Trends in diagnostic approaches for pediatric appendicitis: nationwide population-based study.

BACKGROUND: To define the benefits of different methods for diagnosis of pediatric appendicitis in Taiwan, a nationwide cohort study was used for analysis. METHODS: We identified 44,529 patients under 18 years old who had been hospitalized with a diagnosis of acute appendicitis between 2003 and 2012. We analyzed the percentages of cases in which ultrasound (US) and/or computed tomography (CT) were performed and non-perforated and perforated appendicitis were diagnosed for each year. Multivariate logistic regression analyses were performed to evaluate risk factors for perforated appendicitis. RESULTS: There were more cases of non-perforated appendicitis (N = 32,491) than perforated appendicitis (N = 12,038). The rate of non-perforated cases decreased from 0.068% in 2003 to 0.049% in 2012; perforated cases remained relatively stable at 0.024%~0.023% from 2003 to 2012. The percentage of CT evaluation increased from 3% in 2003 to 20% in 2012; the rates of US or both US and CT evaluations were similar annually. The percentage of neither CT nor US evaluation gradually decreased from 97% in 2003, to 79% in 2012. The odds ratios of a perforated appendix for those patients diagnosed by US, CT, or both US and CT were 1.227 (95% confidence interval (CI) 0.91, 1.65; p = 0.173), 2.744 (95% CI 2.55, 2.95; p < 0.001), and 5.062 (95% CI = 3.14, 8.17; p < 0.001), respectively, compared to patients who did not receive US or CT. The odd ratios of a perforated appendix for those patients 7-12 and ≤6 years old were 1.756 (95% CI 1.67, 1.84; p < 0.001) and 3.094 (95% CI 2.87, 3.34; p < 0.001), respectively, compared to those 13-18 years old. CONCLUSIONS: Our study demonstrated that using CT scan as a diagnostic tool for acute appendicitis increased annually; most patients especially those ≤6 years old who received CT evaluation had a greater risk of having perforated appendicitis. We recommend a prompt appendectomy in those pediatric patients with typical clinical symptoms and physical findings for non-complicated appendicitis to avoid the risk of appendiceal perforation.

Therapeutic effectiveness of percutaneous drainage and factors for performing an interval appendectomy in pediatric appendiceal abscess.

BACKGROUND: In this study, we studied the therapeutic effectiveness of percutaneous drainage with antibiotics and the need for an interval appendectomy for treating appendiceal abscess in children with a research-oriented dataset released by the Bureau of National Health Insurance in Taiwan through the Collaboration Center for Health Information Application (CCHIA). METHODS: We identified 1225 patients under 18 years of age who had non-surgical treatment for an appendiceal abscess between 2007 and 2012 in a Taiwan CCHIA dataset. The treatment included percutaneous drainage with antibiotics or antibiotics alone. We also analyzed data of patient's baseline characteristics, outcomes of percutaneous drainage, and indicating factors for performing an interval appendectomy. RESULTS: Totally, 6190 children had an appendiceal abscess, an 1225 patients received non-operative treatment. Of 1225 patients, 150 patients received treatment with percutaneous drainage and antibiotics, 78 had recurrent appendicitis, 185 went on to receive an interval appendectomy, and 10 had postoperative complications after the interval appendectomy. We found that patients treated with percutaneous drainage and antibiotics had a significantly lower rate of recurrent appendicitis (p < 0.05), a significantly smaller chance of receiving an interval appendectomy (p < 0.05), and significantly fewer postoperative complications after the interval appendectomy (p < 0.05) than those without percutaneous drainage treatment. Older children (13 ~ 18 years) patients were found to have a significantly smaller need to receive an interval appendectomy than those who were ≤ 6 years of age (odd ratio (OR) = 2.071, 95 % confidence interval (CI) = 1.34-3.19, p < 0.01), and those who were 7 ~ 12 years old (OR = 1.662, 95 % CI = 1.15-2.41, p < 0.01). In addition, those treated with percutaneous drainage were significantly less indicated to receive an interval appendectomy later (OR = 2.249, 95 % CI = 1.19 ~ 4.26, p < 0.05). In addition, those with recurrent appendicitis had a significantly increased incidence of receiving an interval appendectomy later (OR = 3.231, 95 % CI = 1.95 ~ 5.35, p < 0.001). CONCLUSIONS: In this study, we used nationwide data to demonstrate therapeutic effectiveness of percutaneous drainage and antibiotics was more beneficial than only antibiotics in treating patients with an appendiceal abscess. We also found three factors that were significantly associated with receiving an interval appendectomy: recurrent appendicitis, being aged ≤ 13 years, and treatment with antibiotics only.

