The Impact of the COVID-19 Pandemic on the Most Common Diagnoses in Pediatric Surgery: Abdominal Pain, Acute Scrotum, Upper and Lower Extremity Injuries-Tertiary Center Experience.

OBJECTIVE: The coronavirus disease-19 pandemic has brought new patterns of behavior among patients and their parents. The reorganization of the health care system has reduced the number of elective surgical procedures in Croatia. In our study, we were interested in whether the pandemic has caused a statistically significant decrease in the number of examinations of children in the emergency department according to the most common diagnoses in pediatric surgery and whether there was a decrease in the number of emergency surgeries. MATERIALS AND METHODS: We retrospectively analyzed data from the Hospital Information System. The analysis included 15 months of the pre-coronavirus disease-19 period and 15 months of the coronavirus disease-19 period. The primary outcome of the study was to determine the cumulative number of all examinations and then to determine the number of examinations according to the most common diagnoses and, consequently, to determine whether there was a statistically significant decrease. The secondary outcome was to determine the cumulative number of all operations and then to determine the number of the most common emergency operations and, consequently, to see if there was a statistically significant decrease. RESULTS: In the 15 months of the pre- coronavirus disease-19 period, a total of 33 646 children were examined in the emergency department, while in the coronavirus disease-19 period, 26 831 were examined (P = .010). Although a decrease was recorded in all categories, a statistically significant decrease was recorded for diagnoses of abdominal pain (P = .007) and lower extremity injuries (P = .014). The total number of operations, due to strict measures and reduction of the elective program, decreased statistically significantly in the coronavirus disease-19 period (P < .0001). The number of most common emergency operations did not decrease statistically significantly. CONCLUSION: This study represents the first longer, 15-month experience of a pandemic in the only and largest children's hospital in Croatia. There is no doubt that coronavirus disease-19 had the effect of reducing the number of examinations in the emergency department for all the most common diagnoses, but the number of operations did not change significantly.

From Ataxia to Diagnosis of Askin Tumor - a Case Report.

Peripheral primitive neuroectodermal tumors (pPNET) are a group of extremely rare, aggressive, malignant tumors that are most often found in the thorax (Askin tumor), abdomen, pelvis, extremities and less frequently in the head and neck. The most important prognostic factor is the stage of the tumor. Significant progress both in surgery and in neoadjuvant and adjuvant chemotherapy and radiotherapy, as well as the improvement in diagnosis by cytogenetic and immunohistochemical analysis, should improve the survival rate. We report a case of a 14-year-old girl, with ataxic gait, cardiopulmonary compensated, without respiratory symptoms, who was referred to our hospital for further examination and treatment of newly discovered tumor of the left hemithorax. After a detailed radiological and laboratory investigation, next step was an extensive thoraco-neurosurgical surgery. After histopathological, cytological and molecular analysis, a diagnosis of Askin tumor was made.

Treating Giant Congenital Nevus With Integra Dermal Regeneration Template in a 9-Year-Old Girl.

Integra dermal regeneration template has been well established in treating deep extensive burns, but there are very few cases reported of treating large full-thickness skin defects such as giant nevi. Apart from psychological and cosmetic burdens, the giant congenital nevus carries increased risk of malignant alteration. We present the case of a 9-year-old girl with a giant congenital nevus on her left lower leg. A total excision was done and she was successfully treated with Integra (LifeSciences Corp, Plainsboro, NJ). Three weeks later, a thin split-skin graft was applied over the neodermal skin layer. The takeoff was 91%. Protected with the silver wound dressing, the rest of the wound healed. A donor site morbidity was minimal, and the final result was excellent both in aesthetic and functional aspects.

Bilateral Ovarian Torsion during Follow-up for Antenatally Detected Ovarian Cysts.

Ovarian torsion is a surgical emergency demanding timely diagnosis and treatment to prevent loss of the ovaries which if happens may result in functional and emotional consequences. Simple (less than 5cm in size) ovarian cysts require follow-up for potential self-resolution. We describe a case of antenatally detected bilateral ovarian cysts that developed bilateral ovarian torsions on follow-up, postnatally.

Torsion of a mesenchymal hamartoma of the liver in a 1-year-old boy.

