Primary Omental Torsion in Children in the Laparoscopy Era: What Have we Learned so far?

BACKGROUND/AIM: Primary omental torsion is uncommon, mimicking appendicitis and other acute abdominal pathologies. It often escapes diagnosis on imaging investigation or conventional open laparotomy. This study aimed to evaluate the effect of laparoscopy on the various parameters of this entity, including incidence, diagnosis, and treatment. MATERIALS AND METHODS: A systematic review was performed, including PubMed and Scopus databases, without a time limit, following the PRISMA principles. A total of 16 articles from January 2000 to December 2023, corresponding to 56 children with primary omental torsion, complied with the research criteria. RESULTS: Primary omental torsion was associated with obesity. Symptoms were right abdomen oriented, often compared to those of acute appendicitis. Preoperative ultrasound displayed low diagnostic accuracy, whereas computerized tomography diagnosed only two thirds of cases. In all patients, the vermiform appendix was normal. CONCLUSION: Laparoscopy affected both diagnosis and treatment of primary omental torsion in children. Easy peritoneal cavity access rendered possible the diagnosis of cases previously discharged as abdominal pain of unknown etiology. Combined with the increased pediatric obesity, it also affected primary omental torsion incidence. The recent pathogenetic theories may be better supported today, as laparoscopy provides a detailed view in situ, and facilitates harvesting of fat tissue from the omentum for molecular investigation. The diagnostic efficiency of laparoscopy is superior to ultrasonography and computerized tomography. Finally, the removal of the ischemic omentum is technically easier compared to the open laparotomy alternative with all the technical difficulties of traction of a vulnerable hemorrhagic tissue through a small incision.

Characteristics and Validation of Pediatric Extremity Vascular Trauma in Dedicated Pediatric and Adult Trauma Centers: A Scoping Review Protocol.

BACKGROUND: Pediatric extremity vascular injuries constitute a rare yet serious entity that can lead to serious complications especially if left untreated or become late diagnosed. In our scoping review, we sought to evaluate different characteristics and outcomes of pediatric and combined adult trauma centers (ATCs) in the management of pediatric extremity vascular injury. METHODS: We sought to analyze various characteristics and parameters that differentiate a dedicated pediatric and a combined pediatric ATC in terms of effectiveness and quality of care in the acute setting and to describe special features and characteristics of an acute vascular disease that constitute pediatric population unique from the aspect of diagnosis and management. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews guidelines to conduct the study. RESULTS: The search identified 8,815 records in title using MeSH terms from PubMed/MEDLINE database among which 12 studies reporting a total of 2,124 pediatric patients with vascular extremity injuries were included for analysis. Incidence of pediatric extremity vascular injury was 0.5%. Upper extremity injuries were the most frequent presenting in 63% of cases followed by lower extremity injuries in 37% of cases. Blunt injuries were marginally more common than penetrating injuries (58% vs. 42%). In-hospital mortality and morbidity ranged from 13.2% to 0.9% and 13% to 30%, respectively. Limb-salvage rates were high, ranging from 92% to 99%. Furthermore, there are no clearly defined clinical guidelines involving the mode of imaging and diagnosis, the surgical specialties involved and the competency of nursing or medical staff overall. CONCLUSIONS: Dedicated children trauma centers theoretically represent the optimal path for acute pediatric trauma admission, especially in complex trauma necessitating vascular reconstruction. However, in the current setting of rapidly increasing health costs and economic crisis worldwide, regional or resource-related factors make this option rather unavailable. In any case, it is imperative the clinicians have a high index of suspicion when confronting with these types of injuries because early diagnosis is highly related with reduced morbidity and superior outcomes.

Serious Rodent Bites to an 8-Month-Old Infant Due to Child Neglect.

Animal bites are among the top causes of preventable traumatic injuries. We describe the case of an 8-month-old female infant who was brought to the emergency department by her grandfather with serious rodent bites on her eyes, nose, right cheek, upper right extremity, and other smaller bites all over her body. This case is another proof of child neglect, or a possible infanticide attempt, as the motives of leaving the child in a hut without proper care, are not cleared up to this date. Rodent bites could be associated with Streptobacillus moniliformis infection and rat-bite fever. If the bites are left untreated for hours, the infant may suffer from hypovolemic shock due to bleeding, a possible fatal situation. The emergency surgical treatment of wounds is of vital importance.

