Esophageal atresia type III? Intraoperative surprise and different approaches.

A newborn was referred due to clinical and radiological suspicion of esophageal atresia (EA) type III. Surgery revealed an esophagus without evident interruptions; however, intraoperative advancement of the nasogastric tube was unsuccessful, and the distal esophagus inflated with each ventilation, indicating the presence of a distal fistula. An intraoperative esophago-tracheobronchoscopy showed a proximal esophageal pouch with a tiny tracheoesophageal fistula and a large distal tracheoesophageal fistula. The esophageal ends were blind but overlapping, with no external discontinuity observed. With the diagnosis of Krediet type IIIc2 esophageal atresia, we performed a meticulous esophago-tracheal dissection, distal fistula closure, and end-to-end anastomosis. Due to hemodynamic instability, the proximal fistula was closed two weeks later via cervicotomy without incidents.

Utility of the derived neutrophil-to-lymphocyte ratio as a predictor of complicated appendicitis in pediatrics.

Between 16-40% of patients present with complicated appendicitis at the time of diagnosis, making early suspicion of appendicular perforation key for initiating timely treatment and reducing morbidity and mortality. This study evaluates the accuracy of the derived neutrophil-to-lymphocyte ratio (dNLR) as a predictor of complicated appendicitis. A diagnostic study was conducted, including patients aged 0-15 years who underwent appendectomy at a pediatric hospital between 2021-2022 (Reg. 2023/390894).

Clinical-pathological correlation of endoscopic findings in eosinophilic esophagitis in the pediatric population.

Eosinophilic esophagitis (EoE) is an immunologic disorder of the esophagus with an increasing incidence in our region of 8.1 cases per 100,000 inhabitants per year. It is characterized by dysphagia, and its diagnosis requires esophagoscopy with biopsies for histopathological analysis, which macroscopically reveals certain characteristic endoscopic findings, though their diagnostic utility remains uncertain. The correlation between these endoscopic findings and the histopathological diagnosis of EoE continues to be a subject of controversy in the pediatric population. This study evaluates the clinical-pathological association of different endoscopic abnormalities in EoE. We conducted an analytical study of patients under 15 years old who underwent esophagoscopy due to highly suspicious symptoms of EoE at a pediatric hospital between 2015 and 2022.

Correlation of endoscopic findings with histological alterations in pediatric ulcerative colitis.

Ulcerative colitis (UC) is a chronic and relapsing inflammatory bowel disease (IBD) characterized by abdominal pain and bloody diarrhea. Its diagnosis requires endoscopy and biopsies for histopathological analysis, revealing characteristic endoscopic findings. Currently, the correlation between these endoscopic abnormalities and the histopathological diagnosis of UC remains a controversial topic in pediatrics. This study evaluates the clinicopathological association of various endoscopic alterations in UC. We conducted an analytical study of patients under 15 years old who underwent upper and lower gastrointestinal endoscopy for suspected IBD at a pediatric hospital between 2015 and 2022.

The "rule of two" in Meckel's diverticulum - Does it truly apply to the pediatric population in our area?

Meckel's Diverticulum (MD) originates from the incomplete obliteration of the omphalomesenteric duct during the seventh week of gestation. The classic clinical description of MD follows the "rule of two: 2% of the population, 2 inches in length, 2 feet from the ileocecal valve, a 2:1 ratio between males and females, and presentation at two years of age. This study evaluates to what extent the "rule of two" applies to a Spanish pediatric cohort.

Association of endoscopic findings and histological alterations in pediatric Crohn's disease.

Crohn's disease (CD) is a type of inflammatory bowel disease (IBD) characterized by chronic, transmural, and relapsing inflammation that can affect any segment of the gastrointestinal tract, from the oral cavity to the anus (1). The clinicopathological association of various endoscopic abnormalities in CD is under study. An analytical study was conducted on patients under the age of 15 who underwent esophagoscopy and/or colonoscopy for suspected IBD at a pediatric hospital between 2015 and 2022 (Reg. No. 3318-0000206). Subjects with normal histopathological findings and those with a histological diagnosis of CD were included. The prevalence of different endoscopic alterations and their association with histopathological abnormalities were compared between patients with Crohn's disease (CD) and those with normal histology (NCD). Of the 502 endoscopies performed during this period, 22 subjects with CD and 14 children with NCD were included. Endoscopic normality, defined as the absence of mucosal abnormalities, was higher among NCD patients (43%), while the most prevalent macroscopic abnormality in CD patients was the presence of ulcers.