We report a case of a one-year-old boy who was referred to our clinic suspected of having acute abdomen. On physical examination, the abdomen was soft, diffusely tender with weak peristalsis. Ultrasonography and MRI of the right hemiabdomen demonstrated a well-defined, solid, expansive formation with slightly lobulated contours and an interspersed inhomogeneous structure with overall dimensions of 59 × 45 × 50 mm. After midline laparotomy was performed, a cystic tumor was found, twisted around a pedicle which was arising from the falciform ligament and it measured 5-6 cm in diameter. The tumor appeared to be necrotic. The mass was ligated and extirpated on the pedicle and sent for histopathological analysis. After the surgery, the boy was hemodynamically stable, without respiratory complications and all laboratory findings were within normal limits. Histopathological analysis showed that the tumor was composed of mesenchymal stroma with sparse glimpses of hepatocytes and bile ducts with partly cystic changes lined by orderly epithelium. Given the clinical data, histology and immunohistochemistry analysis (alpha-fetoprotein, CK8/18, hepatocyte, desmin and CD31) a diagnosis of a twisted mesenchymal hamartoma of the liver was made.

Rare Abdominal Wall Malformation: Case Report of Umbilical Cord Hernia.

The umbilical cord hernia is the rarest form of abdominal wall malformations, anatomically completely different from gastroschisis and omphalocele. It occurs due to the permanent physiological evisceration of abdominal organs into umbilical celom and persistence of a patent umbilical ring. The umbilical cord hernia is often mistaken for omphalocele and called "small omphalocele". Here we present a case of a female newborn with umbilical cord hernia treated in our Hospital. After preoperative examinations surgery was done on the second day of life. The abdominal wall was closed without tension. The aim of this article is to present the importance of the proper diagnose of these three entities and to stimulate academic community for the answer, is this umbilical cord hernia or small omphalocele.

[INITIAL EXPERIENCE WITH TOPICAL NEGATIVE PRESSURE THERAPY IN THE TREATMENT OF PEDIATRIC BURNS].

We are presenting the experience of the Referral Centre for Pediatric Traumatism of the Croatian Ministry of Health in the usage of topical negative pressure therapy (TNP) method for the treatment of pediatric burns. In the period of 20 months we have used negative pressure wound therapy method in eight children aged between 1.5 and 10 years. Burn injuries total body surface area ranged between 3% and 30%. TNP was used either for the wound bed conditioning or for the fixation of skin grafts. Average skin graft "take" was 86% eight days after surgery according to the evaluation by the senior author. Based on our initial experience, we can confirm that TNP is a very useful tool which enables good wound bed conditioning as well as a good fixation tool for skin grafts if the burned area does not exceed 30% of total body surface area.

Duodenal Duplication Cyst: A Rare Differential Diagnosis in a Neonate with Bilious Vomiting.

Bilious vomiting is a relevant sign in neonates that requires immediate evaluation and diagnosis. A duplication of the intestinal tract is a possible cause of obstruction if located distally to the major duodenal papilla of Vater and most of them involve the jejunum, stomach, or colon. Duodenal duplications are very rare and can have an endoscopic or surgical treatment after diagnosis. We present a case of a 16-day-old term newborn that consulted because of bilious vomiting and after evaluation with imaging and upper endoscopy, a duodenal duplication cyst was found at the level of the third portion causing compression of the intestinal lumen that required surgical resolution with duodenocystostomy.

Isolated fallopian tube torsion with partial hydrosalpinx in a premenarcheal girl: a case report.

INTRODUCTION: Isolated fallopian tube torsion as a complication of a preexisting hydrosalpinx is a rare finding in pediatric patients. The obvious rarity of this condition, its subtle diagnostic features and dissonant previous reporting about the appropriate therapeutic approach according to age, future conception capacity and potential complications of possible pregnancies make the decision about which surgical approach to use very difficult. In this report, we describe the case of a patient with such a presentation and review the literature. Very few similar reports of neosalpingostomy in pediatric patients have been published to date. CASE PRESENTATION: In our present report, we describe the case of an 11-year-old Caucasian prepubertal girl who presented to our hospital with complaints of abdominal pain in the right lower quadrant, nausea and vomiting. The diagnostic workup led us to conclude that she had a torsion of the right ovary, which was cystically altered. Exploratory surgery revealed a partial hydrosalpinx and consecutive isolated torsion of the fimbrial part. The proximal isthmic part of the fallopian tube was intact and vital. Restorative surgery was performed to create a neosalpingostomy on the viable isthmic part of the tube and remove the cystic and twisted fimbrial and infundibular parts. CONCLUSION: The surgical procedure described in this report is technically simple and feasible, but leaves doubts about the final outcome.

[A rare tumor of the lung in childhood--inflammatory myofibroblastic tumor]. / Rijetki tumor pluca u djecjoj dobi --inflamatorni miofibroblasticni tumor.

