Single-Incision Pediatric Laparoscopic Surgery: Surgical Outcomes, Feasibility Indication, and the Systematic Review.

Background: Single-incision laparoscopic surgery (SILs) has reported the evidence in basic and advanced pediatric laparoscopy. The objective was to review the feasibility and outcomes between basic and advanced procedures of the conventional laparoscopic surgery (CLs) and the SILs at our institute, and to compare the results with the published studies in a systematic review and meta-analysis. Patients and Methods: A retrospective study was conducted from January 2017 to March 2020. Demographic data, operations, conversion rate, and complications were collected and analyzed. The MEDLINE and PubMed were searched in relation to the pediatric SILs and the pediatric CLs in the published series from 1985 to 2021. We combined our retrospective study with a systematic review for meta-analysis. Results: Two hundred twenty-seven patients underwent pediatric laparoscopic surgery during the study period. The procedures included 199 (87.7%) for basic laparoscopy (appendectomy, cholecystectomy, testicular vessel ligation, closure of indirect inguinal hernia, and hydrocele) and 28 (13.3%) for advanced laparoscopy (Meckel diverticulectomy, pull-through operation for Hirschsprung's disease, choledochal cyst excision, and Nissen fundoplication). There was no statistical significance in operative time, length of stay (LOS), conversion rate, recurrence, and complication. The systematic review demonstrated 19 studies and, combined with our present study, produced 2865 patients for analysis. The meta-analysis reported increased LOS in the SILs group in cholecystectomy (mean difference [MD] 0.23 day, 95% confidence intervals [CI] 0.02-0.43 day, P = .03 and I2 = 0%) and choledochal cyst excision (MD 0.18 day, 95% CI 0.02-0.33 day, P = .03 and I2 = 0%). There was no statistical difference in operative time, LOS, conversion, and complication in other procedures. Conclusion: The SILs is a feasible indication and safe for surgical pediatric laparoscopy including basic to advanced procedure laparoscopy. It is demonstrated that there were no statistical differences in the operative time, LOS, and the complication. However, LOS in some procedures seems to be different due to the complexity and guideline.

Effects of sevuparin on rosette formation and cytoadherence of Plasmodium falciparum infected erythrocytes.

In severe falciparum malaria cytoadherence of parasitised red blood cells (PRBCs) to vascular endothelium (causing sequestration) and to uninfected red cells (causing rosette formation) contribute to microcirculatory flow obstruction in vital organs. Heparin can reverse the underlying ligand-receptor interactions, but may increase the bleeding risks. As a heparin-derived polysaccharide, sevuparin has been designed to retain anti-adhesive properties, while the antithrombin-binding domains have been eliminated, substantially diminishing its anticoagulant activity. Sevuparin has been evaluated recently in patients with uncomplicated falciparum malaria, and is currently investigated in a clinical trial for sickle cell disease. The effects of sevuparin on rosette formation and cytoadherence of Plasmodium falciparum isolates from Thailand were investigated. Trophozoite stages of P. falciparum-infected RBCs (Pf-iRBCs) were cultured from 49 patients with malaria. Pf-iRBCs were treated with sevuparin at 37°C and assessed in rosetting and in cytoadhesion assays with human dermal microvascular endothelial cells (HDMECs) under static and flow conditions. The proportion of Pf-iRBCs forming rosettes ranged from 6.5% to 26.0% (median = 12.2%). Rosetting was dose dependently disrupted by sevuparin (50% disruption by 250 µg/mL). Overall 57% of P. falciparum isolates bound to HDMECs under static conditions; median (interquartile range) Pf-iRBC binding was 8.5 (3.0-38.0) Pf-iRBCs/1000 HDMECs. Sevuparin in concentrations ≥ 100 µg/mL inhibited cytoadherence. Sevuparin disrupts P. falciparum rosette formation in a dose dependent manner and inhibits cytoadherence to endothelial cells. The data support assessment of sevuparin as an adjunctive treatment to the standard therapy in severe falciparum malaria.

Long-Term Outcomes of Sacrococcygeal Germ Cell Tumors in Infancy and Childhood.