Role of cellular indices in predicting post-appendectomy abscess in children.

Up to 20% of advanced appendicitis cases can be complicated by postoperative abscesses, adding morbidity and mortality and prolonging hospital stays. This study examines the utility of two cellular indices as predictors of post-appendectomy abscess compared to cell counts. A diagnostic study was conducted on patients <15 years old who underwent appendectomy at a pediatric hospital between 2021 and 2022 (Reg. 2023/390894). Preoperative values of leukocytes, neutrophils, neutrophil-to-lymphocyte ratio (NLR= neutrophils/lymphocytes), and platelet-to-lymphocyte ratio (PLR= platelets/lymphocytes) were compared between patients with post-appendectomy abdominal abscess (PAA) and those without this complication (NPAA). The area under the ROC curve (AUC) was used to establish the predictive capacity of each parameter for PAA. A total of 89 patients with PAA and 93 NPAA children were included.

Derived neutrophil-to-lymphocyte ratio (dNLR) as a diagnostic biomarker of pediatric acute appendicitis.

Appendicitis stands as the most common surgical emergency in pediatric populations. Despite the existence of numerous diagnostic biomarkers, their utility is constrained by limitations in cost-effectiveness, potentially leading to therapeutic delays. This research aims to determine the diagnostic accuracy of the derived neutrophil-to-lymphocyte ratio (dNLR) in appendicitis. Although its role in this context has been recently described, this is the first study to compare its performance against acute-phase reactants routinely employed in clinical practice. Following approval from the Research Committee (2023/390894), a diagnostic study was conducted including patients under 15 years old undergoing surgery for acute appendicitis (AA) and those presenting with non-surgical abdominal pain (AP).

Transumbilical laparoscopic-assisted appendectomy in children: is it worth it?

INTRODUCTION: Transumbilical laparoscopic-assisted appendectomy (TULAA) is the technique of choice for all types of appendicitis in our Department. It combines the advantages of laparoscopy (global vision and minimally invasion) and open surgery (lower cost). The objective was to assess the results of our TULAA series and compare them to the results of standard laparoscopic appendectomies (SLA) performed during the same period. METHODS: Retrospective review of total appendectomies performed since TULAA introduction (September 2003 to December 2015) with statistic analysis of the results. RESULTS: A total of 1309 patients underwent TULAA approach, but 126 (9.6%) needed reconversion to open appendectomy, 1 (0.08%) to SLA, and 9 (0.7%) introduction of a second port. Mean age and weight of patients was 121.5 ± 36 months and 37.6 ± 14 kg, respectively. Mean operative time was 40.9 ± 15.5 min, ranging from 11 to 110. All types of appendicitis were present, with 394 being complicated (29.9%). Postoperative complications were seen in 168 patients (14.3%), 37 being readmitted (3.2%), and only five needing reintervention (Two intestinal occlusions and three abscess debridement). When comparing TULAA and SLA, there were no significant differences in the length of hospitalization, time to tolerate soft diet, analgesic requirements, and complications depending on the type of appendicitis, but TULAA was significantly faster and cheaper (average 900€). CONCLUSIONS: In our hands, TULAA has shown to be effective, easy to learn, and fast to perform. Low surgical cost is probably its principal advantage, which might be encouraging in times of crisis.

[Placement of pH-monitoring probes using height-related formulas. Is it an applicable method to adults?]. / Colocación de sondas de pHmetría mediante fórmula relacionada con la talla. ¿Es un método aplicable a los adultos?

INTRODUCTION: Oesophageal pH-monitoring allows the quantification of gastric reflux episodes in patients with gastroesophageal reflux disease (GERD). The accuracy of the test depends on correct positioning of the pH sensor 5 cm above the lower oesophageal sphincter (LES). The most precise manner to locate the LES is through prior determination by oesophageal manometry. However, because this technique is uncomfortable, mathematical formulas tend to be used in children. OBJECTIVES: To evaluate the applicability of paediatric formulas to estimate oesophageal length in adults and their effect on diagnostic accuracy. MATERIAL AND METHODS: A prospective study was carried out in adult patients, in whom the distance between the nasal orifice and the LES was determined by manometry and was compared with the estimated height-related distance calculated by four paediatric formulas (numbered 1 to 4). We also evaluated the relationship between the position of the probe and the percentage of reflux detected in our series of impedance measurements. RESULTS: Formula 1 (9.31 + height in cm × 0.197) was the most accurate (comparison of means -0.38 with 95%CI -0.70/-0.06, P = .019). With this formula, none of the patients had estimation errors of ± 6 cm. With formulas 2, 3 and 4, the percentage of error was 4.4%, 1.5% and 32.0%, respectively. CONCLUSION: Oesophageal length estimation in adults by using formula 1 is acceptable and can be used in adult patients who refuse to undergo prior manometry.

