, 45 children were diagnosed with early, acute appendicitis. Ages ranged from 4 to 15 years (mean 9.3) and 32 (75%) were boys. All had routine, clinical laboratory and ultrasound workup. Forty-two improved with antibiotic treatment and were discharged home within 3-5 days, without surgery. Three of them were operated on within 24 hours, another two underwent appendectomy for recurrent appendicitis: one at 2 weeks and the other 2 months after discharge. There was no more recurrent appendicitis in 6-14-month follow-up.nnnCONCLUSIONnOur series of patients with AA treated with antibiotics only are a product of the observation that some children improve with antibiotics alone at a stage in which surgery is still debatable. These results (89% success rate) support the conservative approach in cases of early appendicitis, without increased morbidity in failed cases.

A conservative treatment for ingrown toenails in children.

Abstract Ingrowing nails are not uncommon in children, and even so receive little attention in the pediatric surgery literature. The purpose of the present study was to demonstrate our modification of the conservative treatment of ingrowing nails. Our technique of local treatment combined with patient education for better foot and toe care was successfully used and well tolerated by 19 out of 20 young patients with ingrown toenails.

Elective sonographic evaluation of inguinal hernia in children — an effective alternative to routine contralateral exploration

Four hundred sonographic examinations were performed on 200 children admitted for elective inguinal hernia operations. The sonographic evaluation proved to be accurate in 92% of confirmable diagnoses and is a simple, non-invasive mode of investigating inguinal hernia and patent processus vaginalis. Our data support a policy of contralateral groin exploration during unilateral hernia repair based on preoperative ultrasonographic information.

Blood sampling through peripheral venous catheters is reliable for selected basic analytes in children.

OBJECTIVE: The goal was to determine the interchangeability of peripheral venous catheter (PVC) and venipuncture blood sampling (BS). METHODS: Paired blood samples from hospitalized children were obtained through venipuncture and from existing PVCs, following discard of 2 mL of blood. Comparisons of 9 complete blood count indices (white and red blood cell counts, hemoglobin and hematocrit levels, mean corpuscular volume, mean corpuscular hemoglobin level, red blood cell distribution width, platelet count, and mean platelet volume) and 5 basic chemical analysis indices (sodium, potassium, glucose, chloride, and urea levels) were performed, and hemolysis was documented. RESULTS: Irrespective of gauge, blood samples were obtained successfully from 40 (85.1%) of 47 PVCs, with no abnormal hemolysis. BS through venipuncture took longer than BS from PVCs (175.8 ± 229.6 vs 104.5 ± 53.4 seconds; P = .053) and was associated with significantly more distress/crying (73.1% vs 0%; P < .001). There were no significant differences between venipuncture and PVC samples (paired t test). Twenty-one (6%) of 348 pairs analyzed with the Clinical Laboratory Improvement Amendment standards fell outside the range of acceptable variance (8 of 21 aberrations were attributed to glucose measurements). Bland-Altman analysis indicated that, with the exclusion of glucose measurements, BS from PVCs is reliable, with 29 (6.5%) of 448 pairs exceeding the limits of agreement. Of those, 9 cases were clinically significant, but none would have altered clinical management. CONCLUSIONS: PVC sampling was shown to be a pain-reducing method that can be used for children for selected basic analytes. The findings for glucose were unreliable.

Spinal anesthesia for gastrostomy in an infant with nemaline myopathy.

IMPLICATIONSnWe report a case of spinal anesthesia in an infant with nemaline myopathy. Spinal anesthesia was administered to preempt the potential problems of difficult tracheal intubation and prolonged mechanical ventilation secondary to muscle weakness after the use of IV anesthetics in this patient.

Quadriceps paresis in pediatric groin surgery

Abstractu2002A total of 2,624 groin operations were performed in 2,202 infants and children aged 6 months–14 years during the last 4.5 years. Preventive analgesia was used in all operations, and included ilioinguinal and iliohypogastric nerve block combined with inguinal canal infiltration. In 6 patients transient postoperative quadriceps muscle paresis (QMP) was noted. They required bed rest and monitoring for a few hours, and complete spontaneous recovery was noted in all cases. The aim of this study was to examine the incidence of transient QMP following regional nerve block and to discuss models of possible prevention.

