Effect of Standardized Bundle Care and Bundle Compliance on Reducing Surgical Site Infections: A Pragmatic Retrospective Cohort Study.

BACKGROUND Care bundles for infection control consist of a set of evidence-based measures to prevent infections. This retrospective study aimed to compare surgical site infections (SSIs) from a single hospital surveillance system between 2017 and 2020, before and after implementing a standardized care bundle across specialties in 2019. It also aimed to assess whether bundle compliance affects the rate of SSIs. MATERIAL AND METHODS A care bundle consisting of 4 components (peri-operative antibiotics use, peri-operative glycemic control, pre-operative skin preparation, and maintaining intra-operative body temperature) was launched in 2019. We compared the incidence rates of SSIs, standardized infection ratio (SIR), and clinical outcomes of surgical procedures enrolled in the surveillance system before and after introducing the bundle care. The level of bundle compliance, defined as the number of fully implemented bundle components, was evaluated. RESULTS We included 6059 procedures, with 2010 in the pre-bundle group and 4049 in the post-bundle group. Incidence rates of SSIs (1.7% vs 1.0%, P=0.013) and SIR (0.8 vs 1.48, P<0.01) were significantly lower in the post-bundle group. The incidence of SSIs was significantly lower when all bundle components were fully adhered to, compared with when only half of the components were adhered to (0.3% vs 4.0%, P<0.01). CONCLUSIONS SSIs decreased significantly after the application of a standardized care bundle for surgical procedures across specialties. Full adherence to all bundle components was the key to effectively reducing the risk of surgical site infections.

Zinner syndrome in children: clinical presentation, imaging findings, diagnosis, and outcome.

BACKGROUND: Zinner syndrome (ZS), the association of congenital seminal vesicle cyst (SVC) and ipsilateral kidney anomalies, is rarely diagnosed in childhood. This study aimed to assess presentation, imaging findings, management, and outcome of pediatric ZS. METHODS: Sixteen children with ZS were diagnosed and managed at our hospital from 2003 to 2021. We reviewed the medical records to collect data on initial symptoms, results of imaging studies, complications, operation, and follow-up. RESULTS: Ultrasound was used in all 16 cases as initial diagnostic tool. Fourteen patients were asymptomatic at diagnosis: these were transferred from obstetricians or pediatricians for evaluation of the prenatally or postnatally detected ultrasonic kidney anomalies. SVCs were incidentally noted on ultrasonography. The other two cases initially presented with urinary tract infection (UTI). Kidney anomalies included multicystic dysplastic kidney in 3 and kidney agenesis in 13 patients. Eleven (68.7%) patients had ipsilateral ectopic ureters entering SVC. Four (36.4%) patients had a reflux from urethra into SVC (urethro-cystic reflux) on voiding cystourethrography. Ten (62.5%) patients remained asymptomatic over a mean of 58 months (range, 7-216 months), two patients developed lower urinary tract dysfunction, and five patients had UTIs. Two boys needed SVC removal, and SVC had disappeared in two patients after 2.5-4 years of follow-up. CONCLUSIONS: Unilateral kidney hypodysplasia with ectopic ureter inserting into the ipsilateral SVC is a characteristic sign for diagnosis of ZS. In our case series, ZS was mainly asymptomatic. Urethro-cystic reflux was associated with UTIs in young infants. SVC removal was rarely required. A higher resolution version of the Graphical abstract is available as Supplementary information.

Intraoperative OK-432 pleurodesis for preventing recurrence of primary spontaneous pneumothorax in children and adolescents: a single-center experience.

