Etiology of Appendicitis in Children: The Role of Bacterial and Viral Pathogens.

BACKGROUND: Although acute appendicitis is the most common cause for abdominal surgery in children, its etiology is still largely unknown. The aim of this study was to evaluate the role of bacterial and viral pathogens for the etiology of appendicitis in children. METHODS: Between 2000 and 2010, 277 children underwent appendectomy in our institution. On this collective, a retrospective study was performed on to identify the presence of bacterial or viral pathogens. RESULTS: Intraoperatively, 39% of cases showed acute, 9% of cases chronic, and 41% of cases ulcerous inflammation. Bowel perforation was found in 7% of cases and four percent of the children had no inflammation of the appendix at all. Escherichia coli was the predominant bacterium with an incidence of 27.4%, followed by streptococci (9.8%). Concerning viral pathogens, adenovirus was the most common with an incidence of 5.4% followed by rotavirus (4.7%). Significant correlations between histopathological findings and present pathogens were found: in cases of bowel perforation there were significantly more infections with E. coli bacteria (32.2%, p < .001), streptococci (12.2%, p < 0.001), and Pseudomonas aeruginosa (6.7%, p < .001) whereas chronic inflammations were accompanied with a significantly elevated rate of yersinia infections (2.5%, p = .016). Acute inflammations were significantly more often associated with campylobacter (1.7%, p = .011) and oxyures infections (6.1%, p < .001). In relation to the patients' age, a significant accumulation of different pathogens was observed. CRP- and leukocyte counts showed differences between viral and bacterial inflammations. CONCLUSIONS: Our data indicates that appendicitis in children might be triggered by bacterial and viral pathogens and that the type of pathogen directly correlates with patient age, type of inflammation, and level of inflammation values. To confirm and further evaluate these findings, additional studies need to be conducted.

Spinal anesthesia for inguinal hernia repair in infants: a feasible and safe method even in emergency cases.

BACKGROUND: Inguinal hernia repair is the most frequently performed surgical procedure in infants and children. Especially in premature infants, prevalence reaches up to 30% in coincidence with high rates of incarceration during the first year of life. These infants carry an increased risk of complications due to general anesthesia. Thus, spinal anesthesia is a topic of growing interest for this group of patients. We hypothesized that spinal anesthesia is a feasible and safe option for inguinal hernia repair in infants even at high risk and cases of incarceration. METHODS: Between 2003 and 2013, we operated 100 infants younger than 6 months with inguinal hernia. Clinical data were collected prospectively and retrospectively analyzed. Patients were divided into two groups depending on anesthesia procedure (spinal anesthesia, Group 1 vs. general anesthesia, Group 2). RESULTS: Spinal anesthesia was performed in 69 infants, and 31 infants were operated in general anesthesia, respectively. In 7 of these 31 infants, general anesthesia was chosen because of lumbar puncture failure. Infants operated in spinal anesthesia were significantly smaller (54 ± 4 vs. 57 ± 4 cm; p = 0.001), had a lower body weight (4,047 ± 1,002 vs. 5,327 ± 1,376 g; p < 0.001) and higher rate of prematurity (26 vs. 4%; p = 0.017) compared to those operated in general anesthesia. No complications related to surgery or to anesthesia were found in both groups. The number of relevant preexisting diseases was higher in Group 1 (11 vs. 3%; p = 0.54). Seven of eight emergent incarcerated hernia repairs were performed in spinal anesthesia (p = 0.429). CONCLUSIONS: Spinal anesthesia is a feasible and safe option for inguinal hernia repair in infants, especially in high-risk premature infants and in cases of hernia incarceration.

Postoperative outcome in premature infants with open abdomen.

