Cecal epidermoid cyst: a neonatal case with clinicopathological consideration.

BACKGROUND: Only 10 cases of cecal epidermoid cyst (CEC) have been reported in the literature. Furthermore, its pathogenesis remains unclear. We report a rare case of congenital CEC in neonate, and discuss its clinicopathological findings. CASE PRESENTATION: A cystic lesion was incidentally identified in the retroperitoneal area of the abdominal right lower quadrant during a routine prenatal ultrasonography (US), prompting an ileocolectomy 3 days after birth. This congenital cyst was composed of mucosal lining cells and submucosal connective tissues, and the inner lining mucosa was composed of stratified squamous epithelium and focally mucin-producing ciliated epithelium. Based on the macroscopic and microscopic findings, the cystic lesion was diagnosed as a congenital cecal epidermoid cyst. CONCLUSIONS: The management of a fetal abdominal mass should be tailored individually, considering that epidermoid cysts can occur in the cecum during the perinatal period. We report the clinicopathological findings in this case, including its possible pathogenesis.

Predicting Survival of Congenital Diaphragmatic Hernia on the First Day of Life.

BACKGROUND: This study aimed to determine perinatal risk factors for 30-day mortality of congenital diaphragmatic hernia (CDH) patients and develop a prognostic index to predict 30-day mortality of CDH patients. Identifying risk factors that can prognosticate outcome is critical to obtain the best management practices for patients. METHODS: A retrospective study was performed for patients who were diagnosed with CDH from November 2000 to August 2016. A total of 10 prenatal risk factors and 14 postnatal risk factors were analyzed. All postnatal variables were measured within 24 h after birth. RESULTS: A total of 95 CDH patients were enrolled in this study, including 61 males and 34 females with mean gestational age of 38.86 ± 1.51 weeks. The overall 30-day survival rate was 63.2%. Multivariate analysis revealed that five factors (polyhydramnios, gestational age at diagnosis <25 weeks, observed-to-expected lung-to-head ratio ≤45, best oxygenation index in 24 h >11, and severity of tricuspid regurgitation ≥ mild) were independent predictors of 30-day mortality of CDH. Using these five factors, a perinatal prognostic index for 30-day mortality was developed. Four predictive models (poor, bad, good, and excellent) of the perinatal prognostic index were constructed, and external validation was performed. CONCLUSIONS: Awareness of risk factors is very important for predicting prognosis and managing patients. Five independent perinatal risk factors were identified in this study. A perinatal prognostic index was developed for 30-day mortality for patients with CDH. This index may be used to help manage CDH patients.

Perineal squamous cell carcinoma arising from an epidermal cyst: a case report.

BACKGROUND: Epidermal cysts and squamous cell carcinomas (SCCs) are common skin lesions. However, a malignant change in an epidermal cyst is very rare. The incidence of a malignant change from an epidermal cyst to cutaneous SCC is 0.011-0.045%. In particular, malignant transformation of an epidermal cyst in the perineum is extremely rare. To date, three cases have been reported in the English literature. CASE PRESENTATION: We report a case of 51-year-old male with an approximately 15-cm perineal mass. This mass started to grow suddenly 4 months previously and caused great discomfort in the perineum due to the large size. The patient underwent excision of the mass with a negative margin. Histopathological analysis confirmed a microinvasive SCC arising from a proliferating epidermoid cyst. CONCLUSIONS: Even if benign tumors are suspected, a change in size, pain, ulceration, or discharge should indicate the need for surgical resection due to the possibility of a malignant change.

Congenital adhesion band causing small bowel obstruction: What's the difference in various age groups, pediatric and adult patients?