Reduction in Pediatric Surgery's Emergency Department Visits During COVID-19 Pandemic in a Tertiary University General Hospital in Greece.

Background From January 2020, coronavirus has caused more than three million deaths. Lockdown has been enforced in many countries worldwide, affecting the emergency department visits of many surgical specialties. Methods The purpose of this study was to present the difference in trends in pediatric emergency department visits from March 1 to May 30, 2020, compared to the same 3-month period in 2019 in a tertiary university hospital in Greece, which was one of the referral centers for COVID-19 patients. Results A 42.5% reduction in emergency department visits was observed. In 2020, only 196 patients visited the pediatric surgery emergency department, versus 341 patients in 2019 (p<0.05). The reasons for visiting the emergency department did not change in most categories. Even though visits to the emergency department were reduced, the rates of the distance of the patient's residency from the hospital remained roughly the same. Hospital admission rates remained roughly the same. Conclusion Even though there was a huge decrease in numbers, the reasons for visiting the ED remained roughly the same. The only exception was indoor accidents, which increased in 2020.

Can the ultrasound suggest the emergency operation of a sliding ovary in a hernia sac?

In this case, it is described the importance of ultrasound in children with sliding ovaries in inguinal hernias. If the child has no symptoms, an emergency ultrasound could suggest the manner of the operation, scheduled or emergency.

Dermatofibrosarcoma protuberans in a child, that's why soft tissue lesions are not always innocent in children.

Pediatric soft tissue tumors should be always operated and sent for a biopsy.

Comparison of Two Tubularized Incised Plate Urethroplasty Techniques in Hypospadias Reconstructive Surgery.

BACKGROUND: Hypospadias repair is a challenging type of urogenital reconstructive surgery for which different techniques are currently used. The purpose of this study is to determine the outcomes of distal, mid-shaft and proximal hypospadias repair using two new variations of tubularized incised plate (TIP) urethroplasty (TIP-δ and TIP-ελ) and to compare their complication rates with other already known operative techniques made from the same surgical team. METHODS: This study included 269 boys with hypospadias. The preoperative meatal site was distal in 179 patients, mid-shaft in 44 and proximal in 46. The average age at the operation was 17 months. The technique applied in distal hypospadias was Mathieu in 77 patients, Snodgrass in 28 and (TIP)-δ in 74. The technique applied in mid-shaft hypospadias was a tubularized island flap (TIF) in 12 patients, onlay island flap (OIF) in 5 and TIP-ελ in 27. The operative technique for proximal hypospadias was TIF in 15 patients, OIF in 10 and TIP-ελ in 21. TIP-δ and TIP-ελ are two new variants of TIP operation that we have used in our clinic since 2010. Postoperative complications were recorded, and we compared the outcomes obtained by applying the techniques. RESULTS: The use of TIP-δ in the distal hypospadias and long TIP-ελ in the mid-shaft and proximal hypospadias resulted in significantly fewer complications than the other surgical methods across all cases of hypospadias (p<0.05). CONCLUSION: The type of tissue used for neourethral coverage seems to play an important role in the outcome of hypospadias surgery.

Constipation and dilated bowel: Hirschsprung's disease is not always the case.

A case of a 2-month-old boy with constipation and a localized abdominal distension in the right abdomen and hypogastrium is presented. Plain radiograph, ultrasound exam as well as a barium enema were suggestive of Hirschsprung's disease (HD) (ultrashort segment disease). Nevertheless, rectal suction biopsy was negative for neuronal abnormalities and unexpectedly on plain radiograph vertebral abnormalities were noticed. Subsequently magnetic resonance imaging of the spine and abdomen was performed, to evaluate possible spinal cord lesions and potential abnormalities of the perineal region musculature. A syringe throughout medullary cone was noted. The well-known issue, that the diagnosis of HD does not depend on the imaging (radiological) findings, was confirmed. The step-bystep diagnostic approach from the initial thought of ultrashort segment HD to the later imaging-based diagnosis of syringomyelia is discussed in this present paper.

Acute eosinophilic appendicitis after generalized skin reaction due to unknown cause in a child: Case report and literature review.

