Risk factors for sequelae after surgery for lymphatic malformations in children.

OBJECTIVE: The first-line treatment of lymphatic malformations (LMs) is pharmacological or interventional; however, surgery is still necessary in selected cases. Our aim was to identify factors associated with the occurrence of permanent postoperative complications. METHODS: This was a case series study of children operated on for LMs between 2001 and 2021 and followed-up in our institution. Patients who presented sequelae derived from surgical treatment (cases) and those who did not (controls) were compared. RESULTS: We included 112 children who underwent surgery for LMs in different centers. Forty-nine cases and 63 controls were included (58% male), with a mean age of 34 months. Patients younger than 1 year presented more complications than older children, 59% (n = 29/49) vs 41% (n = 24/49), respectively (P = .02). LMs were in the cervicofacial region in seven patients in the control group compared with 30 of the cases (P ≤ .001), with microcystic malformations the most associated with sequelae (n = 11/15; P = .019). Concerning permanent complications, 88% were neurological (n = 43/49), mainly peripheral facial palsy (n = 17). There was greater postoperative residual disease in controls compared with cases (65% vs 14%, respectively; P ≤ .0001). However, following a second procedure in the control group, there was no significant difference in long-term cure rates (P = .38). CONCLUSIONS: The risk of sequelae following surgery for LM increases significantly in patients younger than 12 months in cervicofacial and microcystic malformations. Because non-radical resections are associated with fewer complications and an optimal long-term cure rate, we consider that aggressive surgical approaches should be avoided if the absence of sequelae is not guaranteed.

Acellular flowable dermal matrix for ostomy reconstruction: a safe and effective minimally invasive technique.

BACKGROUND: Acellular dermal matrices have long been used for complex abdominal wall closure and, more recently, for ostomy reconstruction. PURPOSE: To describe ostomy reconstruction with acellular flowable dermal matrix (AFDM) in a pediatric patient with a complex abdominal wall defect. CASE REPORT: A 14-year-old female who was diagnosed with unspecific hemorrhagic colitis at age 6 months and who underwent several abdominal surgeries (including total colectomy and terminal ileostomy) reported frequent, severe periostomy skin ulcerations secondary to improper fitting and ostomy bag leakage due to multiple periostomy skin retraction as a result of multiple abdominal scars. Under sedation, 2 small (5 mm) peristomal skin incisions were made, through which dissection and release of dermal scar tissue was performed. Afterwards, AFDM 40 mL was injected subcutaneously until a uniform, flat surface around the ostomy was achieved. The patient was discharged a few hours postoperatively, after verification of proper fit of the ostomy bag with no leakage. At 18-month follow-up, the patient was very satisfied with the result, with fewer ostomy bag changes and improved quality of life. CONCLUSION: This case report indicates that AFDM is a safe and effective minimally invasive technique for ostomy reconstruction, with minimal complications and satisfactory medium-term results.

Neutrophil-to-lymphocyte ratio as a predictor of postoperative complications and readmissions after appendectomy in children.

To analyze the role of neutrophil-to-lymphocyte ratio (NLR) in predicting the development of postoperative complications and readmission after appendectomy in children. A retrospective single-centered case-control study was conducted on children who underwent appendectomy between 2017 and 2020. Demographics, time since symptoms onset, laboratory tests at admission, postoperative complications, and readmissions in the first 30 days after surgery were recorded. Sensitivity and specificity analysis of the parameters evaluated were determined by the area under the curve (AUC) represented on the receiver operating characteristic (ROC) curves. A total of 1,214 patients (765 males; 449 females) were included, with a median age at diagnosis of 10.4 years. The median time from symptom onset was 24 h. During the first 30 days after surgery, 149 postoperative complications were reported (12.3%). NLR at admission presented the highest AUC (0.753), with a cut-off point of 10.5 for maximum sensitivity (68.7%) and specificity (86.1%). Readmissions were reported in 45 cases (3.7%). NLR at admission presented an AUC of 0.794 significantly higher than neutrophils (0.696), leukocytes (0.654), and time since symptom onset (0.622), making these differences statistically significant (p < 0.001). The cut-off point of NLR > 12.4 was estimated, with a maximum sensitivity and specificity of 71.0% and 82.3% for predicting readmission. NLR is an independent predictor of postoperative complications and readmission in children with acute appendicitis. While its application in routine clinical practice has yet to be established, the NLR may provide clinicians with a tool for identifying high-risk surgical patients.

