Triplication of the Sigmoid: A Rare Incidental Finding in Association With an Anorectal Malformation During Colostomy Closure.

This case report presents a rare occurrence of triplication of the sigmoid, an unusual congenital anomaly, in a nine-month-old male with a known history of anorectal malformation. The patient, previously diagnosed with anal atresia and a rectourethral (prostatic) fistula, was admitted for the closure of his divided sigmoidostomy as the final step in correcting his anorectal malformation. Unexpectedly, during the release of the distal stoma, the presence of three distinct bowel lumens was discovered. To discern the native bowel, catheters were introduced into each lumen before proceeding with the excision of the triplicated sigmoid and subsequent stoma closure. This case underscores the complexity of diagnosing and managing unusual GI anomalies in the context of anorectal malformations, emphasizing the challenges encountered during surgical interventions.

HoLy-Net: Segmentation of histological images of diffuse large B-cell lymphoma.

Over the last years, there has been large progress in automated segmentation and classification methods in histological whole slide images (WSIs) stained with hematoxylin and eosin (H&E). Current state-of-the-art (SOTA) techniques are based on diverse datasets of H&E-stained WSIs of different types of predominantly solid cancer. However, there is a scarcity of methods and datasets enabling segmentation of tumors of the lymphatic system (lymphomas). Here, we propose a solution for segmentation of diffuse large B-cell lymphoma (DLBCL), the most common non-Hodgkin's lymphoma. Our method applies to both H&E-stained slides and to a broad range of markers stained with immunohistochemistry (IHC). While IHC staining is an important tool in cancer diagnosis and treatment decisions, there are few automated segmentation and classification methods for IHC-stained WSIs. To address the challenges of nuclei segmentation in H&E- and IHC-stained DLBCL images, we propose HoLy-Net - a HoVer-Net-based deep learning model for lymphoma segmentation. We train two different models, one for segmenting H&E- and one for IHC-stained images and compare the test results with the SOTA methods as well as with the original version of HoVer-Net. Subsequently, we segment patient WSIs and perform single cell-level analysis of different cell types to identify patient-specific tumor characteristics such as high level of immune infiltration. Our method outperforms general-purpose segmentation methods for H&E staining in lymphoma WSIs (with an F1 score of 0.899) and is also a unique automated method for IHC slide segmentation (with an F1 score of 0.913). With our solution, we provide a new dataset we denote LyNSeC (lymphoma nuclear segmentation and classification) containing 73,931 annotated cell nuclei from H&E and 87,316 from IHC slides. Our method and dataset open up new avenues for quantitative, large-scale studies of morphology and microenvironment of lymphomas overlooked by the current automated segmentation methods.

Bacterial profile and antibiotic selection for pediatric appendicitis: A retrospective cohort study.

Objective: The objective of this study was to identify the predominant bacteria cultured from the surface of removed appendices in pediatric patients with acute appendicitis and determine the appropriate choice of antibiotics for preoperative and postoperative management. Methods: A 2-year retrospective cohort study was conducted at Mediclinic Parkview Hospital, Dubai, UAE. Patients under 14 years of age with diagnosed acute appendicitis who underwent laparoscopic appendectomy were included. Swab cultures, along with demographic, laboratory, and pathology data, were analyzed. Results: Out of the 56 enrolled patients, 27 (48 %) exhibited bacterial growth on swab cultures, while 29 (52 %) showed no bacterial growth. Escherichia coli (E. coli) was the predominant isolated bacteria, present in 23/27 patients (85 %). Seven patients had co-infections involving E. coli and other bacteria, with Pseudomonas being the second most common bacteria identified in 7/27 patients (25 %). Antibiotic sensitivity testing indicated that 85 % of the isolated bacteria were sensitive to Gentamicin, 63 % to Amoxicillin/Clavulanic acid, 59 % to Trimethoprim + Sulfamethoxazole, and 27 % to Cefazolin. Conclusion: E. coli was the most prevalent bacteria identified on swabs taken from inflamed appendices in pediatric patients. Amoxicillin/Clavulanic acid was determined to be an appropriate choice for preoperative prophylaxis. This study provides valuable insights for guiding the management of pediatric appendicitis and facilitating the appropriate and judicious use of antibiotics.

Appendectomy as part of Ladd's procedure: a systematic review and survey analysis.