BACKGROUND: Primary spontaneous pneumothorax (PSP) commonly occurs in lean, tall, male children and adolescents. To reduce recurrence rates of PSP, chemical pleurodesis could be helpful for patients undergoing video-assisted thoracoscopic surgery (VATS) wedge bullectomy. The efficacy and safety of intraoperative OK-432 (Picibanil) pleurodesis on preventing the recurrence of PSP in pediatric patients remain unclear. METHODS: It is a retrospective observational study in a single center, between 2014 and 2020, enrolled 48 (8 females) pediatric PSP patients with persistent air leakage at the mean age of 16.3 ± 1.1 years to receive VATS wedge bullectomy and pleural abrasion. Twenty patients received additional intraoperative OK-432 pleurodesis. The clinical characteristics of patients, surgical outcomes, and recurrence rates were analyzed. RESULTS: The OK-432 group had longer operation time (118.6 ± 35.6 vs. 96.5 ± 23.3 min; p < 0.05) and higher proportion of postoperative fever (75.0% vs. 28.5%; p = 0.015) than the standard group. No serious adverse events were noted and other surgical outcomes in the two groups were comparable. After a mean follow-up period of 18.1 ± 19.1 months, the OK-432 group had a lower recurrence rate compared with the standard group (5% vs. 28.6%; p < 0.05, odds ratio 0.13, 95% confidence interval: 0.01-1.15), but it had no significant difference in statistics on the Kaplan-Meier curves (log-rank p = 0.105). CONCLUSION: It was the first study that focused on the addition of intraoperative OK-432 pleurodesis for PSP with persistent air leakage in children and adolescents receiving VATS. It demonstrated the efficacy with a low recurrence rate and short-term safety as a single-center experience. LEVEL OF EVIDENCE: Retrospective review, therapeutic study, Level III.

Laparoscopy versus open surgery for idiopathic intussusception in children.

PURPOSE: This study aims to compare the results of laparoscopy and open surgery for idiopathic intussusception in children as well as evaluate the efficacy of ileopexy. METHODS AND MATERIALS: Between January 2007 and July 2013, children aged <18 years who were operated for intussusception in our institution were reviewed. Patients were classified into two groups, laparoscopy (LAP) and open (OPEN). Both groups were further divided into two subgroups, ileopexy (IP) and non-ileopexy (NIP). Parameters investigated included age, gender, operative indication, surgical procedure, type of intussusception, level of intussusceptum, presence of spontaneously reduced intussusception and pathologic lead points, operative time (OP time), time to oral intake (PO time), length of postoperative hospital stay (LOS), and surgical recurrence. RESULTS: There were 23 and 35 patients in LAP and OPEN group, respectively. No significant difference was found on age, operative indication, surgical procedure, type of intussusception, level of intussusceptum, and presence of spontaneously reduced intussusception between both groups. In LAP group, mean OP time was significantly longer; mean PO time and LOS were significantly shorter. One surgical recurrence occurred in each group (p = 0.76). In comparison of LAP-IP (n = 15) and LAP-NIP (n = 8), OP time, PO time, and LOS were similar in both subgroups. One recurrence was noted in LAP-IP (p = 0.46). The overall conversion rate was 13.0 % (6.8 vs. 25 %, p = 0.21). Compared to patients with intussusceptum to ascending colon, the conversion rate was significantly higher in patients with intussusceptum to transverse and descending colon. With the exclusion of conversion, OP time was significantly shorter in LAP-NIP (p = 0.01). CONCLUSION: Laparoscopy should be considered the primary modality for radiologically irreducible or recurrent idiopathic intussusception in children. Ileopexy provides no benefit on recurrence prevention but contributes to longer OP time.

Coexisting gastrointestinal and hepatobiliary tract anomalies in omphalocele and gastroschisis: A twenty-year experience in a single tertiary medical center.

BACKGROUND: Omphalocele and gastroschisis are the two most common congenital abdominal wall defects; however, no previous study has focused on gastrointestinal and hepatobiliary tract malformations in these two conditions. This study aimed to investigate the demographic characteristics, coexisting congenital gastrointestinal and hepatobiliary tract anomalies, hospital course, and outcomes of patients with gastroschisis and omphalocele. METHODS: This is retrospective chart review of all patients admitted to one tertiary medical center in Taiwan between January 1, 2000 and June 30, 2020 with a diagnosis of gastroschisis or omphalocele. The medical records were reviewed to obtain demographic data regarding coexisting gastrointestinal and hepatobiliary tract anomalies and outcomes. RESULTS: Of the 51 patients included, 21 had gastroschisis and 30 had omphalocele. Gastroschisis was associated with a significantly younger maternal age and a higher incidence of small for gestational age. Of the 30 patients with omphalocele, twelve had associated gastrointestinal and hepatobiliary anomalies. Seven of the 21 patients with gastroschisis had gastrointestinal anomalies, and none had hepatobiliary anomalies. Among the omphalocele patients, three (10%) had documented malrotation, and one developed midgut volvulus. Among gastroschisis patients, four patients (19%) had malrotation, and two developed midgut volvulus. There were no statistically significant differences in postoperative complications or mortality rates between those with and without gastrointestinal/hepatobiliary tract anomalies. CONCLUSION: The diversity of coexisting gastrointestinal and hepatobiliary tract anomalies is higher in the omphalocele than in gastroschisis. In addition, we demonstrate that patients with gastroschisis or omphalocele have a higher rate of intestinal malrotation and midgut volvulus.

