Orchiopexy: one procedure, two diagnoses - different male infertility outcomes.

ABSTRACT: Infertility, affecting one in six couples, is often related to the male partner's congenital and/or environmental conditions or complications postsurgery. This retrospective study examines the link between orchiopexy for undescended testicles (UDT) and testicular torsion (TT) in childhood and adult fertility as assessed through sperm analysis. The study involved the analysis of semen samples from 7743 patients collected at Soroka University Medical Center (Beer Sheva, Israel) between January 2009 and December 2017. Patients were classified into two groups based on sperm concentration: those with concentrations below 5 × 10 6 sperm per ml (AS group) and those above (MN group). Medical records and surgical histories were reviewed, categorizing orchiopexies by surgical approach. Among 140 individuals who had undergone pediatric surgery, 83 (59.3%) were placed in the MN group and 57 (40.7%) in the AS group. A higher likelihood of being in the MN group was observed in Jewish compared to Arab patients (75.9% vs 24.1%, P = 0.006). In cases of childhood UDT, 45 (78.9%) patients exhibited sperm concentrations below 5 × 10 6 sperm per ml ( P < 0.001), and 66 (76.7%) had undergone unilateral and 18 (20.9%) bilateral orchiopexy. Bilateral orchiopexy was significantly associated with lower sperm concentration, total motility, and progressive motility than unilateral cases ( P = 0.014, P = 0.001, and P = 0.031, respectively). Multivariate analysis identified UDT as a weak risk factor for low sperm concentration (odds ratio [OR]: 2.712, P = 0.078), with bilateral UDT further increasing this risk (OR: 6.314, P = 0.012). Jewish ethnicity and TT diagnosis were associated with a reduced risk of sperm concentrations below 5 × 10 6 sperm per ml. The findings indicate that initial diagnosis, surgical approach, and ethnicity markedly influence male fertility outcomes following pediatric orchiopexy.

The impact of medical clowns exposure over postoperative pain and anxiety in children and caregivers: An Israeli experience.

While postoperative pain management was shown to reduce unwanted physiological and emotional outcomes, pediatric postoperative pain management remains suboptimal. Medical-clowns were shown to be beneficial in many medical contexts including reduction of stress, anxiety and pain. This study was set to assess the effectiveness of medical-clowns on pediatric postoperative pain reduction. Children age 4 or above, planned for elective hernia repair surgery were recruited. Children were randomly divided to a control or medicalclown escorted groups. Demographical and clinical data were collected using questionnaires and electronic sheets. Children escorted by clowns reported lower levels of pain upon admittance, discharge and 12- hours post-surgery. Statistically significant reduction of parental distress and significantly higher serum cortisol levels were observed in the clown-therapy group. Although small, our study supports the possibility that preoperative medical-clown therapy might be a cheap, safe and yet beneficial method for postoperative pain reduction.

Central venous catheter-associated bloodstream infections.

BACKGROUND: To investigate the epidemiologic and microbiological aspects of long-term central vein catheter (CVC)-associated bloodstream infections (CABSI) in children <18 years old treated at the hemato-oncology unit during 1998-2008. PATIENTS AND METHODS: The two long-term access devices used were Hickman and Port-A-Cath catheters. Information retrieved included demographic data, baseline pathologies, methods of insertion, anatomical insertion sites, duration of use, microbiological, and antibiotic susceptibility data and outcome. RESULTS: There were 178 CABSI episodes; average number of episodes/1,000 catheter days was 4.7. More CABSI episodes were recorded among patients with Hickman catheter than in patients with Port-A-Cath catheter (5.05 vs. 3.57/1,000 catheter days, P = 0.059). The CVC was removed due to BSI in 52/178 (29.2%) episodes. Overall, 243 pathogens were isolated (144 Gram-negative, 92 Gram-positive, and 7 Candida spp). More Enterobacteriaceae spp. were isolated in CABSI in patients with Hickman catheters than in patients with Port-A-Cath catheters (35/103, 34%, vs. 10/65, 15%, P = 0.008); more coagulase-negative staphylococci were isolated in patients with Port-A-Cath catheters than in patients with Hickman catheters (25/65, 38.5%, vs. 23/103, 22.3%, P = 0.02). No differences in pathogen distribution were found between CABSI recorded for jugular versus subclavian veins, open versus close inserted-CVC or for CVC requiring removal versus those treated conservatively. No fatalities directly related to CABSI were recorded. CONCLUSIONS: CABSI rates were higher in patients with Hickman catheters compared with those with Port-A-Cath catheters; Gram-negative organisms were the dominant etiologic agents of CABSI; CABSI in patients with Hickman catheters had different etiologies compared with patients with Port-A-Cath catheters.

Community-acquired complicated intra-abdominal infections in children hospitalized during 1995-2004 at a paediatric surgery department.