BACKGROUND: Ladd's Procedure has been the surgical intervention of choice in the management of congenital intestinal malrotation for the past century. Historically, the procedure included performing an appendectomy to prevent future misdiagnosis of appendicitis, since the location of the appendix will be shifted to the left side of the abdomen. This study consists of two parts. A review of the available literature on appendectomy as part of Ladd's procedure and then a survey sent to pediatric surgeons about their approach (to remove the appendix or not) while performing a Ladd's procedure and the clinical reasoning behind their approach. METHODS: The study consists of 2 parts: (1) a systematic review was performed to extract articles that fulfill the inclusion criteria; (2) a short online survey was designed and sent by email to 168 pediatric surgeons. The questions in the survey were centered on whether a surgeon performs an appendectomy as part of the Ladd's procedure or not, as well as their reasoning behind either choice. RESULTS: The literature search yielded five articles, the data from the available literature are inconsistent with performing appendectomy as part of Ladd's procedure. The challenge of leaving the appendix in place has been briefly described with minimal to no focus on the clinical reasoning. The survey demonstrated that 102 responses were received (60% response rate). Ninety pediatric surgeons stated performing an appendectomy as part of the procedure (88%). Only 12% of pediatric surgeons are not performing appendectomy during Ladd's procedure. CONCLUSION: It is difficult to implement a modification in a successful procedure like Ladd's procedure. The majority of pediatric surgeons perform an appendectomy as part of its original description. This study has identified gaps in the literature pertaining to analyze the outcomes of performing Ladd's procedure without an appendectomy which should be explored in future research.

Assessing clinical outcomes of modified laparoscopic gastrostomy in children: a case control study.

BACKGROUND: With gastrostomy becoming a common surgical procedure within the pediatric population surgeons continued to introduce modifications on the procedure to overcome some of the challenges and minimize complications. Modified U-stitches laparoscopic gastrostomy is gaining favor in some centers including the center of this study. Hence, this study was conducted to evaluate and compare its outcomes. METHODS: Eighty-nine gastrostomy procedures performed between 2013 and 2020 were reviewed to evaluate the surgical outcomes of a novel modified U-stitches laparoscopic gastrostomy (MLG) to the standard laparoscopic gastrostomy (LG) in children. The main outcome measured is the rate of postoperative complications encompassing dislodgement of gastrostomy button, leak around button, local infection, and development of granulation tissue post-surgery which is compared between the two population groups. RESULTS: The rate of leak around the button was found to be significantly less in the MLG (4%) compared to (15%) in the traditional LG approach with a p-value of 0.03. However, the overall complication rate for MGL is 63%; while it is 73% for LG. CONCLUSIONS: The modified U-stitches laparoscopic gastrostomy has a lower rate of complications in comparison to the standard laparoscopic gastrostomy making it a preferred technique for gastrostomy placement in children.

Perineal Groove: Is It More Common Than We Think? Clinical Characteristics of Four Cases and Review of Literature.

Background: Perineal groove is a very rare congenital malformation that usually occurs in females. It has been described as a wet, un-epithelialized mucus tissue extending from the posterior vaginal fourchette to the anterior anal opening. It is generally asymptomatic and self-limited. Due to its rarity, it is often unfamiliar to clinicians, often leading to a missed diagnosis or unnecessary interventions. Methods: During the period from September 2017 to September 2020, four patients (two newborns and 2 infants) were diagnosed with perineal grooves. They were referred to the pediatric surgery clinic because of abnormal findings during their genital examinations. During the same period of time, the clinic received 12 other new patients with various forms of anorectal malformations. Results: All four patients were girls. During examinations by their respective pediatricians, an abnormality in the perineum was noted in each of the patients. The depth of the grooves varied between the four patients and extended from the anus to the vaginal fourchette. None of the patients experienced any other symptoms related to the malformation. All the cases were referred to the pediatric surgeon by their pediatricians as a diagnosed anal fissure or abnormal finding in the genitalia. In all four patients, the mothers did not take folic acid during the pregnancy. The four patients were observed, and no surgery was needed; in three of the cases, there was a complete spontaneous resolution while the fourth patient still remains under observation. Conclusions: Perineal groove is a rare malformation with a low incidence rate. It is more common in female infants and usually self resolves before the age of 2 years. The condition is diagnosed on clinical examination; however, it is easily misdiagnosed and may lead to unnecessary interventions and surgery.

Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial.

OBJECTIVE: The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children. METHODS: A pilot randomized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children. Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were randomized either to treatment with antibiotics or to surgery. Follow-up was for 1 year. RESULTS: Fifty patients were enrolled; 26 were randomized to surgery and 24 to nonoperative treatment with antibiotics. All children in the surgery group had histopathologically confirmed acute appendicitis, and there were no significant complications in this group. Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis. Another 6 patients have had an appendectomy due to recurrent abdominal pain (n = 5) or parental wish (n = 1) during the follow-up period; none of these 6 patients had evidence of appendicitis on histopathological examination. CONCLUSIONS: Twenty-two of 24 patients (92%) treated with antibiotics had initial resolution of symptoms. Of these 22, only 1 patient (5%) had recurrence of acute appendicitis during follow-up. Overall, 62% of patients have not had an appendectomy during the follow-up period. This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted.