BACKGROUND: A congenital adhesion band is a rare condition, but may induce a small bowel obstruction (SBO) at any age. However, only a few sporadic case reports exit. We aimed to identify the clinical characteristics of congenital adhesion band manifesting a SBO stratified by age group between pediatric and adult patients. METHODS: The medical records of all patients with a SBO between Jan 1, 2009 and Dec 31, 2015 were retrospectively reviewed. Cases associated with previous surgical procedure and cases of secondary obstruction due to inflammatory processes or tumor and other systemic diseases were excluded. The patients were divided into two groups according to age below or above 18 years: pediatric and adult. The basic clinical characteristics were analyzed and compared between groups. RESULTS: Of 251 patients with a SBO, 15 (5.9%) met the inclusion criteria; 10 cases in pediatric group (mean age 17.9 ± 38.7 months) and 5 cases in adult group (mean age 60.0 ± 19.7 years). The pediatric group (66.6%) included 3 neonates, 5 infants, and 2 school children. They usually presented with bilious vomiting (50.0%) and abdominal distention (60.0%), and demonstrated a high rate of early operation (80.0%) and bowel resection (70.0%). In contrast, the adult group (33.3%) presented with abdominal pain (100%) in all cases and underwent a relatively simple procedure of band release using a laparoscopic approach (60%). However, group differences did not reach statistical significance. In addition, two groups did not differ in the time interval to the operation or in the range of the operation (p = 0.089 vs. p = 0.329). No significant correlation was found between the time interval to the operation and the necessity of bowel resection (p = 0.136). There was no mortality in either group. CONCLUSIONS: Congenital adhesion band is a very rare condition with diverse clinical presentations across ages. Unlike adult patients, pediatric patients showed a high proportion of early operation and bowel resection. A good result can be expected with an early diagnosis and prompt management regardless of age.

Neonatal Iliopsoas Abscess: The First Korean Case.

Iliopsoas abscess (IPA) is rare in neonates. We present a case of neonatal IPA that was initially believed to bean inguinal hernia. A 20-day-old male infant was referred to our hospital for herniorrhaphy after a 2-day history of swelling and bluish discoloration of the left inguinal area and leg without limitation of motion. Abdominal and pelvic ultrasonography suggested a femoral hernia, but the anatomy was unclear. Abdominal computed tomography revealed a multi-septated cystic mass extending into the psoas muscle from the lower pole of the left kidney to the femur neck. Broad spectrum antibiotics were initiated, and prompt surgical exploration was planned. After opening the retroperitoneal cavity via an inguinal incision, an IPA was diagnosed and surgically drained. Culture of the abscess fluid detected Staphylococcus aureus, sensitive to methicillin. The patient was discharged without complication on the 17th postoperative day.

Cell adhesion and in vivo osseointegration of sandblasted/acid etched/anodized dental implants.

The authors describe a new type of titanium (Ti) implant as a Modi-anodized (ANO) Ti implant, the surface of which was treated by sandblasting, acid etching (SLA), and anodized techniques. The aim of the present study was to evaluate the adhesion of MG-63 cells to Modi-ANO surface treated Ti in vitro and to investigate its osseointegration characteristics in vivo. Four different types of Ti implants were examined, that is, machined Ti (control), SLA, anodized, and Modi-ANO Ti. In the cell adhesion study, Modi-ANO Ti showed higher initial MG-63 cell adhesion and induced greater filopodia growth than other groups. In vivo study in a beagle model revealed the bone-to-implant contact (BIC) of Modi-ANO Ti (74.20%±10.89%) was much greater than those of machined (33.58%±8.63%), SLA (58.47%±12.89), or ANO Ti (59.62%±18.30%). In conclusion, this study demonstrates that Modi-ANO Ti implants produced by sandblasting, acid etching, and anodizing improve cell adhesion and bone ongrowth as compared with machined, SLA, or ANO Ti implants. These findings suggest that the application of Modi-ANO surface treatment could improve the osseointegration of dental implant.

Maximum intensity projection using bidirectional compositing with block skipping.