BACKGROUND: Premature infants treated with laparostomy in the first days of their life represent a group of complex patients with high morbidity and mortality rates. Laparostomy is a surgical treatment method in which the peritoneal cavity is opened anteriorly and deliberately left open, hence often called "open abdomen". The aim of this study was to analyze crucial factors influencing the postoperative outcome of premature infants treated this way. METHODS: Between March 2002 and August 2012, we treated 40 premature infants with a median gestational age of 29 weeks (range from 24 to 34 weeks) with open abdomen in our institution. Their data were analyzed retrospectively. They were divided into two groups depending on in-hospital survival. RESULTS: Indications for surgery were ileus (n = 16), spontaneous intestinal perforation (n = 11), gastroschisis (n = 8) and necrotizing enterocolitis (NEC, n = 5). The overall in-hospital mortality was 43 % (17 of 40 patients). Postoperative anemia was the only significant factor influencing mortality rates in our patients (10 vs. 14 patients; p = 0.028). Neither the indication of surgery, nor week of gestation, nor birth weight had any significant influence on postoperative survival. Twenty-one of the 23 surviving patients reached fascia closure. CONCLUSIONS: In our study, outcome of premature infants with open abdomen in the first days of their life seems to depend more on an operation and a postoperative course without complications than on the preoperative conditions of the children. Postoperative anemia seems to be a significant negative prognostic marker. Patients reaching fascia closure mainly survive.

Paediatric and adolescent traumatic gastrointestinal injuries: results of a European multicentre analysis.

AIM: Paediatric gastrointestinal injuries (GIIs) are rare, and the aim of this multicentre study was to evaluate their outcomes in a large cohort. METHODS: Hospital databases of 10 European paediatric surgical centres were reviewed for paediatric traumatic GIIs managed between 2000-2010. RESULTS: Ninety-seven patients with a median age of 9 years (0-17 years) were identified, with 72 blunt and 25 penetrating GIIs. Initial diagnostics in 90 patients led to correct diagnosis in 71%. Diagnostics were delayed in 26 patients (median 24 h). Eighty-two patients required surgery (67 laparotomy, 12 laparoscopy and three other approaches). There was a 50% conversion in the laparoscopic group. Median hospital stay was 10 days (range 1-137 days), with longer duration influenced by associated injuries (n = 41). Diagnosis <24 h was associated with significantly shorter hospital stay compared to more than 24 h (p = 0.011). In one-third of patients, morbidities were not related to a diagnostic delay or type of injury. There were five lethal outcomes, four due to associated injuries. CONCLUSION: Initial diagnostics in traumatic paediatric GIIs provide false negatives in one-third of patients. Diagnostic delay <24 h is associated with a significantly shorter hospital stay. Although laparoscopy is associated with a conversion rate of 50%, it can be used for diagnosis in suspected cases to avoid nontherapeutic laparotomy.

Is biocompatibility affected by constant shear stress?--comparison of three commercially available meshes in a rabbit model.

Mesh implants as standard treatment for tissue defects can be adapted to patient's needs by specific bioactive coatings. The biophysical interaction with the surrounding tissue must be understood to describe the influence of coatings qualitatively and quantitatively. This study investigates the use of meshes to repair diaphragmatic defects. The physical stress in this tissue is high in comparison to other applications. Therefore, knowledge gained from this experimental model can be applied to other locations. Meshes were implanted on surgically created diaphragmatic defects in growing rabbits. A standardized load model was used to investigate 33 rabbits. The commercial products Ultrapro®, Surgisis®, and Proceed® were implanted. The adhesive properties of the meshes as well as the defect size were determined macroscopically at explantation after 4 months. Sections of the explanted meshes and diaphragms were examined histologically and immunohistochemically. The median defect size for all mesh groups decreased from the initial size of 10 mm down to 4.5 mm at explantation. No statistically significant differences were seen between the three mesh groups. Surgisis® was found to be completely disintegrated after 4 months. Ultrapro® and Proceed® showed no macroscopic differences compared to their original appearance. Both sealed the original diaphragmatic defect as tightly as at time of implantation. Histological and immunohistochemical analyses showed significant differences between the three mesh groups. Proceed® caused stronger inflammatory reaction in the surrounding tissue and inferior connective tissue formation. Regarding the composition of the newly generated tissue within the defect area, Ultrapro® and Surgisis® were found superior. This can sufficiently be explained by the different gradient of inflammatory reaction in the surrounding tissue. Because Surgisis® offers no sufficiently lasting support for the diaphragmatic defect, our future main focus for mesh modification is laid on Ultrapro®.