UNLABELLED: Information on the epidemiologic, clinical, microbiologic and therapeutic aspects of community-acquired complicated intra-abdominal infections in paediatrics is limited. The objectives of this study were to investigate the epidemiologic, clinical, microbiologic and therapeutic characteristics of community-acquired complicated intra-abdominal infections occurring in children aged 1 month-15 y. Medical charts and microbiology data of all children hospitalized with complicated intra-abdominal infections were retrospectively examined. Complicated intra-abdominal infections were defined as infections extending beyond the viscus of origin into the peritoneal space, with subsequent development of abscess or peritonitis. One hundred and twenty-three patients with complicated intra-abdominal infections (99/123, 80% >5 y of age) were included; 113 (92%) had complicated acute appendicitis. Twelve (10%) patients underwent computerized tomography-guided percutaneous drainage of periappendicular abscesses. The mean rate of complicated intra-abdominal infections among patients with complicated acute appendicitis was 10% without significant changes during the study years. Positive intra-abdominal cultures were recorded in 97/108 (90%) evaluable patients; 65/97 (67%) cases were characterized by mixed bacterial flora growth. One hundred and ninety pathogens (aerobes n=164, 86%; anaerobes n=26, 14%) were isolated. Escherichia coli was the most common pathogen (94 isolates, 57%). In vitro amoxicillin/clavulanate coverage of E. coli and Klebsiella spp was modest (81% and 86%, respectively). The ampicillin/gentamicin/metronidazole regimen was more appropriate in vitro than the amoxicillin/clavulanate regimen (3/80, 4% resistant pathogens compared with 8/43, 19%; p=0.02). Post-operative complications were recorded in 33/123 (27%) patients. Time until defervescence to < 37.5 degrees C was shorter in children with periappendicular abscess than in children with generalized peritonitis (6+/-4 vs 4+/-3 days; p=0.009). IN CONCLUSION: (1) most community-acquired complicated intra-abdominal infections occurred as a result of acute appendicitis; (2) the rate of complicated intra-abdominal infections among patients with acute appendicitis was low and without significant changes during the study period; (3) E. coli was the most frequently isolated pathogen; (4) amoxicillin/clavulanate provided only partial coverage for complicated intra-abdominal infection pathogens and should be used with caution in the empiric treatment of complicated intra-abdominal infections.

Pediatric wandering spleen successfully treated by laparoscopic splenopexy.

Wandering spleen is a rare clinical condition associated with a high incidence of splenic torsion and infarction. The preferred treatment is splenopexy to reposition the spleen in the left upper quadrant of the abdomen. We report the case of a 12-year-old girl who presented with intermittent abdominal pain. An abdominal sonography was diagnostic of wandering spleen. The patient was successfully treated by laparoscopic splenopexy. The spleen was repositioned in the left upper quadrant and fixed to the posterior abdominal wall by a mesh patch attached by staples. To reinforce the splenopexy we created an additional support by plicating the phrenocolic ligament and suturing it to the lateral abdominal wall, making a pouch for the inferior pole of the spleen. The postoperative course was rapid and uneventful. A normal spleen position was verified by radionuclide scans at 3 days and 6 months postoperatively. Laparoscopic splenopexy is an excellent option for organ-preserving treatment in wandering spleen.

Twelve years of minimally invasive surgery in children and adolescents: a single center experience.

BACKGROUND/PURPOSE: Minimally invasive surgery plays an important role in the daily practice of pediatric surgeons. However, there have been few reports of large series of patients. The aim of this paper is to report our experience over the past 12 years with a broad range of pediatric laparoscopic procedures. METHODS: We performed a retrospective analysis of 1084 minimally invasive procedures conducted in the department of pediatric surgery from June 1992 to March 2004. RESULTS: The mean age of the patients was 14 years (range, 1-19). Seven hundred forty-six operations (69%) were thoracoscopic sympathectomy for hyperhydrosis. Other common operations were high ligation of spermatic vessels (n=98), cholecystectomy (n=65), exploration of nonpalpable testes (n=53), appendectomy (n=55), female adnexal surgery (n=24), and splenectomy (n=13). Thirty miscellaneous procedures included Nissen fundoplication, liver biopsies, diagnostic laparoscopy, Morgani and Bochdalek hernia repair, Swenson procedures, V-P shunt placement, splenic and hepatic cyst removal, thorcoscopy for pleural empyema, treatment of gastric ulcer perforation, and nephrectomy. We reviewed the indications for surgery, the surgical technique, and the outcome for each procedure. All patients in this series were well at follow-up and there was no long-term morbidity. CONCLUSION: Although laparoscopic procedures have gained an integral place in pediatric surgery and are relatively safe, advanced laparoscopic procedures should be developed, practiced and evaluated in dedicated surgical units to ensure a broad base of experience on which to base future decisions and guidelines.

How much of a misnomer is "asymptomatic" intestinal malrotation?

BACKGROUND: Intestinal malrotation is usually observed in the neonatal period with signs of acute high intestinal obstruction due to midgut volvulus. However, malrotation presenting beyond the neonatal period and well into adult life is associated with a variety of atypical and frequently non-specific gastrointestinal symptoms that may often cause prolonged delay in diagnosis and appropriate treatment. OBJECTIVES: To emphasize the difficulty in predicting the risk of midgut volvulus based on age or symptoms, and to recommend surgery in all patients found to have intestinal malrotation even if they are considered asymptomatic. METHODS: We reviewed 41 patients with malrotation treated over a period of 24 years at the Soroka University Medical Center. RESULTS: In our series, 27 patients (66%) had acute midgut volvulus while 14 (34%) had malrotation found during investigation of various long-term gastrointestinal non-specific symptoms. Two patients died of total parenteral nutrition-related sepsis following extensive resection of small bowel. A total of 28 patients was available for long-term follow-up and are asymptomatic. CONCLUSIONS: We recommend elective laparotomy and Ladd procedure in all patients found to have intestinal malrotation. This will prevent the catastrophic results of midgut volvulus and a variety of gastrointestinal symptoms wrongly attributed to other conditions in the span of a lifetime.