Is laparoscopic appendectomy in children associated with an uncommon postoperative complication?

BACKGROUND: Laparoscopic appendectomy (LA) is controversial due to the high rate of intraabdominal abscess (IAA). We report a postlaparoscopic appendectomy complication (PLAC) observed in pediatric patients discharged after an uneventful postoperative period. METHODS: In this case series, a review of the medical records of children who underwent LA or open appendectomy (OA) during a 5-year period was performed. The diagnosis of PLAC was based on three well-defined criteria: time of appearance, clinical and laboratory findings, and ultrasonographic characteristic features. RESULTS: A total of 374 patients underwent appendectomy (LA, 129 patients; OA, 245 patients). One patient with conversion of LA to OA and 35 patients with gangrenous or perforated appendicitis (seven from the LA group and 28 from the OA group) were excluded from the study. After LA, nine children developed intraabdominal complications during their hospitalization (six infiltrate in the right lower quadrant and three IAA); these were also excluded. Discharge from the department was done when three conditions were fulfilled: normal body temperature, normal leukocyte count, and passage of a stool. Among the 112 LA patients, PLAC was observed in 15 (13.4%), aged 12.5 +/- 2.9 years, who were discharged after LA in 2.7 +/- 0.9 days. Number of PLAC and time of its appearance were not significantly different in patients with normal or pathological appendix. Sonographic findings of PLAC at admission were fluid alone (n = 11), edematous mesenteric fat (n = 7), thickening of bowel wall (n = 9), and more than one sign (n = 9). At repeated sonography, these signs were present in all patients, and IAA developed in one of them. All children were successfully treated with antibiotics for 10.1 +/- 3.9 days, one of whom underwent a CT-guided percutaneous drainage for IAA. CONCLUSIONS: PLAC may be the result of a slow development of local interstitial infection in the ileocecal area due to mesothelial damage caused by CO2 pneumoperitoneum and local thermal effect produced by energized systems. This may explain its delayed appearance and the efficacy of the antibiotic treatment.

Pharmacological effects of the continuous administration of an LHRH agonist in the ageing male rat: comparison with orchidectomy.

The age-related changes in tissue response to chronic treatment for 1 month with a potent LHRH agonist were investigated in the ageing male rat, and the observed pharmacological effects were compared with orchidectomy. In both young (4 months) and old (22 months) rats, treatment resulted in a significant decrease in the weights of prostates and testes, a decrease in plasma LH and testosterone levels, a loss of LH receptors in the testes and in a complete depletion of prostatic nuclear androgen receptors, reaching levels observed after castration. In young rats, treatment with an LHRH agonist or orchidectomy induced a three- or sixfold increase in prostatic creatine kinase (CK) activity which may have been induced by the local stimulatory effect of oestradiol arising from the conversion of precursor steroids secreted by the adrenal. On the other hand, in old rats, 7 days after orchidectomy or after treatment with an LHRH agonist a twofold increase or no change was induced in prostatic CK activity respectively. SDS gel electrophoresis patterns of cytosolic prostatic proteins of young rats treated with an LHRH agonist or young rats orchidectomized 7 days previously revealed the presence of several intensified proteins, two of them having apparent molecular weight of 67 kDa and 43 kDa, whereas in the old rats treated with LHRH agonist or old rats castrated 7 days previously, these two proteins were not intensified. The results of this study confirmed that continuous treatment with an LHRH agonist to young and old rats induces medical castration since the pharmacological effects observed were the same as those induced with surgical castration.(ABSTRACT TRUNCATED AT 250 WORDS)

Phenotypic pattern of B cells in the appendix: reduced intensity of CD19 expression.