Use of Surgisis for abdominal wall reconstruction in children with abdominal wall defects.

AIM: Abdominal wall defects in children can present a challenge to the pediatric surgeon. Despite the development of new materials and modifications of surgical technique, no single approach has been established. The purpose of this study was to evaluate the authors experience using porcine small intestine submucosa for abdominal closure. PATIENTS AND METHODS: A retrospective review of all patients with abdominal wall defects who underwent reconstruction with Surgisis at the authors' institution from 2004 to 2011 was performed. Patient demographics, cause of defect, recurrence, rate of infection, and length of follow-up were reviewed. RESULTS: A total of 24 patients were identified as having Surgisis implanted for abdominal wall defects. The most common etiology of abdominal defect was omphalocele. All patients went on to heal wounds. Four patients developed postoperative seroma formation and another two had wound infection. Two recurrences in the form of incisional hernia were observed. Both resolved spontaneously without intervention during the follow-up. The median follow-up period was 5 years (range 2-9 y). No significant predictors of complications were identified. CONCLUSIONS: Surgisis is an effective adjunct in the repair of abdominal wall defects in children. Complication rates remain low. In addition, recurrence may disappear spontaneously as the patch absorbed and replaced by scar tissues. Further studies are warranted.

Histopathological examination of the prepuce after circumcision: Is it a waste of resources?

BACKGROUND: The aim of this article is to evaluate the histopathological findings of foreskin after circumcision for medical indications and to find out if analyzing the biopsy is a waste of resources. MATERIAL AND METHODS: This retrospective analysis was carried out of the medical records and histopathological findings of 112 boys who underwent circumcision from June 2002 to June 2005. The study group consisted of 52 boys that were circumcised for medical indications, while the control group consisted of 60 boys who underwent circumcision for religious belief. RESULTS: The mean (range) age of children in the study group was six (2-12) years. 36 boys had phimosis, 15 had recurrent balanoposthitis and one had paraphimosis as an indication for circumcision. Balanitis xerotica obliterans (BXO) was diagnosed in eight out of 52 biopsies (15%). In five of the eight BXO, the histopathological examination revealed focal lichenoid infiltrate which was considered as early form of BXO. There was no suspicion of BXO in the physical examination of those five patients. Chronic inflammation was reported in seven patients, while minor changes in the form of minimal inflammation and oedema were found in another 15 patients. The rest of the biopsies (22 patients) showed normal preputial pathology. The histopathological examinations of the control group revealed chronic inflammation in three patients and acute inflammation with cellular oedema in another three patients. CONCLUSIONS: There is a place for routine biopsy after circumcision for medical indications. The clinical examination failed to suspect 5 of the 8 cases of BXO that were diagnosed by histopathology.

Circumcision of preschool boys in Baghdad, Iraq: prevalence, current practice and complications.

Circumcision is probably one of the most ancient surgical operations and has been performed more than any other operation. The aim of this study is to assess the prevalence of circumcision in preschool boys and to present an overview of the current practices and complications in Baghdad, Iraq. A statistical survey was conducted at the Central Teaching Hospital for Children in Baghdad, Iraq during the period April 2003 to October 2004. The survey consisted of structured interviews with the accompanying parents while waiting for their children's routine appointments. A total of 4000 boys were included. 2443 (61%) were circumcised and the prevalence of circumcision increased from 18% at 6 months of age to reach 92% at 6 years. Only 180 (7.4%) boys had a medical reason while the rest were circumcised for religious reasons. Parents were the only determinant in deciding the time and place of religious circumcision. Circumcision was performed by a doctor in 732 (30%) boys, by a nurse in 1276 (52%) and by a traditional circumciser in 435 (18%). Post-operative complications were encountered in 209 (8.5%) boys. Circumcision is an important surgical procedure that should be performed by trained medical staff in medical institutions. Circumcision performed by medical professionals caused significantly less complications.

Novel mutations in the MNX1 gene in two families with Currarino syndrome and variable phenotype.

