Pentraxin-3: A strong novel biochemical marker for appendicitis in children.

INTRODUCTION: Appendicitis is the most common surgical disease evaluated by pediatric surgeons in the emergency department. Despite the history, physical examination, laboratory tests and imaging methods, the misdiagnosis may be observed often in children. Pentraxin-3 (PTX-3) is an acute phase protein which is produced directly in the inflammatory tissue. Our aim was to investigate the diagnostic value of PTX-3 levels in appendicitis in pediatric patients and compare it with the other serum parameters. METHODS: Eighty-eight patients (aged <18 years) were included in this study [Group 1 (n = 28) healthy volunteers, Group 2 (n = 28) patients with non-specific abdominal pain, Group 3 (n = 34) patients underwent appendectomy]. Serum white blood cell (WBC), absolute neutrophil count (ANC), neutrophil/lymphocyte ratio (NLR), C-reactive protein (CRP) and PTX-3 values were measured. RESULTS: Median serum levels of WBC were higher in Group 2 and 3 than Group 1. ANS, NLR, CRP and PTX-3 were higher in Group 2 than Group 1 and were higher in Group 3 than the other groups. The highest sensitivity was found in NLR >3.5 [94.1 (95% CI = 80.3-99.3)] and PTX-3 > 5.6 ng/mL [91.8 (95% CI = 76.3-98.1)]. PTX-3 has the highest specificity among all of the parameters [90.7 (95% CI = 79.7-96.9)]. The area under the ROC curve showed that the diagnostic value of PTX-3 was greater than any other parameter [0.979 (95% CI = 0.92-0.99)]. CONCLUSION: In this study, we have shown that PTX-3 is very useful with high sensitivity and specificity in the diagnosis of appendicitis compared to WBC, ANS, NLR and CRP as a first in the literature.

Importance of Clinical Decision Making by Experienced Pediatric Surgeons When Children Are Suspected of Having Acute Appendicitis: The Reality in a High-Volume Pediatric Emergency Department.

OBJECTIVE: The aim of the present study was to compare the pediatric appendicitis score (PAS), the Alvarado score (AS), white blood cell count (WBC), absolute neutrophil count (ANC), C-reactive protein (CRP) level, procalcitonin level, and ultrasound (US) data, with the appendectomy decisions of pediatric surgeons diagnosing acute appendicitis (AA) in a real-life setting; this was a top-level, high-volume pediatric emergency department (PED) in a developing country. METHODS: The study was conducted prospectively between January 2012 and June 2013 in the PED of the Tepecik Teaching and Research Hospital in Izmir, Turkey. The study was observational in nature; no attempt was made to influence indications for exploration or the timing thereof. Children aged 4 to 18 years presenting to the PED on suspicion of AA were included. The WBC, ANC, CRP level, and procalcitonin level were measured, and US was performed on all patients on admission. The PAS and AS were calculated. An operative decision was made by each pediatric surgeon who had the results of laboratory and radiological tests. The criterion standard for AA was histopathological assessment. RESULTS: Upon receiver operating curve (ROC) analysis, the areas under the ROCs (AUROCs) of the WBC, ANC, CRP level, procalcitonin level, US positivity, PAS, AS, and decisions of pediatric surgeons supported by laboratory and US data were 0.734, 0.741, 0.671, 0.675, 0.670, 0.831, 0.794, and 0.910, respectively. When US data were employed only in cases with PASs 4 to 7, the sensitivity increased but specificity decreased. The sensitivity and specificity of pediatric surgical decisions were 100% and 82.50%, respectively. The difference between the PAS AUROC and the pediatric surgeon decision-making AUROC was significant (P = 0.0393; 95% confidence interval, 0.0470-0.226). CONCLUSIONS: Good pediatric surgical decision making supported by laboratory and US data for those suspected of AA may be the most effective diagnostic tool in a high-volume PED in a developing country.

Postoperative apnea after inguinal hernia repair in formerly premature infants: impacts of gestational age, postconceptional age and comorbidities.

