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PURPOSE: This study was aimed to compare the success rate between patients who underwent general anesthesia and deep sedation. METHODS: Patients who were diagnosed with intussusception and had no contraindications would receive non-operative treatment first by undergoing pneumatic reduction. The patients were then split in to two groups: one group underwent general anesthesia (GA group), while the other underwent deep sedation (SD group). This study was a randomized controlled trial which compared success rate between two groups. RESULTS: A total of 49 episodes diagnosed with intussusception were random into 25 episodes in GA group and 24 episodes in SD group. There was no significant difference in baseline characteristic between the two groups. The success rates of GA group and SD group were equally 88.0% (p = 1.00). Sub-analysis of the success rate was lower in the patients with high-risk score for failed reduction. (Chiang Mai University Intussusception (CMUI) failed score in success VS failed = 6.9 ± 3.2 vs. 10.3 ± 3.0 p = 0.017). CONCLUSION: General anesthesia and deep sedation offered similar success rates. In cases of high risk of failure, general anesthesia should be considered to accommodate the switch to surgical management in the same setting if the non-operative approach fails. The appropriate treatment and sedative protocol also increase the success of reduction.
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Sedação Profunda , Intussuscepção , Humanos , Intussuscepção/etiologia , Sedação Profunda/efeitos adversos , Sedação Profunda/métodos , Anestesia Geral/efeitos adversos , Resultado do Tratamento , Enema/métodosRESUMO
PURPOSE: To identify prognostic factors of postoperative Hirschsprung-associated enterocolitis (HAEC). METHOD: A retrospective cohort study of Hirschsprung patients between 2006 and 2021 was conducted. Patients with anorectal malformation and non-definitive surgery were excluded. Associated factors for postoperative HAEC were reported with hazard ratio (HR) and 95% confidence interval (CI). RESULTS: Forty-nine patients were excluded due to concurrent anorectal malformation and incomplete data. Of 274 patients, 75 patients (27.4%) had at least one episode of postoperative HAEC. There were 28 patients (37.3%) who had multi-episodes of HAEC. The total episodes of post-operative HAEC in this study were 121 episodes (36.8%). In multivariable survival analysis, significant factors associated with postoperative HAEC were the aganglionic level above sigmoid colon (HR = 3.47, p = 0.023, 95% CI 1.19-10.09), and total colonic aganglionosis (HR = 14.83, p = 0.004, 95% CI 2.33-94.40). The patients who experienced clinical enterocolitis before 2 weeks after surgery significantly developed more postoperative HAEC (HR = 5.32, p = 0.038, % CI 1.09-25.92). The incidence of postoperative HAEC was increase in patients with postoperative obstructive symptoms (48.0%). One patient died due to severe sepsis from postoperative HAEC, while three others required intensive care. CONCLUSIONS: The long involvement of aganglionic segment and early postoperative HAEC was significantly associated with postoperative HAEC. Frequent follow-up, parental education, and early treatment are recommended in these individuals, particularly in the first year after surgery.
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Malformações Anorretais , Enterocolite , Doença de Hirschsprung , Humanos , Lactente , Estudos de Coortes , Estudos Retrospectivos , Malformações Anorretais/complicações , Prognóstico , Enterocolite/etiologia , Enterocolite/complicações , Doença de Hirschsprung/complicações , Doença de Hirschsprung/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologiaRESUMO
This study aimed to validate the "Chiang Mai University Intussusception Failed Score (CMUI)" for intussusception non-operative reduction. Both a 2-year retrospective and a 5-year prospective consecutive review of patients with intussusception were conducted. Data were collected from January 2013 to December 2020. Related retrospective data of a developmental set from two centers from January 2006 to December 2012 were used. Ten prespecified prognostic factors for failed reduction were collected and from these a predictive score was calculated. The actual results of non-operative reduction were collected and set as a reference standard. Altogether, 195 episodes of intussusception were found. Twenty-two patients were excluded due to contraindications; therefore, a total of 173 episodes were included in the validation dataset. The development data set comprised 170 episodes. We found that no statistical significance was found from comparing the areas under the ROC of two datasets (p-value = 0.31), while specificity of the validation set was 93.8% (88.1-97.3). This temporal validation showed a high specificity and a high affinity for prediction of failed reduction as the development dataset despite being in an era of a higher successful reduction rate. The intensive reduction protocols might be introduced among patients with high-risk scores.
