Reasons for Delayed Diagnosis of Pediatric Acute Appendicitis during the COVID-19 Era: A Narrative Review.

Global pandemics cause health system disruptions. The inadvertent disruption in surgical emergency care during the Coronavirus Disease 2019 (COVID-19) pandemic has been the topic of several published studies. Our aim was to summarize the reasons that led to the delayed diagnosis of pediatric appendicitis during the COVID-19 era. This systematic literature search evaluated studies containing pediatric appendicitis patient data regarding outcomes, times to hospital admission or times from symptom onset to emergency department visit. Studies elucidating reasons for delays in the management of pediatric appendicitis were also reviewed. Ultimately, 42 studies were included. Several reasons for delayed diagnosis are analyzed such as changes to public health measures, fear of exposure to COVID-19, increased use of telemedicine, COVID-19 infection with concurrent acute appendicitis, recurrence of appendicitis after non-operative management and increased time to intraoperative diagnosis. Time to hospital admission in conjunction with patient outcomes was extracted and analyzed as an indicative measure of delayed management. Delayed diagnosis of acute appendicitis has been documented in many studies with various effects on outcomes. Suspicion of pediatric acute appendicitis must always lead to prompt medical examination, regardless of pandemic status. Telemedicine can be valuable if properly applied. Data from this era can guide future health system policies.

The Impact of Obesity on Perioperative Outcomes for Children Undergoing Appendectomy for Acute Appendicitis: A Systematic Review.

Today, the prevalence of obesity in the pediatric population has increased dramatically. Acute appendicitis (AA) is the most common surgical condition among pediatric patients. We aimed to investigate the impact of obesity on postoperative outcomes in terms of operative time (OT), length of stay (LOS), surgical site infection (SSI), overall complications, adverse events, and mortality in children undergoing appendectomy for acute appendicitis. An extensive search of the literature in PubMed and Google Scholar was conducted to evaluate the outcomes of normal weight (NW), overweight (OW), and obese (OB) children who underwent appendectomy. Although no statistically significant differences were noted in perioperative outcomes and overall postoperative complications between OW/OB and NW children in the majority of the included studies, prolonged OT and LOS and SSI were found in some studies. Moreover, no differences in terms of readmissions and ED visits were recorded. We conclude that the impact of obesity on postoperative outcomes for children undergoing appendectomy for AA is unclear, and, therefore, no safe conclusions can be drawn with the currently available data. Due to the lack of high-quality studies, further research is required to optimize the surgical approach and prevent unwarranted complications.

Ileal bypass for pruritus relief in a 3-year-old boy with advanced progressive familial intrahepatic cholestasis: how effective is it?

Progressive familial intrahepatic cholestasis (PFIC) is a group of liver disorders that manifest in early childhood with cholestasis and pruritus resulting progressively in liver failure. We present a case of a 3-year-old boy with advanced PFIC from refractory pruritus. In order to offer an effective treatment of pruritus, our patient underwent ileal bypass and after a 2-month period free of symptoms, unexpectedly relapsed after a Rota viral infection. Finally, the child underwent orthotopic liver transplantation. Patients with advanced PFIC do not seem to benefit from nontransplant invasive interventions regarding the relief of pruritus.

Severe acute respiratory syndrome coronavirus 2 pandemic related morbidity and mortality in patients with pediatric surgical diseases: A concerning challenge.

The global spread of the novel severe acute respiratory syndrome coronavirus 2 has had serious consequences in terms of patient morbidity and mortality and overburdened health care systems as well as the socioeconomic implications. In the absence of effective therapies and vaccinations during the viral outbreak, the major and most concise means to control viral spread is spread prevention. Although information concerning the impact of severe acute respiratory syndrome coronavirus 2 on pediatric surgical patients has greatly expanded, relevant comprehensive studies are scarce. However, pandemic related morbidity has increased, while under normal circumstances mortality could have been minimized.

A Review of History and Challenges of Evidence-Based Pediatric Surgery.