BACKGROUND: Maximum intensity projection (MIP) is a volume rendering technique that determines the pixel intensity as the maximum of all values sampled along the viewing direction. MIP has been successfully applied to diagnose bone fractures in computed tomography (CT) and the stenosis of vascular structures in magnetic resonance angiography (MRA). However, MIP has a major drawback in that the depth and occlusion information cannot be perceived in the output images. The most universal way to alleviate this problem is to occasionally change the viewpoint for depth perception. To support this function in real time, MIP should be performed at an interactive frame rate. OBJECTIVE: We develop an efficient rendering algorithm for MIP so that MIP is performed at an interactive frame rate without a loss of image quality. METHODS: The proposed method predicts the position of the maximum intensity for each ray using blockwise maximum bounds, after which it performs bidirectional compositing toward both ends of the ray from this predicted position. During the compositing process, block skipping is used as an acceleration method. RESULTS: The proposed method outperformed the block skipping method using the sequential compositing with a speed-up factor of 2.2 ∼ 2.8 depending on the data set without any degradation of the image quality. CONCLUSION: We proposed an efficient rendering technique for MIP. Our method was superior to the conventional block skipping method with respect to the rendering speed and degree of performance consistency.

A rare case of infected urachal cyst leading to intestinal obstruction in a 3-month-old boy with febrile urinary tract infection: Case report.

RATIONALE: Urachal anomalies are rare and can present with various clinical manifestations. Urachal remnants, in particular, can be difficult to diagnose because of atypical symptoms at presentation. This study reports a case of intestinal obstruction in an infant secondary to an infected urachal cyst. PATIENTS CONCERNS: A 3-month-old boy with a known febrile urinary tract infection developed acute abdominal distension. DIAGNOSES: Abdominal ultrasound (US) and computed tomography (CT) revealed a nonspecific, ill-defined soft tissue density at the mid-abdomen, associated with intestinal obstruction. INTERVENTIONS: Emergency exploratory laparotomy was performed. The site of the obstruction was found to be at the mid-small bowel; the proximal small bowel was markedly distended, and the small bowel and sigmoid colon were adherent to urachal remnant. The urachal remnant was excised, and the peritoneal adhesions were lysed. OUTCOMES: The day after surgery, the patient was discharged without any complications. LESSONS: Intestinal obstruction is an exceedingly rare presentation of urachal remnants. This case highlights that urachal anomalies should be considered in the differential diagnosis in patients with intestinal obstruction and a concurrent febrile urinary tract infection.

In vitro comparative study of wall portbased high-frequency chest wall oscillation device and internal air-pulse generator device.

Owing to environmental and disease issues, the use of high-frequency chest wall oscillation (HFCWO) devices in hospitals is consistently increasing. This study proposes a cost-effective actuator-less HFCWO device that utilizes an external wall port utility in hospitals to generate the positive and negative pneumatic pressures required for HFCWO treatment instead of an embedded mechanical actuator. The manufactured prototype with the no-amplification (NO-AMP) setting contained an electric pressure regulator to enable intensity level adjustment and two solenoid valves to enable vibration frequency adjustment, whereas the prototype with the pre-amplification (PRE-AMP) setting contained an additional air reservoir and an air-pressure booster. The prototype device was tuned to output average local maximum values in the pressure waveform similar to a commercial VEST-205 device at an 8-12 Hz frequency and 2-4 pressure intensity levels. In vitro comparative experiments demonstrated that the prototype device showed similar local maximum pressures to those of the VEST-205 (mean absolute pressure difference, <3 mmH2O); in contrast, the proposed device showed significantly higher local minimum pressures than those of the VEST-205 (mean absolute pressure difference, >8 mmH2O). Additionally, the driving sound of the proposed device was 17.0-17.8 dB higher than that of VEST-205. We conclude that the proposed device has the potential to substitute for conventional HFCWO devices under the limited but most frequently used operating conditions, although more detailed modifications are necessary in future studies to improve its performance and clinical usability.

A novel animal model of abdominal aortic aneurysm by mechanical injury.

