Martin Salö

Appendicitis in Children: Evaluation of the Pediatric Appendicitis Score in Younger and Older Children

Background. This study aimed to evaluate Pediatric Appendicitis Score (PAS), diagnostic delay, and factors responsible for possible late diagnosis in children <4 years compared with older children who were operated on for suspected appendicitis. Method. 122 children, between 1 and 14 years, operated on with appendectomy for suspected appendicitis, were retrospectively analyzed. The cohort was divided into two age groups: ≥4 years (n = 102) and <4 years (n = 20). Results. The mean PAS was lower among the younger compared with the older patients (5.3 and 6.6, resp.; P = 0.005), despite the fact that younger children had more severe appendicitis (75.0% and 33.3%, resp.; P = 0.001). PAS had low sensitivity in both groups, with a significantly lower sensitivity among the younger patients. Parent and doctor delay were confirmed in children <4 years of age with appendicitis. PAS did not aid in patients with doctor delay. Parameters in patient history, symptoms, and abdominal examination were more diffuse in younger children. Conclusion. PAS should be used with caution when examining children younger than 4 years of age. Diffuse symptoms in younger children with acute appendicitis lead to delay and to later diagnosis and more complicated appendicitis.

Appendicostomy in preschool children with anorectal malformation: successful early bowel management with a high frequency of minor complications.

Aim. The aim of this study is to evaluate postoperatively bowel symptoms of antegrade colon enema through appendicostomies in preschool children with anorectal malformation (ARM). Method. 164 children with ARM operated on with posterior sagittal anorectal plasty were included. The malformations were classified according to Krickenbeck classification. Seventeen children in preschool age had an appendicostomy. The bowel symptoms according to the Krickenbeck follow-up were analysed pre- and postoperatively. All complications were registered. A questionnaire on the use of the appendicostomy was answered. Results. The median age (range) at the time of the appendicostomy was 4 (1–6) years. The observation time was 5 (0.5–14) years. The main indications for appendicostomy were incontinence and noncompliance to rectal enemas. Postoperatively there was a significant decrease in soiling and constipation (P < 0.001). The total complication rate was 43% with infections (29%), stenosis (12%), and retrograde leakage (0). The median time required for giving enema in the appendicostomy was 45 minutes (range: 15–120) once a day varying from 2 times/week to 3 times/day. And: complications are less frequent than in older children. Conclusion. Appendicostomy in preschool children with ARM is a way to achieve fecal cleanness before school start. The infection rate was high, but other complications are less frequent than in older children.

Repeated Liver Resection for Colorectal Liver Metastases: A Comparison with Primary Liver Resections concerning Perioperative and Long-Term Outcome.

Introduction. 60% of patients operated for colorectal liver metastases (CRLM) will develop recurrent disease and some may be candidates for a repeated liver resection. The study aimed to evaluate differences in intraoperative blood loss and complications comparing the primary and the repeated liver resection for metastases of colorectal cancer (CRC), as well as to evaluate differences in long-time follow-up. Method. 32 patients underwent 34 repeated liver resections due to recurrence of CRLM an studied retrospectively to identify potential differences between the primary and the repeat resections. Results. There was no 30-day postoperative mortality or postoperative hospital deaths. The median blood loss at repeat resection (1850 mL) was significantly (P = 0.014) higher as compared to the primary liver resection (1000 mL). This did not have any effect on the rate of complications, even though increased bleeding in itself was a risk factor for complications. There were no differences in survival at long-term follow-up. Discussion. A repeated liver resection for CRLM was associated with an increased intraoperative bleeding as compared to the first resection. Possible explanations include presence of adhesions, deranged vascular anatomy, more complicated operations and the effects on the liver by chemotherapy following the first liver resection. 30 out of 32 patients had only one reresection of the liver.

Ultrasound for appendicitis: Performance and integration with clinical parameters

Objective. To evaluate the performance of ultrasound in pediatric appendicitis and the integration of US with the pediatric appendicitis score (PAS) and C-reactive protein (CRP). Method. An institution-based, retrospective study of children who underwent abdominal US for suspected appendicitis between 2012 and 2015 at a tertiary pediatric surgery center. US results were dichotomized, with a nonvisualized appendix considered as a negative examination. Results. In total, 438 children were included (mean 8.5 years, 54% boys), with an appendicitis rate of 29%. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for US were 82%, 97%, 92%, and 93%, respectively, without significant age or gender differences. Pediatric radiologists had significantly higher sensitivity compared to general radiologists, 88% and 71%, respectively (p < 0.01), but no differences were seen for specificity, PPV, and NPV. The sensitivity, NPV, and negative likelihood ratio for the combination of negative US, PAS < 5, and CRP < 5 mg/L were 98%, 98%, and 0.05 (95% CI 0.03–0.15). Conclusion. US may be a useful tool for evaluating children with suspected appendicitis, regardless of age or gender, and should be the first choice of imaging modalities. Combining US with PAS and CRP may reduce several unnecessary admissions for in-hospital observation.