Purpose. The aim of this study was to evaluate long-term outcomes of sacrococcygeal germ cell tumors (SC-GCTs) over a 15-year period. Materials and Methods. A retrospective review was conducted of all pediatric patients treated for SC-GCTs at our hospital from 1998 to 2012. Results. Fifty-seven patients were treated for SC-GCTs with the most common in Altman's classification type I. Age at surgery ranged from one day to 5.6 years. Tumor resection and coccygectomy were primarily performed in about 84% of the cases. Pathology revealed mature, immature, malignant sacrococcygeal teratomas (SCTs), and endodermal sinus tumors (ESTs) in 41 (72%), 4 (77%), 6 (10.5%), and 6 (10.5%), respectively. Recurrence of discase occurred in 3 of 41 patients with mature teratomas (7.3%); 2 recurrences with mature teratomas and one recurrence with EST. Five of 6 malignant SCTs and 3 of 6 ESTs responded well to the treatment. Alpha-fetoprotein (AFP) level was elevated in both malignant teratomas and ESTs. No immediate patient death was noted in any of the 57 cases, but 4 patients with malignant tumors and distant metastasis succumbed at home within 2 years of the initial treatment. Conclusion. Benign SCTs have a significant recurrence rate of approximately 7%. Close follow-up with serial AFP level monitoring should be done for 5 years after initial tumor resection and coccygectomy. The survival rate for malignant SC-GCTs with distant metastasis was unfavorable in the present study.

Clinical differences between choledochal cysts in infancy and childhood: an analysis of 160 patients.

BACKGROUND: Choledochal cysts (CDC) can become symptomatic at any age. Clinical features of infants and older children are different and have been documented by many authors. OBJECTIVE: The aim of this report was to study the differences in clinical spectrum of CDC between the infants and children treated at our hospital during a 17-year period. MATERIAL AND METHOD: A retrospective study was conducted of 160 patients with CDC treated at Queen Sirikit National Institute of Child Health between 1996 and 2012. The patients were categorized into 2 groups based on age at clinical presentation: an infantile group (up to one year old) and a childhood group (over one year old). Clinical characteristics of patients in the infantile and childhood groups were compared with statistical analysis using the Chi-square and Fisher's exact test. RESULTS: Of the 160 patients with CDC, 48 cases (30%) were categorized in the infantile group and 112 cases (70%) in the childhood group. Over three-quarters ofthe patients in the infantile group presented with jaundice and acholic stool, and this incidence was significantly higher than in the childhood group (77% vs. 46.4%, p = 0.001 and 50% vs. 13.4%, p < 0.001). Abdominal pain was the most common symptom of patients in the childhood group, whereas it was noted in only a small number of those in the infantile group (82.1% vs. 8.3%, p < 0.001). Average amylase level in CDC content was markedly elevated in the childhood group but much lower in the infantile group (43,630.5±90,234.5 vs. 79±189.9, p < 0.001). Only type I and type IV CDC as defined by Todani's classification were found in our patients, and there were no statistical differences in incidences of type I and type IV in the two groups (79.2% vs. 67.8% and 20.8% vs. 32.2% p > 0.05). Neonates and infants with CDC had a significantly higher risk of liver cirrhosis than did the childhood group (25% vs. 8%, p < 0.001). However, surviving patients with cirrhosis in both groups were doing well at least 3 years after surgical CDC excision. CONCLUSION: Neonates and infants with CDC were more likely to present with jaundice and acholic stool, whereas older children were more likely to present with abdominal pain. Amylase level in CDC content was markedly elevated in the childhood group but at a much lower level in the infantile group. Neonates and infants with CDC tended to develop liver cirrhosis earlier and more often than older children.

How to manage low gut obstruction in neonates with immature ganglion cells in the colonic wall?