Influence of the elasticity module of synthetic and natural polymeric tissue substitutes on the mobility of the diaphragm and healing process in a rabbit model.

Mesh implants are frequently used in congenital diaphragmatic hernia. This experimental study aimed to examine the influence of different materials on the diaphragmatic movement over time as well as their mechanical qualities after 4 months. Ultrapro®, Surgisis®, and Proceed® were implanted onto a diaphragmatic defect in growing rabbits. Diaphragmatic mobility was determined at three time points. At 4 months, defect shrinkage and mechanical properties were measured. The break strength decreased for Ultrapro® and Surgisis®, but did not change relevantly for Proceed®. Ultrapro® (32.46 N/cm) and Proceed® (31.75 N/cm) showed a four-fold higher resistance to tearing than Surgisis® (8.31 N/cm). The elasticity of Ultrapro® showed no significant difference compared to Surgisis® (p = 0.75). Proceed®, on the other hand, was more than twice as elastic as Ultrapro® or Surgisis® (p = 0.015). Ultrapro® had a higher spring rate (6.48 N/mm) compared to Surgisis® (3.82 N/mm) or Proceed® (5.23 N/mm). Observing the standardized movement rates of the diaphragm for each mesh group over time the only statistical differences were seen for the Proceed® group. On account of its material qualities Ultrapro® was found to be the most suitable mesh material for demanding locations in our model.

[Mechanical ileus in childhood--causes and surgical therapy]. / Mechanischer Ileus im Kindesalter--Ursachen und operative Therapiemassnahmen.

BACKGROUND: The present study examines the causes and surgical management in children who underwent surgery for a mechanical Ileus. PATIENTS: We studied all children up to the age of 18 years who had undergone a surgical intervention for a mechanical ileus between 1.1.1996 and 31.12.2006. 89 children were included in this retrospective study. RESULTS: Of the total of 89 children 15 were newborn (16.9 %), 23 babies (25.8 %), 19 toddlers (21.3 %) and 32 school children (36 %) at the time of the operation. 51 of the 89 children had undergone at least one previous abdominal operation. Intraoperative findings showed the cause for the ileus to be adhesions in 56 and a bowel invagination in the remaining 11 children. Associated malformations were found in 34 children, the most frequent being malformations of the heart and gastrointestinal tract. The most frequent surgical intervention was adhesiolysis in 56 children (62.9 %), followed by the reposition of invaginated intestine in 11 (12.4 %). Bowel resection was necessary in 23 children (25.8 %). CONCLUSION: The risk for developing an ileus due to adhesions increases with the number of previous operations. Surgical intervention for an ileus aims to decompress the overstretched bowel and to restore gastrointestinal flow by removing the mechanical obstruction. One third of the children with an ileus have accompanying malformations. Children with a mechanical ileus should undergo surgery as soon as possible.

The Gist of literature on pediatric GIST: review of clinical presentation.