Acute eosinophilic appendicitis (AEA) is a rare variant of appendix inflammation possibly linked to allergy. Histopathological evidence of eosinophilic infiltration of the muscularis propria and edema separating the muscle fibers is the gold standard for the diagnosis. Here, we report a case of a young boy with AEA following a skin reaction of possible allergic origin. A 6-year-old male was presented to the emergency department with a two-day diffuse abdominal pain and tenderness in the right lower quadrant. A possible allergic reaction had occurred five days before as a pruritic rash. There was no history of allergy and the stool examination was negative for parasites. The initial diagnosis was acute appendicitis, and appendectomy was performed. The histopathological diagnosis was AEA. Further studies on the proper diagnostic and treatment approach of AEA before surgery are required.

Predictive model of heterotopy in Meckel's diverticulum in children.

BACKGROUND: The presence of heterotopic tissue in Meckel's diverticulum (MD) increases the incidence of future complications. Based on this concept, this study aimed to detect clinical and morphological parameters able to predict the probability of heterotopy in incidentally discovered uncomplicated MD and to develop a risk-based classification tool. METHODS: The clinical records of 146 patients who underwent MD resection were reviewed. MD complications (bleeding, inflammation, perforation or involvement in pathological processes such as intussusception) and MD dimensions (width, length and the product width × length) were evaluated in association with heterotopy. Regression analysis was used to explore the discrete effect of clinically relevant parameters, which were subsequently combined in a Classification and Regression Tree. RESULTS: The probability of heterotopy was higher in complicated MDs. The width of the base of the MD and the product width × length were also significant predictors of heterotopy. A stepwise combination (Classification and Regression Tree model) of (i) uncomplicated macroscopic presentation, (ii) width <2.5 cm, (iii) age <10 years and (iv) product width × length <4 cm2 resulted in a null probability of heterotopy in our study group. CONCLUSION: The combination of MD-related clinical and morphological parameters using advanced statistical tools may assist in estimating the probability of heterotopy. This may be applied in incidentally discovered uncomplicated MDs during abdominal surgery for other morbidities. Prospective studies are required to confirm our findings and test the practical usefulness of the classification tool developed here.

The use of a perimeatal-based penile skin flap to cover the repair of a tubularized incised plate urethroplasty: from experimental surgery to clinical practice.

OBJECTIVE: To prospectively evaluate the efficacy and safety of a perimeatal-based penile skin flap for neourethral coverage after repair of distal hypospadias with tubularized incised plate urethroplasty (TIPU). METHODS: In 12 New Zealand white rabbits a ventral urethral defect was created and reconstruction was accomplished with continuous suture. An epithelialized defect-based flap was harvested from the penile skin to cover the repaired defect. The animals were euthanized on the 28th postoperative day and their penises were processed for microscopic examination. In 32 children with distal hypospadias a TIPU was performed. A penile skin flap was created immediately below the distal end of the neourethra and used to cover the urethroplasty. RESULTS: Histological examinations revealed complete restoration of continuity of the stratified squamous epithelium without evidence of inflammation or fistula formation with full consistency with the underlying papillary reticular and corium. There were no cases of fistula formation. One patient developed meatal stenosis. All patients had a satisfactory cosmetic appearance and excellent functional results. CONCLUSION: The formation of a perimeatal-based skin flap is a simple and safe method of providing additional cover for the constructed neourethra after TIPU, minimizing the fistula rate.

Effect of VEGF on angiogenesis in pedicle penile skin flaps: an experimental study of urethral reconstruction in rabbits.

INTRODUCTION: The aim of this study was to investigate the expression of vascular endothelial growth factor (VEGF) in pedicle penile skin flaps (PPSFs) used for urethral reconstruction in rabbits and the effect of exogenous VEGF on the angiogenesis process in the PPSFs. METHODS: We randomly divided 28 male New Zealand rabbits into two sets of animals. A ventral urethral defect was created in all animals. In the first set of animals (first experiment, n = 10), a PPSF was used for the repair and VEGF expression in the flap was estimated on days 1, 2, 3, 5, and 7 postoperatively. The second set of animals (second experiment, n = 18) included three groups: control, untreated, and VEGF groups. In control group (n = 6), the defect was repaired by simple closure. In untreated (n = 6) and VEGF (n = 6) groups, a PPSF was used for the reconstruction. In VEGF group, exogenous VEGF was injected subdermally on the postoperative day corresponding to the peak endogenous VEGF expression (first experiment results). The animals were sacrificed on the 21st postoperative day and the angiogenic activity was assessed. A p < 0.05 was considered statistically significant. RESULTS: The highest expression of endogenous VEGF in PPSFs was noted on postoperative day 3. Angiogenesis in control, untreated, and VEGF groups was 23.06 ± 4.1, 30.00 ± 6.9, and 34.7 ± 6.9 (mean values ± standard deviation) vessels per optical field, respectively. There were statistically significant differences between control-untreated groups (p = 0.04) and untreated-VEGF groups (p < 0.0001), and indicative difference between untreated and VEGF groups (p = 0.064). CONCLUSIONS: VEGF is expressed in PPSFs, used for urethral reconstruction in rabbits. Flap angiogenesis is much higher than angiogenesis in simple wound closure. VEGF injection on postoperative day 3 seems to enhance angiogenesis in flaps.