UNLABELLED: The lymphoid tissue of the appendix is considered as part of the gut-associated lymphoid tissue (GALT). In order to understand better the immunological significance of the appendix we analyzed the cellular composition of normal and inflamed human appendix tissue by flow cytometer with special attention to expression of the CD19 and CD5 markers on B cells. Cellular analysis was also performed on peripheral and appendical vein blood samples as well as on omentum and peritoneal fluid samples. The study population included seventeen patients aged 2-15 yr. (mean age - 11.5 yr.) undergoing appendectomy. Ten children were diagnosed with acute appendicitis while 7 had a normal appendix. RESULTS: Compared to the peripheral blood, the appendix contained a significantly higher percentage of CD19 cells (47.6% of total lymphocytes versus 15%, p<0.0001), and B1 cells (4.98% of total lymphocytes versus 2.42%, p=0.001). In addition, the intensity of CD19-staining was markedly decreased in the appendix (mean - 395.7), and also in the omentum (mean - 398.2) as compared to peripheral lymphocytes (mean - 497.7, p<0.0001 for both comparison). Comparison between the inflamed and the non-inflamed appendices revealed that the inflamed appendix contained a significantly higher proportion of B1 cells (5.64% of total lymphocytes versus 3.53%, p=0.032), and also a higher B1/b cell ratio (0.13 vs. 0.07, p=0.01). CONCLUSIONS: These results indicate that the appendix tissue contains higher number of B1 (and B) cells compared to the peripheral blood and that these cells play a role in the primary immune response to acute infection/inflammation in the appendix. Appendiceal B cell population is unique in term of CD19 intensity expression on their surface.

Choledochoduodenostomy for benign and malignant biliary tract diseases.

Although nonsurgical alternative treatments for primary or retained common bile duct stones--such as dissolution of gallstones with deoxycholic acids and, especially endoscopic papillotomy--have become available, choledochoduodenostomy (CDS) has been used with increasing frequency over the past decade, with extension of the indications for its use. We report our experience with side-to-side CDS in 116 patients with benign (65 patients) and malignant (46 patients) biliary diseases. Even though the mean age of our patients with benign disease--patients who underwent urgent operations because of obstructive jaundice (74%), liver damage (approximately 60%), and other biliary complications--was 66.8 years, the perioperative mortality was 3.07% and the long-term follow-up results were excellent with no biliary complications. In regard to the controversy about the use of CDS in malignant biliary obstructions, our experience shows that none of the 42 patients had any complication due to malignant invasion of the stoma, and only one patient had ascending cholangitis; the perioperative mortality in this group was 8.6%. In our opinion, CDS is a relatively safe, definitive procedure for treatment of benign and malignant biliary diseases, with good long-term results in high-risk, aged patients.

Acute appendicitis following abdominal trauma.

Acute appendicitis (AA) is generally considered to be a consequence of lumenal obstruction and inflammation of the appendix. At the beginning of the 20th century, trauma was considered to be one of the possible causes of AA but this relationship has not been examined much since then. Our experience with three cases of AA following blunt abdominal trauma led to an extensive review of the world literature on the subject. We believe that abdominal trauma might be causative of AA. The potential for this hazardous and easily missed diagnostic entity should be appreciated in cases of blunt abdominal trauma both for sound clinical decision making and for its potential medical and legal implications.

Appendiceal colic in children: a true clinical entity?

BACKGROUND: Unexplained recurrent abdominal pain is a frequent problem in the pediatric population. An organic cause is found in 10 percent of children. Recurrent abdominal pain is responsible for multiple hospital admissions and patient evaluations. In some children, partial luminal obstruction of the appendix without inflammation may be the cause of this pain, and is defined as "appendiceal colic." STUDY DESIGN: During a period of five years, we performed a prospective study among children admitted for right lower quadrant abdominal pain. Children operated on for suspected acute appendicitis were eliminated from the study. Among the remaining patients, those with recurrent pain were evaluated for appendiceal colic. Medical histories were obtained, and the patients underwent physical examinations, routine laboratory studies, stool cultures, abdominal roentgenograms, and sonography scans (including the pelvic region in girls). Precise radiologic evaluation of the appendix was performed by barium swallow in 22 children or by barium enema in four. The diagnosis of appendiceal colic was made if the following three criteria were met: a history of longer than one month with three or more recurrent attacks of right lower quadrant abdominal pain; localized tenderness in the right lower abdomen without signs of peritoneal irritation or inflammation; or radiologic findings at barium examination consisting of irregular filling of the appendix, nonfilling or partial filling of the appendix after 24 hours, or nonemptying of the appendix after 72 hours. Children thus diagnosed underwent elective appendectomy, which was performed only after an additional episode of abdominal pain. RESULTS: Twenty-six children (average age 11.4 years) were treated by appendectomy and of these, 23 (88.5 percent) experienced pain relief in the immediate postoperative period. The remaining three children had pain relief within four months after appendectomy. CONCLUSIONS: Appendiceal colic may be a true clinical entity. Children suffering from appendiceal colic may benefit from elective appendectomy.