PURPOSE: Evidence-based pediatric surgery (EBPS) refers to the use of the best available evidence in making personalized decisions concerning the management of each pediatric surgical patient. This study aims to provide a comprehensive review on past and present evidence-based clinical decision, and challenges in pediatric surgery. MATERIAL AND METHODS: A literature search was conducted according to a set of criteria in PubMed for historical and current peer-reviewed studies regarding EBPS. RESULTS: One hundred forty-five full-text published articles focusing on EPBS findings over the past 25 years were included. The rarity of many congenital anomalies, the inability to establish multicenter collaborations, the failure to perform double-blinded studies in children, the pediatric surgeons' reluctance to perform ethically unacceptable sham operations and their skepticism shown in accepting and implementing the documented results instead of applying their personal clinical practice methods and surgical techniques are among problems that hamper the accomplishment of randomized controlled trials (RCTs). CONCLUSIONS: RCTs remain limited in clinical pediatric surgery practice due to problems in the design and publication of these trials. Moreover, skepticism exists regarding acceptance and implementation of the documented results of RCTs. Notwithstanding, pediatric surgeons must establish evidence-based centers in order to increase the number of well-designed RCTs, properly evaluate clinical research, make effective evidence-based clinical decisions and develop high-quality of pediatric surgeries care in the future.

Safety assessment of open appendectomies for complicated acute appendicitis in children: a comparison of trainees and specialists.

PURPOSE: The aim of this study was to compare the outcome of children with complicated acute appendicitis (CAA) who underwent open appendectomy (OA) performed either by trainees under the direct supervision of an SPS, or an SPS. METHODS: Two hundred thirty eight patients with CAA were reviewed operated on either by a junior trainee (JT) or a senior trainee (ST) under the direct supervision of an SPS or by an SPS. The outcome measures were the overall rate of complications, operative time (OT), length of hospital stay (LHS) and 30-day readmission rate. RESULTS: No statistical differences were observed between the three groups regarding the overall complication rates and 30-day readmission rate. Although, no statistical differences were observed in the mean OT between the three groups, the mean OT for perforated appendicitis (PA) performed by JTs was significantly longer than when performed by SPSs (p 0.012). Furthermore, there was a statistically significant difference between JTs and SPSs in terms of LHS for patients with PA (p 0.028). CONCLUSION: This study suggests that no statistical differences were observed between the supervised trainees and SPSs regarding the overall complication rate and 30-readmission rate when they performed OA for GA or PA except of a longer OT and LHS for PA performed by JTs.

Management of complicated acute appendicitis in children: Still an existing controversy.

Complicated acute appendicitis (CAA) is a serious condition and carries significant morbidity in children. A strict diagnosis is challenging, as there are many lesions that mimic CAA. The management of CAA is still controversial. There are two options for treatment: Immediate operative management and non-operative management with antibiotics and/or drainage of any abscess or phlegmon. Each method of treatment has advantages and disadvantages. Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events. In many cases, non-operative management with or without drainage and interval appendectomy is advised. The reasons for this approach include new medications and policies for the use of antibiotic therapy. Furthermore, advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries. However, questions have been raised about the risk of recurrence, prolonged use of antibiotics, lengthened hospital stay and delay in returning to daily activities. Moreover, the need for interval appendectomy is currently under debate because of the low risk of recurrence. Due to the paucity of high-quality studies, more randomized controlled trials to determine the precise management strategy are needed. This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.

The Effect of TISSEEL® on Colorectal Anastomosis Healing Process in a Diabetic Animal Experimental Model.

BACKGROUND/AIM: Diabetes mellitus is an established risk factor of colorectal anastomosis failure. The purpose of the present study was to evaluate the effect of TISSEEL® in anastomotic healing. MATERIALS AND METHODS: Forty male, Sprague-Dawley rats were used. Diabetes was induced in half of them by intraperitoneal injection of Streptozotocin, 60 mg/kg. One week after the injection, animals were operated and a 1 cm segment was removed and an end-to-end hand sewn anastomosis was performed. TISSEEL® was applied in each group (diabetic, non-diabetic) following randomization. RESULTS: The pathology analysis revealed improved tissue remodeling in the TISSEEL® group, both for the normoglycemic and the diabetic group. Specifically, the extent of inflammation was decreased (p<0.001), whereas fibroblast and collagen formation were improved (p=0.040 and p=0.008). Neovascularization was also improved (p=0.047). CONCLUSION: Application of TISSEEL® on colorectal anastomoses improves healing in rats that suffer from severe hyperglycemia.