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Intussuscepção , Humanos , Lactente , Intussuscepção/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , UniversidadesRESUMO
The diagnosis of Hirschsprung's disease (HSCR) relies on history, physical examination, and investigations. Some of investigation modalities could not be done in primary hospital. This study was aimed to develop the clinical score model for diagnosing and early referrals of HSCR, especially in areas where investigations were not available. Overall 483 consecutive suspected HSCR patients who were under 15 years old from January 2006 to December 2020 were included in this study, with 207 (42.86%) patients diagnosed with HSCR and 276 (51.14%) patients in the non-HSCR group. Five clinical parameters were included in the prediction model. The AuROC of clinical parameters, which included having an age younger than one month, male gender, the term infant, history of delayed meconium passage, and history of enterocolitis, was 72%. The prediction score ranged from 0-7, with a score 0-3 meaning a low risk to be HSCR (LHR+ = 0.37). We concluded that patients with suspected HSCR who had clinical score 4-7 had a high probability to be HSCR and, thus, it was suggested that these patients have an early referral for further investigations, which were contrast enema and rectal suction biopsy. In the case of a low probability of HSCR, clinical observation is still warranted. This clinical scoring system can be used as a screening tool to prevent delay diagnosis and complications.
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BACKGROUND: Gastroschisis is the most common congenital abdominal wall defect. Due to the exposure of midgut to amniotic fluid, the recovery of bowel function is often delayed. This study aimed to identify the factors associated with the successful early enteral feeding in gastroschisis and to develop further guidelines of treatment. METHODS: A retrospective cohort study of gastroschisis babies from January 2006 to December 2015 was done. Exclusion criteria were incomplete data and death. Successful early enteral feeding was defined when full feeding was achieved within 21 days of life. RESULTS: One hundred and five gastroschisis patients were divided into a successful early-feeding group (n = 56, 53%) and a non-successful early-feeding group (n = 49, 46%). In multivariable analysis, significant factors for successful feeding clustered by primary treatment were female (RR = 1.38, P value < 0.001), gestational age > 36 weeks (RR = 1.23, P value < 0.001), age at surgery less than 10 h (RR = 1.15, P value < 0.001), postoperative extubation time < 4 days (RR = 1.39, P value < 0.001), and age when feeding started less than 10 days (RR = 35.69, P value < 0.001). CONCLUSION: Several factors were found to be associated with successful early enteral feeding. The modifiable factors found in this study were surgery within 10 h, early postoperative extubation within 4 days, and feeding started before 10 days of life. These will guide the management of gastroschisis to achieve successful early enteral feeding.
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Nutrição Enteral/métodos , Gastrosquise/cirurgia , Feminino , Humanos , Recém-Nascido , Masculino , Período Pós-Operatório , Estudos Retrospectivos , Fatores de TempoRESUMO
Intussusception in a premature baby is a rare condition. We report a male preterm infant, who developed abdominal distension and abdominal wall erythema. He was operated with suspicion of NEC but an ileo-ileal intussusception and intestinal perforation were encountered at operation.