Rare presentation in a rare case of pancreatic extraosseous Ewing's sarcoma: A case report.

RATIONALE: Extraosseous Ewing's sarcoma is a rare tumor which is aggressive with poor prognosis; it can occur anywhere in the body, but scantily in the pancreas. Pancreatic Ewing's sarcoma is not reported commonly, with inconsistent clinical manifestations. In this regard, early recognition of this disease is very important for the patient's sake. PATIENT CONCERNS: A 16-year-old boy presented with left lower quadrant abdominal pain for 2 months, and left flank pain with dysuria for 1 month. DIAGNOSIS: Abdominal and renal ultrasonography found a mass between the spleen and left kidney as well as left renal pelvic dilatation. Abdominal computed tomography found a heterogenous mass derived from the tail of the pancreas. Serial examinations revealed that the mass was a pancreatic Ewing's sarcoma. Furthermore, no metastasis was documented. INTERVENTIONS: The tumor was totally excised after 6 months of chemotherapy, which included 10 courses of neoadjuvant chemotherapy with vincristine, epirubicin, and cyclophosphamide, alternating with ifosfamide and etoposide. The patient completed consolidation chemotherapy with vincristine, epirubicin, and cyclophosphamide, alternating with ifosfamide and etoposide for 5 courses. Radiotherapy was applied to the tumor-involved region and tumor bed. OUTCOMES: To date, the malignancy has not recurred since the treatment was completed 4 years ago. There are no complications from the treatment for the patient. LESSONS: The pancreas is a very rare extraosseous location for Ewing's sarcoma. Pancreatic extraosseous Ewing's sarcoma should be regarded as a differential diagnosis of non-urinary originated left flank pain with dysuria in adolescents.

Primary diaphragmatic yolk sac tumor and review of the literature.

Primary yolk sac tumor of the diaphragm in children is very rare, and diagnosis of a diaphragmatic tumor poses challenges to clinical physicians. Here, we report a primary diaphragmatic yolk sac tumor in a 9-month-old girl, together with a review of 4 earlier reported cases in the English literature. Carboplatin-containing regimen successfully decreased the tumor size and a total resection of the tumor was made subsequently. The patient was disease-free 8 months after the completion of treatment.

A retrospective study of clinical features and outcome in patients with refractory or recurrent hepatoblastoma: A single institution experience.

BACKGROUND: Hepatoblastoma (HB) is the most common childhood primary hepatic malignancy. The overall survival rate in patients with HB has reached more than 80% over the past decades. The poor prognostic and high-risk HB have been defined, but the treatment and cure of refractory or relapsed HB is still an arduous task. METHODS: The complete records of HB in patients under the age of 18 at the MacKay Memorial Hospital between 1990 and 2019 were examined. RESULTS: The treatment results for 11 patients with refractory or relapsed HB are presented. The multi-modality treatment records were reviewed and the clinical characteristics associated with poor outcome included multifocal lesions, low α-fetoprotein, great vessel invasion and metastases. Delayed liver tumor surgery was carried out in eight cases. The median duration of follow-up for the 11 patients was 48.6 months (range 1.9 to 316.8 months). The 5-year and 10-year overall survival rate were 62.3% ± 15% (SE) and 49.9% ± 16.4% (SE), respectively. Most treatment-related toxicities were tolerable. The major concern during long term follow-up was irreversible high-frequency hearing loss. CONCLUSION: Patients with refractory/relapsed HB are still a thorny issue and more research is needed to improve the outcome.

A 4-year-old boy presenting with recurrent croup.

