K. Paya

Perforating appendicitis: An indication for laparoscopy?

AbstractBackground: This pilot study was performed to reassess the widespread postulate that laparoscopic surgery is contraindicated in cases of perforating appendicitis. Methods: A total of 75 children (appendiceal perforation: n= 67; perityphlic abscesses and peritonitis: n= 8) were analyzed in a prospective nonrandomized trial. Ten of them were treated by laparoscopic appendectomy. Results: In the laparoscopy group, both pain and hospitalization were less time-consuming (i.e., by 50% and 19%, respectively). Antibiotics use was down from 2.6 over 6 days to 2.2. over 5.5 days, while the duration of surgery was up by 52%. Wound healing disturbances occurred in 10% (n= 1) and postoperative fever in 50% (n= 5) of patients, compared to 14% (n= 9) and 15% (n= 10) in the group treated by open surgery. All severe complications requiring reintervention (10%; massive subcutaneous abscess, n= 3; retrocolic abscess, n= 2; adhesion-related ileus, n= 3; appendicular stump, n= 1) were associated with open surgery. Conclusions: There was not a single major complication in the laparoscopy group. These unexpected results are in contrast to previous reports and have prompted us to initiate a prospective randomized trial.

Pulmonary echinococcosis (hydatidosis) in children: Results of surgical treatment

From 1986–1996, 33 children with 49 pulmonary hydatid cysts underwent surgical treatment in Vienna and Istanbul. Cysts were unilateral in 28 and bilateral in 5 cases; unruptured cysts (URC) were diagnosed in 19 patients, and 14 children presented with ruptured cysts (RC). Ten patients had cysts in other organs (liver, spleen, central nervous system) in addition to pulmonary cysts. Diagnosis was primarily based on chest X‐ray and computed tomography scan. In Austrian children, a new combination of serological tests was used successfully (71% positive).

Retroperitoneal necrotizing fasciitis in a 4-year-old girl

Necrotizing fasciitis is a rare but serious condition with a poor prognosis both in adults and in children. Retroperitoneal localization is mostly associated with fatal outcome. Early diagnosis, extensive and repeated surgical debridement, and use of antibiotics are necessary. Herein the authors report on a 4-year-old girl in whom retroperitoneal necrotizing fasciitis developed after she suffered from pyelonephritis. In this case, the outcome was favorable because of early surgical intervention, confirming the diagnosis.

Value of circulating immune parameters in renal transplantation

Abstract Diagnosis of acute kidney graft rejection is based on conventional parameters such as creatinine (Crea), Crea-clearance, body temperature, urinary volume, body weight. Taken together they are inexpensive, noninvasive and attain a relatively high sensitivity. In many patients, however, kidney biopsies have to be obtained to ascertain the presence of acute rejection. The presence or absence of rejection might also be authenticated by monitoring serum immune parameters, capable of predicting the onset of clinically relevant immunologic activity. This would provide information on the response to antirejection therapy before graft dysfunction becomes clinically manifest. The following parameters were selected based on their specific characteristics: • ⊎ c-ICAM-1 (intercellular adhesion molecule). Allograft transplantation leads to a chronic or acute immune response that is related to increased expression and release of c-ICAM-1. c-ICAM-1 is expressed on almost all cell types, including macrophages, T- and B-lymphocytes during activation, as well as unstimulated vascular endothelial cells. Healthy individuals show a mean serum level of 230 (130 to 300) ng/mL. • ⊎ s-TNF-R (tumour-necrosis-factor receptor). Elevated s-TNF-R levels are observed in any type of immune response but also eventuate in acute or chronic renal failure as a retention phenomenon. s-TNF-R binds with high affinity and specificity to TNF and acts as an immunobiological regulator of the pluripotent TNF-mediated functions. The complete receptor molecule is expressed on fibroblasts, endothelial cells (EC), myeloid cells, as well as on mitogen-stimulated lymphocytes. • ⊎ s-IL2-R (interleukin-2-receptor). Monoclonal antibodies to IL2-R inhibit T-cell proliferation and counteract renal allograft rejection. IL2-R-bearing cells are crucial in graft rejection, and agents that kill these cells boost graft survival: anti-IL2-R antibodies administered prophylactically to renal allograft patients reduce the rate of early graft rejection. Its mean level in normal individuals is 256 ± 112 U/mL. • ⊎ Neopterin. Is significantly related to T-cell-mediated pathologies and, therefore, can provide clinically useful information on infection, cancer, autoimmunity and graft rejection. Neopterin release from renal epithelial cells has been shown to be stimulated by IFN-γ. Its mean serum level in normal individuals is 5.4 ± 2.3 nmol/L. • ⊎ s-MHC-1 (major histocompatibility complex). Consists of a 44,000-kD intracellular and a short extracellular polypeptide chain designated β2-microglobulin (β2-MG). MHC-1 is the receptor for CD8+ cytotoxic T cells, with the amount of MHC products apparently determining the susceptibility of target cells to being lysed. • ⊎ ELAM-1 (endothelial leukocyte adhesion molecule). Is a glycoprotein (E-selectin) expressed on cytokine-activated (TNF-alpha, IL2, LPS) endothelial cells. Endothelial cells constitute the interface between allograft and the hosts immune system. Endothelial cell functions play a pivotal role in inflammatory responses and vessel behaviour, and might assume a pathogenic role in allograft rejection. E-selectin is the most likely mediator of initial lymphocyte binding to endothelial cells by mediating, in contrast to the integrins, adhesion of resting lymphocytes. The ligands for ELAM-1 are carbohydrates. The present study was performed to establish (1) potential correlations of these parameters with the course of rejection, infection, or of stable condition, in renal allograft recipients and (2) whether antirejection therapy is capable of influencing these parameters. As noninvasive methods for measuring target-organ levels of cytokines or inflammatory markers are not available, a critical appraisal of the sensitivity and specificity of these parameters in peripheral blood during graft rejection appears warranted.