The present study established a novel and reproducible animal model to study abdominal aortic aneurysms. In total, 22 adult Lewis rats underwent a procedure to produce mechanical injuries at the infrarenal aorta which was opened temporarily. The aortas were injured 6 times and repaired. Those rats were divided into 2 groups and the aortic aneurysm tissue was harvested after 42 (6-week group) or 63 (9-week group) days and evaluated for the progression of aortic aneurysms. In the 6-week group, changes in the aneurysm were observed in 6/10 (60%) rats and the mean maximum diameter of the aorta demonstrated a 119% increase in size from the baseline measurement. In the 9-week group, changes in the aneurysm were observed in 8/11 (88%) rats and the mean maximum diameter of aorta demonstrated a 133% increase in size. Additional findings from the aortic aneurysm tissue were found microscopically, including the destruction of the tunica media and the elastic fiber. The present study demonstrated that this novel animal model for the development of abdominal aortic aneurysms (AAAs) produced by mechanical injury may have high reproducibility and similar gross and microscopic morphology to humans. This model could be helpful to investigate the treatment of AAAs.

Three-dimensional reduced-symmetry of colloidal plasmonic nanoparticles.

Owing to their novel optical properties, three-dimensional plasmonic nanostructures with reduced symmetry such as a nanocrescent and a nanocup have attracted considerable current interest in biophotonic imaging and sensing. However, their practical applications have been still limited since the colloidal synthesis of such structures that allows, in principle, for in vivo application and large-scale production has not been explored yet. To date, these structures have been fabricated only on two-dimensional substrates using micro/nanofabrication techniques. Here we demonstrate an innovative way of breaking symmetry of colloidal plasmonic nanoparticles. Our strategy exploits the direct overgrowth of Au on a hybrid colloidal dimer consisting of Au and polystyrene (PS) nanoparticles without the self-nucleation of Au in an aqueous solution. Upon the overgrowth reaction, the steric crowding of PS leads to morphological evolution of the Au part in the dimer ranging from half-shell, nanocrescent to nanoshell associated with the appearance of the second plasmon absorption band in near IR. Surface-enhanced Raman scattering signal is obtained directly from the symmetry-broken nanoparticles solution as an example showing the viability of the present approach. We believe our concept represents an important step toward a wide range of biophotonic applications for optical nanoplasmonics such as targeting, sensing/imaging, gene delivery, and optical gene regulations.

Suppressive role of vascular endothelial growth factor on intestinal apoptosis in induced necrotizing enterocolitis in rats.

Purpose: Necrotizing enterocolitis (NEC) is a devastating disease that can cause mortality in preterm babies. NEC may develop through an apoptotic pathway that is known to be inhibited by vascular endothelial growth factor (VEGF). This study determined whether VEGF exerted a protective effect against the development of NEC and apoptosis in rats. Methods: To determine the effect of VEGF in NEC rats, neonatal rats were randomized into 4 groups: the control group, the NEC group, the NEC + intraperitoneal VEGF (50 ng/kg) group (NEC + VEGF IP group), and the NEC + oral VEGF (50 ng/kg) group (NEC + VEGF OR group). NEC was induced by lipopolysaccharide/hypoxia and cold stress. The animals were sacrificed 72 hours later. After laparotomy, we obtained a region of the proximal small bowel from the ileocecal valve about 18 cm in length. Results: The NEC histological grade, apoptosis histological score, and caspase-3 activity were lower in the NEC + VEGF IP and OR groups than in the NEC group. In the NEC + VEGF IP and OR groups, the messenger RNA expression of apoptotic and inflammatory genes, such as Bax, NF-κB, p53, Fas, FasL, and PAF-R, but not that of Bcl-2, was decreased, as was the Bax/Bcl-2 protein ratio. Histological analysis revealed that the apoptosis-blocking effect of VEGF was more effective in the NEC + VEGF IP group than in the NEC + VEGF OR group. Conclusion: We identified apoptotic and inflammatory genes to confirm the preventive effect of VEGF pretreatment on NEC in rats. This study presents a novel approach to prevent apoptosis via VEGF pretreatment in rats with lipopolysaccharide/hypoxia-induced NEC.

Scrotal pyocele secondary to gastrointestinal perforation in infants: a case series.