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PURPOSE: The nonoperative reduction of intussusception in children can be performed safely if there are no contraindications. Many risk factors associated with failed reduction were defined. The aim of this study was to develop a scoring system for predicting the failure of nonoperative reduction using various determinants. PATIENTS AND METHODS: The data were collected from Chiang Mai University Hospital and Siriraj Hospital from January 2006 to December 2012. Inclusion criteria consisted of patients with intussusception aged 0-15 years with no contraindications for nonoperative reduction. The clinical prediction rules were developed using significant risk factors from the multivariable analysis. RESULTS: A total of 170 patients with intussusception were included in the study. In the final analysis model, 154 patients were used for identifying the significant risk factors of failure of reduction. Ten factors clustering by the age of 3 years were identified and used for developing the clinical prediction rules, and the factors were as follows: body weight <12 kg (relative risk [RR] =1.48, P=0.004), duration of symptoms >48 hours (RR =1.26, P<0.001), vomiting (RR =1.63, P<0.001), rectal bleeding (RR =1.50, P<0.001), abdominal distension (RR =1.60, P=0.003), temperature >37.8°C (RR =1.51, P<0.001), palpable mass (RR =1.26, P<0.001), location of mass (left over right side RR =1.48, P<0.001), ultrasound showed poor prognostic signs (RR =1.35, P<0.001), and the method of reduction (hydrostatic over pneumatic, RR =1.34, P=0.023). Prediction scores ranged from 0 to 16. A high-risk group (scores 12-16) predicted a greater chance of reduction failure (likelihood ratio of positive [LR+] =18.22, P<0.001). A low-risk group (score 0-11) predicted a lower chance of reduction failure (LR+ =0.79, P<0.001). The performance of the scoring model was 80.68% (area under the receiver operating characteristic curve). CONCLUSION: This scoring guideline was used to predict the results of nonoperative reduction and forecast the prognosis of the failed reduction. The usefulness of these prediction scores is for informing the parents before the reduction. This scoring system can be used as a guide to promote the possible referral of the cases to tertiary centers with facilities for nonoperative reduction if possible.
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PURPOSE: To identify the risk factors for failure of nonsurgical reduction of intussusception. METHODS: Data from intussusception patients who were treated with nonsurgical reduction in Chiang Mai University Hospital and Siriraj Hospital between January 2006 and December 2012 were collected. Patients aged 0-15 years and without contraindications (peritonitis, abdominal X-ray signs of perforation, and/or hemodynamic instability) were included for nonsurgical reduction. The success and failure groups were divided according to the results of the reduction. Prognostic indicators for failed reduction were identified by using generalized linear model for exponential risk regression. The risk ratio (RR) was used to report each factor. RESULTS: One hundred and ninety cases of intussusception were enrolled. Twenty cases were excluded due to contraindications. A total of 170 cases of intussusception were included for the final analysis. The significant risk factors for reduction failure clustered by an age of 3 years were weight <12 kg (RR =1.48, P=0.004), symptom duration >3 days (RR =1.26, P<0.001), vomiting (RR =1.63, P<0.001), rectal bleeding (RR =1.50, P<0.001), abdominal distension (RR =1.60, P=0.003), temperature >37.8°C (RR =1.51, P<0.001), palpable abdominal mass (RR =1.26, P<0.001), location of mass (left over right side) (RR =1.48, P<0.001), poor prognostic signs on ultrasound scans (RR =1.35, P<0.001), and method of reduction (hydrostatic over pneumatic) (RR =1.34, P=0.023). The prediction ability of this model was 82.21% as assessed from the area under the receiver operating characteristic curve. CONCLUSION: The identified prognostic factors for the nonsurgical reduction failure may help to predict the reduction outcome and provide information to the parents.
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The pathogenesis of intussusception without obvious anatomical leading points remains unclear. The objective of this study was to determine a feasibility of association between certain gastroenteritis viruses and intussusception. This was a prospective cohort study. Forty intussusception cases and 136 acute gastroenteritis controls with comparable age and gender were separately consecutively enrolled and relevant clinical data of both groups were recorded. The clinical specimens collected from all patients were screened for adenovirus, rotavirus, norovirus, and astrovirus by PCR and RT-PCR using specific primers. The genomes of detected viruses were characterized further to identify their genotypes by nucleotide sequencing. In 40 intussusception cases, adenovirus, rotavirus, and norovirus were detected in 12 (30.0%), 2 (5.0%), and 2 (5.0%), respectively while astrovirus was undetectable. In contrast, 136 acute gastroenteritis patients, adenovirus, rotavirus, and norovirus were detected in 11 (8.1%), 24 (17.7%), and 24 (17.7%) patients, respectively and again astrovirus was undetectable. The detection of adenovirus in intussusception patients was significantly higher than those in the control group (P < 0.001) with an odd ratio of 4.87 (95%CI: 1.95, 12.16). Interestingly, molecular analysis of adenovirus genome demonstrated that all of adenovirus detected in intussusception patients belonged to adenovirus C. This could be a potential risk factor or pathogenesis for developing intussusception in the cases of those without apparent anatomical leading points. J. Med. Virol. 88:1930-1935, 2016. © 2016 Wiley Periodicals, Inc.