Tissue polypeptide-specific antigen in pediatric patients: Assessment of normal values

Measurement of serum concentrations of tissue polypeptide-specific Antigen (TPS) has been demonstrated to the useful in diagnosis and monitoring of adult epithelial tumors. So far, no data have been available on normal or pathologic TPS values in children. Therefore, the present study was designed to evaluate the normal values of TPS in childhood. Using a commercial enzyme linked immunosorbent assay (ELISA) kit, serum TPS was determined in 361 healthy children. Median (M) TPS was found to be 107 U/l at birth (n = 124). By the end of the first week, the value rose to M = 150 U/l (n = 68) and then continuously decreased with age (1 week-1 year, n = 45, M = 88 U/l; 1-7 years, n = 75, M = 51 U/l) until reaching the adult level (8-18 years, n = 49, M = 34 U/l). Additionally, the serum TPS values of 45 mothers right after delivery (M = 161 U/l) were assessed, and there was no correlation to the marker levels determined in the cord blood of their children. The age-dependent distribution of serum TPS in healthy children must be taken into account in the clinical application of this tumor marker.

Appendicoliths and appendectomy in the pediatric population

ZusammenfassungGRUNDLAGEN: Kotsteine der Appendix sind eine bekannte Ursache für die Appendizitis. Das Vorhandensein eines Appendikolithen per se könnte daher eine Indikation zur Appendektomie darstellen. METHODIK: Retrospektive Untersuchung über einen Zeitraum von 6 Jahren aller Blinddarmoperationen. Verlauf und Diagnose wurden in Bezug auf das Vorhandensein eines Appendikolithen für verschiedene pädiatrische Altersgruppen erhoben. Diese wurden in folgende Gruppen eingeteilt: 0–4 Jahre, 4–6 Jahre, 6–10 Jahre, 10–14 Jahre, 14–18 Jahre, sowie 3 Kategorien (keine Blinddarmentzündung, Blinddarmentzündung, Perforation) zugeordnet. ERGEBNISSE: Neunhundertneunzig Patienten waren inkludiert. Die Inzidenz eines Appendikolithen betrug 28,6%, bei 4–6 jährigen 37,6%. Appendikolithen führten signifikant häufiger zur Perforation (odds ratio 2,27; p < 0,0001), in den Altersgruppen 0–6 Jahre vs 6–18 Jahre betrug die odds ratio: 10,2; (p < 0,0001). Der präoperative Krankheitsverlauf ist signifikant hänger in der Gruppe ohne Appendikolith (p = 0,04). SCHLUSSFOLGERUNGEN: Appendikolithen sind ein hoch signifikanter Faktor für das Auftreten einer spontanen Perforation. Das rechtfertigt die Appendektomie zur Vermeidung der Perforation bei zufällig entdecktem Appendikolith.SummaryBACKGROUND: Improved diagnostic techniques increase the number of incidental findings of appendicoliths even without any patient complaints. Appendicoliths are one cause for appendicitis, and seem to justify elective appendectomy. METHODS: Retrospective evaluation of all patients who underwent appendectomy within a period of 6 years. Stratification into 5 groups: 0–4, 4–6, 6–10, 10–14 and 14–18 years and categorization into 3 possible outcomes: no appendicitis, appendicitis, perforated appendicitis. RESULTS: Nine hundred and ninety patients were included. The incidence of appendicoliths was 28.6%, rising to 37.6% in preschool children. Appendicoliths were strongly associated with appendiceal rupture (odds ratio totally: 2.27; p < 0.0001; age group 0–6 years vs 6–18 years odds ratio: 10.2; p < 0.0001). Preoperative history was significantly higher in patients without appendicolith (p = 0.04). CONCLUSIONS: Appendicoliths are significantly associated with spontaneous perforation. Therefore elective appendectomy in the presence of an appendicolith is justified to avoid perforation.

Asymmetric Pectus Carinatum as Sequela of Minimally Invasive Pectus Excavatum Repair

A very rare complication of minimally invasive repair of pectus excavatum, the development of pectus carinatum, was recently reported. This is an unexpected sequela that was never described when the method of Ravitch was used to repair pectus excavatum. We describe a similar case. However, in contrast to the symmetric pectus carinatum noted by Hebra et al., a very asymmetric hump of the anterior thorax, limited to the right side, developed in our patient, with extremely unappealing cosmetic consequences. The cause appears to have been an overly tight bar resulting from fast growth during puberty.

Transumbilical Access for Pneumoperitoneum (Modified Hasson Procedure) in Laparoscopy in Children and Adolescents

Two principal methods are used to introduce the pneumoperitoneum in laparoscopic procedures. The first and most common technique is blind insertion of the Veress needle, followed by blind puncture of the abdominal wall with a sharp trocar. The second is the open method first described in 1971 by Hasson. Either method produces a scar at least 3 to 4 cm long in the umbilical region. We present a study of 191 consecutive cases (age range, 1.6–29 years; median, 12 years) in which a longitudinal transumbilical access through the lower umbilicus was achieved for insertion of a blunt trocar. The technique is compared with the periumbilical transverse incision and the gridiron incision. Our technique renders a much better cosmetic result and better stability, while maintaining the safety of the Hasson method.