Mucosal appendicitis: How can it be differentiated from nonappendicitis?

OBJECTIVES: Mucosal appendicitis is defined by neutrophilic infiltration limited to the mucosa, with no transmural invasion; it is currently a controversial entity. The aim of our study was to determine whether mucosal appendicitis represents an early stage of acute appendicitis (AA) or should be considered a negative appendectomy. METHODS: A retrospective study was performed of children with suspected AA who underwent surgical treatment between 2017 and 2020. The participants were divided into 2 groups according to histologic appendiceal findings: mucosal appendicitis (MA) and negative appendicitis (NA). Demographic, clinical, ultrasound, and laboratory features were compared between the groups. RESULTS: A total of 1269 patients with suspected appendicitis in whom appendectomy was performed were included, with a median age of 10.5 years. Mucosal appendiceal inflammation was histologically confirmed in 30 cases (MA group), while no inflammation or other pathologic findings were observed in 25 cases (NA group), with no differences in demographic, clinical, or ultrasound features between the groups. Those in the MA group presented with significantly higher leukocyte and neutrophil counts and higher neutrophil to lymphocyte ratios (NLRs) than those in the NA group (P < .001). The NLR was the parameter with the highest area under the curve (0.736) for the diagnosis of MA. A cutoff of 3.20 was established, with a maximum sensitivity and specificity of 62.5% and 78.9%, respectively. CONCLUSIONS: Mucosal appendicitis presents with laboratory and histologic inflammatory features that can be distinguished from nonappendicitis and should therefore be considered a pathologic entity within the spectrum of AA. Preoperative leukocyte and neutrophil counts and NLRs may help reduce the number of negative appendectomies.

Sedoanalgesia in the Debridement of Pediatric Burns in the Emergency Department: Is It Effective and Safe?

BACKGROUND: The routine use of sedoanalgesia has increased the number of potential minor surgical procedures that can be performed in the Emergency Department (ED) without requiring general anesthesia and, thus, hospital admission. Our aim is to analyze the effectiveness and safety of the use of sedoanalgesia in childhood burns treated in the ED. METHODS: A retrospective study was conducted in burned children in whom burn debridement was performed under sedoanalgesia in the ED between 2017 and 2021 in a tertiary referral center for burns. We collected demographic variables, burn features and the type of sedoanalgesia performed in each case, including its effectiveness and associated adverse effects. RESULTS: A total of 227 patients (118 males, 109 females) were included, with a median age of 25 months. In total, 99.2% of the burns were thermal (69.2% scald burns), with a mean total body surface area (TBSA) burned of 4%. The most commonly used drugs were intravenous ketamine (35.7%), intravenous ketamine + midazolam (15.4%), intranasal fentanyl + midazolam (14.1%) and intranasal fentanyl (10.6%). The effectiveness of sedoanalgesia was considered satisfactory in 95.2% of the cases, with an adverse effect rate of 7.5%, without severe adverse effects reported. CONCLUSIONS: The use of sedoanalgesia in the ED in the early treatment of childhood burns achieves high effectiveness and safety. It is postulated as a quality indicator; thus, it should be known by all pediatric healthcare practitioners.

Neutrophil-to-lymphocyte ratio as a predictor of surgical site infection in acute appendicitis.