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Infecções por Adenoviridae/complicações , Adenovírus Humanos/genética , Intussuscepção/etiologia , Intussuscepção/virologia , Infecções por Adenoviridae/virologia , Adenovírus Humanos/classificação , Adenovírus Humanos/isolamento & purificação , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Diarreia/virologia , Fezes/virologia , Feminino , Gastroenterite/virologia , Humanos , Lactente , Intussuscepção/epidemiologia , Intussuscepção/fisiopatologia , Masculino , Mamastrovirus/genética , Mamastrovirus/isolamento & purificação , Norovirus/genética , Norovirus/isolamento & purificação , Estudos Prospectivos , Rotavirus/genética , Rotavirus/isolamento & purificação , Tailândia/epidemiologia , Adulto JovemRESUMO
PURPOSE: Intussusception is a common surgical emergency in infants and children. The incidence of intussusception is from one to four per 2,000 infants and children. If there is no peritonitis, perforation sign on abdominal radiographic studies, and nonresponsive shock, nonoperative reduction by pneumatic or hydrostatic enema can be performed. The purpose of this study was to compare the success rates of both the methods. METHODS: Two institutional retrospective cohort studies were performed. All intussusception patients (ICD-10 code K56.1) who had visited Chiang Mai University Hospital and Siriraj Hospital from January 2006 to December 2012 were included in the study. The data were obtained by chart reviews and electronic databases, which included demographic data, symptoms, signs, and investigations. The patients were grouped according to the method of reduction followed into pneumatic reduction and hydrostatic reduction groups with the outcome being the success of the reduction technique. RESULTS: One hundred and seventy episodes of intussusception occurring in the patients of Chiang Mai University Hospital and Siriraj Hospital were included in this study. The success rate of pneumatic reduction was 61% and that of hydrostatic reduction was 44% (P=0.036). Multivariable analysis and adjusting of the factors by propensity scores were performed; the success rate of pneumatic reduction was 1.48 times more than that of hydrostatic reduction (P=0.036, 95% confidence interval [CI] =1.03-2.13). CONCLUSION: Both pneumatic and hydrostatic reduction can be performed safely according to the experience of the radiologist or pediatric surgeon and hospital setting. This study showed that pneumatic reduction had a higher success rate than hydrostatic reduction.
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OBJECTIVE: To evaluate diagnostic accuracy of some important clinical manifestations and different investigations in infantile cholestasis. MATERIAL AND METHOD: Infants diagnosed with prolong conjugated hyperbilirubinemia and admitted to Chiang Mai University Hospital between Jan 1999 and Feb 2003. Demographic and clinical data were recorded Routine biochemical tests, and serology for TORCHS infections were carried out. An abdominal ultrasonography, DISIDA scan and percutaneous/open liver biopsy were performed. Hyperechoic band at the level of portal bifurcation, named triangular cord (TC) sign was blindly assessed on ultrasonography by the same radiologist. The patients were diagnosed as BA if either operative findings of atretic common bile duct/ gallbladder or evidence of bile duct obstruction demonstrated by intraoperative cholangiography was noted RESULTS: Sixty-one patients were diagnosed as BA (n = 31) and NH (n = 30) with an average age at diagnosis of 88.6 and 63.1 days respectively. Concerning clinical presentations, only the presence of acholic stool was significantly different between BA and NH (p = 0.006). The GGT level of greater than 500 IU/L was significantly found in BA (p < 0.001). The acholic stool and GGT level more than 500 IU/L were highly specific for BA at 100 and 96.6% respectively. In addition, the sensitivity and specificity of US-TC and DISIDA scan were 87.4, 100 and 89. 7, 92.0% respectively. The accuracy for diagnosis of BA were highest by DISIDA scan (96.3) followed by US-TC (86.9), GGT level of > 500 IU/L(81.0) and acholic stool (80.3) in order CONCLUSION: There was no single laboratory investigation that could precisely make a definite diagnosis of BA. The acholic stool and GGT level of higher than 500 IU/L were highly specific for BA. The TC in ultrasound is noninvasive and easily available tests when combined with acholic stool and the GGT level is suggested plan of management.