PURPOSE: It is common practice for premature infants undergoing elective inguinal hernia (IH) repair to be hospitalized for postoperative apnea monitoring. This study evaluated the risk of apnea after IH repair with regard to gestational age (GA) and postconceptional age (PCA) in formerly premature infants. METHODS: Formerly premature infants who had undergone elective IH repair between 01/2000 and 12/2012 were reviewed retrospectively in terms of GA, PCA, body weight, and comorbidities. All postoperative apneas were evaluated. RESULTS: A total of 428 formerly premature infant charts were reviewed. Eleven babies had postoperative apnea. Infants younger than 45 weeks PCA were found more prone to develop postoperative apnea after IH repair. In older infants (PCA between 46 and 60 weeks), comorbidities create predisposition to apnea postoperatively. These comorbidities are bronchopulmonary dysplasia, necrotizing enterocolitis and former apnea episodes. Anemia and lower birth weight are also risk factors. CONCLUSION: This study suggests that low GA and PCA, low birth weight, anemia, and complicated past medical history affect respiratory complication rates, particularly apnea in formerly premature infants undergoing elective IH repair. Severe apneas occurred earlier than mild ones. Overnight monitoring is mandatory in small infants with low GA and PCA. Otherwise healthy, older infants may be operated on outpatient basis.

The relationship between clinical findings and esophageal injury severity in children with corrosive agent ingestion.

BACKGROUND: The aim of the study was to investigate the indicators of corrosive esophageal injury (EI) severity in children. METHODS: We retrospectively reviewed data from children who accidentally ingested corrosive substance and underwent endoscopic evaluation over a one-year period. A total of 134 consecutive children with corrosive agent ingestion who underwent diagnostic endoscopy (74 boys, 60 girls) were included in this study. Patients were divided into two groups as low-grade and high-grade EI. Statistical differences and predictive values of common signs and symptoms and white blood cell (WBC) count of patients with low- and high-grade EI were analyzed. RESULTS: The majority of patients (70%) were asymptomatic at the initial examination. We found that drooling saliva and oral lesions were significantly more frequent in high-grade injury (p<0.05). Mean WBC count in the high-grade EI group was significantly higher than in the low-grade EI group (p=0.000). Sensitivity, specificity and predictive values of clinical findings in children were analyzed; none of them was shown to be valuable for estimating EI severity. WBC count was sensitive, but it is not a good predictor. CONCLUSION: Our study demonstrated the relationship between clinical findings and corrosive EI severity in children with accidental corrosive ingestion, but direct visualization of the esophagus is required for definitive diagnosis.

Modified Leadbetter-Politano Ureteroneocystostomy: A Safer Procedure.

PURPOSE: Open surgical reimplantation of ureters is a highly successful procedure, with reported correction rates of 95 to 99 percent regardless of the severity of vesicoureteral reflux (VUR). Leadbetter-Politano ureteroneocystostomy is one of the most preffered technique for open ureteroneocystostomy.  The authors report the modified Politano-Leadbetter technique with extravesical mobilization and transection of the ureter at the level of ureterovesical junction and intravesical reimplantation. Materials and Methods: Fifty-seven children with unilateral VUR, underwent modified Leadbetter-Politano ureteral reimplantation with extravesical mobilization and transection of the ureter at the level of ureterovesical junction and intravesical reimplantation. Persistence of VUR despite endoscopic correction, breakthrough infections, complications due to antibiotics, progressive renal scarring, reflux nephropathy, and parental preference were indications for open reimplantation. Operations were done by two full-time pediatric surgeons. Operation time and hospital stay of the patients, reflux persistency, voiding dysfunction and complications were recorded.  Results: No ipsilateral VUR was detected postoperatively. Mean operation time was 76.54 min (±8.76 min; range, 70-86 min) Mean duration of the hospital stay is 82.31 h (±9.78 h; range, 71-93 h). Postoperative gross hematuria was not seen in any patients. No voiding dysfunction and no late complications was encountered.  Conclusions: Modified Leadbetter-Politano technique is a good option to treat VUR with success rate up to 100% without any major complicatons such as viscus perforation and ureteral obstruction. It is a rather simple technique that require less operative time.

Clinical features and treatment of ruptured pulmonary hydatid cyst in children.