Calcitonin Gene-Related Peptide Downregulates Expression of Inducible Nitride Oxide Synthase and Caspase-3 after Intestinal Ischemia-Reperfusion Injury in Rats.

BACKGROUND: Various investigations have demonstrated that calcitonin gene-related peptide (CGRP) plays an important role in mediating ischemic preconditioning. CGRP has been shown to mimic the protective effects of ischemic preconditioning and mitigate ischemia-reperfusion (I/R) injury in the heart, brain, gastrointestinal system, and other tissues. This study aimed to examine whether CGRP, a proven intestinal cytoprotective molecule, exerted its protective effects through modulation of inducible nitride oxide synthase (iNOS) and apoptosis after intestinal I/R injury. METHODS: This animal study randomly divided 30 rats into the following five groups: (1) the normal control group, (2) the ischemia group with normal saline, (3) the I/R group with normal saline, (4) the ischemia group with CGRP (300 µg/kg), and (5) the I/R group with CGRP (300 µg/kg). Levels of iNOS messenger RNA (mRNA) and protein, and caspase-3 protein were determined by real-time quantitative polymerase chain reaction and Western blotting analyses, respectively. Statistical analysis was performed using analysis of variance with Dunn test. RESULTS: The mRNA levels of iNOS increased after the intestinal ischemia or intestinal reperfusion phase (p < 0.01), and CGRP pretreatment significantly decreased iNOS mRNAs and protein levels (p < 0.01). The expression protein levels of caspase-3 increased after the intestinal ischemia or intestinal reperfusion phase. CGRP pretreatment significantly decreased the levels of caspase-3 proteins. CGRP intestinal cytoprotection is mediated, in part, by downregulation of expression of iNOS and caspase-3 after intestinal I/R injury. CONCLUSION: The study indicates that the cytoprotective role of CGRP (i.e., antiapoptotic effect) after I/R injury could be via downregulation of iNOS, which may relieve I/R tissue damage by blocking iNOS activity.

National trends in therapeutic approaches and outcomes for pediatric appendicitis: a Taiwanese nationwide cohort study.

PURPOSE: To define the pattern of therapeutic approaches for pediatric appendicitis and compare their benefits in Taiwan, we analyzed a research-oriented dataset released by the Bureau of National Health Insurance in Taiwan through the Collaboration Center for Health Information Application (CCHIA) to document the impact of the rise of laparoscopic treatment on outcomes. METHODS: We identified 22,161 patients under 18 years who had been hospitalized with a diagnosis of acute appendicitis between 2007 and 2012 in the CCHIA. Statistical comparisons between the Laparoscopic appendectomy (LA) and open appendectomy (OA, control) groups were computed using a Chi squared test. The odds ratios (ORs) and 95% confidence intervals (CIs) of risk factors for intra-abdominal abscess (IAA) and postoperative bowel obstruction (PBO) were derived from multivariate logistic regression models. RESULTS: In each respective year, the incidence of LA increased from 29.17% in 2007 to 57.4% in 2012, while that of OA decreased from 70.83% in 2007 to 42.60% in 2012; incidences of non-perforated appendicitis and perforated appendicitis with LA or OA seemed similar. The length of hospitalization between an LA and OA for non-perforated appendicitis was the same, but that with an LA was shorter for perforated appendicitis. The adjusted ORs for IAA and PBO for those patients with perforated and non-perforated appendicitis were 6.30 (95% CI = 5.09-7.78; p < 0.001) and 6.49 (95% CI = 4.45-9.48; p < 0.001); while for those cases undergoing an LA and OA, they were 0.50 (95 % CI = 0.40-0.62; p < 0.001) and 2.07 (95% CI = 1.45-2.95; p < 0.001), respectively. The ORs of IAA and PBO for those patients ≤6 and 7-12 years of age were 1.67 (95% CI = 1.23-2.25; p = 0.001) and 1.20 (95% CI = 0.97-1.49; p = 0.095), and 1.88 (95% CI = 1.08-3.24; p = 0.025) and 1.47 (95% CI = 1.01-2.14; p = 0.043), respectively, compared to those aged 13-18 years. CONCLUSIONS: Our study demonstrated that young age and perforated appendicitis can affect postoperative IAA and PBO. LA appeared beneficial in reducing the length of hospitalization and postoperative IAA, but had an increasing risk of PBO. Although laparoscopic approach for pediatric appendectomy is increasing in our country, the different hospital levels and pediatric surgeon's laparoscopic experience must be evaluated in further study.