Croup is common in children but recurrent croup is unusual. A 4-year-11-month-old boy presented with recurrent croup. Physical examination revealed decreased breath sounds over left lower chest. Chest x-ray disclosed segmental atelectasis over left lower chest and a mass shadow over mediastinum.

Long-term treatment results of hepatoblastoma at a single institution in Taiwan.

From 1990 to 2004, there were 23 consecutive patients with hepatoblastoma treated at Mackay Memorial Hospital in Taipei, Taiwan. There were 7 patients of stage I, 3 of stage II, 13 of stage III, and none had stage IV disease. Two siblings had congenital hepatoblastoma and both survived. Two patients were prematurity. Beckwith-Wiedemann syndrome, isosexual precocity, chronic B hepatitis presented in 1 patient each. In addition to surgery, we used cisplatin 90 mg/m/d on day 1 and epirubicin 25 mg/m/d for days 1 to 3 as first-line chemotherapy. Each course was repeated every 3 weeks. Epirubicin was chosen because of its lower cardiotoxicity. Carboplatin/etoposide and vincristine/cyclophosphamide/5-fluorouracil were the second-line chemotherapy for considering cumulative toxicity of first-line chemotherapy. If initial total excision was feasible, postoperative chemotherapy of 4 to 6 courses were given. Three patients died of progressive disease, infection, and relapse 1 each. The median duration of follow-up for 20 survived patients was 94 months. The 5-year event-free and overall survival rates were 73.9%+/-9.2% (SE) and 87%+/-7.0%, respectively. Tumor recurred in 5 patients. The commonest toxicity was febrile neutropenia. There was no cardiotoxicity event. In conclusion, with sequential combination of surgery and chemotherapy, the treatment results for hepatoblastoma were satisfactory as compared with other groups.

Paecilomyces lilacinus peritonitis complicating peritoneal dialysis cured by oral voriconazole and terbinafine combination therapy.

Fungal peritonitis (FP) is a serious complication in patients on continuous ambulatory peritoneal dialysis (CAPD). We report a case of CAPD-related FP caused by Paecilomyces lilacinus in a 15-year-old uraemic boy. The infection was successfully treated by combination therapy consisting of oral voriconazole and terbinafine, which has not been previously reported in the treatment of FP.

Retrograde Ureteral Catheterization: A Possible New Treatment for Renal Fungal Balls in Very Low Birth Weight Infants.

Invasive candidiasis is a serious pathogen of late-onset sepsis in very low birth weight infants. Kidney is the most common organ involved, and it causes morbidity and mortality, especially when fungal balls are formed. We report a 34-day-old female infant (born at 28 weeks' gestation, 1152 g) with systemic fungal infection complicated obstructive uropathy. On sonography, the fungal balls filled the entire pelvis without hydronephrosis. Percutaneous nephrostomy was not feasible. In addition to systemic antifungals, we successfully performed cystoscopy-assisted retrograde ureteral catheterization to decompress the pelvis, which also provided a route for local amphotericin B irrigation to achieve therapeutic concentration without nephrotoxicity.

Biliary cysts in children--long-term follow-up in Taiwan.

BACKGROUND: This study analyzed the clinical presentation, postoperative morbidity and mortality and incidence of associated extrahepatic biliary atresia in children with biliary cysts in Taiwan. METHODS: We retrospectively reviewed the records of 158 pediatric patients with biliary cysts seen between June 1981 and July 2004, with follow-up ranging from 12 months to 22 years (mean, 11.2 +/- 6.1 years). Patients were divided into three groups: biliary atresia-associated biliary cyst (BABC, 21 patients), non-biliary atresia-associated choledochal cyst (NBACC) in infancy (37 patients), and late NBACC (> 1 year of age, 100 patients). RESULTS: BABC accounted for 36.2% of the infantile biliary cysts in this study. Extrahepatic cysts in late NBACC had a greater mean diameter than those in infantile NBACC and BABC (21.5 mm vs. 16.0 mm vs. 7.9 mm, p < 0.001). Cholangitis was the most serious complication within 3 months postoperatively in all three groups, resulting in four deaths (two in the infantile NBACC group and one each in the other two groups). Liver cirrhosis developed during long-term follow-up in nine of the 21 patients with BABC, four of whom died. Three of these nine patients underwent liver transplantation and remained well during follow-up. Chronic complications in NBACC occurred mainly in late IVa cases, with persistent intrahepatic dilatation developing in 12 of 35 patients and intrahepatic stones in five. Elevation of serum alanine aminotransferase (ALT) was found preoperatively in 85% of late NBACC and 35% of infantile NBACC cases. Postoperative normalization of ALT occurred after a mean of 152 +/- 23 days and 158 +/- 67 days in late NBACC and infantile NBACC, respectively. Higher ALT levels before operation were associated with a longer period until normalization. CONCLUSION: The possibility of BABC must be included in the differential diagnosis when a small extrahepatic cyst (< 8 mm in diameter) with prolonged jaundice is found in infancy. Postoperative follow-up is essential for patients with NBACC due to their frequently prolonged elevation of serum ALT and possibility of residual intrahepatic dilatation. Cholangitis was the major cause of death within 3 months postoperatively in this study.