Backgroud and objectives. Rupture is the main complication of the pulmonary hydatid cyst (HC). The aim of this study was to evaluate the clinical features and treatment of ruptured pulmonary HC. METHOD: The medical records of children who had undergone surgery between January 1999 and December 2017 for pulmonary HC were retrospectively evaluated. One hundred forty seven of these patients had ruptured HC at the time of diagnosis. The gender, age at the time of diagnosis, sociogeographic status (i.e., from urban or rural population group), symptoms, affected lung region, cyst dimensions, preoperative complications, medical treatment duration, and associated morbidities were evaluated. RESULTS: The study included 649 patients with pulmonary HC. Mean age was 9,8 (2-17) years. Three hundred forty four patients were male and 305 were female. The most common symptoms were, cough accompanying mucopurulent sputum, hydropthysis and dyspnea in patients with ruptured HC. The diagnosis of all the patients were established in the light of the findings obtained from two-sided chest x-ray and CT of the thorax. Simple cystotomy via posterolateral thoracotomy was the treatment of choice. Cappitonage was not performed in any patients. Lung resection was performed only if there was an irreversible and disseminated pulmonary destruction. CONCLUSION: Rupture of the pulmonary HC is the most common and also the most feared complication. Rupture may be either intrabronchial or intrapleural. Radiologic imaging is diagnostic. Rupture of the pulmonary HC must be considered as an emergent issue. Simple cystotomy amd removal of the laminated membranes are adequate treatment of choice. Meticulous closure of the bronchial openings is mandatory to avoid prolonged air leak. Cappitonage is unnecessary.

Secondary phimosis after circumcision.

OBJECTIVE: Male circumcision is one of the most common surgical procedures worldwide. Although it is widely performed because of health issues, in Muslim-majority countries, the primary motivation yielding to male circumcision is religious. It is a relatively safe procedure with a low overall complication rate. We herein report an underrated complication of circumcision that can be termed as "secondary phimosis." MATERIAL AND METHODS: The medical records of 25 boys with post-circumcision secondary phimosis were reviewed. Demographics of the patients, method of circumcision, type of provider, peroperative findings and comorbidities were recorded. RESULTS: Between January 2005 and December 2016, 25 boys with post-circumcision secondary phimosis were treated surgically. The median age of the patients was 3 (2-5) years. The majority of the patients were circumcised by the Gomco clamp or Plastibell method (n=16). Of the patients' circumcisions, six were performed by the freehand method, and three by the dorsal slit method. In 15 boys, circumcision was performed by a traditional provider. Of the boys, seven were circumcised by a physician, and three were circumcised by a pediatric surgeon. All the patients were re-circumcised. The common peroperative finding was the redundant mucosal inner layer of the prepucium. Excess suprapubic fat was present in 12 patients. CONCLUSION: Although circumcision is known as a minor surgical practice with low complication rate, it must be performed safely and especially by experienced physicians/surgeons. Secondary phimosis is a technical error that is caused by insufficient removal of the inner mucosal layer of the prepucium. Re-circumcision of the patient is inevitable, causing the patient second trauma.

Self-introduced intravesical magnets in a 3-year-old boy: Case report.

Özdemir T, Orhan G, Candan B, Köylüoglu G. Self-introduced intravesical magnets in a 3-year-old boy: Case report. Turk J Pediatr 2019; 61: 286-288. Self-introduced intravesical foreign bodies are commonly seen in adults and are rarely encountered in children. The underlying cause may be a psychiatric disorder for sexual gratification or inquisitiveness as in children. We herein report a 3-year-old boy who was presented with pathological lower urinary tract symptoms and a radiopaque, irregular shaped object in bladder detected by direct abdominal radiograph. Preoperative diagnosis was bladder calculus. Cystolithotomy was planned via Pfannenstiel approach. During operation, self-introduced small magnets and a metallic bead which stuck together were detected. Intravesical foreign bodies are important considerations in the differential diagnosis of pathological lower urinary tract symptoms. In this case, magnets that were stuck together and a metallic bead mimicked bladder calculus radiologically. However, irregular shape of the intravesical object may arouse a suspicion about the nature.

The cause of abdominal mass in a child with celiac disease: Rapunzel syndrome. A case report.

CONTEXT: Rapunzel syndrome is a rare form of gastric trichobezoar that develops through outstretching of the bezoar from the stomach to the intestine. CASE REPORT: A 12-year-old girl who had been diagnosed with celiac disease six years earlier was brought to the department of pediatric gastroenterology because of abdominal distension. A palpable mass was detected. A trichobezoar that stretched to the small intestine was removed surgically. The patient was diagnosed as having anxiety and depressive disorder, and treatment started. Following the treatment, her previous trichophagia completely disappeared. CONCLUSION: Presence of trichobezoar should be kept in mind, especially when young girls who have psychiatric problems suffer from gastrointestinal symptoms.