Background: Surgical site infection (SSI) is one of the most common complications after appendectomy, which carries high associated morbidity. Therefore, it is essential to determine SSI predictive factors in order to prevent its occurrence. The aim of this study is to explore the role of neutrophil-to-lymphocyte ratio (NLR) as a predictor of SSI after appendectomy in children. Methods: A single-center, retrospective cohort study was performed in children who underwent appendectomy between 2017-2020. Demographics, time since symptoms onset, laboratory tests at admission, ultrasound appendiceal diameter, rate of complicated appendicitis, surgical aproach, surgery time and SSI rate were analyzed. Follow-up was performed during hospitalization and at outpatient clinic at 2 weeks and 30 days postoperatively to assess the surgical wound aspect. Diagnostic cut-off values of these markers for SSI prediction were based on the significance in the univariate analysis. Variables with a P value <0.05 in the univariate analysis were then entered into the multivariate analysis. Results: A total of 1,136 patients (710 males; 426 females) were included. SSI was reported in 53 patients (4.7%) during the 30-day follow-up after appendectomy (SSI group), with no demographic differences with the control group. Time since symptoms onset was significantly higher in SSI group (24 vs. 18 hours; P=0.034), as well as ultrasound appendiceal diameter (10.5 vs. 8.5 mm; P=0.010). Complicated appendicitis was observed in about 60% of both groups, without differences in surgical approach between them. Surgery time was statistically higher in the SSI group (62.4 vs. 47.9 min; P<0.001). SSI group presented higher counts of leukocytes, neutrophils and NLR than control group (P<0.001). NLR was the parameter with the highest area under the curve (AUC) (AUC =0.808; P<0.001), with a cut-off point of 9.8 with maximum sensitivity (77.8%) and specificity (72.7%). NLR was an independent predictive factor for SSI in the multivariate analysis [odds ratio (OR) 1.82 (1.13-2.73); P<0.01]. Conclusions: NLR value at admission was the most promising predictive factor for the development of SSI in children undergoing appendectomy. It is an easy, simple, inexpensive, and rapid method to detect patients at high risk for SSI. However, further prospective studies are still needed to confirm these results.

How does the number of training years in pediatric surgery affect appendectomy outcomes?

INTRODUCTION: Appendectomy has traditionally been considered as a training operation for junior pediatric surgeons during their training period. However, with the increase of laparoscopic appendectomy, there has been a growing concern about the performance of this procedure by junior trainees. Our aim is to analyze intra-/postoperative appendectomy outcomes according to the number of training years during Pediatric Surgical residency training program. METHODS: A retrospective study was performed in patients who underwent appendectomy between 2018 and 2021 in our institution, who were divided into 5 groups according to the number of training years of the junior surgeon who performed the intervention (Y1-Y5). Demographics, complicated appendicitis rate, operation time, and postoperative complications were compared. A stratified analysis according to the technique performed (open/laparoscopic) was performed. RESULTS: A total of 1274 appendectomized patients were analyzed, of which 1257 (98.7%) were operated on by junior trainees (81 in Y1; 407 in Y2; 337 in Y3; 261 in Y4; and 171 in Y5) without demographic differences between groups. As the year of training increased, an elevation in complicated appendicitis rate was observed, although without statistically significant differences. However, laparoscopic/open appendectomies ratio increased with increasing year of training (p < 0.001). Operative time decreased significantly with increasing year of training (p < 0.001), both in open and laparoscopic appendectomies. There were no significant differences in postoperative complications, nor in the stratified analysis according to surgical technique. CONCLUSION: Appendectomy performed by junior pediatric surgery trainees can be considered a safe procedure from the first year of training, regardless of the technique used.

Mortality predictive factors in congenital hepatic hemangioma: a case-control study.

Congenital hepatic hemangiomas (CHHs) are benign vascular tumors whose clinical, histological, and genetic correlation has recently been described in patients with long-term survival, although no mortality risk factors have been identified to date. The aim of this study is to analyze predictors of mortality in patients with CHH. A retrospective single-center case-control study of consecutive CHH patients diagnosed in our institution between 1991 and 2021 was performed, who were classified into two groups according to their survival. Demographic, gestational, imaging, and laboratory data at diagnosis were collected and compared between both groups. A total of 29 patients were included (12 males; 17 females) of whom 5 died as a result of CHH evolution due to cardiac failure and coagulopathy, with a median age of 11 days until death. No differences in demographic or gestational data were reported. There were neither differences when comparing imaging tests, nor in location, number of affected liver segments, or CHH estimated volume. Upon laboratory data at diagnosis, deceased patients had a significant elevation of median liver enzymes [glutamic-oxaloacetic transaminase (359 u/L vs. 45 u/L; p < 0.01) and glutamic-pyruvic transaminase (313 u/L vs. 20 u/L; p < 0. 01)], as well as a decreased median platelet count (85,250/µL vs. 337,000/µL; p < 0.01), prothrombin activity (54% vs. 93%; p < 0.01), and fibrinogen (131 mg/dL vs. 284 mg/dL; p < 0.01), with no differences in blood count or biochemistry data. CONCLUSIONS: CHH clinical behavior can be innocuous or life-threatening. Thrombocytopenia, coagulation disorders, and increased liver enzymes at diagnosis seem to be the main predictors of mortality. WHAT IS KNOWN: • Congenital Hepatic Hemangiomas (CHHs) are benign vascular tumors whose clinical behavior can be innocuous or life-threatening. WHAT IS NEW: • Thrombocytopenia, coagulation disorders and increased liver enzymes at diagnosis seem to be the main predictors of mortality in these patients.