Inflammatory myofibroblastic tumor (IMT) is a rare benign neoplasm, mainly involving the lungs of the children. It represents 0.7% of all lung tumors. It was first described by Brunn in 1939.2 Diagnosis is very difficult and often only possible after resection of the tumor. We would like to present a case of pulmonary IMT in a 13-year-old girl who presented with symptoms like cough, shortness of breath, and chest discomfort. Chest X ray and computed tomography revealed the presence of a right lower lobe lung mass. Its clinical and radiological findings were diverse and non specific. The mass was removed in toto, histopathology confirmed the inflammatory myofibroblastic tumor of the lung. Intraoperative and postoperative courses were uneventful. The patient has been without any signs of relapse 2 years after the surgery.

Cystic lymphangioma of jejunal mesentery mimicking acute appendicitis: case report.

Cystic lymphangiomas of the small bowel mesentery are rare manifestations of intra-abdominal tumors. Usually, they are discovered incidentally during examination for an unrelated abdominal illness. We present a case of a 4-year-old boy who was admitted to our hospital because of the right lower quadrant acute abdominal pain suspect of acute appendicitis. At laparotomy, a giant, cystic, encapsulated and lipomatous mesenterial mass was found, 15 x 15 x 10 cm in size, infiltrating the jejunum. The tumor was located 70 cm from Treitz's ligament. Extirpation of tumor mass with intestinal resection of the involved loops was necessary. Pathologic examination confirmed the diagnosis of mesenteric cystic lymphangioma. Although they are rare, cystic mesenteric lymphangiomas should be considered as a possible cause of acute abdomen and treated with surgical resection. Prognosis after surgical removal is excellent.

Pulsed dye laser treatment of vascular lesions in childhood.

Almost all congenital vascular abnormalities affect the skin and are evident from birth or become so during the first few weeks of life. The two most common types of vascular birthmarks, hemangiomas and vascular malformations, may appear to be very similar but their course and treatment are different. Hemangiomas appear in the first few weeks of life and usually regress spontaneously over time. Vascular malformations are always present from birth even though they might not be apparent, never disappear and often grow during the person's lifetime and may vary extremely from high blood flow lesions, sometimes located in critical sites that may be life-threatening to asymptomatic spots of mere aesthetic concern. Laser therapy nowadays has become indispensable in the management of pediatric vascular lesions. With a proper balance of wavelength, energy density and pulse duration, the laser energy of thermo coagulation could be molded to effectively manage different lesions. Both dermatology and plastic surgery have been transformed by understanding vascular lesions biology and modern laser technology. As a result, we can now provide an optimal selective treatment with minimal collateral damage. Although alternatives such as the potassium titanyl phosphate (KTP), red/infrared (IR), or intense pulsed light lasers are available, pulsed dye lasers continue to be the standard of care for the majority of pediatric vascular lesions.

Expression and prognostic value of the Ki-67 in Wilms' tumor: experience with 48 cases.

PURPOSE: Ki-67, tumor proliferation marker, is an important prognostic factor in a variety of cancers. In the present study, we investigated the expression and the prognostic value of Ki-67 in nephroblastoma. METHODS: Ki-67 expressions were investigated by immunohistochemistry on paraffin-embedded material in 48 children operated on because of nephroblastoma. Patients were treated according to SIOP protocol. The mean follow-up period was 5.4 years. A proliferation index was obtained by immunohistochemistry using anti-Ki-67 anti-body. RESULTS: The mean Ki-67 proliferation index in the blastemal type was 12.3%, and in the epithelial type, 21.4%. In the anaplastic type, Ki-67 proliferation index was: in the blastemal component 20%, in the stromal 21%, and in the epithelial 31%. In the mixed tumor type, Ki-67 proliferation index was assessed as: in the blastemal component 10%, in the epithelial 33% and in the stromal 31.5%. Proliferation index for the epithelium was significantly higher than those found for the blastema (P = 0.001). A correlation between Ki-67 and tumor stage found proliferation index significantly higher in stages I and II (P = 0.002). CONCLUSION: The results support the conclusion that Ki-67 is a relevant marker for assessing the proliferative activity and tumor cell dynamics of nephroblastoma, but it may not be a good clinical prognostic marker.

The relationships between self-esteem, emotional reactions and quality of life in pediatric locomotory trauma patients.