(99m)Tc-DMSA scintigraphy diagnosing crossed renal ectopia with fusion in a three years old boy.

A 3 years old boy with a history of surgery for orchidopexy was admitted to our hospital with fever and abdominal pain. Clinical examination and laboratory investigations revealed urinary tract infection with renal involvement. Ultrasonography demonstrated a solitary left kidney and raised the suspicion of a fusion anomaly. Voiding cystography disclosed grade III vesicoureteral reflux and technetium-99m dimercaptosuccinic acid scintigraphy revealed right to left crossed renal ectopia with fusion (L-shaped kidney). The patient is undergoing standard follow-up for the early detection of possible renal complications. In conclusion, L-shaped kidney is a rare entity and the (99m)Tc-DMSA scintigraphy played an important role on timely diagnosis.

Acute appendicitis in preschoolers: a study of two different populations of children.

OBJECTIVE: To assess the incidence and the risk factors implicated in acute appendicitis in preschoolers in our region. METHODS: Over a 7-year period, 352 children underwent appendectomy for suspected acute appendicitis. Of these, data for 23 children were excluded because no inflammation of the appendix was found on subsequent histology. Of the remaining 329, 82 were ≤ 5 years old (i.e., preschool children) and 247 were 5-14 years old. These two groups of children were further divided according to their religion into Muslims and Christian Orthodox: 43 of the children aged ≤ 5 years were Muslims and 39 were Christian Orthodox. A household questionnaire was designed to collect data concerning age, gender, type of residence area, living conditions, vegetable consumption, and family history of surgery for acute appendicitis as preschool children. The removed appendices were also assessed histologically for the amount of lymphoid tissue. RESULTS: Acute appendicitis of preschoolers developed more frequently in Muslims (39.4%) than in Christians (17.7%; p < 0.001). The lack of inside toilet facilities at home, overcrowded living conditions, living in rural areas, and the amount of appendix lymphoid tissue were significantly more frequent among the Muslim preschool children (p < 0.05), while there were no statistically significant differences between Muslim and Christian children with regard to gender, the family history of acute appendicitis, or the vegetable consumption (p > 0.05). CONCLUSIONS: In our region, the percentage of preschool-aged Muslim children with acute appendicitis was remarkably high. One possible explanation for this finding could be the higher amount of lymphoid tissue in the wall of the appendix in Muslim preschool children together with their low standard of hygiene.

Optimal timing for repair of an inguinal hernia in premature infants.

PURPOSE: The aim of this study was to determine the optimal timing for inguinal herniotomy in premature infants treated in the neonatal intensive care unit. METHODS: A two-institutional-center retrospective study was performed including 41 prematures at gestational age 28-35 weeks who underwent herniotomy within 1 week of diagnosis [short-waiting group (SWG), median 5 days, n = 25] or more than 1 week after diagnosis [long-waiting group (LWG), median 30.55 days, n = 16]. Gestational age, birthweight, post-conceptional age at diagnosis, age at diagnosis, post-conceptional age at surgery, age at surgery, weight at surgery, timing of surgery, operative time, and occurrence of incarceration, postoperative apnea, hernia recurrence, testicular atrophy, and hospital stay were compared between the two groups. Statistical analysis was performed using one-way ANOVA. RESULTS: Twelve preoperative episodes of incarceration occurred: three in the SWG and nine in the LWG (P < 0.05). Six infants had apnea postoperatively: four in the SWG and two in the LWG (P > 0.05). Follow-up revealed five hernia recurrences, one in the SWG and four in the LWG (P < 0.05); four testicular atrophies were found, one in the SWG and three in the LWG (P > 0.05). CONCLUSION: Early elective herniotomy should be considered in prematures in order to avoid perioperative morbidity and to reduce the risk of incarceration and subsequent testicular ischemia, and hernia recurrence.

Acute poisoning among children admitted to a regional university hospital in Northern Greece.