Clinical criteria for diagnosing perforated appendix in pediatric patients.

OBJECTIVE: To determine predictive variables associated with a perforated appendix in pediatric patients with acute appendicitis. METHODS: This is a retrospective, cross-sectional, observational study from a medical center with more than 2000 beds (230 beds in Department of Pediatrics and Pediatric Surgery), with a mean admission of more than 12000 cases and 2200 surgeries per year. The outcome variable was perforated appendix, and the predictive variables included demographic and clinical factors. RESULTS: During a 6-year period, appendectomies were performed on 274 patients ranging in age from 1 to 18 years. Perforated appendix was found in 100 children (36.5%). Predictive factors significantly associated with perforated appendix were age younger than 9 years, abdominal pain of more than 2 days' duration, temperature of more than 37.9 degrees C, peritoneal signs, and erythrocyte sedimentation rate of more than 25 mm/h. Abdominal ultrasound was performed in 89 patients (32%). For perforated appendix, the ultrasound had a sensitivity of 35%, specificity of 98%, positive predictive value of 95%, and negative predictive value of 55%. Indications for an abdominal ultrasound were determined from a scoring system using the predictive variables significantly associated with perforated appendix. CONCLUSION: The use of our proposed scoring system to determine the indications to perform an abdominal ultrasound may prove to assist in deciding treatment (medical vs surgical) for children with perforated appendix. Initial antibiotic treatment followed by interval appendectomy would become a more likely treatment option if our study results can be validated in a prospective study.

Gastric volvulus in children.

Gastric volvulus (GV) is a rare disease in children that may not be recognized early in its course. We retrospectively analyzed 15 patients under 18 years of age who presented to our medical center with GV between January 1995 and June 2005. Patients with complete volvulus and acute obstruction requiring immediate intervention were defined as acute GV. Chronic GV was diagnosed in the presence of partial volvulus with chronic, nonspecific symptoms and signs. Chronic GV (12/ 15) was more common than acute GV (3/15). Organoaxial GV was the most common type (9/15), and there was a high incidence (6/15) of associated anomalies that predisposed to the condition. None of our patients had Borchardt's triad (acute localized epigastric distension, unproductive retching, and the inability to pass a nasogastric tube) which is described in adults with acute GV. Acute GV was immediately treated surgically, but conservative management was successful in patients with chronic idiopathic GV. When acute GV in children fails to exhibit the full gamut of Borchardt's triad, the diagnosis may be delayed. Immediate surgical reduction is recommended for acute GV. For chronic idiopathic GV, the treatment may be based on the age at diagnosis, the severity of symptoms, and how patients are expected to comply with conservative measures.

Clinical analysis of chronic peritoneal dialysis related peritonitis in children.

In most countries, chronic peritoneal dialysis (PD) is the preferred dialysis mode for children and adolescents below the age of 15 years with end-stage renal disease. PD-related peritonitis is a serious complication that has a great impact on uremic patients'outcome. We retrospectively reviewed the charts of a total of 22 uremic children who underwent chronic peritoneal dialysis. The total peritonitis rate in our study was one episode every 23.7 patient-months, and there was no significant difference in the incidence of peritonitis between children with automated peritoneal dialysis and those with continuous ambulatory peritoneal dialysis (p=0.219). Staphylococcus aureus was the most common causative organism, accounting for 13.3% of the episodes of peritonitis. The combination therapy of vancomycin plus ceftazidime is effective for common pathogens in peritonitis. Rare microorganisms, e. g., fungus and mycobacterium, should be taken into consideration when the response to initial treatment is poor. Early diagnosis and treatment is important to prevent sequelae and mortality.