Choledochoduodenostomy for benign biliary tract disease in the elderly.

Endoscopic sphincterotomy is an available nonoperative alternative treatment for recurrent or residual common bile duct stones. Nevertheless, immediate, intraoperative and definitive treatment is needed in patients with common duct stones and other pathologies that are prone to develop into such complications, which is important especially in aged high-risk patients during recurrent operations and nonoperative instrumental interventions. To evaluate the safety of choledochoduodenostomy in elderly patients, we reviewed our experience with 55 patients over the age of 70 years with benign biliary tract diseases. Even though the majority of patients (69%) had obstructive jaundice and were operated on urgently, there was one death (1.8%) due to cardiac failure, and nine (16.3%) early postoperative complications including subphrenic abscess, disruption of wound and pneumonia (one case of each), wound infection (three cases) and urinary tract infections (three cases). There were no complications related to the procedure itself. In a follow-up period of one to 12 years, neither cholangitis nor sump syndrome were documented.

Penetration of ciprofloxacin into human peritoneal tissue following a single oral dose of 750 milligrams.

The penetration of ciprofloxacin into the peritoneal tissue was studied in 10 patients after a single oral dose of 750 mg given 5.6 hours (mean) before elective laparotomy. The mean tissue level was 0.29 micrograms/ml (range, 0.082 to 0.96 micrograms/ml) while the mean concomitant serum level was 1.3 micrograms/g (range, 0.52 to 2.57 micrograms/g). The achieved concentrations are above the minimum inhibitory concentrations (MICs) of ciprofloxacin for most gram-negative bacteria commonly involved in intra-abdominal infections.

Unusual presentation of esophageal communicating duplication in a child.

Communicating esophageal duplication and true congenital esophageal diverticulum are entities rarely encountered during childhood. The authors report an unusual case of midesophageal communicating duplication with secondary upper esophageal obstruction.

Successful treatment of recalcitrant warts in pediatric patients with carbon dioxide laser.

AIM: Warts are difficult to treat and none of the several modes of treatment suggested for their cure has been proven to be the most effective. We evaluated the efficacy of a modification of the CO (2) laser technique for recalcitrant warts in pediatric patients. PATIENTS AND METHODS: During a period of 5 years, 40 consecutive pediatric patients (average age: 12.7 +/- 2.8 years) were treated by CO (2) laser for 54 recalcitrant warts. Previous treatments were caustic and/or surgical procedures (average 2.7 procedures). Local anesthesia or digital block was performed in all patients, with intravenous sedation in two patients. The laser was used at 5 W in super-pulse mode throughout the procedure. The skin was cut with the focused laser beam in a circular fashion, about 5 mm around the wart, until all the layers of the skin down to the subcutaneous tissue were penetrated. The lesion was drawn aside and excised, using the laser beam as a scalpel. No curettage was used. The base of the wart was then vaporized with the laser in a defocused fashion, until a clean surgical field was obtained. Follow-up was weekly up to 1 month, and at 3, 6, and 12 months. RESULTS: Warts were located on fingers (24 cases), in the plantar area (10 cases), on hands (9 cases), knees, and legs (4 cases each), arms (2 cases) and elbow (1 case). Twenty-seven patients (67.5 %) had a solitary wart and the other 13 children had multiple warts (up to 6) at one or more locations. Fingers were the most common location of multiple warts (10 cases). All patients underwent the procedure in one session. No case of intractable operative bleeding, local infection, or prolonged exudative drainage was encountered. One patient complained of severe transient postoperative pain. The healing time was 4 to 5 weeks. At 12 months, there was no recurrence of the warts. No significant or disabling scarring was noticed, but hypopigmentation was noted in 11 cases (27.5 %). CONCLUSION: This technique provides a high success rate with minimal side effects and is well tolerated by young patients.

General peritonitis induced by rectal examination: an unusual complication of primary psoas abscess.

Primary psoas abscess is a relatively rare disease with highest incidence in children and adolescents. It usually presents with fever, abdominal pain and limp. Limping tends to incriminate musculoskeletal problems below the pelvis, but movement of the hip involves the psoas muscle which is mostly retroperitoneal and intimately related to pelvic and intraperitoneal organs. Although the current tendency is to use abdominal sonography, rectal examination is still a valuable step in clinical examination, and may help to assess a pelvic mass or abscess. The following case report describes the elusive nature of psoas abscess and a rare occurrence of abscess rupture and peritonitis, immediately after rectal examination.