A Child Diagnosed With Treatment-Resistant Polyarteritis Nodosa: Can the Clinical Diagnosis Be Different?

Polyarteritis nodosa (PAN) is a necrotizing systemic vasculitis involving the wall of small and medium sized arteries. The histological aspect is defined by the presence of fibrinoid necrosis and an infiltrate rich in neutrophil polynuclears in the artery wall and rare granulomas. CECR1 (Cat Eye Syndrome Chromosome Region 1) gene mutation causing adenosine deaminase 2 (ADA2) deficiency is also associated with systemic inflammation, vasculopathy, and frequently PAN. Strokes, neurological involvement, and gastrointestinal involvement have poor prognosis in the cases with ADA2 deficiency particularly in early stage. In this article, we report a 17-year-old male patient diagnosed with PAN who had severe gastrointestinal system involvement that was resistant to intensive and conventional immunosuppressive treatment and showed a fatal course despite the emergency surgical intervention. After the patient was exitus, he was detected to have a heterozygous mutation (V276A) of familial Mediterranean fever (FMF) and also a homozygous ADA2 mutation. The aim of this article is to highlight that ADA2 deficiency may be present in treatment-resistant PAN cases who apply due to severe systemic involvement. In this case, accompanying FMF mutation was also observed.

[Spontaneous bile duct perforation: a rare cause of acute abdominal pain during childhood]. / Spontan koledok perforasyonu: Cocukluk çaginda nadir bir akut karin nedeni.

BACKGROUND: Spontaneous perforation of the bile duct (SPBD) is a rare cause of acute abdominal pain during childhood. Pancreatico-biliary malfunction has been postulated to contribute to its etiology. Factors related to diagnosis and treatment and difference from the other common causes of acute abdominal pain are emphasized. METHODS: Five patients (3 boys, 2 girls, mean age 4.6) were admitted with peritonitis and operated with initial diagnosis of perforated appendicitis. During laparotomy, SPBD was detected. Presentation, laboratory findings and operative technique of the patients were evaluated retrospectively. RESULTS: Common complaints were abdominal pain and bilious vomiting. Abdominal distention was present in all patients. Leukocytosis and mild hyperbilirubinemia were detected in 5, elevated serum transaminase levels in 4, hyperglycemia in 1 and constipation in 1 patient(s). Abdominal ultrasonography showed a large amount of free fluid. During laparotomy, sterile bile peritonitis was detected initially. After exploration, SPBD was seen. T-tube drainage of the bile duct was carried out. Patients were discharged after removal of the T-tubes. Pancreatico-biliary malfunction was detected in 4 of 5 patients. CONCLUSION: In patients with generalized peritonitis, elevated transaminase levels and hyperbilirubinemia, SPBD must be considered. Even though the T-tube drainage is the treatment of choice, Roux-en-Y hepatico-portoenterostomy may be mandatory in certain patients.

Etiology and Outcome of Cholelithiasis in Turkish Children.

OBJECTIVE: The aim of this study was to examine the etiology of gallstones in children and responses to ursodeoxycholic acid (UDCA) treatment. METHODS: 74 children with cholelithiasis were recruited, and underwent ultrasonography to detect gallstones. All relevant clinical information was recorded in a structured proforma. RESULTS: The commonest risk factor was a family history of gallstones. Most children responded to UDCA treatment in the first six months; children with hemolytic diseases showed no response to UDCA. CONCLUSION: UDCA treatment may be useful before surgery in asymptomatic patients of cholelithiasis without hemolytic diseases.

A rare cause of neonatal hypertension: Congenital mesoblastic nephroma.

Soyaltin E, Alaygut D, Alparslan C, Özdemir T, Arslansoyu-Çamlar S, Mutlubas F, Kasap-Demir B, Yavascan Ö. A rare cause of neonatal hypertension: Congenital mesoblastic nephroma. Turk J Pediatr 2018; 60: 198-200. A rare cause of neonatal hypertension: Congenital Mesoblastic Nephroma (CMN) is a rare renal tumor in childhood and has been reported with palpable abdominal mass, hypertension, hematuria, polyuria and hypercalcemia. Histopathologically it has been classified into two histological types: classic and cellular. We present a 32-week gestation infant and his histopathology reports of cellular CMN presented with refractory hypertension.