Free radial forearm flap in an adult with hypospadias.

A 22-year-old man presented with a scarred neophallus and complex hypospadias. The local penile skin was inadequate for urethral repair. A 16 cm free radial forearm flap was used for urethral replacement. Microvascular anastomosis allowed this flap to remain viable and functional. One year postoperatively, the patient had satisfactory functional and cosmetic outcomes. A small fistula developed in the course of the proximal anastomosis, and it was successfully repaired. Our case describes the successful use of a free radial forearm flap for urethral reconstruction.

Fulminant Clostridium septicum infection mimicking appendicitis in a healthy child.

A 5-year-old boy with Clostridium septicum enterocolitis presented with severe right lower abdominal pain. On the day after admission, shock, neutropenia and pneumoperitoneum prompted a laparotomy. Gangrene of the ileum and colon was identified, associated with a fatal Clostridium septicum infection.

Lipoblastoma/lipoblastomatosis: a clinicopathologic study of 16 cases in Taiwan.

Lipoblastoma/lipoblastomatosis is an uncommon benign lipomatous tumor affecting mainly infants and children. It presents as a painless mass located frequently in upper and lower extremities. The present study was conducted to characterize the clinicopathologic features of lipoblastoma/lipoblastomatosis in a Chinese population. A retrospective survey of 16 cases of pathologically confirmed lipoblastoma/lipoblastomatosis from 1988 to 2002 was performed. The available clinical information and histological sections were reviewed. The study involved 10 males and 6 females ranging in age from 5 to 49 months (median, 11.5 months). The patients presented with mass involving neck (n = 5), inguina (n = 3), feet (n = 2), arm (n = 1), leg (n = 1), thorax (n = 1), mesentery (n = 1), buttock (n = 1), and presacral region (n = 1). The lesions were removed surgically. Histologically, the majority (11/16) of primary tumors were of diffuse type. Follow-up ranging from 5 to 125 months was available in 13 patients. Four patients experienced a recurrence of tumors in the neck (n = 2) and lower extremities (n = 2) 11-84 months after operation. The most common site of involvement of lipoblastoma/lipoblastomatosis in our series was the neck. A follow-up period of more than 3 years is recommended for patients with this condition.

Retroperitoneal teratomas in infancy and childhood.

Retroperitoneal teratoma poses a significant problem in the differential diagnosis of Wilms' tumor, neuroblastoma, and other intraabdominal tumors. In an attempt to establish the best diagnostic and treatment modality, we reviewed our experience with retroperitoneal teratomas at a single institution in a 5-year period. Between January 1998 and December 2002, retroperitoneal teratomas were identified in 10 patients, seven females and three males, ranging from age 4 days to 12 years, with seven patients under the age of 1 year. The presence of calcifications or bony structure within the tumor was revealed on abdominal ultrasound study or computed tomography in nine of the 10 lesions. Total excision was performed in nine patients; another patient with grade III immature teratoma received postoperative chemotherapy besides excision. One patient with grade III immature teratoma who did not receive postoperative chemotherapy had a local recurrence 6 months later and was treated by repeated surgical excision and postoperative chemotherapy. All of these patients were free of disease at 8 months to 5 years of follow-up. Retroperitoneal teratomas were usually noted in patients under the age of 1 year. Though large, they are mostly benign lesions with no apparent connection to the retroperitoneal organs and are amenable to curative excision, but histologic evidence of grade III immature teratoma or malignancy demands aggressive postoperative chemotherapy to prevent local recurrence.