Infantile hepatic hemangioma: current state of the art, controversies, and perspectives.

Infantile hepatic hemangioma (IHH) is a common vascular tumor, distinctive for its perinatal presentation, rapid growth during the first year of life, and subsequent involution. Although they generally follow a benign course, some tumors have been reported to undergo malignant transformation. The diagnosis of IHH is based on patient's medical history, physical examination, and imaging. Moreover, the management of this vascular tumor is based on clinical presentation and includes observational, medical, surgical, and radiological interventional treatment options. The present review presents the currently available data in the literature on the diverse aspects of the terminology, epidemiology, clinical presentation, pathogenesis, diagnosis, indications for surgery, malignant potential, and long-term outcomes of these tumors.Conclusion: No formal guidelines have yet been established for the treatment of these hepatic lesions, and the therapeutic strategies implemented vary widely from simple observation to medical, radiological, and surgical interventions in the prism of multidisciplinary teams.What is Known:• Infantile hepatic hemangioma is the most common benign tumor of the liver in infancy, but despite its benign nature, it can present with life-threatening complications.• The treatment strategies range from simple observation to a series of medical, surgical, and radiological interventions.What is New:• This review gives an overview of the developments and current status about the management of IHH.• The aim of this study is to clear up the confusion and controversy that exists about terminology, diagnosis, and treatment of IHH.

Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis.

PURPOSE: This study carried out a meta-analysis to compare immediate surgery (IS) with conservative treatment (CT) of complicated acute appendicitis (CAA) in children. METHODS: Systematic literature research was performed for relevant studies published from 1969 to date. Trials of IS compared with CT were included. Outcomes of interest were postoperative morbidity and length of hospital stay (LOS). RESULTS: Fifteen trials were studied (1.243 patients). CT achieved better rates of any complication type (odds ratio [OR] 0.22, [95% confidence interval (CI): 0.14, 0.38], p = 0.001) and wound infection (OR: 0.40 [95% CI: 0.17, 0.96], p = 0.041). Neither intraabdominal abscess (OR: 1.03 [95% CI: 0.31, 3.37], p = 0.958) nor postoperative ileus (OR: 0.29 [95% CI: 0.06, 1.44], p = 0.130) was affected by the treatment option. The polled difference in LOS showed a trend for shorter LOS in the IS group (standard mean difference [SMD]: 0.25 [95% CI: 0.07, -0.43], p = 0.007). CONCLUSIONS: IS was associated with shorter LOS, while overall complication rates and wound infection declined significantly with CT. The development of intraabdominal abscess and postoperative ileus was not affected by the treatment of choice. The heterogeneity of most studies depicts the need for randomized controlled trials (RCTs) to discover safe management of CAA in children. LEVEL OF EVIDENCE: III: Type of study: Meta-analysis.

Healing after Resection of Colonic Endometriosis and Growth Factor-enriched Agents: An Experimental Rat Model.