Pyocele in infants is rarely described in the literature, but it is an emergent condition that requires rapid recognition and treatment to prevent testicular loss. If peritonitis due to gastrointestinal perforation occurs, abdominal contamination may spread through a patent processus vaginalis in an infant, which may lead to pyocele. We report the cases of three infants with scrotal pyocele due to the spread of infection or inflammatory material from the intraperitoneal cavity through a patent processus vaginalis. Two infants were surgically treated, while the other was treated with percutaneous aspiration and intravenous antibiotic administration. Although rare, pyocele should be considered in the differential diagnosis of acute scrotum in infants, especially in infants who previously had peritonitis due to gastrointestinal perforation.

Distinctive clinical features of spontaneous pneumoperitoneum in neonates: A retrospective analysis.

BACKGROUND: Spontaneous pneumoperitoneum (SP) without gastrointestinal perforation rarely occurs in neonates, with most SP cases being idiopathic. Although SP usually follows a benign clinical course with favorable prognosis, it can become life-threatening in certain situations. In these cases, urgent surgical intervention may be required. Therefore, it may be difficult to decide when or how to perform prompt interventions. AIM: To demonstrate the distinct clinical features of SP to guide appropriate management by comparing characteristics between SP and typical pneumoperitoneum secondary to gastrointestinal perforation. METHODS: We retrospectively reviewed electronic medical records and identified 37 neonates with radiological evidence of pneumoperitoneum who were treated at our institution. Clinical variables were compared between neonates with SP without gastrointestinal perforation (Group A) and those with pneumoperitoneum secondary to gastrointestinal perforation (Group B). Clinical variables between groups were compared using Student's t-test and the chi-square test. The risk factors related to mortality were examined using multi-logistic regression analysis. RESULTS: Group A comprised 35.1% (13/37) of the patients. The frequency of persistent pulmonary hypertension (53.8%) and pneumothorax (46.2%) before the development of pneumoperitoneum was significantly higher in group A than in group B (P = 0.004). Platelet count and partial pressure of arterial oxygen (PaO2) were significantly lower in group A (P = 0.015 and 0.025, respectively). Overall mortality was significantly higher in group A than in group B (76.9% vs 16.7%, P = 0.001). Only preterm infants were significantly associated with high mortality (P = 0.041; odds ratio = 18.0). Accompaniment with persistent pulmonary hypertension and pneumothorax were also significantly high (P = 0.004) in group A, but these were not strongly associated with high mortality. CONCLUSION: This study identified a higher mortality rate in patients with SP than that described in previous reports. Neonates with SP were more likely to have thrombocytopenia, pneumothorax, and persistent pulmonary hypertension. Prematurity was the most significant factor affecting mortality.

Comparison of three image comparison methods for the visual assessment of the image fidelity of compressed computed tomography images.

PURPOSE: This study aimed to comparatively evaluate three different image comparison methods: alternate display without an intervening blank image (AWOB), alternate display with an intervening blank image (AWB), and side-by-side display (SSD), in terms of the perceptual sensitivity to image differences between Joint Photographic Experts Group 2000 (JPEG2000) compressed body CT images and their originals. METHODS: A total of 50 body CT images obtained with five different scan protocols (5-mm-thick abdomen, 0.67-mm-thick abdomen, 5-mm-thick lung, 0.67-mm-thick lung, and 5-mm-thick low-dose lung) were compressed to one of five compression ratios (reversible, 6:1, 8:1, 10:1, and 15:1) using JPEG2000 algorithm. The fidelity of the compressed images was visually assessed on a four-grade scale independently by five radiologists using each of the three image comparison methods of AWOB, AWB, and SSD. The fidelity grading results for the 40 irreversibly compressed images were compared between the three image comparison methods using the Friedman tests with post hoc Tukey tests. The number of image pairs with no perceptible difference was compared using the exact tests for paired proportions. The time required for the fidelity assessment for all of the 50 compressed images was also compared using the Friedman tests with post hoc Tukey tests. RESULTS: For the 40 irreversibly compressed images, the fidelity grade was significantly lower for AWOB than for AWB or SSD (p < 0.01 for all readers); however, there was no significant difference between AWB and SSD (p-value range, 0.06-0.92). The percentage of image pairs with no perceptible difference tended to be smaller for AWOB than for AWB (p < 0.01 for all readers) or SSD (p < 0.01 for readers 1-3, p = 0.04 for reader 4, and p = 0.23 for reader 5). However, there was no significant difference between AWB and SSD (p-value range, 0.12- >0.99). For all of the 50 compressed images, the fidelity grading time significantly increased in the order of AWOB, SSD, and AWB. CONCLUSIONS: In assessing the image fidelity of JPEG2000 compressed body CT images, AWOB yields lower fidelity grade and requires less fidelity grading time than AWB or SSD, indicating that AWOB is most sensitive to image differences among of them.