Intra-abdominal cystic lymphangiomas in infancy and childhood.

BACKGROUND: Cystic lymphangiomas (CL) rarely present as intra-abdominal masses. Abdominal CL is often discussed in conjunction with mesenteric cysts; however, their histology, location and age of presentation differ significantly. In an attempt to establish a best diagnostic and treatment modality, we report our experience dealing with intra-abdominal CL during a 5-year period. METHODS: Between January 1998 and December 2003, 12 patients, 7 boys and 5 girls, with a diagnosis of CL were reviewed. Modes of clinical presentation, location of CL, methods of diagnosis, surgical intervention and histological examination were all analyzed. RESULTS: The ages of the 12 patients ranged from 8 days to 6 years. Eleven of the 12 patients were symptomatic with abdominal pain, abdominal distention or palpable mass , dysuria and severe acute abdominal pain mimicking appendicitis. Abdominal ultrasound was done preoperatively in all patients. At laparotomy, 5 CL were located in the omentum, 5 in the mesentery, and another 2 in the retroperitoneum. All omental CL were completely excised without difficulty. CL removal required resection of both the cyst and intestine in 2 patients. One of 2 retropritoneal CL was removed with small areas of the posterior wall of the cyst remaining on the inferior vena cava (IVC). There were no major postoperative complications, deaths, or recurrences in this series. CONCLUSIONS: Intra-abdominal CL are usually involved in young children and are usually symptomatic. A preoperative diagnosis is possible with ultrasound study. Complete excision of the cysts with or without intestinal resection is mandatory to prevent recurrence. The long-term prognosis is excellent.

Urachal anomalies in children: experience at one institution.

BACKGROUND: The embryological and anatomical features of urachal anomalies have been well defined. Because of the variable clinical presentations, uniform guidelines for evaluation and treatment are lacking. In an attempt to establish an optimal diagnostic and treatment modality, we report our experience with urachal anomalies at a single institution over a 10-year period. METHODS: The records of 20 patients with urachal abnormalities were reviewed. These included 12 males and 8 females with ages from 1 day to 12 years (average, 3 years). The evaluation included symptoms and signs, and results of fistulography, sonography, and voiding cystography. Postoperative conditions were also reviewed. RESULTS: The presenting complaint was umbilical discharge in 14 patients, umbilical discharge with marked umbilical granulation tissue in 2, periumbilical erythema in 3, and abdominal pain in 1. Diagnostic evaluation included fistulography in 5 cases, sonography in 13, and voiding cystourethrography in 3. The 3 variants of urachal anomalies included a patent urachus in 4 patients (20%), urachal sinus in 13 (65%), and an infected urachal cyst in 3 (15%). Treatment consisted of primary excision with a cuff of the bladder in 3, excision with ligation in 1, excision of the sinus in 13, incision and drainage in 3, and secondary excision in 1. There was 1 postoperative wound infection. CONCLUSION: Diagnosis and treatment of urachal anomalies can be made with certainty if a good physical examination and proper imaging study are performed. Voiding urethrocystography might not be required in view of the fact that none of the patients studied had an associated urinary tract anomaly.

Adenocarcinoma of the jejunum: a pediatric case report.

The clinical history and surgical findings of an adenocarcinoma of the jejunum in a 15-year-old boy are reported. The diagnosis of small bowel carcinoma remains difficult, primarily because of the rarity of the disease and the ambiguity of its symptoms. We reviewed the literature on this subject and found a total of seven cases of adenocarcinima of the jejunum and ileum in patients under 20 years of age. We report this case for its rarity and the findings which should alert the pediatricians including intermittent abdominal pain, severe loss of body weight, and stools positive for guaiac.