Preliminary results of the use of carboxytherapy in the treatment of pathologic scars: A minimally invasive alternative.

BACKGROUND: Carboxytherapy involves injecting carbon dioxide in the dermal and subcutaneous layers to achieve an increase in the local microvascularization of the tissue where it is applied. Our aim is to analyze its effectiveness in the treatment of pathological scars, as well as its adverse effects. METHODS: We conducted a prospective single-center study in patients under 18 years of age with atrophic and hypertrophic scars caused by surgical interventions or trauma, mainly burns. Each patient underwent two sessions, 6 weeks apart in time. Scar quality was evaluated using the Vancouver Scar Scale before the first session and 6 weeks after the second session. Adverse effects observed during the procedure and at follow-up in outpatient clinic were collected. RESULTS: A total of 16 patients were included (5 males; 11 females), with a median age of 12.7 years (interquartile range 8.5-15.2), in whom 25 pathologic scars were treated (14 atrophic and 11 hypertrophic). All sessions were performed under sedation, and patients were discharged the same day, without the need for hospitalization. Regarding scar quality, an improvement was observed in the median Vancouver scale score at 6 weeks after the second session (7 points) compared to the initial median score (12 points), this difference being statistically significant (p = 0.031). No serious adverse effects were observed during the procedure or during subsequent follow-up, with a median follow-up of 14 weeks. CONCLUSIONS: Carboxytherapy is an effective and safe minimally invasive therapy for pathologic scars, achieving a significant improvement in scar quality, with almost no contraindications. LEVEL OF EVIDENCE: Level IV. TYPE OF STUDY: Prospective Single-Center Case Series.

Pediatric Burns Debridement Under Sedoanalgesia During the COVID-19 Pandemic: A Cost-Effective Alternative.

Early debridement of childhood burns under sedoanalgesia in the emergency department (ED) may help to reduce the need of surgery and delay in treatment. We performed a retrospective study in burned children who underwent debridement in the ED under sedoanalgesia between March 2020 and December 2020 (COVID group), and were compared with the same months in 2019 (control group). Demographics, burns features, admission rate, and estimated costs associated were collected. A total of 733 children presented at the ED with burns (302 COVID group and 431 control group) without significant differences in burn features between them. Admission rate was significantly lower in COVID group (9.4% vs 19.4%; P < .001), as was the total associated cost for each group ($101 585 vs $209 656; P < .001). The use of sedoanalgesia for the early treatment of pediatric burns in the ED during COVID-19 pandemic is a cost-effective alternative that has reduced the need for hospital admission and associated costs.

The effectiveness of matrix ablation with silver nitrate in the treatment of ingrown toenails. A single-center case-control study.

BACKGROUND: Partial onychectomy with chemical matrixectomy is considered the gold standard treatment for stage II-III ingrown toenails (IT). However, there are scarce reports describing the use of silver nitrate in IT management in adolescents. Our aim is to analyze the effectiveness of matrix ablation with silver nitrate and compare it with partial onychectomy by electrocautery. METHODS: A retrospective study of adolescent patients with stage II-III IT was performed. Those who underwent electrocautery matricectomy in a major outpatient surgical center (Group A) and those who were treated with silver nitrate at an outpatient clinic (Group B) were compared. Efficacy was determined by recurrence and postoperative infection rates. RESULTS: Two hundred and nine patients were included (86 group A; 123 group B), with a total of 382 partial onychectomies (151 group A; 231 group B). Group B patients exhibited a lower recurrence rate (4.7%) when compared to group A (11.2%, p = .02), and had a lower postoperative infection rate (4.0% group A vs. 1.7% group B; p = .18), although not statistically significant. CONCLUSION: Silver nitrate chemical matricectomy after partial onychectomy is an effective treatment for IT in adolescents, with few postoperative complications and low recurrence rate. Therefore, it should be considered as a possible alternative to electrocautery matricectomy.