BACKGROUND: Neonates with immature ganglion cells in the colonic wall may have the clinical picture similar to Hirschsprung's disease, especially total colonic aganglionosis. Management of this entity depends on the judgment of each clinician. OBJECTIVE: The aim of this study was to review management of clinical low gut obstruction in neonates with presence of immature ganglion cells in the colon. MATERIAL AND METHOD: A retrospective study of neonates with clinical low gut obstruction due to presence of immature ganglion cells treated between 2007 and 2012 was reviewed. RESULTS: Six patients, one term and 5 pre-term neonates, were proven to have immature ganglion cells in the colonic wall. They presented with delay or failure to pass meconium, progressive abdominal distension and bilious vomiting after birth. Abdominal films showed generalized small bowel dilatation and barium enemas revealed a microcolon in 4 of them. They underwent laparotomy between 4 and 11 days of life. A microcolon with a transitional zone (Tz) was seen at the terminal ileum, 30-75 cm proximal to the ileocecal valve. Colonic biopsy and the appendix revealed presence of immature ganglion cells and ileal biopsy at the Tz showed presence of normal ganglion cells. An ileostomy was performed at the Tz in all of the 5 premature neonates, while an enterostomy was not done in term infant. Closure of the enterostomy in the 5 premature cases was performed after they had been proven to have mature ganglion cells in the colonic wall by a rectal biopsy after the age of 3 months. All of the 6 cases were doing well on the last follow-up between 1 and 3 years. CONCLUSION: Functional low gut obstruction in neonates caused by immaturity of the colonic ganglion cells should be managed by laparotomy including biopsies of the colon, appendix and terminal ileum with enterostomy at the Tz. Closure of the enterostomy is done after presence of mature ganglion cells proven by a rectal biopsy after 3 months of age. Full-term neonates with immature ganglion cells in the colonic wall may be successfully managed conservatively without enterostomy.

Clinical outcomes of esophageal atresia: comparison between the Waterston and the Spitz classifications.

INTRODUCTION: Preoperative prognostic predictors are important for surgeons and parents to estimate the survival of patients with esophageal atresia (EA). The aim of this study was to update the clinical outcomes of EA treatment by comparing between the Waterston and the Spitz classification. MATERIALS AND METHODS: Medical records of the patients with EA treated at Queen Sirikit National Institute of Child Heath from 2003 to 2010 were reviewed. All of the patients were categorised into 3 groups of the Waterston and 3 groups of the Spitz risk factor criteria for comparing of the differences in each group and each classification. RESULTS: One hundred and thirty-two patients (81 males and 61 females) were treated for EA during the study period. Applying the Waterston classification, survival rate was 100% in group A, 91.5% in group B and 48.8% in group C. There was no statistical difference between the survival rate in group A and group B (P = 0.119) but significant difference between group B and group C (P = 0.000). Using the Spitz classification, survival rate was 97.4% in group I, 64.4% in group II and 27.3% in group III. There was obviously statistical difference of the survival rate between each group (group I vs group II, P = 0.000; group II vs group III, P = 0.041). CONCLUSION: Comparing with the prognostic predictors, the Spitz classification was more valid than the Waterston criteria. The Spitz classification is suitable to use for preoperative predictor to parental counselling and comparing of treatment outcomes of EA among paediatric tertiary care centres.

Clinical outcome of patients with gastroschisis: what are the differences from the past?

OBJECTIVE: The aim of the present study was to review the experience in management of neonates with gastroschisis and analyze the differences in the clinical outcome during a 24-year period. MATERIAL AND METHOD: A retrospective study of patients with gastroschisis treated at Queen Sirikit National Institute of Child Health (QSNICH) between 1986 and 2009 was conducted. Patients' information was compared between the first period (1986-1997) and the second period (1998-2009) regarding demographic data, modes of operative procedures and results of the treatment. The statistical differences were analyzed by the Chi-square, Fisher exact and student t-test with a p-value less than 0.05 considered significant. RESULTS: During a 24-year period, 919 neonates with gastroschisis were treated at QSNICH; 342 cases (161 males and 181 females) in the first 12-year period and 577 cases (295 males and 282 females) in the second 12-year period. The incidence of gastroschisis at Rajavithi Hospital was 0.26: 1,000 live births in the first period and 1.03: 1,000 live births in the second period. Average birth weight of the patients and average maternal age in both periods were not significantly different (p > 0.05). Congenital anomalies were found in approximately 15% of the patients in each period. Regarding modes of the operative treatment, primary closure of the abdominal wall defect was attempted in 23.7% of the patients during the first period and increased to 44% in the second period. The overall survival rate in the second period was better than the first period with statistical significance (92.4% vs. 75.4%, p < 0.001). In addition, complications in the second period were less than those in the first period, except for necrotizing enterocolitis, which was more frequent in the second period. CONCLUSION: The obvious differences in patients with gastroschisis during the 24-year period were the increased incidence, increased successful primary closure of the abdominal wall defect and increased overall survival rate between 1998-2009. Improvement of the clinical outcomes reflected improved neonatal care including surgical techniques, parenteral nutrition, respiratory care and anesthetic practice.