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Colestase/diagnóstico , Hiperbilirrubinemia/diagnóstico , Fatores Etários , Colestase/sangue , Colestase/diagnóstico por imagem , Feminino , Humanos , Hiperbilirrubinemia/sangue , Hiperbilirrubinemia/diagnóstico por imagem , Lactente , Recém-Nascido , Testes de Função Hepática , Masculino , Cintilografia , Fatores de Tempo , UltrassonografiaRESUMO
BACKGROUND: The purpose of the present study was to evaluate the epidemiology and outcomes of choledochal cysts in children. METHODS: We performed a retrospective review of the records of all cases of choledochal cyst in children 0-14 years of age presenting at Chiang Mai University Hospital from May 2000 to February 2007. Demographic and clinical data, including laboratory and radiographic studies, as well as surgical and nonsurgical treatments and outcomes, were recorded. RESULTS: There were 32 patients (25 female) with a mean age at diagnosis of 4.1 years (range: 1 month to 14.8 years). The most common clinical presentation was jaundice (n = 17), followed by abdominal pain (n = 16), nausea/vomiting (n = 10), and abdominal mass (n = 8). Based on the Tondani modification of the Alonso-Lej classification, 20 cases were type I, whereas 9, 2, and 1 of the patients had types IV, V, and II, respectively. Biliary tract infections, including cholecystitis (n = 5) and cholangitis (n = 3), were the most common preoperative complications. Twenty-six patients had definitive surgery consisting of cystectomy with Roux-en-Y hepaticojejunostomy. Postoperative complications were noted in 3 patients and included intestinal obstruction, bleeding, and cholangitis. Three patients died, all younger than 2 years of age (p = 0.022). CONCLUSION: The epidemiology of choledochal cysts in Thai children was similar to cases reported from other regions. Early diagnosis and treatment, particularly in children under 2 years of age, should be emphasized, because these patients are at a higher risk for development of chronic liver disease and poor outcome.
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Cisto do Colédoco/epidemiologia , Cisto do Colédoco/cirurgia , Adolescente , Criança , Pré-Escolar , Cisto do Colédoco/diagnóstico , Cisto do Colédoco/terapia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Tailândia/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: It was believed that more than 90 per cent of children with colorectal polyp had a single lesion, located in the rectosigmoid colon, therefore, sigmoidoscopy with polypectomy was the treatment of choice. After a wide use of pediatric colonoscopy, this concept has been changed. MATERIAL AND METHOD: This study was aimed to describe clinical characteristics of colorectal polyp in Thai children. Medical records of children with colorectal polyp were retrospectively reviewed. Comparison between polyposis coli and children with less than 5 polyps were also analyzed. RESULTS: There were 93 patients, 43 females and 50 males. The average age was 5.1 years. Lower GI bleeding and prolapse of rectal polyp comprised the two most common presentations, 93.5 and 39.8 per cent, respectively. The mean duration of symptoms was 5.6 months. Only 50.6 per cent had rectal polyp noted by digital examination. Investigations included sigmoidoscopy (n = 77), colonoscopy (n = 16), and barium enema (n = 16). Eight per cent of the cases had more than 5 polyps. Location of the polyps was noted in the rectosigmoid colon (88.2%), descending colon (4.3%), right-sided colon (4.3%), and pancolonic (3.2%). Of all the patients, 11.8 per cent had the polyp above the rectosigmoid region, whereas 50 per cent of those who underwent colonoscopy (n = 16) had the polyps noted proximal to this region. Older age, lower hematocrit, and more frequent right-sided polyps were significantly associated with polyposis coli (p < 0.05). Only 2 patients with polyposis coli were treated by colectomy. Histopathology included juvenile polyp (95%), inflammatory pseudopolyp (2.5%), and hyperplastic polyp (2.5%). CONCLUSION: Most of the children with colorectal polyp had juvenile polyp that is commonly found in the rectosigmoid colon. However, a significant number of patients had carrying polyps proximal to the rectosigmoid region, which would be easily missed by sigmoidoscopy. With the concern of malignancy change particularly in children with polyposis coli, routine colonoscopy should be considered as an initial investigation in children with colorectal polyp.