Familial intussusception: report of a case with recurrence in the youngest sibling and review of the literature.

The etiology of idiopathic intussusception is unknown. Occurrence of intussusception in more than one patient in a same family is rare. A familial predisposition is suspected. We present a family in which the two children suffered from intussusception with recurrence in the youngest sibling and review the literature.

Alkalinizing local anesthetic does not decrease pain during injection for dorsal penile nerve block.

STUDY OBJECTIVE: To evaluate whether alkalizing local anesthetic with sodium bicarbonate reduces pain related to infiltration of local anesthetic during dorsal penile nerve block for circumcision. DESIGN: Prospective, randomized, double-blind, controlled study. SETTING: E. Wolfson Medical Center, Holon, Israel. PATIENTS: 144 patients aged 15 to 54 years (mean +/- SD = 22.7 +/- 8.8 years), randomized before the block into four groups of 36 patients each. INTERVENTIONS: Group A (control) received a standard solution of 1 mg/kg lidocaine 2% mixed with 0.5 mg/kg bupivacaine 0.5% without epinephrine (pH = 6.3). Patients in Group B, Group C, and Group D received this mixture added with 8.4% sodium bicarbonate for a mean final pH of 6.90, 7.16, and 7.43, respectively. Penile block was performed using a 23-gauge needle by an anesthetist who was blinded to the pH of the solution. MEASUREMENTS AND MAIN RESULTS: Patients were questioned regarding pain suffered during injection of the anesthetic solutions by another physicians who also was blinded to the drug used. Pain was rated by a previously reported subjective pain scale. Mean pain scales were 2.0 +/- 0.17, 2.3 +/- 0.15, 2.2 +/- 0.16, and 1.94 +/- 0.15 for Groups A to D, respectively. The differences between these results were not statistically significant. CONCLUSION: Alkalinizing the acidic local anesthetic solution by sodium bicarbonate does not decrease pain related to infiltration during penile nerve block for circumcision.

Epididymitis in childhood: a clinical retrospective study over 5 years.

BACKGROUND: Acute scrotal pain in children presents a major diagnostic and therapeutic challenge. Epididymitis has been considered uncommon in childhood. The clinical spectrum and therapeutic policy of the acute scrotum in children is continually being reassessed. OBJECTIVES: To determine whether there has been an increase in the incidence of epididymitis in children and to advocate a more selective surgical approach to the acute scrotum. METHODS: We conducted a retrospective review of 65 children admitted to our department of pediatric surgery with the diagnosis of acute scrotum during a 5 year period. RESULTS: Of the 65 children admitted with the diagnosis of acute scrotum, epididymitis was diagnosed in 42 (64.6%). The remaining cases included torsion of the testis in 12 patients (18.5%), torsion of the appendix testis in 5 (7.7%), scrotal pain and minimal physical findings in 4 (6.1%), and scrotal hematoma and idiopathic scrotal edema in one patient each. Doppler ultrasound of the groin, color Doppler ultrasound of the testis and testicular nuclide scintigraphy (Tc-99m scan) examinations were performed on 49, 30 and 57 occasions, respectively; the Tc-99m scan was the most effective tool. All the patients with epididymitis were diagnosed before surgical intervention and were treated conservatively. CONCLUSIONS: We observed an increasing frequency of epididymitis in children admitted with the diagnosis of acute scrotum.

[The chorionic gonadotropin hormone: possible cause of seminoma?]. / L'hormone gonadotrophine chorionique: cause possible de séminome?

Two cases of seminoma that appeared in young males who had received high dosages of Chorionic Gonadotrophin Hormone (HCG) as treatment for secondary sterility are presented. The authors suggest that this treatment has an etiological or at least permissible role in the development of these tumors. Careful examination with testicular biopsy is recommended on all males receiving hormone treatment for oligospermia, and follow-up should continue after cessation of the treatment.

[Acute intestinal occlusion caused by phytobezoar in Israel. Role of oranges and persimmons]. / L'occlusion intestinale aiguë par phytobézoards en Israël. Rôle de l'orange et du persimmon.