Partial androgen insensitivity syndrome with R840H mutation in androgen receptor: report of one case.

Androgen insensitivity syndrome (AIS) is the major cause of male pseudohermaphroditism. The severity of the disorders varies widely, ranging from the phenotypic women with female external genitalia in cases of complete AIS to the phenotype of ambiguous genitalia in partial androgen insensitivity syndrome (PAIS) and a rare group of phenotypic normal males with azoospermia. Here, we report an infant of PAIS with a missense mutation at position 2881 (G-->A) in exon 7, encoding substitution of histidine for arginine at codon 840 of the androgen receptor (AR) gene. Both the biochemical and molecular studies are presented. Establishing the diagnosis of PAIS is very important for gender assignment to an infant of ambiguous genitalia. The molecular analysis will facilitate genetic counselling to the maternal side relatives for carrier detection and prenatal diagnosis.

Treatment Results of Extracranial Malignant Germ Cell Tumor with Regimens of Cisplatin, Vinblastine, Bleomycin or Carboplatin, Etoposide, and Bleomycin with Special Emphasis on the Sites of Vagina and Testis.

BACKGROUND: The survival of children with malignant germ cell tumor (GCT) increased over the past 2 decades with platinum-based chemotherapy. This report has three objectives: (1) comparison of PVB (cisplatin, vinblastine, and bleomycin) with JEB (carboplatin, etoposide, and bleomycin) regimens; (2) treatment modality of vaginal GCT; and (3) management of stage I testicular yolk sac tumor (YST) in boys under 2 years old. METHODS: From January 1, 1987 to December 31, 2010, 81 patients with malignant extracranial GCT were treated. Two consecutive protocols, PVB followed by JEB, were used. Girls with vaginal YST received minimal surgery and chemotherapy. Boys under 2 years old with Stage I testicular YST received surgery with or without chemotherapy. RESULTS: As of June 30, 2012, the 10-year overall survival (OS) was 95 ± 3% (standard error) and the event-free survival (EFS) was 88 ± 4%. With PVB, 35 patients had 10-year OS of 91 ± 5% and EFS of 89 ± 5%. With JEB, 25 patients had 7-year OS of 96 ± 5% and EFS of 96 ± 5%. All five girls with vaginal YST were cured with vagina-preserved strategy. In 32 boys age under 2 years old with stage I YST, 16 with light chemotherapy were all in EFS, whereas two of 16 patients without chemotherapy relapsed. After PVB, six patients developed nephrotoxicity and one had pulmonary fibrosis. CONCLUSION: Girls with vaginal YST who received minimal surgery and chemotherapy had excellent prognosis and sexual organs were preservable. Light chemotherapy after surgery is a treatment option for boys under 2 years old with stage I YST to decrease relapse rate. Both JEB and PVB are effective. JEB resulted in more myelosuppression but otherwise less serious long-term toxicity than PVB.

Neural-crest tumor presenting with chronic diarrhea: a report of three cases.

The association of chronic diarrhea with neural-crest tumors is uncommon. In the past 12 years, we encountered three cases of neural-crest tumors presenting initially as chronic diarrhea. The incidence of chronic diarrhea in patients with neural-crest tumors at our hospital during this period was 3.8%. These patients (two girls and one boy aged between 15 to 28 mo) presented with a 3-week to 6-month history of chronic diarrhea of unknown cause. A posterior mediastinal mass or abdominal mass found on sonography and chest roentgenography eventually led to the diagnosis of neural-crest tumor in these patients. Pathology revealed ganglioneuroblastoma in two cases and neuroblastoma in one. All three patients received chemotherapy and underwent surgery. Diarrhea ceased postoperatively in all three patients. Although one of the patients died of septic shock during chemotherapy, the other two remained free of disease at 30 and 22 months of postoperative follow-up, respectively. A high index of suspicion is needed to identify cases of neural-crest tumor from the presenting symptom of chronic diarrhea.