Management of recurrent intussusception: nonoperative or operative reduction?

PURPOSE: The aim of this study was to determine how to manage children with recurrence of intussusception. METHODS: Medical records of patients treated for intussusception from 1976 to 2008 at the Queen Sirikit National Institute of Child Health were reviewed. Information on patients who developed recurrent intussusception was extracted to study patterns of recurrent attack and suitable management procedures. The statistical differences were analyzed by the χ² and the Student t test, with a P value < .05 considered significant. RESULTS: During the study period, 1340 patients were treated for 1448 episodes of intussusceptions, with an average of 40 cases per year. There were 108 episodes of recurrent intussusception in 75 patients (45 males and 30 females). The overall recurrence rate was 8%. Patient age at the first episode ranged from 3 months to 12 years (average, 14.9 months). The time interval before each recurrence ranged from 1 day to 3.2 years (average, 7.8 months). The number of recurrences ranged from 1 to 5 attacks. Recurrent intussusception occurred in 35 (15.8%) of 222 children following successful hydrostatic barium enema (BE) reduction and in 55 (11.4%) of 482 after successful pneumatic or air enema (AE) reduction. There was no statistical difference between the recurrence rates after the 2 nonoperative procedures (P = .08). Recurrent intussusception developed in 14 (3.0%) of 457 patients after operative manual reduction. Recurrence was not observed after intestinal resection for initial irreducible intussusception in 175 patients. The remaining 4 recurrent episodes occurred after spontaneous reduction. Of the 108 episodes of recurrence, BE and AE reductions were successful in 25 (96.2%) of 26 attempts and in 57 (92%) of 62 attempts, respectively. Seven patients had their first episode of intussusception treated surgically. All 7 when they recurred were successfully treated with either BE or AE reduction. Operative intervention was needed in 23 episodes of recurrent intussusception; 18 were reduced manually, and 5 required intestinal resection. Overall, 7 (9.3%) of the 75 recurrences had a pathologic lead point: colonic polyps in 4 cases and Meckel diverticulum in 3 cases. There were no deaths among the 75 patients with recurrent intussusception. CONCLUSIONS: Recurrent intussusception should be initially treated by nonoperative reduction. Laparotomy is needed in cases with failure of BE or AE reduction, in cases with suspicion of a pathologic lead point, and in selected cases with several episodes of recurrence. The treatment of recurrent intussusception, in general, should be similar to that of primary intussusception.

Influence of Down's syndrome on management and outcome of patients with congenital intrinsic duodenal obstruction.