STUDY OBJECTIVE: To examine the potential beneficial effect of platelet-rich plasma (PRP) and fibrin sealant (TISSEEL; Baxter Healthcare Corporation, Deerfield, IL) on bowel wound healing after shaving of an experimentally induced endometriotic lesion. DESIGN: A single-blind, randomized study (Canadian Task Force classification I). SETTING: A certified animal research facility. ANIMALS: Thirty female Sprague-Dawley rats. INTERVENTIONS: Experimental colonic endometriosis was induced by transplanting endometrial tissue to all animals (first surgery). Thirty rats were then randomized to 1 of 3 groups according to treatment; PRP (group 1, n = 10), fibrin sealant (group 2, n = 10), or no agent (group 3, n = 10) was applied after shaving of the endometriotic nodule (second surgery). MEASUREMENTS AND MAIN RESULTS: Colonic endometriosis was successfully induced in all subjects. Four days after the second surgery, the animals were euthanized, and microscopic evaluation was performed. The pathologist was blinded to the treatment method. Histopathologic analysis revealed that compared with the control group, collagen disposition was found in a significantly higher expression in both the PRP and fibrin sealant groups (p = .011 and p = .011, respectively). Distortion of the integrity of the colon layers was statistically more pronounced in the control group compared with the fibrin sealant group (p = .033), whereas greater new blood vessel formation was observed in the fibrin sealant group compared with the control (p = .023). No histologic evidence of residual or recurrent disease was detected. CONCLUSION: Both PRP and fibrin sealant appear to be safe and associated with improved tissue healing during shaving for the excision of colonic endometriosis, attributed to the enhanced collagen disposition, neovascularization, and protection of the integrity of colon layers. Clinical trials are warranted to confirm the feasibility of PRP and fibrin sealant in the clinical setting.

What are the Risk Factors Responsible for the Delay in Diagnosis of Acute Appendicitis in Children? Eleven-year Research from a Single Institution.

INTRODUCTION: We conducted a retrospective analysis of 602 children operated on for acute appendicitis (AA) in our department between 1/2007 and 12/2017. AIM: The aim of this study was to identify factors that are related to a delay in diagnosing AA in children. Furthermore, we'd like to strengthen our previous preliminary results by a) adding gender as a new factor and b) studying a much larger population. MATERIALS AND METHODS: The time that elapsed from the onset of symptoms to the surgical intervention was associated with gender, age, obesity, use of antibiotics prior to diagnosis, and the initial examination by a paediatric surgeon or another physician. Univariate and multivariate logistic regression method (backward method) was applied. RESULTS: The diagnosis of AA was delayed by at least 48 hours in 287 patients (group A, 47.7%) and was made within 48 hours in 315 patients (group B, 52.3%). In multivariate model we noticed that boys who were examined by a paediatric surgeon and didn't take antibiotics had decreased odds of having length of diagnostic period >48 hours, girls who received antibiotics compared to girls who do not use antibiotics are almost 12 times more likely to have length of diagnostic period >48 hours, the very young age has а main effect оn the diagnostic delay and girls who have been examined by other physician compared to females who have been examined by paediatric surgeon have decreased odds of having length of diagnostic period >48 hours. CONCLUSIONS: Therefore, physicians examining children with abdominal pain must keep in mind the multiple causes of diagnostic delay that may exist alone or in combination, and which can lead to serious complications and lengthen the hospital stay. Performing repeated examinations and asking for advice from a specialist specifically for children who are a special category of patients, in areas where it is rather impossible to use imaging techniques, could be the key to correctly diagnosing and treating AA.

Antioxidants in experimental ischemia-reperfusion injury of the testis: Where are we heading towards?

Testicular torsion (TT) is a medical emergency that primary affects newborns and young adolescents. It causes testicular injury due to the torsion of the spermatic cord and its components, initially in the venous blood flow and finally in the arterial blood flow. Prompt diagnosis and early surgical management are necessary in managing this urgent situation. The process of the pathophysiological events in ischemia-reperfusion is multifactorial and deals with the perception of the oxidative stress responsible for the consequences of ischemia/reperfusion (I/R) stress following TT. Duration and severity of torsion also play a significant role in the oxidative stress. A detrimental result of the defense system of the testes takes place resulting finally in testicular atrophy and impaired function. Antioxidant factors have been experimentally studied in an effort to front this state. They have been classified as endogenous or exogenous antioxidants. Endogenous antioxidants comprise a structure of enzymic enzymatic and non-enzymic enzymatic particles presented within cytoplasm and numerous other subunits in the cells. Exogenous antioxidants include a variety of natural and pharmaceutical agents that may prevent or ameliorate the harmful effects of I/R injury. In this study we review those factors and their ability to enhance the oxidative status of the testis. A feature insight into where we are heading is attempted.