The main aim of this study was to establish the relationships between several psychosocial characteristics in children and adolescents differently treated for isolated long tubular bones' fractures. Examined variables were: self-esteem, basic emotional reactions toward illness or injury including depression and anxiety, as well as perception of quality of life and social support during the treatment. Whole sample comprehends 135 patients, both gender, 10-18 years of age, treated for mentioned fractures in period 2003-2005 at the Departments of Pediatric Surgery of 3 hospitals: University Hospital Centre in Rijeka and Clinical Children's Hospital in Zagreb, both in Croatia and University Hospital in Mostar, BiH. 73 patients were treated conservatively (CT), 40 of them underwent Elastic Stable Intramedullary Nailing (ESIN) and 22 of them underwent other surgical techniques (OST). Basic methods of work were: interview to collect data for half-structured socio-demographical questionnaire, evaluation of medical records and self-reported questionnaires including: Rosenberg Self-esteem Scale (RSS), Children Depression Inventory (CDI), Spielberg State Trait Anxiety Inventory (STAI), Short Form 36 Health Survey (SF-36) and Test of Perception of Social Support (TPSS). RSS, CDI and STAI were administered to the patients at baseline and after 6 months of the trauma, while SF-36 and TPSS after 1 month of the trauma. Results of this study point to close and strong relationships between examined variables, mostly statistically significant at level p < 0.01 in all patients with fractures, regardless of the type of the treatment. There were also statistically significant differences in all variables between first and second measure; self-esteem increased and depression and anxiety decreased during the time in all patients (with different dynamics regarding the type of treatment); higher perception of social support enhanced that effect. Perception of quality of life in whole sample in summary measures was statistically significant at level p < 0.01 correlated positively with self-esteem and negatively with depression and anxiety, thus connection with perception of social support was statistically significant only in sibdomain of physical pain. There was also statistically significant difference in self-perception of quality of life related to psychosocial variables according to the type of treatment (F = 3.27; p = 0.01). Results of this study suggest that there are strong connections between physical trauma and different psychosocial variables in patients which point at need of understanding locomotory trauma in children in wider context including physical state and social functioning of the patient as well as the choice of type of treatment of fractures which influences complete process of healing.

Two-port laparoscopic management of an autoamputated ovarian cyst in a newborn.

A 4-week-old newborn underwent laparoscopic removal of a hemorrhagic cyst measuring 4 cm in diameter. Preoperative diagnostics suggested autoamputation, which is a rare complication of fetal ovarian torsion. The laparoscopic procedure, lasting 26 minutes, was performed, without any major intraoperative complications--bleeding, rupture, or leakage. The modified 2-port technique was used. The identification of all structures was exact. The hemorrhagic cyst was freed of the cyst bed, suctioned to fit the size of the umbilical port, and removed. The presentation of a blind adnexal stump proved autoamputation. The condition of the contralateral ovary was verified. The authors present the laparoscopic procedure with the emphasis on the technique.

The quality of life during the treatment of long bone fractures in children and adolescents.

This paper evaluates and compares basic emotional reactions towards the illness, as well as the quality of life in relation to the various types of treatment of isolated long tubular bone fractures of extremities in children and adolescents. This prospective clinical research comprehends 135 patients (94 males and 41 females), aged 10 to 18, treated for the mentioned bone fractures in the period from October 2003 till March 2005 at The Departments for Pediatric Surgery of three hospitals: the Clinical Hospital Centre in Rijeka (88.8% of the patients), the Clinical Children's Hospital in Zagreb (9.7% of the patients) both in Croatia, and 1.5% of the patients in the Clinical Hospital in Mostar (Bosnia and Herzegovina). 53.3% of the patients were treated conservatively, 29.6% of them underwent the elastic stable intramedullary nailing (ESIN), while the remaining 17.1% of the patients were treated with other surgical techniques (AO-plates or Kirschner-wire ostheosyntheses). The basic methods were self-reported questionnaires: the Spielberg State Trait Anxiety Inventory (STAIl) to establish momentary anxiety and the Short Form-36 Health Survey (SF-36) to evaluate quality of life, i.e. the perception of the illness during treatment. The STAI1 was administered twice to the patients: within 1 week of the experienced trauma (at baseline) and 6 months after the trauma, whereas the SF-36 was administered only once, i.e. a month after the experienced trauma. Our results point at an increased anxiety indicators in all the patients immediately after the experienced trauma, mostly in patients treated surgically, especially those who underwent the ESIN method; whereas after 6 months from the experienced trauma the anxiety indicators were greatly reduced. The quality of life was better in patients who underwent a conservative treatment, both physically and mentally, than in those surgically treated. This points to the fact that the surgical method itself despite its type, is an additional stressor which causes additional anxiety and depressive reaction. Our results suggest (from psychological point of view) that the conservative method of treating long bone fractures in children and adolescents should be used since it causes less emotional reactions on the illness ascertaining a better health experience during the treatment than the active surgical treatment (regardless of the type), which should be practised with criticism and according to strict surgical indications. If the surgical treatment should be necessarily adopted, we should take into consideration the possibility of psychologically preparing the patients in order to diminish the psychological reaction on the surgical treatment.