AIM/BACKGROUND: To provide a review of existing literature on pediatric GIST with focus on clinical presentation. METHODS: A MEDLINE search was conducted in July 2007 to give an overview on literature concerning pediatric gastrointestinal stromal tumors (GISTs) with a focus on clinical presentation, using keywords "gastrointestinal stromal tumor" and one of the following "young/boy/girl/child/children/pediatric." Two of the authors sorted the resulting abstracts by relevance for a review on clinical aspects of pediatric GIST if they were in English language, not explicitly only reporting of adults and describing clinical features of patients. RESULTS: One hundred and six articles were found, 43 of which were excluded because they did not match the criteria mentioned above. We found 97 patients in the articles meeting our criteria, of which 38 cases had to be excluded, because of lacking clinical data, negative staining for CD117 or syndromal occurrence. This left 59 patients for analysis of clinical symptoms in the presentation of nonsyndromal CD117-positive GIST in children. DISCUSSION: Clinical feature most frequent was anemia in 86.4% (n=51) symptomatic either through acute or subacute bleeding. There was no palpable tumor in 88.1% (n=52), no abdominal pain in 84.7% (n=50), and no vomiting in 88.1% (n=52). Girls tend to show more high-grade tumors and existing case reports show a 2.7-fold higher incidence in females. Altogether epithelioid cell tumors are most frequent, although in boys spindle-cell tumors are reported more often. On the basis of National Institute of Health criteria (6) tumors were low grade in 22% (n=13), medium grade in 37.3% (n=22), and high grade in 35.6% (n=21). There were more high-grade tumors in girls than in boys (40.5% vs. 28.6%). Local excision was the operation most often performed, but details of surgery were missing in most cases. CONCLUSIONS: Pediatric GIST is a rare but considerable diagnosis in chronic anemia, which is the most frequent clinical finding with this tumor entity. Recent review articles focus on histopathologic criteria but omit clinical features and course of disease. In nonsyndromal CD117-positive GIST, girls tend to show more high-grade tumors and existing literature on pediatric GIST shows a 2.7-fold higher incidence in females. Altogether epithelioid cell tumors are most frequent, although in boys spindle-cell tumors are reported more often. Together with known differences in molecular changes and local as well as systemic tumor behavior this strongly suggests that pediatric GIST represents a different entity than adult GIST. After establishment of clear-cut pathologic features in the past, reports on preoperative diagnostic findings, long-term follow-up, and therapy have to be emphasized to clarify the relationship of these entities.

Contralateral inguinal hernia in childhood and youth: which child will develop a contralateral inguinal hernia?

This work addresses the controversial topic of the exploration of the contralateral side in the presence of a one-sided inguinal hernia in infancy. In a prospective study of 368 children with one-sided inguinal hernia, we demonstrated the consecutive development of a contralateral hernia in 22 (6%) of the children. We found that the child's age at first operation represents a risk factor for the development of a consecutive hernia. At an age of less than two months we found a highly significant (P < 0.0001) accumulation of consecutive hernias. These consecutive contralateral hernias appear significantly often (P < 0.0009) within the first two post-operative months in children at least two months old. In view of these findings, we see an indication for routine simultaneous repair on both sides for children aged less than two months at first presentation.

[Medicine between humanitarianism and competition: the patients' point of view]. / Medizin zwischen Humanität und Wettbewerb: Ein aktuelles Patientenmeinungsbild.

BACKGROUND: An open medical market is supposed to be a promising tool for preserving the meagre resources of the German public health care system. The competition between humane and economic practice induces conflicts which burden physicians as well as patients. To analyse this problem by scientific means, inpatients were interviewed with the help of a standardised protocol. PATIENTS AND METHODS: During 10 weeks 524 inpatients were interviewed. The structured questionnaire consisted of nine closed-ended questions with multiple-choice answers. Question 3 included a free amendment. The gender ratio was balanced, and the age pattern represented the typical patient collective of our clinic. RESULTS AND CONCLUSION: The majority of patients expect negative changes in their medical service and the social attitude towards patients and physicians due to promoted medical competition. Besides an increasing financial load, losses in trust, self-determination, and therapeutic freedom are expected. Instead a responsible transparency will not be achieved. Patients still judge the economically dominated reforms on the German health care market with scepticism or even hostility. In their point of view future discussions must aim at a more modern attitude towards health economics in order to bridge the schism they perceive between medical competition and humanitarianism. The understanding of strong financial management as a prime condition for stable social security is the basis of synergies to deal with upcoming reforms.

[Fair allocation of reduced resources in the German health care system. The patient's view]. / Gerechte Verteilung knapper Gesundheitsressourcen. Ein aktuelles Patientenmeinungsbild.

BACKGROUND: The financial resources in the German Public Health care system are running short due to reduced budgets and demographic changes. Reform plans of the state, backers, and care providers seem to neglect patients' needs. To analyse this problem by scientific means, inpatients were interviewed as to their views concerning fair allocation. PATIENTS AND METHODS: During 6 weeks, 532 inpatients were interviewed. The structured questionnaire consisted of eight closed-end questions with multiple choice answers. The gender ratio was balanced, and the age pattern represented the typical patient collective of our clinic. RESULTS AND CONCLUSION: The majority of the patients do not support the reform plans in the German public health care system. They feel comfortable with the present medical standard and quality of health care and wish no reductions in the medical service. The required individualisation of risk and care is rejected. Thus patients reveal an almost dichotomous understanding of medical care on the one hand and its cost on the other. Modern reform and change concepts need effective professional public relations to increase public understanding and reduce objections to unpopular measures.