Outcomes of Various Interventions for First-Time Perianal Abscesses in Children

Introduction. In children treated surgically for first-time perianal abscesses, discovery and excision of concomitant fistulas may also be warranted. Aim. To evaluate children of varying age after incision and drainage of first-time perianal abscesses, examining recurrences rates with and without search for a fistula. Method. A retrospective review was conducted, analyzing children (ages 0–15 years) treated for first-time perianal abscesses at a tertiary pediatric surgical center, with a minimum follow-up of 6 months. Results. A total of 104 patients subjected to 112 treatments for first-time perianal abscesses were eligible. Surgical procedures constituted 84 (75%) of treatments, searching for fistulas in 49 (58%). In 34 (69%), fistulas were confirmed and treated. In the surgically treated subset, the recurrence rate was higher if no attempt was made to exclude a fistula (46%), as opposed to confirmed absence of a fistula (27%) or concurrent fistulotomy (9%; p = 0.02). Younger patients showed a higher recurrence rate (12/26; 46%), compared with older counterparts (11/58; 19%) (p = 0.002). Conclusion. In children surgically treated for first-time perianal abscess, recurrence rates appear to be lowered by locating and treating coexisting fistulas.

Evaluation of bowel function in healthy children: Untreated constipation is common

We evaluated bowel function in healthy children with regard to gender and age.

Single-Port Laparoscopy-Assisted Appendectomy in Children : A Method Described

Single-incision laparoscopic appendectomy (SILA) has gained popularity in children, and several different techniques have been described, including intracorporeal and extracorporeal techniques and single-channel and multi-channel single-port techniques. However, there has been a concern that exteriorizing an infected appendix through the umbilical channel would increase the risk of postoperative wound infections. This report aims to describe a technique for single-port laparoscopy-assisted appendectomy (SPLAA) using an operative laparoscope and conventional laparoscopic instruments, as well as a VersaStep™ sheath to protect the wound edge while removing the appendix from the abdomen.

Anastomotic Strictures after Esophageal Atresia Repair: Timing of Dilatation during the First Two Postoperative Years

Background  We determined time frames for dilatation of anastomotic strictures (ASs) occurring during the first 2 years after esophageal atresia (EA) repair. Methods  A retrospective study was conducted on children with EA (Gross type C) who underwent direct repair between January 2008 and March 2015 at a single tertiary center of pediatric surgery. Endoscopic signs of stricture were indications for dilatation because the endoscopy provides more reliable information than X-ray imagining methods. Results  Among our cohort of 49 children with EA, 19 (39%) required at least one esophageal dilatation. All children required initial dilatation within the first year of life and none was older than 1 year during initial dilatation ( p  < 0.01). A median of three dilatations (range: 1–13) took place per patient, with 87% performed during the first postoperative year. The timing of initial dilatation in the first year (< 6 months, 14/19 [74%] vs. 6–12 months, 5/19 [26%]) was predictive of the need for dilatation beyond the first year (9/14 [64%] vs. 0/5 [0%]; p  = 0.03) but not of more numerous dilatations (median, 3 vs. 1; p  = 0.07). Conclusion  The need for dilatation within 6 months postoperatively predicts the need for dilatation after 1 year, but it does not indicate the number of dilatations that will be needed.

Congenital Heart Disease and Its Impact on the Development of Anastomotic Strictures after Reconstruction of Esophageal Atresia

Background The aim was to explore if severe congenital heart disease (CHD) influenced the need for dilatation of anastomotic strictures (AS) after the repair of esophageal atresia (EA). Methods A retrospective case-control study was conducted examining AS in children with EA and Gross type C. The spectra of CHD and cardiac interventions were reviewed. The frequency of dilatations of AS during the first year following EA reconstruction was compared between children with and without severe CHD requiring cardiac surgery during their first year of life. Endoscopic signs of stricture were an indication for dilatation. Results Included in the follow-up for AS were 94 patients who had EA reconstructions, of whom 10 (11%) children had severe CHD requiring surgery during the first year including 19 different cardiac interventions. In total, 38 patients needed dilatation of esophageal AS, distributed as six (60%) with severe CHD and 32 (38%) without severe CHD (p = 0.31). Conclusion Severe CHD was present in 11% of children with EA. Esophageal AS developed in 60% children with concomitant CHD, but although high, it did not reach statistical difference from children without CHD (38%).

Treatment and Outcome for Children with Esophageal Atresia from a Gender Perspective

Background Besides the incidence of esophageal atresia (EA) being higher in males, no other gender-specific differences in EA have been reported. The aim of this study was to search for gender-specific differences in EA. Methods A retrospective study was conducted at a tertiary center for pediatric surgery. The medical charts of infants born with EA were reviewed. 20 girls were identified, and 20 boys were selected as matched controls with respect to concomitant malformations. Their treatment and outcome were evaluated. Results Polyhydramnios was more common in pregnancies with boys, 40%, versus girls, 10%, with EA (p < 0.01). In total, 36 (90%) children had patent ductus arteriosus, without any gender difference (18 and 18, resp., p=1). The distribution of days at the different levels of care was not equally distributed between boys and girls. Boys with EA had significantly more postoperative days (median 5 days) in the ward than girls (median 5 and 2 days, resp., p=0.04). No other gender-specific differences in surgical treatment, complications, or symptoms at follow-up were identified. Conclusion Polyhydramnios appears to be more frequent in pregnancies with boys than girls with EA. In this study, boys have longer stays than girls at the pediatric surgery ward.