Ivo Jurić

Prospective validation of Alvarado score and Pediatric Appendicitis Score for the diagnosis of acute appendicitis in children.

Objectives The purpose of this study was to compare the results of the Alvarado and Pediatric Appendicitis Score (PAS) scoring systems and to establish which one is more reliable in setting the diagnosis of acute appendicitis in children. Methods All children operated on because of acute appendicitis from October 2011 to May 2013 were enrolled in this prospective study. Both clinical scoring systems have been compared over the same patients, and cutoff values were determined by the receiver operating characteristic curve analysis. Results A total of 311 patients were included in the study, and 265 (85.2%) of them had acute appendicitis. Mean Alvarado score for patients with appendicitis was 8.2 and 6.7 for those without (P < 0.001). Mean PAS for patients with appendicitis was of 7.8 and 6.6 for those without (P < 0.001). Based on the ROC curve analysis, a cutoff value for both scoring systems was 7. In patients with acute appendicitis and Alvarado score of 7 or higher, the correct diagnosis would have been set in 236 patients (sensitivity, 89%; specificity, 59%; positive predictive value, 93.1%), whereas in patients with acute appendicitis and a PAS of 7 or higher, the correct diagnosis would have been set in 228 patients (sensitivity, 86%; specificity, 50%; positive predictive value, 90.1%). No significant difference was found in sensitivity and specificity between the observed scoring systems. Conclusions Both scoring systems can be of assistance in setting the diagnosis of acute appendicitis, but none has adequate predictive values in assessing acute appendicitis and none can be used as an exclusive standard in setting the diagnosis of acute appendicitis in children. The final decision still remaines on the opinion of an expert pediatric surgeon.

Elastic Stable Intramedullary Nailing for Pediatric Long Bone Fractures: Experience with 175 Fractures

Purpose: To demonstrate the effectiveness of intramedullary fixation of displaced long bones shaft fractures in skeletally immature children using the elastic stable intramedullary nails. Patients and methods: The case records of 173 children who underwent fixation with titanium intramedulary nails because of long bones fractures were reviewed. The average age of the patients was 11.7 years, and mean follow-up was 41.3 months. There were 55 humeral, 42 forearm, 42 femoral and 36 tibial fractures. Subjective satisfaction was assessed. Results: All patients achieved complete healing at a mean of 7.5 weeks. Complications were recorded in 11 (6.3%) patients and included: one neuropraxia, six entry site skin irritations, two protrusions of the wires through the skin and two skin infections at the entry site. In a subjective measure of outcome at follow-up, 89% of patients were very satisfied and 11% satisfied; no patients reported their outcome as not satisfied. The implants were removed at a median time of six months from the index operation. Conclusion: Elastic Stable Intra-medullary Nailing is the method of choice for the pediatrics patients, because it is minimaly invasive and shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction.

Frequency of portal and systemic bacteremia in acute appendicitis

Abstract Background : Acute appendicitis is the most common condition requiring an emergency abdominal operation in childhood. In the present study, we analyzed the frequency of portal and systemic bacteremia in 42 patients with acute appendicitis and determined the microbial agents responsible for an acute appendicitis and for portal and systemic bacteremia.

Management of blunt pancreatic trauma in children

PurposeBlunt abdominal trauma is the major cause of abdominal injury in children. Because of the retroperitoneal location, insidious signs and symptoms and the lack of sensitivity with common imaging modalities often lead to difficulties in making an accurate diagnosis. The most common complication is the formation of a pancreatic fistula, pancreatitis and a pancreatic pseudocyst, which usually manifests within 3 or 4 weeks after injury.MethodsThe case records of seven children (4 male, 3 female) treated for blunt pancreatic injury in the department of pediatric surgery, University Hospital, Split were reviewed.ResultsThe treatment modalities were selected according to the grade of the pancreatic injury, hemodynamic status and associated injuries. Because all of the patients were classified as grade I or II according to the American Association for the Surgery of Trauma (AAST) classification, a conservative treatment was selected for all seven patients. In four patients the conservative treatment resulted in the total regression of the clinical, biochemical and radiological signs within four weeks (AAST grade I). In the other three patients, pancreatic pseudocysts arose within 3 or 4 weeks after the injury (AAST grade II).ConclusionsThe status of the main pancreatic duct and the location of the pancreatic injury constitute the basis of the AAST scoring system. This scale should be used as a guide to selecting a surgical or conservative strategy. Based on these data, two factors appear to be the most important determinants of the treatment strategy for children with pancreatic injury: the grade of the pancreatic injury, which is determined according to the status of the main pancreatic duct and the clinical status of the patient.

Pediatric tibial eminence fractures: arthroscopic treatment using K-wire.

Background: Fractures of the tibial intercondylar eminence are observed mostly in children and adolescents, often after minimal trauma. The purpose of this paper is to evaluate the use of K-wire fixation for the arthroscopic treatment of tibial eminence fractures in children. Patients and Methods: From January 2002 through January 2009 ten patients were treated arthroscopically because of the intercondylar eminence fracture in a Department of pediatric surgery, University Hospital Split. Arthroscopically controlled reposition was done, and using mobile X-ray two crossed K-wires were introduced percutaneously from the proximal part of the tibia to the fractured intercondylar eminence. Subjective outcome was obtained using IKDC subjective questionnaire. Results: Average hospitalization time was 11 days. Average duration of treatment was 12.5 weeks. Average follow-up was 42 months. Follow-up radiographs showed union in all cases. The mean IKDC subjective score was 96/100. Clinically, all patients exhibited a solid endpoint on the Lachman test. The global IKDC objective score was normal in eight knees and nearly normal in two knees. Conclusion: Arthroscopic reduction and fixation by Kirschner wires or a small fragment screw is the best way for treatment intercondylar tibial eminence fractures, in the pediatric population, because is not crossing the epiphyseal plate.