[Current patient perceptions of the physician]. / Der Arzt in der Wahrnehmung des Patienten. Ein aktuelles Meinungsbild.

BACKGROUND: The structure and organisation of German hospitals currently are undergoing radical change forced by reforms in the German public health system. Operating procedures, efficiency assays, and management programs compete with the traditional philanthropic relationship between physician and patient. To analyse this problem by scientific means, inpatients were interviewed in standardised fashion on current expectations, ideals, and experience with that relationship. PATIENTS AND METHODS: During 4 weeks, 507 inpatients were interviewed. The structured questionnaire used consisted of nine closed multiple-choice questions. The proband sex ratio was balanced, and their age pattern represented the typical patient collective in our clinic. RESULTS AND CONCLUSION: The patient perception of physicians' roles described clear priorities. Besides a skilled expert, the patients were looking for a friend and guide through their disease, diagnosis, and therapy. The paternalistic relationship between physician and patient thus is not very antiquated. In contrast, material institutional criteria, provision of services, and hotel-like atmosphere played secondary roles.

[Liver laceration following a kick in a soccer game]. / Leberruptur nach einem Fusstritt im Fussballspiel.

Severe intraabdominal injuries in soccer are very rare. We present the case of an 18 year old soccer player who suffered from a grad IV liver laceration following a kick during a soccer game. After primary explorative laparatomy and liver packing in a hospital nearby the patient was transferred to our clinic. Following CT scan the injury was treated by suture of liver parencym lacerations, argon laser coagulation and pile duct repair. In soccer severe intraabdominal injuries should be expected following players collision at high velocity or kicking with the foot or the knee.

A case of bilateral inguinal hernia recurrence in infancy: investigations on collagen metabolism.

BACKGROUND: Recurrent inguinal hernias in early infancy are rare. We report on a case of a 3-month-old male infant suffering bilateral inguinal hernia recurrence (RINGH). Due to previous observations of an altered collagen metabolism in hernia patients, a severe connective-tissue pathology in the infant was hypothesised. METHODS: Hernial sac tissue of the infant was analysed and compared to specimens from five children operated upon one-sided primary inguinal hernias (controls). In paraffin-embedded sections, we determined the distribution of collagen types I and III by crosspolarisation microscopy and the expression of matrix metalloproteinase 2 (MMP-2) by immunohistochemistry. In fibroblast cultures, expression of collagen types I and III and of MMP-2 was investigated by RT-PCR (real-time polymerase chain reaction) and zymography. Electron microscopical investigations were performed exemplarily in two fibroblast cultures to compare cell morphology. RESULTS: No differences in collagen I/III ratios between RINGH and controls were found either on protein or on mRNA level. Immunohistochemical and RT-PCR analysis of MMP-2 showed a lowered expression in the RINGH patient, as compared to controls, whereas the gelatinolytic activity of MMP-2 did not differ between the groups. Electron microscopical investigations showed similar cell arrangement and morphology. CONCLUSIONS: To conclude, a marked biochemical correlate to a severe connective-tissue pathology in the infant suffering inguinal hernia recurrence could not be found. With regard to the slight differences in the expression of MMP-2, a possible role in the genesis of inguinal hernia recurrence cannot be ruled out.

[Assisted death in daily surgical practice--an interdisciplinary discussion with examples]. / Sterbehilfe im chirurgischen Alltag. Eine interdisziplinäre Diskussion anhand von Falldarstellungen.

New laws for assisted patient death in The Netherlands and Belgium have resulted in animated discussion about the permissibility of the practice in Germany. Physicians here are being confronted more and more by patients and their relatives with the wish for assisted death. Polls confirm that the majority of this population supports active death assistance, whereas doctors reject it. At a symposium in October 2002 (Clinically Assisted Death and Human Dignity-A Dutch-German Dialogue), case studies illustrating this question were presented. The present study compiles viewpoints of physicians, ethicists, theologians, jurist, politicians, and journalists.