Intussusception Management in Children: A 15-Year Experience in a Referral Center.

OBJECTIVE: To report a 15-y, single-center experience in the management and outcomes of ileocolic intussusception (ICI) episodes. METHODS: A retrospective study was performed in patients with ICI episodes, who were treated at a single quaternary referral center from 2005 to 2019. Data evaluated included patient demographics, clinical presentation, treatment modalities, hospital stay, complications, and outcomes. RESULTS: A total of 546 ICI episodes (66.1% males) were included, with a median age at diagnosis of 15 mo. Enema reduction was performed in 478 patients (87.6%), with an overall success rate of 85.8%. Hydrostatic saline enema was the most effective method (89.3%) when compared to pneumatic (80.6%) or barium enema (79.8%), this difference being statistically significant (p = 0.031). No associated complications were observed during nonoperative reduction. Surgical treatment was performed in 101 patients, in whom 36 bowel resections were performed. Postoperative complications were reported in 6 patients (5.9%). Hospital stay was significantly longer in patients with operative management (median 5 d vs. 1 d; p < 0.001). CONCLUSIONS: Nonoperative management has a high overall success rate and low complication and recurrence rates. Saline enema reduction presents the highest effectiveness, and should be considered the first-line treatment.

Neutrophil-to-Lymphocyte Ratio as a Predictor of the Need for Surgical Treatment in Children's Intussusception.

OBJECTIVE: Neutrophil-to-lymphocyte ratio (NLR) is an emerging inflammatory marker in abdominal pathologies. Ileocolic intussusception (ICI) involves a progressive intestinal inflammation, and the effectiveness of nonsurgical treatment (enema) might be related to the inflammation degree, although no previous studies have investigated this relationship. Our aim is to identify predictors of the need for surgical treatment in ICI. MATERIALS AND METHODS: A single-center, retrospective, case-control study was performed in children with ICI, who were treated with initial nonsurgical management between 2005 and 2019. Patients were divided in two groups: A (effective enema) and B (need for surgery). Admission demographic and clinical and laboratory data were analyzed. Specificity and sensitivity of the different parameters as predictors of the need for surgical treatment were determined by receiver operating characteristic (ROC) curves. RESULTS: A total of 511 patients were included (410: group A; 101: group B), without statistically significant demographic differences. Group B presented significantly higher frequency of vomiting, bloody stools, and longer median time since symptoms onset (24 vs. 8 hours; p < 0.001). Group B presented higher median laboratory inflammatory markers than group A: NLR (6.8 vs. 1.8; p < 0.001), neutrophils (10,148 vs. 7,468; p < 0.001), and C-reactive protein (CRP; 28.2 vs. 4.7; p < 0.001). In ROC curve analysis, NLR had an area under the curve of 0.925, higher than neutrophil count (0.776; p = 0.001), CRP (0.670; p = 0.001), and time since symptoms onset (0.673; p = 0.001). It was estimated a cut-off point of NLR greater than 4.52 (sensitivity: 73.2%; specificity: 94.5%). CONCLUSION: High NLR values imply a high degree of bowel inflammation and might anticipate the need for surgical treatment in ICI in children. LEVEL OF EVIDENCE: III.

The role of the neutrophil-to-lymphocyte ratio in avoiding negative appendectomies.