Superior Vesical Fissure as an Incomplete Form of Bladder Exstrophy: A Case Report with Clinico-Pathological Correlation and a Comprehensive Literature Review.

Multiple variants of classic bladder exstrophy have been described, all of them infrequent. Superior vesical fissure is a mild variant of this pathology in which genital involvement is scarce or absent. To date, there are only isolated reports of this entity. We report a full-term female patient of Arabian descent with a clinical and radiological diagnosis of superior vesical fissure that was surgically corrected in our center with a favorable evolution. Histological study, supported by immunohistochemical techniques, showed squamous and transitional epithelium and discrete chronic inflammation. Our literature review identified 26 reports of superior vesical fissure (including ours), with high heterogeneity in terms of clinical characterization and associated malformations and with only two histological reports. The clinical evolution of the patients reported in the literature was favorable, with lower morbidity and mortality than in classical forms of bladder exstrophy.

Antibiotic treatment of post-appendectomy abscesses in children, regardless of size: a twelve years' experience.

Intra-abdominal abscesses are a common issue after appendectomy. Antibiotics have shown efficacy in treating smaller abscesses, while larger ones have traditionally been treated with drainage. This study assesses the efficacy of antibiotics for post-appendectomy intra-abdominal abscess (PAA) in children regardless of size. Case-control study of children with PAA admitted at our hospital from 2010 to 2022. The efficacy of antibiotics was compared between abscesses less and more than 6 cm in diameter. The Institutional Review Board has approved this study. A total of 1766 appendectomies were performed from 2010 to 2022 with an incidence of PAA of 5% (n = 89): age 9.3 IQR 5.8, 63% male (n = 56). Sixty-seven patients presented with a ≤ 6 cm abscess (controls) and 22 children had a > 6 cm PAA (cases). Length of intravenous antibiotics were higher in cases (15 IQR 7 days) than controls (12 IQR 4 days), p = 0.003. The efficacy of antibiotics in controls was 97% whereas 86.4% in cases (p = 0.094), reoperation was needed in 2/67 controls and 3/22 cases, with no differences in complications or readmission. The length of stay was longer in cases (15 IQR 6 days) than controls (13 IQR 5 days), p = 0.042. Antibiotics seem a safe treatment for PAA in children regardless of the size. However, this approach is associated with a longer period of intravenous antibiotics and hospital stay, although not with a higher rate of therapeutic failure, complications or reoperations.

Rescue by pneumoenema under general anaesthesia of apparently non-reducible intestinal intussusception.

UNLABELLED: When an enema in the radiology unit is unsuccessful in treating intussusception, patients must undergo surgery. A further attempt at reduction under general anaesthesia in the operating room prior to laparotomy could avoid surgical intervention. A prospective study was carried out from 2002 to 2010 on paediatric patients with intestinal intussusception who underwent a deinvagination procedure in radiology with no anaesthesia. Unresolved cases were included in either group 3a (direct surgery) or group 3b (pneumoenema under general anaesthesia in the operating room), depending if the paediatric surgeon on duty wanted or not to participate in the study. Ninety-eight patients were included in the study. Six patients (group 1) were immediately operated after diagnosis because peritonitis was clinically suspected. Sixty-seven patients were successfully treated with an anaesthesia-free procedure in the radiology department (group 2). Of the 25 cases with initial treatment failure (group 3), 11 were assigned to group 3a (immediate laparotomy) and 14 to group 3b (pneumoenema with general anaesthesia). All patients in the 3b group were successfully treated by this procedure. There were no differences between the groups in terms of age, sex or evolution time. The average length of hospital stay and the number of repeated hospitalizations were significantly higher for group 3a. CONCLUSION: We consider that general anaesthesia increases effective reduction pressures and could avoid many surgeries in apparently non-reducible intestinal intussusceptions.