OBJECTIVES: The aim of our study was to elucidate the current pattern of acute poisoning among children admitted to a regional University Hospital in the prefecture of Evros in Northern Greece. We also compared the obtained findings with those of two previous studies performed in the same region. METHODS: Demographic and clinical data, management, and outcome of children with acute poisoning were recorded in our region, during the past 5-years (2005-2009, period C) and compared to similar studies carried out in the periods 1985-1989 (period A) and 1995-1999 (period B). RESULTS: Comparison between the three periods showed that in period Athe lower incidence of children's acute poisoning (CAP) was observed. Also this revealed a 20%-reduction in the frequency of poisoning over the past 5-years (period C) compared to period B (p = 0.219), a significant increase in tobacco intoxication over the years (in the order A-C; p < 0.001 for comparisons of periods A and B, and periods B and C), while poisoning from insecticides-pesticides decreased (p < 0.001). The incidence of poisoning via salicylates significantly reduced from 9.7% in period A to 6.2% in period B, and further to 4.7% in period C (p = 0.016), whereas during the same periods poisoning via paracetamol increased from 2.3% to 5.1% and then to 10.4%, respectively (p < 0.001). Atrend toward a higher incidence of suicide attempt via poisoning was found during the three periods (from 3.0% in period A to 4.7% and 6.6%, in periods B and C, respectively; p = 0.049). CONCLUSIONS: The frequency of acute poisoning among children has decreased over the past 5 years. The incidences of poisoning via paracetamol and tobacco, and attempted suicide have increased in recent years. Targeted and continuous educational preventive programs are mandatory.

Lipoblastoma on the posterior side of the neck.

Lipoblastoma is a rare benign pediatric tumor derived from embryonic fat, and only two cases of lipoblastoma located on the posterior side of the neck have been reported in the literature. Here, we present the third case of posterior neck lipoblastoma in a 13-month-old healthy girl, who presented with a firm, posterior cervical mass. The tumor was completely resected following ultrasonography, computerized tomography, and magnetic resonance imaging evaluations. Histological examination of the resected tissue showed the typical characteristics of lipoblastoma. The child's postoperative progress was uneventful and no recurrence was observed 27 months after the operation. The clinical manifestations, radiologic and histopathologic findings, and treatment of this lesion are discussed.

Effect of passive smoking on lung function and respiratory infection.

OBJECTIVE: To study the effect of environmental tobacco smoke to children's health and more specifically to the development of respiratory tract infections and also its influence to their respiratory function. METHODS: We studied 586 children from the district of west Thrace in Greece aged 5-14 years, randomly selected from 20 primary and 10 secondary schools in regards their exposure to tobacco smoke, and its possible relation with respiratory tract infections. We assessed respiratory function by spirometry. Epidemiological data were also analysed. RESULTS: Children who were exposed to environmental tobacco smoke had higher risk for upper and lower respiratory tract infections in comparison to children who lived in a smoke free environment (3 fold and 2 fold, respectively. Their lung function was also reduced with decreased values of FEV1, FEF50, PFR (values p<0.001). CONCLUSION: Passive smoking has an unfavorable effect in respiratory function of children and predisposes them to respiratory tract infections. Every effort should be undertaken in order to avoid exposure of children to environmental tobacco smoke.

Acute abdomen in children due to extra-abdominal causes.

BACKGROUND: Acute abdominal pain in children is a common cause for referral to the emergency room and for subsequent hospitalization to pediatric medical or surgical departments. There are rare occasions when the abdominal pain is derived from extra-abdominal organs or systems. The aim of the present study was to establish the most common extra-abdominal causes of acute abdominal pain. METHODS: The notes of all children (1 month-14 years of age) examined for acute abdominal pain in the Accident and Emergency (A&E) Department of Alexandroupolis District University Hospital in January 2001-December 2005 were analyzed retrospectively. Demographic data, clinical signs and symptoms, and laboratory findings were recorded, as well as the final diagnosis and outcome. RESULTS: Of a total number of 28 124 children who were brought to the A&E department, in 1731 the main complaint was acute abdominal pain. In 51 children their symptoms had an extra-abdominal cause, the most frequent being pneumonia (n = 15), tonsillitis (n = 10), otitis media (n = 9), and acute leukemia (n = 5). CONCLUSION: Both abdominal and extra-abdominal causes should be considered by a pediatrician who is confronted with a child with acute abdominal pain.