Safe removal of upper esophageal coins by using Magill forceps: two centers' experience.

Coin ingestion with subsequent esophageal coin impaction is common in children. Considerable debate surrounds the choice of technique for the removal of esophageal coins. This study demonstrates a minimally invasive technique for upper esophageal coin extraction. A retrospective review was conducted of 165 children who had upper esophageal coins extracted by using a Magill forceps. One hundred fifty-six coins (96.4%) were successfully removed without any complications. The average time taken to remove the coin was 33 seconds. Use of the Magill forceps technique minimizes instrumentation of the esophagus and is an easy, safe technique for removing coins from the upper end of the esophagus.

Bilateral cervical chondrocutaneous remnants: a case report and review of the literature.

Cervical chondrocutaneous remnants are less common lesions, which are encountered at the lateral neck. They are similar in appearance to preauricular tags, which are more frequent. Bilateral appearance of this pathology is quite uncommon. The lesions always present at birth, and are located in the middle or lower third of the lateral neck with a significant prevalence of location anterior to the sternocleidomastoid muscle. The overlying skin is similar to the surrounding neck skin and the lesion is painless, lacking any inflammation or discharge. Surgically there is no connection with deep underlying structures. The therapy of choice should be complete surgical removal. Several associated anomalies may accompany cervical chondrocutaneous remnants. Thus these patients must be evaluated carefully in order to detect any additional anomaly. We herein report a four-year-old patient with bilateral cervical chondrocutaneous remnant located at the inferior third of the lateral neck anterior to the sternocleidomastoid muscle. We also review the literature for patients with bilateral cervical chondrocutaneous remnants and discuss embryologic and diagnostic aspects.

Isolated omental panniculitis in a child with abdominal pain: case report. / Paniculitis epiploica aislada en un niño con dolor abdominal: a propósito de un caso.

Isolated omental panniculitis is a rare entity mostly seen in adults. It presents with the inflammation of the fatty tissue of the omentum. The symptoms may vary from local (e.g. abdominal tenderness or palpable mass) to systemic manifestations including abdominal pain, back pain, fever, weight loss and bowel disturbances. We presented this case as a first awareness of omental panniculitis in a child which must be kept in mind at the differential diagnosis of ileus so that unnecessary surgeries might be avoided.

La paniculitis epiploica aislada es una entidad rara, mayormente observada en los adultos. Se presenta con inflamación del tejido adiposo del epiplón. Los síntomas varían entre manifestaciones locales (por ejemplo, dolor a la palpación abdominal o una masa palpable) y sistémicas, que incluyen dolor abdominal, dolor de espalda, fiebre, descenso de peso y trastornos intestinales. Presentamos este caso como una primera acción de sensibilización respecto de un caso de paniculitis epiploica en un niño, afección que debe tenerse en cuenta en el diagnóstico diferencial del íleo a fin de evitar cirugías innecesarias.

A case of proximal jejunal ectopic pancreas causing sporadic vomiting.

Aberrant rests of pancreatic tissue can be found throughout the gastrointestinal system and are known as pancreatic heterotopia or ectopic pancreas (EP). Authors report a 12-year-old girl with jejunal EP with a long-lasting history of sporadic bilious vomiting. Upper gastrointestinal (GI) study showed delayed passage beyond duodeno-jejunal junction. During laparotomy a 2x2 cm mass was encountered on the mesenteric border of the jejunum, 3 cm distal to the ligament of Treitz. Histopathologic examination revealed pancreatic tissue. The mass was excised and end-to-end anastomosis was performed. Postoperative course of the patient was uneventful and she is doing well after 10 months. Intestinal obstruction due to EP has been reported to occur only if it causes intussusception. Intestinal obstruction without intussusception due to jejunal EP has not been reported. In our case, the EP tissue was located just beneath the mucosa and involved the muscular layer. The foreign body effect of the EP tissue involving the muscular layer may cause dysmotility and/or local spasm, which we think were responsible for the long-lasting sporadic bilious vomiting in our patient.