Continuous lumbar/thoracic epidural analgesia in low-weight paediatric surgical patients : practical aspects and pitfalls

PurposeContinuous epidural anaesthesia attenuates perioperative stress and avoids the need for systemic opioids. In addition, it may prevent the need for postoperative mechanical ventilation. The aim of the study was to prospectively follow the perioperative course of young infants treated with continuous thoracic/lumbar epidural anaesthesia for major surgery.MethodsData were collected prospectively from 44 epidural anaesthetics in 40 infants (18 premature or former premature) weighing 1,400–4,300xa0g who underwent major abdominal surgery (33 cases), thoracic surgery (5), or both (1), or ano-rectal surgery (5) at our centre.ResultsEpidural placement was achieved easily in all cases, with high quality analgesia for 24–96xa0h. Tracheal extubation was delayed after 4 anaesthetics due to muscle relaxant overdose (nxa0=xa01), surgeon’s request (nxa0=xa02), and systemic opioid administration before epidural anaesthesia was considered (nxa0=xa01). Intraoperative complications included haemodynamic instability (nxa0=xa01) and vascular catheter placement (nxa0=xa05). Postoperative complications included meningitis (nxa0=xa01), insertion site erythema (nxa0=xa07), apnoea (nxa0=xa06; 4 premature and 2 full-term infants) and tracheal re-intubation (nxa0=xa06).ConclusionsContinuous epidural analgesia is effective in low-weight infants undergoing major surgery. The trachea may be extubated immediately after surgery. Attention should be paid to the unique anatomical, physiological, and pharmacological aspects. The patients should be monitored carefully for pain, respiratory failure, and meningitis (an extremely rare complication).

The Value of Ultrasound in the Diagnosis of Congenital Hypertrophic Pyloric Stenosis

The charts of 103 children with a clinically and surgically confirmed diagnosis of congenital hypertrophic pyloric stenosis were retrospectively reviewed. We found a significant correlation between sonographic and surgical measurements of the muscular thickness of the pylorus (r = .987, P<.001). In 73.7% (76 cases), the clinical picture of gastric outlet obstruction was present when the thickness of the enlarged pyloric muscle was 3.0 mm or more. In 26.3% (27 cases), the pyloric muscle was less than 3.0 mm wide. For 10 patients in whom the muscle width was less than 2.5 mm by sonography, a barium meal was necessary to confirm the diagnosis. The width of the pyloric muscle is the most important factor in the sonographic diagnosis of pyloric stenosis, and even a width of less than 3.0 mm may be associated with clinically significant obstruction.

Preoperative sonography of the inguinal canal prevents unnecessary contralateral exploration

The need for contralateral inguinal exploration in children during unilateral inguinal hernia repair remains controversial. We questioned whether an elective preoperative sonographic examination of the contralateral inguinal canal was accurate enough to prevent unnecessary exploration of the asymptotic side. Sonography (US) of the groins was performed randomly in 200 out of 600 patients awaiting unilateral hernia repair over a 1.5-year period during 1990–1991. The patients and their medical records were reviewed in 1994, 3–4 years following surgery. Four hundred infants and children underwent unilateral inguinal hernia repair without preoperative US, based on the clinical diagnosis (group I). Of the remaining 200, 160 (group II)_ had the clinical diagnosis confirmed by US. Forty patients with US evidence of a contralateral hernia or hydrocele (group III) were excluded from the study. At follow-up after 3–4 years, 26 patients in group I presented with a hernia in the opposite groin 2 weeks to 2 years following surgery. The incidence of a subsequent contralateral hernia in patients under 1 year, 1–2 years, and older than 2 years was 7.3%, 9.6%, and 4.5%, respectively. None of the patients in group II presented with a clinically evident hernia during the follow-up period. These findings suggest that US is a readily available, non-invasive, and accurate method of preoperative evaluation of the groins. Our policy of contralateral exploration based on the US findings was shown to be reliable in preventing unnecessary surgical exploration of the unaffected inguinal canal.

Interrupted air column in the large bowel on plain abdominal film: A new radiological sign of intussusception

Intussusception is a frequent cause of small bowel obstruction in infants and toddlers. Early confirmation and treatment are paramount. We have recognized a fairly consistent radiological finding in plain abdominal x-rays that had not been described previously. The study compares the x-ray findings of patients with proven intussusception with those of patients with colicky abdominal pain related to other causes. In association with the relevant symptoms, this interrupted air column in the large bowel should alert one to the possibility of intussusception.