Forty-one patients were operated upon for acute intestinal obstruction secondary to the presence of phytobezoars, 34 of these patients (83%) having a history of previous gastric surgery for ulcer. The etiologic factor in 44% of cases was oranges and in 56% persimmons (Kakis). Treatment was by enterotomy in 27 patients (65,85%) and by "milking" in 14 (34,15%). Postoperative mortality was 2,44% (1 case). Recurrence was noted in three cases (7,3%) including one with an ileocutaneous fistula, treatment being by enterotomy in 2 cases and "milking" in the third patient. First intention intestinal resection was never required. Five patients required several admissions for subacute obstruction treated conservatively. These findings suggest that gastric surgery predisposes to intestinal obstruction by phytobezoar. Careful exploration of the digestive tube and particularly the stomach should avoid postoperative relapse, while prevention depends on a dietary regimen avoiding excessive intake of foods rich in cellulose, particularly oranges and persimmon fruit.

Evaluation of a possible inflammatory response after appendectomy for non-perforated appendicitis in children.

BACKGROUND: The inflammatory process in the post-appendectomy period is not well characterized. In a pilot study, we prospectively followed the kinetics of different inflammatory mediators before and after appendectomy in children, and compared the results of the groups open appendectomy (OA) and laparoscopic appendectomy (LA). MATERIAL AND METHODS: Levels of sP-selectin, tPA, MCP-1, IL-6, IL-8, sVCAM-1, and sCD40L were measured before appendectomy and on the next three consecutive days in the serum of 25 children (16 males and 9 females) aged 7 - 16 years (mean 12.6+/-2.47 years) with non-perforated acute appendicitis. RESULTS: LA and OA were performed in 16 and 9 patients respectively. None of the markers of inflammation differed significantly by surgical approach at any point of observation. However, sP-selectin, MCP-1 and sVCAM-1 levels were found to have significantly different postoperative kinetics with a trend towards higher values in the laparoscopic group compared to the open appendectomy group (p=0.034, p=0.016 and p=0.025, respectively). CONCLUSIONS: The cytokines sP-selectin, MCP-1 and sVCAM-1 may play a role in the possible post-appendectomy cytokine activation after non-perforated appendicitis. Since this phenomenon is more evident after LA than after OA, the contribution of the different LA procedures has to be further investigated.

Artificial nodules of the penis. Report of six cases among Russian immigrants in Israel.

BACKGROUND: Artificial penile nodules are foreign bodies implanted under the skin of the penis to enhance sexual pleasure. It is frequently encountered in Asian countries, but rarely in western countries. Most of the subjects are soldiers, drug addicts, sailors, prisoners, or members of low economic groups. GOAL OF THE STUDY: Our experience and review of the literature are reported. STUDY DESIGN: During a circumcision program among Russian adult immigrants in Israel, such plastic nodules were encountered. RESULTS: The nodules were found in six men, for a prevalence of 0.64%. CONCLUSION: Physicians should be familiar with this practice in certain groups of men, and especially Asian men. This report suggests that it may be widespread elsewhere in the world.

Treatment of the toe tourniquet syndrome in infants.

INTRODUCTION: The "toe tourniquet syndrome" is the circumferential strangulation by human hair or fibers of one or more toes in infants, which may induce prolonged ischemic injury and tissue necrosis. Release of the strangulation is mandatory to avoid autoamputation of the digit. We recently encountered several incompletely treated cases and would like to emphasize the effective method of treatment. METHODS: A retrospective analysis of pediatric emergency department records of patients treated for "toe tourniquet syndrome" during 1990 to 2001 was performed. Patients undergo a short, longitudinal, deep incision over the area of strangulation on the dorsal aspect of the toe, until the phalanx bone, which allows the complete section of the constricting fibers to be removed without injury to the anatomical structures of the toe. RESULTS: Twenty-one infants (12 boys and nine girls), aged 0-11 months (average 4.6 months), were treated for tourniquet syndrome of one (15 infants) or two (six patients) toes. In 12 patients (57.1%) the right foot was involved. Eight patients (38.1%) had undergone an attempt in the previous few days to release constriction. No complications were encountered. CONCLUSION: The above-described technique is simple and safe and secures the complete release of the strangulation by removal of all hairs or fibers without injury to the anatomical structures of the toe.