PURPOSE: Children with Down's syndrome (DS) have been reported to have a high incidence of congenital heart disease (CHD) and respiratory tract infection. These anomalies and complications lead to poor outcomes, especially after treatment of congenital intrinsic duodenal obstruction (CIDO). The aim of this study was to review and compare the outcome of management of CIDO at a single tertiary institute for children in Thailand. METHODS: We reviewed the medical records of patients with CIDO, who were treated at Queen Sirikit National Institute of Child Health (Bangkok, Thailand) from 1997 to 2006. The patients were classified into 2 groups: A = CIDO with DS and B = CIDO with non-DS (NDS). Each group was then divided into 2 subgroups: A(1) = DS without CHD, A(2) = DS with CHD, B(1) = NDS without CHD, and B(2) = NDS with CHD. Comparisons of management and outcome between group A and group B, subgroup A(1) and subgroup B(1), and subgroup A(2) and subgroup B(2) were performed. Statistical differences were analyzed by the chi(2) test at a P < .05. RESULTS: A total of 227 patients (male-female = 108:119) underwent surgical correction of CIDO. Of 227 patients, 86 (37.9%) were shown to have DS (group A), and 141 (62.1%) were NDS patients (group B). Demographic information did not differ between the groups, except for the mothers' age at pregnancy and the operative procedure used for duodenoduodenostomy. Group A had a higher incidence of CHD than group B (66.3% vs 26.2%; P < .05). Early outcome regarding survival rate (SR) was not statistically different between groups (87.2% vs 92.9%; P = .15), but the rate of early postoperative complications in group A was higher than that in group B (45.3% vs 31.1%; P = .03). The overall SR of group A at long-term follow-up was worse than that in group B (68.6% vs 86.7%; P < .05). Late complications and sequelae in group A were also more frequent than in group B (34.6% vs 9.2%; P < .05). When comparing early outcome between DS and NDS patients without CHD, the SR of subgroup A(1) was lower than that of subgroup B(1) (86.5% vs 96.5%; P = .04), but the rate of early postoperative complications did not differ (41.5% vs 24.1%; P = .05). At long-term follow-up, the overall SR of subgroup A(1) was worse than that of subgroup B(1) (73% vs 95.6%; P < .05) because of a higher incidence of late death because of recurrent respiratory tract infection in the A(1) subgroup. In addition, late complications and sequelae were more common in subgroup A(1) than in subgroup B(1) (37.5% vs 8.9%; P < .05). In patients with CHD, there was no statistical difference between early and long-term results of SR or complications between subgroup A(2) and subgroup B(2). The overall SR at long-term follow-up was 63% in subgroup A(2) and 56% in subgroup B(2) (P = .5). CONCLUSIONS: Early outcome of CIDO management revealed minimal differences between DS and NDS patients. However, these differences were clearer in long-term outcomes. The DS patients had lower long-term SR and higher rates of complications and sequelae than NDS patients. It is concluded that DS negatively impacts the management and outcome of patients with CIDO.

Atresia of the jejunum and ileum: what is the difference?

BACKGROUND: Atresia of the jejunum and ileum is one of the major causes of neonatal intestinal obstruction. Most affected newborn infants present with bilious emesis and abdominal distention. Traditionally, jejunal and ileal atresia have been grouped together as jejunoileal atresia. OBJECTIVE: To elucidate the difference between jejunal and ileal atresia. MATERIAL AND METHOD: A retrospective analysis of patients diagnosed with jejunal or ileal atresia, who were treated at the Department of Surgery, Queen Sirikit National Institute of Child Health during January 1988 to December 2007, was carried out. RESULTS: There were 74 patients with jejunal atresia and 68 patients with ileal atresia. The mean birth weight and gestational age of patients with jejunal atresia were significantly lower than those with ileal atresia. Antenatal perforation occurred more frequently in ileal atresia. Postoperative course was more prolonged and mortality was higher injejunal atresia. Prolonged ileus and anastomotic dysfunction requiring long-term parenteral nutrition were the major causes of complications leading to death. CONCLUSION: There were many differences between patients with jejunal atresia and those with ileal atresia. The more compliant jejunal wall allows massive dilatation upon obstruction with subsequent loss of peristaltic activity, thus poorer outcome in comparison with ileal obstruction. We suggest that atresia of the jejunum and ileum be considered differently.

Bilateral Morgagni hernias association with left Bochdalek diaphragmatic hernia: a very rare anomaly.