Assessment of defecation function beyond infantile period for transanal single-stage endorectal pull-through in Hirschsprung disease.

PURPOSE: Transanal single-stage endorectal pull-through (TERPT) procedure for patients with Hirschsprung disease (HD) has favorable outcomes, with a lower complication rate. Nevertheless, various degrees of bowel dysfunction and fecal incontinence can persist for a long time in some patients. The aim of this study was to assess the mid- and long-term outcomes of TERPT performed during the infantile period after the completion of toilet training. METHODS: We retrospectively reviewed 82 patients aged ≥4 years who underwent TERPT during the infantile period after the pathological diagnosis of HD between 2001 and 2013. Functional outcomes were investigated according to the answers of the Bowel Function Score (BFS) questionnaire, a previously validated 7-item questionnaire about bowel habits. Normal values were obtained in a previous study on BFS for children in Western countries, and a one-sample t-test was used for statistical analysis. RESULTS: Overall, BFS was similar in all investigated age groups. On comparing fecal soiling and social problems between the HD and normal populations, a lower score at an early age in patients with HD was noted; however, the scores became similar when the patients were 7 years of age. Stool frequency decreased continuously but was not significantly different between the 2 groups. CONCLUSION: The functional outcomes of TERPT performed during the infantile period, after completing toilet training, were similar to that of the normal population. In most cases, uncomfortable symptoms were diminished and functions improved with age.

Surgical perspectives of symptomatic omphalomesenteric duct remnants: Differences between infancy and beyond.

BACKGROUND: The clinical manifestations of omphalomesenteric duct remnant (OMDR) can vary with the age at diagnosis, from asymptomatic incidental findings to symptoms related to gastrointestinal complications. The lifelong complication rates are reported as 4%-34%, and complications are more common in patients younger than 2 years of age. The authors attempted to identify different clinical features and management for the various pediatric age groups. AIM: To find surgical perspectives for the pediatric age-related variants of OMDR and make recommendations for optimal management. METHODS: The medical records of pediatric patients diagnosed with OMDR were reviewed retrospectively. Fifteen patients diagnosed based on incidental findings during other surgeries were excluded. The patients were divided into two groups based on age: < 12 mo (infants) and > 12 mo (beyond infancy). We analyzed the demographic characteristics, clinical manifestations, diagnostic tools, surgical procedures, and clinical outcomes of the patients and compared them for the age groups. Chi-squared and Fisher's exact tests were used for nominal scales and a Mann-Whitney test was used for ratio scales. RESULTS: A total of 35 patients (7 infants, 28 children beyond infancy) were finally included. In both groups, Meckel's diverticulum (MD) was the most common type of OMDR, while umbilical lesions were more common in the infant group (P = 0.006). Hematochezia and abdominal pain were common in the beyond infancy group, while umbilical lesions were the most frequent symptoms in the infant group. Several diagnostic tools were used, but Meckel's scan was most useful in diagnosing OMDR in patients with painless rectal bleeding. Minimally invasive surgery was more commonly performed for children than for infants (P = 0.016). Single-incision laparoscopic surgery (SILS) was performed for fifteen patients who underwent laparoscopic surgery. There were only three cases of postoperative complications, and all patients survived in good condition. CONCLUSION: The clinical type of OMDR varies with age, umbilical lesions in infants, and MD beyond infancy. SILS is effective for managing children with MD regardless of age.