The presentation of asymptomatic palpable movable mass in female inguinal hernia.

UNLABELLED: The surgical approach to the inguinal canal in girls is identical to that in boys. The sliding hernia which contains the ovary with or without the fallopian tube occurs occasionally in female patients. In our clinical experience, we found that a hydrocele in the labium, also presenting with an asymptomatic palpable movable mass, mimics a sliding hernia with ovary. In an attempt to differentiate between hydrocele and sliding inguinal hernia with ovary in female patients, we report our experience dealing with the two situations at a single institution within a 5-year period. Between July 1997 and June 2002, 1800 infants and children underwent surgery for inguinal hernia at Chang Gung Children's Hospital, of whom 580 were female infants and girls aged 1 month to 14 years (mean, 5.7 years). Some 32 patients (5.3%) presented with an asymptomatic palpable movable mass over the labium major. Pre-operative sonography was performed for all cases. Twenty-six female infants aged 1 month to 18 months (mean 5 months) had sliding hernia; both the ovary and fallopian tube were contained. Six girls aged 2 years to 6 years (mean 4.6 years), had hydrocele of the canal of Nuck. The accuracy of pre-operative diagnosis with sonography was 100%. CONCLUSION: Sonography is an easy and accurate pre-operative diagnostic procedure. We suggest that sonography be performed routinely in all female cases with an inguinal hernia containing a palpable movable mass.

Pathological analysis of congenital cervical cysts in children: 20 years of experience at Chang Gung Memorial Hospital.

BACKGROUND: Congenital cervical cysts are frequently encountered in pediatric populations, and constitute one of the most intriguing areas of pediatric pathology. This report analyzes cervical cysts in Taiwanese children diagnosed at Chang Gung Memorial Hospital (CGMH) over the past 20 years. The pathologic and clinical findings are reviewed. METHODS: Files on 331 patients under the age of 18 years, with a diagnosis of congenital cervical cyst at CGMH from January 1, 1983 to June 30, 2002, were retrieved from the Department of Pathology. There were 204 boys and 127 girls. We reviewed the histology of all cases and correlated it with clinical information in the medical records. RESULTS: Thyroglossal duct cysts, the most common congenital neck cyst, accounted for 54.68% of all cases, followed by cystic hygromas (25.08%), branchial cleft cysts (16.31%), bronchogenic cysts (0.91%), and thymic cysts (0.30%). Nine cases (2.72%) remained unclassified. CONCLUSIONS: This is the largest series regarding pediatric cervical cysts in the literature to date. Thyroglossal duct cysts were the most common congenital cervical cyst encountered. Our experience indicates that each type of cyst has its unique location in the neck and is highly associated with its embryonic origin. Complete and precise clinical information is a prerequisite in order for pathologists to make accurate diagnoses of congenital cervical cysts.

Idiopathic hypertrophic pyloric stenosis in identical twins.

Idiopathic hypertrophic pyloric stenosis (IHPS) was thought to be a congenital disease traditionally, even though several published reports assumed IHPS was an acquired disease. The pathogenesis and inheritance patterns of IHPS are not fully understood. Except for the familial recurrence of IHPS, concordance of IHPS in monozygotic or dizygotic twins was also noted, but occurrence in female twins is rare. From July 1992 through June 2000, 130 patients were diagnosed with IHPS in our hospital including one pair of female twins. We present the finding in the twins and review the associated articles about the pathogenesis and inheritance patterns of IHPS.

Computed tomography-guided percutaneous drainage of intra-abdominal abscesses in neutropenic children.

The mortality associated with undrained intra-abdominal abscesses is high. Computed tomography-guided percutaneous drainage (CT-PD), a minimally invasive technique, allows a drainage catheter to be inserted into fluid collections throughout the body with minimal risk. We described two neutropenic patients with intra-abdominal abscesses treated with CT-PD after they failed to respond to antimicrobial therapy. With this modality, the surgery was successfully avoided or delayed. We are of an opinion that CT-PD is an efficient and simple urgent radiology procedure.