[Urachal remnant and acute abdomen: when it's not what it seems].

Among the causes of acute surgical abdomen, infection of a urachal remnant may go unnoticed despite routine complementary studies. We present three cases in boys aged 11, 6, and 4 years who were brought to the emergency department for right iliac fossa pain, fever, and urinary symptoms. Examination and complementary tests results were compatible with acute complicated appendicitis and were sent to surgery. While in the operating room, appendicitis was excluded and inflammatory changes suggestive of infection of the urachal remnant were documented. Complications of urachal remnants should be considered in the differential diagnosis of acute surgical abdomen, since advanced infection of the urachus may be a cause of confusion. A more accurate presumptive diagnosis can change the therapeutic/surgical approach and follow-up.

Unusual radiological finding in foreign bodies ingestion: three esophageal coins.

Case description: A 5-year-old girl presented to the emergency department with a history of foreign body ingestion. A cervico-thoracoabdominal radiograph demonstrate a foreign body in the esophagus, which seemed to show a double rim sign suspecting a button battery. After an emetic episode and expelling a coin, the child became asymptomatic. Close inspection of the X-ray demonstrated that the image was formed by superimposition of 3 circumferential objects of different sizes. Another X-ray observed the persistence of two superimposed objects. Clinical findings: The girl presented with sialorrhea, odynophagia, and nausea. Vital signs and physical examination were normal. There was no significant medical history. Treatment and Outcome: With the suspicion of multiple impacted esophageal objects, the patient was then taken to the operating room. During the flexible esophagoscopy 2 coins were found in the esophagus, both were removed without difficulty. The patient had an uneventful postoperative recovery and there have been no long-term complications. Clinical relevance: Unusual radiographic findings regarding esophageal foreign bodies have been reported, however, we describe the first case of a child with 3 coins impacted in the esophagus and a new radiological finding in foreign bodies ingestions that allow to avoid misdiagnosis and improve outcomes.

Descripción del caso: Una niña de 5 años es llevada a urgencias tras la ingesta de un cuerpo extraño. La radiografía cérvico-toraco-abdominal evidenció un cuerpo extraño esofágico con signo de doble halo, lo que hizo sospechar una pila de botón. Tras un vómito con expulsión de una moneda los síntomas desaparecieron. Una inspección minuciosa de la radiografía demostró que la imagen estaba formada por la superposición de 3 objetos circunferenciales de diferentes tamaños. Una nueva radiografía mostró persistencia de dos objetos superpuestos. Hallazgos clínicos: La niña refería odinofagia, náuseas y tenía sialorrea. Los signos vitales y el examen físico eran normales. No tenía antecedentes médicos relevantes. Tratamiento y desenlace: Con la sospecha de impactación esofágica múltiple, la paciente fue llevada al quirófano. Durante la esofagoscopia se encontraron 2 monedas en el esófago que fueron extraídas sin dificultad. La evolución postoperatoria fue favorable y no hubo complicaciones a largo plazo. Relevancia clínica: Aunque se han reportado hallazgos radiográficos inusuales en cuerpos extraños esofágicos, describimos el primer caso de un niño con 3 monedas impactadas en el esófago y un nuevo hallazgo radiológico en la ingesta de cuerpos extraños que permite evitar diagnósticos erróneos y mejorar los desenlaces.

Ankyloblepharon filiforme adnatum: presentation of a case.

Ankyloblepharon filiforme adnatum is a rare malformation, which may appear either in isolation, or with associated findings. We report a case of ankyloblepharon filiforme adnatum without associated anomalies, and discuss the management, and need for careful examination to exclude other anomalies.

Intravesical Oxybutynin for Urgent Bladder Rescue in a Newborn with Posterior Urethral Valves.

Posterior urethral valves are the most common cause of bladder outlet obstruction in male newborns. Initial catheter drainage alleviates the urethral obstruction before definitive management by valve ablation. Newborns with posterior urethral valves often present with hypercontractile bladders that may inhibit upper tract drainage despite bladder catheterization. Anticholinergic agents are commonly used to treat detrusor hyperactivity, with oxybutynin being the most commonly used. We report the first case of a newborn with posterior urethral valves and ureterovesical junction obstruction caused by detrusor hypertrophy who underwent urgent intravesical instillation of oxybutynin at high doses in an attempt to avoid a diversion procedure.