An easy-to-follow algorithm to improve pre-operative diagnosis for appendicitis in children.

GOAL: To evaluate physician compliance with use of a diagnostic algorithm for appendicitis in children. Our secondary objective was to determine the impact of the algorithm on diagnostic accuracy and morbidity. METHODS: We conducted a clustered randomized trial in eight centers. A total of 866 patients were included and, depending on the period of randomization at particular centers, 543 patients were managed before the formal institution of the diagnostic algorithm; their diagnostic management was compared to that of the subsequent 323 patients. RESULTS: There was a 29.1% mean increase in the use of imaging studies included in the algorithm after algorithm set-up, rising from 50.8 to 79.9% (P<0.02). When we used a composite endpoint of "poor results" (grouping patients with incorrect diagnoses and/or post-operative complications), no statistically significant difference was found between the two periods (85/543 (15.6%) before vs. 45/323 (13.9%) after set-up, P=0.5). But when the number of incorrect diagnoses of appendicitis made without the use of the algorithm was compared to that of patients who took advantage of the algorithm, the difference was highly significant (67/332 [20.2%] vs. 63/534 [11.8%], P<0.001), and the rate of unnecessary appendectomy decreased from 11.9 to 5.3% (P<0.01). CONCLUSIONS: Our diagnostic algorithm improved the adherence to good practice for the diagnosis of appendicitis in children, reducing the rates of unnecessary appendectomy and morbidity. This strategy, combining laboratory tests and imaging, should permit pediatric surgeons to adapt their therapeutic approaches to specific cases.

Mesenteric hernia: a rare cause of intestinal obstruction in children.

A 3-year-old boy presented with small bowel obstruction resulting from incarceration of the distal ileum in a mesentric defect. Attempted laparoscopy was unsuccessful. The hernia was reduced successfully at laparotomy.

[Koff's urethral mobilization: report of 26 hypospadias presenting a distal division of the corpus spongiosum]. / Translation uréthrale de Koff: à propos de 26 hypospades présentant une division distale du corps spongieux.

AIM: To evaluate the Koff urethral mobilization in 26 patients with distal division of the corpus spongiosum. MATERIAL AND METHOD: Twenty six hypospadias underwent Koff's urethral mobilization between January 1st 1999 and January 31st 2001. All cases were performed by the senior author. The mean age at surgery was 36.3 months (14 to 117 months). All cases had a distal division of the corpus spongiosum. RESULTS: The mean follow-up was 4.64 months (1-24 months): Four cases (15%) presented with a penile bleeding when the dressing was removed 4 days after the procedure. One of them went back to theatre to stop the bleeding. Five (19.2%) presented with a late meatal stenosis requiring a secondary meatotomy. One had a urethral fistula which disappeared spontaneously a few months later. All had a satisfactory cosmetic result. DISCUSSION AND CONCLUSION: These results are compared with other series published and it seems that a full penile urethral mobilization is a significant alternative procedure whose main advantage is to avoid the use of any non-urethral tissues to reconstruct the hypospadiac urethra. The selection of cases must be cautious to avoid secondary meatal stenosis which seems to be related to ischaemia of the distal hypoplastic urethra.