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Pólipos do Colo/diagnóstico , Pólipos do Colo/epidemiologia , Colonoscopia/métodos , Polipose Adenomatosa do Colo/diagnóstico , Polipose Adenomatosa do Colo/fisiopatologia , Adolescente , Sulfato de Bário , Criança , Pré-Escolar , Pólipos do Colo/complicações , Enema , Feminino , Hemorragia Gastrointestinal/etiologia , Humanos , Lactente , Recém-Nascido , Masculino , Prolapso , Estudos Retrospectivos , Tailândia/epidemiologiaRESUMO
The aim of this study was to reassess the accuracy of the triangular cord sign, the triangular cord sign coupled with abnormal gall-bladder length, and an irregular gall-bladder wall in the diagnosis of biliary atresia. The ultrasonograms of 46 infants with cholestatic jaundice were reviewed for the triangular cord sign, gall-bladder length and gall-bladder wall without knowledge of the clinical data. Of the 23 infants with biliary atresia, 22 had the triangular cord sign whereas 17 infants with other causes of cholestatic jaundice did not have the triangular cord sign. The sensitivity, specificity, accuracy and positive predictive value of the triangular cord sign in the diagnosis of biliary atresia were 95.7, 73.9, 84.8 and 78.6%, respectively. The sensitivity, specificity, accuracy and positive predictive value of the triangular cord sign coupled with abnormal gall-bladder length in the diagnosis of biliary atresia were all 95.7%. Gall-bladder wall irregularity was seen in seven of 14 infants (50%) with biliary atresia whose gall bladders contained bile on ultrasound and in two of 22 infants (9.1%) without biliary atresia whose gall bladders contained bile on ultrasound. At the medical centre where this study was performed and where infants present with cholestatic jaundice at an advanced stage, the ultrasonographic triangular cord sign coupled with abnormal gall-bladder length is more reliable than the ultrasonographic triangular cord sign alone or gall-bladder wall irregularity in the diagnosis of biliary atresia.
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Atresia Biliar/diagnóstico por imagem , Vesícula Biliar/diagnóstico por imagem , Colestase/diagnóstico por imagem , Colestase/etiologia , Humanos , Lactente , Veia Porta/diagnóstico por imagem , Valor Preditivo dos Testes , Sensibilidade e Especificidade , UltrassonografiaRESUMO
OBJECTIVE: To study the clinical manifestations of gastrointestinal cytomegalovirus disease in children with human immunodeficiency virus infection. METHODS: Review of clinical records of eight human immunodeficiency virus-infected children and histopathologically confirmed gastrointestinal cytomegalovirus disease from 1995 to 2001. RESULTS: Six of the eight children were younger than 1 year. The most common clinical presentations were fever and chronic diarrhea. Lower gastrointestinal hemorrhage and bowel perforation were noted in four and three patients, respectively. The colon was the most commonly affected site, followed by the small bowel and esophagus. The diagnosis was established by histopathology, obtained during endoscopy and surgery. Mucosal edema, erythema, and ulcer comprised the most common endoscopic findings. Two patients with fever, chronic diarrhea, and lower gastrointestinal bleeding developed remission after being treated with a 14-day course of ganciclovir. CONCLUSION: Gastrointestinal cytomegalovirus disease can result in serious life-threatening complications, such as bowel perforation and massive gastrointestinal bleeding. Patients with chronic diarrhea and fever of unidentified cause might benefit from gastrointestinal endoscopy for early diagnosis and treatment. Although ganciclovir does not eradicate the infection and relapses are frequent, this treatment can prevent complications and reduce morbidity.