[Laparoscopic decapsulation of congenital splenic cyst]. / Laparoskopska dekapsulacija prirodene ciste slezene.

Nonparasitic splenic cysts are uncommon and may be congenital or post-traumatic in origin. Complications may include enlargement with pain, rupture, and infection. The laparoscopy is widely accepted method in the treatment of this condition with numerous approaches. A technique of partial decapsulation-fenestration designed to minimize the risk of splenic loss and cyst recurrence is presented.

A 5-year experience of a minimally invasive technique for correction of pectus excavatum in Croatia.

The aim of this study was to assess the results of 5-year experience with minimally invasive operation without medial incision and resection cartilages for correction of pectum excavatum. From 2000 we made in our Hospital minimally invasive technique for the correction of pectus excavatum. 75 patients were treated by minimally invasive technique. A convex steel bar is inserted under the sternumtrough small bilateral Incisions. The steel bar is inserted with the convexity facing posteriorly, and when it is in position, the bar is turned over. After 2 years the bar is removed when permanent remolding has occurred. Initial excelent results were maintained in 54 patients (normal chest), good results in 16 (mild residual pectus) and poor in 5 (severe recurrence requiring further treatment). The mean follow-up since surgery were 3 months to 3 years. Average blood loss was 25 ml. Average length of hospital stay was 8 days. Patients returned to full activity after 2 month. Complications were pneumothorax in 12 patients, pneumonia in 6 patients and displacement of the steel barr requiring revision in 2 patients. Poor results occurred because steel bar was too soft in 3 patients, and soft sternum in 2 patients with Marfan's syndrome. The minimally invesive technique is effective without cartilage incision and resection or sternal osteotomy.

Has Ombrëdanne's method of hypospadic urethra reconstruction been ignored with reason?

From January 1970 to December 1979 inclusive, 193 boys (aged 2 to 16) underwent surgery for distal hypospadia using Ombredanne's method at the Department of Pediatric Surgery University Hospital Center Rijeka and at the Department of Pediatric Surgery Zagreb. Follow-up period was 7 to 20 years (mean 13.4). 20 (10.36%) subjects had post-operative organic complications and 15 (7.77%) of them required surgical correction. According to these findings, the success rate using Ombredanne's method of reconstruction of the hypospadic urethra in no way lags behind the success rate using MAGPI and Mathieu's methods as well as Preputial island flap urethroplasty for analogous cases. Out of 193 subjects who underwent surgery, 80 (41.45%) of those who were sexually mature and had normal psychosexual development were questioned. In this sample, 75 (93.75%) were satisfied with the post-operative appearance of the penis while only 5 (6.25%) were dissatisfied, 3 of which had hypoplastic penis. In 78 (97.50%) subjects questioned, the post-operative urinary squirt was normal and two of them had weak urinary squirt (2.50%), due to meatal stenosis. In conclusion, Ombredanne's method of reconstruction of the urethra in boys with distal hypospadia is equally successful as other methods used for this purpose.

Papillary cystic neoplasm of the pancreas: a rare presentation.

UNLABELLED: Papillary cystic neoplasm is a rare tumor and is usually found in young female patients. PROCEDURE: Here we describe a rare case of PCN in 16 year old girl, which was presented with abdominal pain in last 3 years. Preoperative diagnosis was suggested by ECHO and CT of the abdomen. The sonographic examination of the abdomen showed a tumor measuring 6.5 x 5.5cm in diameter in epigastrium. It was excised totally. Histological description confirmed the diagnosis of PCN. The patient is currently in good health without signs of relapse 3 years after surgery. DISCUSSION: Our patient is one of the very few adolescent patients with PCN who was treated successfully with surgery. ECHO and CT of the abdomen suggested the diagnosis which was confirmed by histopatological examination. CONCLUSION: The diagnosis of PCN is suspected by ECHO and CT of the abdomen and confirmed by specific histologic features. Prognosis is good and tumor should be excised whenever detected.