INTRODUCTION: The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory biomarker that is easily calculated with data from the differential white blood cell count. The aim of our study was to analyse the role of the NLR in the detection of negative appendectomies and to compare its usefulness with other clinical, sonographic and laboratory factors previously described. METHODS: We conducted a retrospective study in patients aged less than 16 years who underwent appendectomy in our hospital between 2017 and 2020. We divided patients into 2 groups based on appendiceal histological findings: NA group (negative appendicitis: absence of appendiceal inflammation) and PA group (positive appendicitis: presence of inflammation in any layer of the appendiceal wall). We analysed demographic, clinical, sonographic and laboratory characteristics. RESULTS: We included a total of 1269 patients, 1244 in the PA group and 25 in the NA group, with no differences between groups in demographic characteristics. The proportion of patients that presented with nausea and vomiting was significantly smaller in the NA group compared to the PA group (P < .001), and there were no other differences in symptoms. The appendiceal diameter on ultrasound was significantly smaller in the NA group (8.1 ±â€¯2.1 vs. 9.7 ±â€¯2.8 mm; P < .001). The white blood cell and neutrophil counts and the NLR were significantly higher in the PA group (P < .001), as was the level of C-reactive protein (18.6 vs. 2.6; P = .005). The ROC curve analysis revealed that the NLR was the parameter with the highest AUC (0.879) for the diagnosis of negative appendicitis, with a cut-off point of 2.65 for a maximum sensitivity of 84.2% and specificity of 83.8%. CONCLUSION: The NLR is the preoperative parameter that best discriminates patients without acute appendicitis. Values of less than 2.65 should make clinicians contemplate diagnoses other than appendicitis.

The Use of Acellular Dermal Matrix (Integra Single Layer) for the Correction of Malformative Chest Wall Deformities: First Case Series Reported.

Introduction Autologous tissue transfers have been used in chest wall reconstruction for decades, with high morbidity. Recently, acellular dermal matrices (ADMs) have emerged as an alternative. The aim of this article is to report our initial experience in the reconstruction of malformative chest wall deformities with ADM. Methods A prospective observational study was performed in patients with malformative chest wall deformities, who were reconstructed with ADM at our institution between 2018 and 2020. We analyzed demographic variables, surgical features, postoperative complications, and cosmetic results at 12 months' follow- up. Results Four male patients were included (median age: 16 years). Two patients had bilateral costal anomalies, one patient had a unilateral chest deformity, and one patient had Poland syndrome. In all patients, blunt dissection of the subcutaneous cellular tissue overlying the defect was performed through 2.5 to 3 cm skin incisions, creating a pouch. Afterwards, several sheets of Integra Single Layer were placed in the pouch, to replace the volume defect. All patients were discharged same-day. No postoperative infections, hematomas, or seromas were observed. Only one patient presented with a partial surgical wound dehiscence. Revisions were performed at 1, 3, 6, and 12 months. All 4 patients were satisfied with the cosmetic outcome (Nuss Questionnaire: median score: 16 points; Q1-Q3: 22-26). Conclusion The use of ADM in malformative chest wall deformities reconstruction has not been previously described in children. This study demonstrates that the use of ADM is a safe and reliable technique. However, more studies with long-term follow-up are warranted.

Indocyanine Green (ICG)-Guided Identification of Hypermetabolic Pancreatic Nodules in Focal Congenital Hyperinsulinism: A Case Report in a 3-Month-Old Infant.

Indocyanine green (ICG)-guided near-infrared fluorescence has been recently adopted in pediatric surgery, although its use in the treatment of congenital hyperinsulinism has not been reported. We present a case of focal congenital hyperinsulinism in which ICG-navigation with ICG was used during surgical treatment. A 3-month-old infant was referred to our institution from a peripheral hospital for episodes of persistent hypoglycemia since birth, with no response to intravenous treatment with diazoxide, octreotide, or hydrochlorothiazide. An abdominal positron emission tomography-computed tomography scan showed a hypermetabolic nodule in the proximal portion of the body of the pancreas, compatible with focal congenital hyperinsulinism. A heterozygous mutation in the ABCC gene (Ala1516Glyfs*19) frameshift type inherited from the father was identified, which supported this diagnosis. Laparoscopy-assisted surgery was performed with ICG-guided near-infrared fluorescence, with intravenous injection of 16 mg ICG (2 mg/mg), which allowed localization of the focal lesion in the body of the pancreas. The lesion was resected with bipolar electrocautery and intraoperative histological study confirmed complete resection. Plasma glucose values normalized 6 hours after surgery and the patient was discharged 5 days later. In conclusion, the use of ICG in the treatment of congenital hyperinsulinism helps to identify hypermetabolic pancreatic nodules, decreasing the likelihood of incomplete resection.