Morgagni hernia association with Bochdalek diaphragmatic hernia is a very rare congenital anomaly. The authors reported a 2-year-and-2-month-old boy with Down syndrome who has a history of recurrent pneumonia over a one-year period. A chest film of the first admission at 6 months of age revealed only minimal pulmonary infiltration and normal findings of both sides of the diaphragm. The last investigations with chest films and CT scan were suggestive of sequestration of the right lung with left Morgagni and left Bochdalek diaphragmatic hernias. An exploratory laparotomy revealed bilateral Morgagni and left Bochdalek hernias with hernial sacs in all of the diaphragmatic defects. All of the hernial sacs were excised and the diaphragmatic defects were closed with 2-0 silk interruptedly. Postoperative course was uneventful and he was doing well during his follow-up at one year.

Successful separation of thoracopagus conjoined twins with a single extra-hepatic biliary system.

A pair of thoracopagus conjoined twins were separated at the age of 3 months at Khon Kaen Regional Hospital, Thailand on November 19, 2004. Pre-operative investigations showed separate hearts, joined duodenum, and fusion of the livers. Separation of the extra-hepatic biliary systems was suspected. Operative findings revealed fusion of the intestines from the second part of the duodenum to the terminal ileum with two normal colons. An intussusception was found at the terminal ileum. Fusion of the livers with only one extra-hepatic biliary system was noted In one of the twins, the gastrointestinal tract was anastomosed with Roux-en- Y enteric loop to one area of good bile drainage at the cut surface of liver Post operative course was hectic but both twins recovered satisfactorily. Both are doing well at present, two years after the separation. This was the first reported case of thoracopagus conjoined twins with complex biliary tract anomalies in Thailand. From the literature, pre-operative investigations in most cases of these conjoined twins failed to define the precise anatomy of the biliary system and may be misleading as in the presented case. The mortality rate remains high. Meticulous pre-operative planning, decision-making in the operative field and postoperative management as well as a multidisciplinary team are very important for a successful separation.

Tubularized, incised plate urethroplasty in hypospadias repair: experience at Queen Sirikit National Institute of Child Health.

BACKGROUND: Hypospadias is the most common penile anomaly. Many techniques have evolved during the past 150 years to address chordee and construct a neourethra. The current concept of understanding of chordee and emphasis upon preserving the urethral plate have brought hypospadias surgery over the last decade near its ultimate goal of a reconstructed penis that is functional and cosmetically normal. Warren T Snodgrass primarily reported successful urethral plate preservation urethroplasty in 1994. The urethral plate can be primarily tubularized without an additional skin flap after a dorsal midline relaxing incision is made known as tubularized incised plate urethroplasty. It is currently used worldwide by pediatric urologists due to its advantages. The authors also performed this technique and initial experience at Queen Sirikit National Institute of Child Health, Bangkok, Thailand is reported. MATERIAL AND METHOD: 88 of 180 hypospadias boys were treated with tubularized incised plate urethroplasty for primary repair of hypospadias over a 24 month period. All had moderate to severe chordee. Urethral plate preservation is the principle concept of this technique and the entire length of the urethral plate was incised along the midline and the neourethra was tubulized over a 6 or 8 Fr. catheter. The chordee usually disappeared after the penis was degloved. Dorsal plication was performed in mild residual chordee. A subdartos flap was created to cover the neourethra and pressure dressing applied with bactracin gauze for 7 days. The urethral stent was removed on the 7th post-operative day. RESULTS: The tubularized, incised plate urethroplasty was performed in 88 boys, age range from 6 months to 12 years. The operative time was 60 to 100 minutes. Follow-up was up to 18 months. There were 13 distal penile, 60 midshaft and 15 penoscrotal types. All penes had excellent cosmetic appearance, even in complicated cases. The pinhole and large fistulas were noticed in 10 and 3 penes respectively (14%). All fistulas were repaired successfully at a later date. Twenty cases had a mild degree of meatal stenosis of which 18 had good response to self meatal dilatation by their parents and 2 underwent a meatotomy procedure. No urethral diverticulum or stricture was noticed during follow-up. CONCLUSION: Even though high percentages of fistula complications were noticed in the authors' experience, they seemed to be acceptable and easy to correct. This technique seems to be suitable for both distal and proximal hypospadias. The advantages of this technique include its simplicity, low complication rate, very good appearance of the glans penis and normal meatus in most boys. Tubularized incised plate urethroplasty is now the procedure of choice for distal and proximal hypospadias repair.