The Currarino syndrome (CS) consists of a sacral defect, an anorectal malformation and a pre-sacral mass. It manifests as an autosomal dominant congenital malformation in familial settings, with varying penetrance. The disease-causing gene, Motor neuron and pancreas homeobox-1 (MNX1), is known to be mutated in almost all familial cases, but due to the lack of genotype-phenotype correlation, there is a need for better clinical and molecular genetic characterization of the CS. Here, we report two novel mutations in the MNX1 gene in two cases. Each case was found to be familial upon further investigation of the other members of each family. The first affected case (a one year old boy) exhibited a missense mutation, p.Phe289Ser, in exon 3 in the highly conserved third helix of the homeodomain, which is considered to affect the DNA binding property and transcription regulation of the protein. The mutation seemed to display full penetrance of the disease in this family, but with different time of on-set. The second affected case (a 5 months old boy) displayed a 13 basepair insertion in exon 1, creating a complex frameshift mutation which results in a premature truncation of the protein that lacks the third helix homeodomain. Other members of the boy's family, who harbored the same mutation, were found to be completely asymptomatic. In conclusion, we detected two novel mutations in the MNX1 gene in cases with CS, which supports mutational analysis in the diagnosis of CS, even though the variability in the genotype and phenotype correlation maintains.

Transverse testicular ectopia: three additional cases and a review of the literature.

PURPOSE: Transverse testicular ectopia (TTE) is a well described, rare congenital abnormality of testicular descent, in which both testes migrate through one inguinal canal. The objective of this work was to present three cases of TTE, one of them with a common vas deferens. To our knowledge, a fused vas deferens has only been reported four times in previously published reports. METHODS: Three patients presented with inguinal hernia and contralateral cryptorchidism. In case 1, the diagnosis of TTE was made preoperatively by palpating two testes in one hemiscrotum. The diagnosis of case 2 was made intraoperatively and was found to be of a rare form in which the two vasa deferentia fused in the inguinal canal to form a common vas deferens. The diagnosis of case 3 was also done intraoperatively and a laparoscopy was performed to document the anatomy of TTE and to rule out the presence of Müllerian duct remnants. We also performed a literature search for other reports of TTE. RESULTS: The three cases were operated with trans-septal orchidopexy. In addition, laparoscopy was performed in case 3 to clarify the anatomy. Biopsy revealed normal testicular tissue from both testes in the first two patients. Follow-up with ultrasound, 6 months after operation showed normal size and blood flow of both testes. CONCLUSION: Transverse testicular ectopia should be suspected in a boy with an inguinal hernia and contralateral non palpable testis. Trans-septal orchidopexy is recommended when vasa deferentia are fused. Laparoscopy is useful to document the anatomy and to rule out the presence of Müllerian remnants.

Decision making in the management of hydroceles in infants and children.

UNLABELLED: The aim of this article was to establish a ground for evidence-based decision making in dealing with hydroceles, according to the age of the child and the presenting signs and symptoms. This prospective cohort study was conducted at Al-Kademyia Teaching Hospital in Baghdad, Iraq, during the period from December 2001 to December 2005. There were two groups of patients: group 1 involved 121 patients that presented with hydroceles at less than 1 year of age that were followed up to their first birthday to monitor the fate of hydroceles. Group 2 involved 140 patients, 1-12 years of age, who presented with hydroceles and had surgery. Their age, the affected side, diurnal changes in size, and the findings at surgery were recorded. In group 1, 89% of patients with hydroceles had spontaneous resolution or showed marked improvement during the first year of life and only 11% required an operation. The indications for surgery were the presence of an associated inguinal hernia (7%) and development of a huge hydrocele (3%). In group 2, 83% of patients with hydroceles presented within the first 5 years of age. Diurnal changes in the size of hydroceles were encountered in 92% of cases. CONCLUSION: 89% of patients with infantile hydrocele will have a spontaneous resolution owing to the ongoing changes in the patent processus vaginalis. Surgical intervention in the first year of life is only required for those who have an associated inguinal hernia and for those with hydroceles that become huge in size.

Bowel injuries caused by ingestion of multiple magnets in children: a growing hazard.

PURPOSE: There are no definite guidelines on the management of ingested magnetic objects in children. The aim of this study was to present our experience and to highlight the importance of strict follow-up. METHODS: Within 6 months period, four children presented to the emergency department after ingestion of multiple magnets. We reviewed retrospectively the patients' documents, radiological reports, operative findings and outcome. We also performed a literature search for all reports of multiple magnets ingestion on MEDLINE and EMBASE. RESULTS: Daily abdominal radiographs to monitor migration of magnetic objects together with clinical examination revealed early detection of perforations in two patients. Explorative laparoscopy and suturing of perforations resulted in a rapid recovery and good cosmetic appearance. Literature search resulted in 44 published articles with a total of 52 cases of multiple magnet ingestion in children. CONCLUSIONS: This report stresses the need for prompt follow-up and early detection of complications in order to operate those patients without delay. Laparoscopy is the method of choice in exploring the abdomen when perforation is suspected.