Experience with a Hybrid Procedure Involving Laparoscopic Fundoplication with Percutaneous Endoscopic Gastrostomy in Chronically Ill Children.

Gastrostomy with concurrent laparoscopic Nissen fundoplication (LNF) is often performed as a laparoscopic gastrostomy (LG) by surgeons. Since 2014, we started performing percutaneous endoscopic gastrostomy (PEG) as gastrostomy with LNF. This study aims to compare the outcomes of LG and PEG with LNF. Patients were recruited into two groups: LNF with LG (historical control) or PEG. Demographic data, operation time, time to start feeding, time to full feeding, length of hospital stay (LOS), and complications were compared between the groups. Fourteen patients underwent LNF with LG and 49 underwent LNF with PEG. The median age and body weight of patients were 4.25 years and 14.15 kg in the LG group and 2.58 years and 10.60 kg in the PEG group, respectively. Operation times were significantly shorter in the PEG group (1.81 vs. 2.61 h). The times to start feeding and full feeding as well as LOS were shorter in the PEG group. Nevertheless, complications were similar in both groups. In conclusion, PEG with LNF was associated with significantly shorter operation times, times to start feeding and reach full feeding, and LOS. PEG is a suitable method for LNF in chronically ill children.

Reducing Supply Cost by Standardization of Surgical Equipment in Laparoscopic Appendectomy.

BACKGROUND AND OBJECTIVES: Compensation for increased medical services from reimbursement systems are sometimes insufficient. Generally, appendectomies are performed by individual surgeons with their preferred instrument. Surgical equipment standardization is known to reduce medical cost without compromising patient safety. Hence, we investigated the effectiveness of surgical equipment standardization to reduce the required operative cost for laparoscopic appendectomy at our tertiary hospital. METHODS: Nine surgeons at our tertiary hospital agreed to use standardized equipment for laparoscopic appendectomy. We compared outcomes among patients who underwent laparoscopic appendectomy between December 2012 and June 2013 before standardization (control group) and between August 2015 and February 2016 after standardization. Participating provider and staff convenience was also surveyed using a questionnaire. RESULTS: The implementation of standardized equipment for laparoscopic appendectomy decreased intraoperative supply cost from US $552.92 to $450.17. Operative times also decreased from 73.8 to 53.3 minutes. However, hospital days and complication rates remained unchanged. Participants responded that surgical equipment standardization improved efficiency in the operating room and reduced the cost. CONCLUSION: Surgical equipment standardization in laparoscopic appendectomy is effective in reducing intraoperative supply cost without compromising patient safety.

Alimentary Tract Duplication in Pediatric Patients: Its Distinct Clinical Features and Managements.

PURPOSE: Alimentary tract duplication (ATD) is a rare congenital condition that may occur throughout the intestinal tract. Clinical symptoms are generally related to the involved site, size of duplication, or associated ectopic mucosa. This study aimed to identify clinical implications by anatomical locations and age group and then suggest a relevant management according to its distinct features. METHODS: We retrospectively reviewed the clinical data of pediatric patients who received a surgical management due to ATD. Furthermore, data including patients' demographics, anatomical distribution of the duplication, clinical features according to anatomical variants, and outcomes were compared. RESULTS: A total of 25 patients were included in this study. ATD developed most commonly in the midgut, especially at the ileocecal region. The most common clinical presentation was abdominal pain, a sign resulting from intestinal obstruction, gastrointestinal bleeding, and intussusception. The non-communicating cystic type was the most common pathological feature in all age groups. Clinically, prenatal detection was relatively low; however, it usually manifested before the infantile period. A laparoscopic procedure was performed in most cases (18/25, 72.0%), significantly in the midgut lesion (p=0.012). CONCLUSION: ATD occurs most commonly at the ileocecal region, and a symptomatic one may usually be detected before the early childhood period. Surgical management should be considered whether symptom or not regarding its symptomatic progression, and a minimal invasive procedure is the preferred method, especially for the midgut lesion.