Epigastric heteropagus twins: a report of four cases.

Epigastric heteropagus twins (EHT) is a rare form of conjoined twins. It refers to unequal and asymmetric conjoined twins in which the dependent part (parasite) is attached to the epigastrium of the dominant part (autosite). The authors herein report four cases of EHT. Omphalocele was present in 3 patients. Surgical excision of the parasite and repair of the abdominal wall defect were successful in three cases. Three infants had associated cardiac anomalies and one of them died during surgery from cardiopulmonary failure.

Conjoined twins: surgical separation in 11 cases.

Eleven pairs of symmetrically conjoined twins underwent surgical separation at the Queen Sirikit National Institute of Child Health. Six were omphalopagus, 4 were thoracopagus and 1 was pygopagus. Eight were female and 3 were male. Three pairs were separated on emergency or semi-emergency bases, and the remaining 8 pairs were separated electively at an older age. Of the 3 pairs who had early emergency separations, one pair, whose combined birth weight was only 2,500 g, underwent emergency separation at the age of 44 days after the death of one twin. The second twin also expired one hour after the separation. In the remaining 2 pairs, early separation was done because of the deterioration of one twin due to complex cardiac anomalies. In both cases, the infants with cardiac anomalies expired but the others survived the separation satisfactorily. In one pair of thoracopagus conjoined twins, one twin had cyanotic cardiac anomalies. They were electively separated at the age of 2 years and 9 months. The twin with cardiac anomalies expired 2 hours after surgery, but the other survived the separation satisfactorily. In the remaining 7 pairs who underwent elective separations, both twins of each pair survived the separation satisfactorily. However, one twin expired unexpectedly 10 days after the separation.

Splenic lymphangioma and presentation with frequent urination: a case report.

Lymphangioma of the spleen is a rare disorder with a clinical manifestation ranging from incidental findings of an abdominal mass to symptomatic abdominal pain. The authors reported a case of splenic lymphangioma with the presenting symptom of frequent urination in a 9-year-old boy. A large firm mass was found at the left upper quadrant, 12 cm in diameter. The diagnosis was confirmed by ultrasonography and computerized tomographic (CT) scan. The symptoms of frequent urination disappeared after operative splenectomy. No evidence of recurrence occurred over a 3-year follow-up.

Technology assessment for management of congenital diaphragmatic hernia: immediate versus delayed surgery.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is one of the high-risk diseases in pediatric surgery, especially in neonates with symptom presentation within 6 hours after birth. Opinion regarding the time of surgery has gradually shifted from immediate repair to a policy of stabilization and delayed repair. Whether delayed surgery is beneficial remains controversial. OBJECTIVE: To evaluate the outcomes regarding whether delayed surgical repair improves survival in CDH neonates, who are symptomatic immediately after delivery, is more beneficial than immediate surgery. MATERIAL AND METHOD: Data were obtained by searching MEDLINE (1966-2002) and the Cochrane Database, Issue 2, 2003 using the term "congenital diaphragmatic hernia" and "surgery". Inclusion criteria were randomized controlled trial (RCT), prospective trial (PT), retrospective analysis (RA) and meta-analysis (MA). Information from the literature was analyzed by the computer program of Epi Info Version 3. Statistical significance was reliable at the level of p < 0.05. RESULTS: Twenty-five studies were obtained and RCT:RA was 2:23. Analysis of results of CDH management revealed that pre-operative stabilization and delayed surgery improved the survival rate in 14 of 25 in the literature (p < 0.05), while the remaining 11 articles showed no statistical difference of survival between immediate and delayed surgery (p > 0.05). CONCLUSION: From the evidence-based analysis, the results of CDH management between immediate versus delayed surgery were unclear. From the reviewer's experience at the Queen Sirikit National Institute of Child Health, the strategy of pre-operative stabilization and delayed surgery had better improved survival of CDH than immediate surgery.