Titanium intramedullary nailing for treatment of simple bone cysts of the long bones in children.

Background Simple or unicameral bone cysts are common benign fluid-filled lesions usually located in the long bones of children before skeletal maturity. Pathological fracture is common, and is often the presenting feature. Aim The objective of the present study was to evaluate the results of titanium intramedullary nailing for the treatment of unicameral bone cysts with or without a pathological fracture. Methods During the period 2001 to 2007, flexible intramedullary nailing for the treatment of a unicameral bone cyst was performed in 18 children. Four of these patients presented with a pathological fracture. The cyst was located in the humerus in 14 patients, in the femur in three, and in the tibia in one. The diagnosis was based on typical radiographs and computed tomography. The mean age of the patients at the time of surgery was 9.4 years, and the mean duration of follow-up was 53 months. Radiographic evaluation was performed, and the cyst was classified as completely healed, healed with residual radiolucency, recurred, or having no response. Results Mean hospital stay was 24 hours. At one to four weeks postoperatively, all patients were pain free and had full range of motion of adjacent joints. Radiographic signs of cyst healing were present at three months in all patients, and all cysts healed ompletely. All of the cysts responded to treatment, with no cyst recurrence. No major complications were observed. Conclusion Elastic intramedullary nailing has the twofold benefits of continuous cyst decompression, and early immediate stability to the involved bone segment, which permits early mobilization and return to normal activities

Unusual cause of small intestine obstruction in a child Small intestine anisakiasis: report of a case

Introduction Anisakiasis is caused by human infection by the anisakis larvae, a marine nematode found in undercooked or raw fish. Infection with the parasite Anisakis simplex is common in Japan and northern European countries. With the increased popularity of eating sushi and raw fish infection with anisakis is expected to rise. Case presentation We present the case of a 14-year-old boy who had eaten sushi 3 days before the onset of symptoms and had small bowel obstruction caused by enteric anisakiasis. To the best of our knowledge this is the first reported case of intestinal anisakiasis presenting as a bowel obstruction in a child. Conclusion Enteric anisakiasis is very rare, and its diagnosis is usually made after laparotomy. Nevertheless, when signs of acute abdomen develop after the ingestion of raw fish, such as sushi or sashimi, the possibility of enteric anisakiasis should be considered.

Acute appendicitis as a complication of varicella.

INTRODUCTION Obstruction of the appendiceal lumen is the primary cause of appendicitis. The most common causes of luminal obstruction are fecaliths and lymphoid follicle hyperplasia. Additionally, bacterial infections or enteric and systemic viral diseases can cause a reaction of the lymphoid follicle. CASE PRESENTATION An 11-year-old boy with active phase of chickenpox presented on our Pediatric surgery emergency department under the impression of acute appendicitis. An appendectomy was performed on the same day. An inflamed and edematous retrocecal appendix was removed during surgery. Histological investigation of the appendix revealed transmural acute inflammation, with diffuse proliferation of inflammatory cells, with characteristic intranuclear inclusion surrounded by a clear halo. The PCR analysis of peripheral blood and appendix tissue specimen revealed positive VZV DNA. CONCLUSION We have shown that varicella-zoster virus infection of the appendix is associated with acute appendicitis and possibly also with severity of the disease.

A Comparison of Endoloop Ligatures and Nonabsorbable Polymeric Clips for the Closure of the Appendicular Stump During Laparoscopic Appendectomy in Children

BACKGROUND The aim of this prospective trial was to evaluate the clinical outcomes of nonabsorbable polymeric clips in laparoscopic appendix stump closure in children by comparing the endoloop ligature. PATIENTS AND METHODS From June 2011 to June 2016, 277 children who underwent laparoscopic appendectomy were included in the study. The patients were divided into two groups based on the technique used for appendiceal stump closure: there were 101 patients in the polymeric clips group and 176 in the endoloop group. The risk of intraoperative and postoperative complications was investigated for two different techniques to close the appendiceal stump. RESULTS Among the 277 patients who underwent laparoscopic appendectomy, no intraoperative complications and 17 (6.1%) postoperative complications were recorded. There were no significant differences between the groups with respect to the postoperative complications (P = .546). The median length of the operation was 10 minutes shorter when the polymeric clips were used (P < .001). The median hospital stay was also shorter in the polymeric clips group (P = .008). Costs of polymeric clip were significantly lower (€ 17.64) compared to endoloop (€ 34.16). CONCLUSIONS Closure of the appendix stump with polymeric nonabsorbable clips in laparoscopic appendectomy reduces operative time and may be a cost-effective and simpler alternative to widely used endoloops.

Extremely rare presentation of Frantz’s tumour: synchronous localisation in the pancreatic head and tail

Introduction Solid pseudopapillary tumour of the pancreas is a rare lesion with low malignant potential occurring predominantly in young women. This is a report of an extremely rare occurrence of synchronous presentation of pseudopapillary tumour in the pancreatic head and tail of a 16-year-old female patient. Case presentation The patient presented with a three-month intermittent upper abdominal pain and swelling. Computed tomography scan showed two separate masses, involving the pancreatic head and tail. The patient underwent surgery, where successful tumour enucleation of both tumours was performed. Histological report confirmed solid pseudopapillary tumour of the pancreas with the low malignant potential. Conclusion To the best of our knowledge, this is the first report of synchronous presentation of pseudopapillary tumour of the pancreas.