Venocutaneous fistula.

This is the first description of venocutaneous fistula, a late complication of elective laparoscopic cholecystectomy that arose 18 months after the initial operation. Postoperatively, the patient twice developed an abscess in the abdominal wall at the former site of the umbilical trocar. The first abscess occurred on the 6th postoperative day; the second, after 14 months. After an additional 4 months, a fistula opening appeared just below the umbilicus. Fistulography revealed a connection with the venous system of the omentum majus. During subsequent resection of the fistula, a pigment gallstone was retrieved from the base of the fistula.

Treatment of extrahepatic bile duct disease in infancy and early childhood.

Extrahepatic bile duct disease is a rare finding in infancy and early childhood. However, there is an increasing number of patients operated at this age reported in the literature. This increase may have multifactorial reasons, e.g. real increase, better ability of detection as a result of better diagnostic techniques and knowledge of predisposing factors of extrahepatic bile duct disease in childhood, especially in early childhood and infancy. The following report describes three cases of extrahepatic bile duct disease in infancy and early childhood treated at the Department of Surgery of the University of Technology in Aachen, Germany. From 1986 to 1998 28 Patients below 18 years were operated at our Department of Surgery. There was a recognizable increase of patients in 1996, 1997 and 1998. Whereas from 1986 to 1995 an average of 1.5 Cholecystectomies in pediatric patients were done, the years from 1996 to 1998 show an average of 5,33 patients operated per year. Every patient obtained a Cholecystectomy -- 15 conventional open Cholecystectomies and 13 Laparoscopies, which were primarily performed in children in our clinic in 1991. Besides cholecystectomy in one case a Hepaticoenterostomy was necessary and in another case surgical treatment of the Papilla of Vater and the Common Bile Duct was performed. In 22 patients symptomatic Cholelithiasis was the indication for a Cholecystectomy. Another Patient had a gallbladder polyp consisting of heterotopic Duodenal glands, two patients showed a shock gallbladder following trauma and cardiac operation and three patients had chronic Cholecystitis without gallstones. Clinical data was collected and retrospectively reviewed. Additionally, we created a personal questionnaire to carry through a follow-up. Three Patients were less than 3 1/2 years old. The youngest patient was only 5 months old and presented with Cholelithiasis and Choledocholithiasis. Another male patient, aged 2 years received a Cholecystectomy and a Hepaticoenterostomy because of a Choledochal Cyst Type Ib (Todani-Classification). And a 3-year-old-girl had a shock gallbladder caused by thromboembolism following cardiac operation nine days before.

Enterostomy complications in infancy and childhood.

BACKGROUND: A number of severe gastrointestinal disorders in infancy and childhood may require the formation of an enterostomy as a crucial part of the treatment of the disease itself. This study reviews our pediatric patients with regard to the morbidity and mortality of enterostomy formation and closure over an 8-year period. PATIENTS AND METHODS: Sixty-eight enterostomies in infants and children and 60 consecutive enterostomy closures in retrospect are reported on. This includes colostomies, jejunostomies, ileostomies, and Mikulicz procedures. RESULTS: In most instances, a transverse colostomy was performed. The most frequent indications were intestinal obstruction and necrotizing enterocolitis. More than half of the children were less than 1 month of age at the time of surgery. We observed an overall complication rate of 38.2% following enterostomy formation, with stoma prolapse being the most common, but faced major complications (such as sepsis, peritonitis, and enterocutaneous fistula) in only 10.3%. Complications after enterostomy closure were encountered in 20%. The overall mortality was 7%. CONCLUSION: Enterostomy formation and closure in the pediatric age group with severe underlying disease is still associated with substantial morbidity.

Operative treatment of a congenital pancreatic pseudocyst: a case report.

Congenital pancreatic pseudocysts are very rare and have so far been described in only 4 cases. We report on a patient with a congenital pancreatic pseudocyst diagnosed only intraoperatively. We show with this case that diagnosis is difficult. Furthermore, we show the histology and operation method.