Erythropoietin and sildenafil protect against ischemia/reperfusion injury following testicular torsion in adult rats.

Testicular torsion/detorsion causes severe tissue damage due to ischemia/reperfusion injury. The present study investigated the protective effect of erythropoietin and sildenafil against ischemia/reperfusion injury following unilateral testicular torsion/detorsion in adult rats. A total of 28 adult male rats were included, and were divided into the following groups: Group A (n=5), sham operated; groups B (n=5), C (n=5), D (n=5) and E (n=8), undergoing right testis torsion and detorsion after 90 min. Group B received no drug treatment. Rats in the groups C and D received low-dose (1,000 IU/kg) or high-dose (3,000 IU/kg) erythropoietin, while those in group E received sildenafil (0.7 mg/kg), through intraperitoneal injection after 60 min of torsion. The right testis was extracted 24 h after detorsion, and the tissue was subjected to histopathological examination and immunohistochemical assessment of cleaved caspase-3 expression. Histological alterations and the quality of spermatogenesis were scored according to the Cosentino and the Johnsen scoring systems, respectively. The results demonstrated normal testicular architecture in group A, while the other groups showed ischemic cellular damages, with the worst scores observed in group B. Groups D and E presented better scores compared with group C. Regarding the quality of spermatogenesis, the best scores were observed in group A, and the worst in group B. Groups C, D and E presented similar results, which were improved in comparison to group B, however, not compared to group A. Furthermore, cleaved caspase-3 levels were lower in groups A, D and E, with equal results observed. Group C had higher levels of cleaved caspase-3 compared with these groups, but lower than group B, which presented the highest cleaved caspase-3 levels. In conclusion, erythropoietin and sildenafil protect testis from ischemia/reperfusion injury by decreasing cellular damage and attenuating apoptosis.

The role of laparoscopy in the identification and management of missing accessory spleens after primary splenectomy: A case report and literature review.

We present a 7-year-old boy with recurrent thrombocytopenia after primary laparoscopic splenectomy for immune thrombocytopenia (ITP). Imaging modalities (ultrasound, computed tomography scan, and scintigraphy) revealed two accessory spleens while the subsequent second laparoscopy revealed 11, which were successfully removed. The relevant medical literature is reviewed, and the value of laparoscopy for chronic ITP is highlighted.

Chronic Intussusception Associated with Malrotation in a Child: A Variation of Waugh's Syndrome?

Chronic intussusception is a relatively uncommon disease most commonly observed in older children. Waugh's syndrome represents a rare entity characterized by intestinal malrotation and acute intussusception. We report a very unusual case of intestinal malrotation associated with chronic intussusception. Clinical presentation, radiological findings, and managing of this association are discussed in the light of the available literature.

Circumscribed Storiform Collagenoma Associated with Rubinstein-Taybi Syndrome in a Young Adolescent.

Rubinstein-Taybi syndrome is a rare congenital neurodevelopmental disorder characterized by dysmorphic features, skeletal abnormalities, growth deficiency, and mental retardation. Circumscribed storiform collagenoma is a distinct benign fibromatous tumor that presents either as solitary tumor or in association with other syndromes. In this report, we describe a 16-year-old male with Rubinstein-Taybi syndrome associated with circumscribed storiform collagenoma. To our knowledge, this association has not been previously described in the literature.

Local peritonitis as the first manifestation of Crohn's disease in a child.

Crohn's disease (CD) can occur anywhere in the gastrointestinal tract from the mouth to the anus and sometimes it presents in a nonspecific manner. Herein we describe a case of local peritonitis as the first manifestation of CD in an 11-year-old girl, and the subsequent method of treatment.

Testicular dysmorphism in infantile abdominoscrotal hydrocele: insights into etiology.

Testicular dysmorphism (TD) associated with infantile abdominoscrotal hydrocele (ASH) may be due to the pressure effect of hydrocele on the testis or may be a developmental abnormality. Only a few reports are referred to the etiology of testicular changes in infantile ASH. We present an additional case of infantile ASH together with a review of the literature, focusing on insights into etiology of TD and its appropriate management.