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.

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.

Long-term angiogenic activity of free grafts and pedicle flap in a rabbit urethroplasty model.

PURPOSE: We studied the late angiogenic activity of free grafts and a pedicle flap in a rabbit urethroplasty model to determine whether angiogenic activity plays a role in late outcomes of urethral reconstruction in rabbits. METHODS: Twenty-eight rabbits were randomly divided into five groups according to the method used to bridge a urethral defect as an onlay patch: Control, simple closure of urethral defect (Group O1); free penile skin graft (FPSG, Group A1); buccal mucosal graft (BuMG, Group B1); bladder mucosal graft (BlMG, Group C1); and pedicle penile skin flap (PPSF, Group D1). Angiogenic activity of the patch on postoperative day 84 was assessed by immunohistochemistry. RESULTS: The angiogenic activity in Groups O1, A1, B1, C1, and D1 was 23.33 ± 4.92 (means ± SD), 42.89 ± 6.52, 55.78 ± 3.46, 53.61 ± 6.17, and 24.11 ± 9.07 vessels per optical field, respectively. There were statistically significant differences (p < .001) between Group O1 and A1 B1, C1, Group A1 and B1, C1, D1, Groups B1 and D1 and Groups C1 and D1, but not between Groups O1 and D1 (p = 1.000) and Groups B1 and C1 (p = .872). The long-term angiogenic activity of all the groups was significantly lower (p < .001) than in the corresponding early groups. CONCLUSIONS: Although the angiogenic activity of all the groups decreased in the late assessment, the buccal mucosal graft continued to exhibit elevated angiogenesis above bladder or skin (free or pedicle) graft. Therefore, buccal mucosal patch graft might be preferable because of its easier harvesting.

Lipopolysaccharide-binding protein: a potential marker of febrile urinary tract infection in childhood.

BACKGROUND: Urinary tract infections (UTIs) are encountered frequently in children, and their early diagnosis and treatment are important. This study evaluates the diagnostic value of serum concentrations of lipopolysaccharide-binding protein (LBP), an acute-phase protein, in children with febrile UTI and compares it to those of the total white blood cell count (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6). METHODS: The study population comprised 77 consecutive patients with a first-episode febrile UTI (33 boys) with a median age of 11 months [interquartile range (IQR), 5.5-33 months], 21 healthy controls (11 boys) with a median age of 10 months (IQR, 5-20.5 months) and 58 febrile controls with a fever due to other causes (28 boys) with a median age of 12.5 months (IQR, 7-30 months). LBP, IL-6, PCT, and CRP were measured for both patients and control groups. RESULTS: The serum levels of LBP (p < 0.001), CRP (p < 0.001), PCT (p = 0.001), IL-6 (p = 0.002), ESR (p = 0.020), and WBC (p < 0.001) were higher in patients with febrile UTI than in the healthy and febrile control groups. The LPB cut-off value for best sensitivity and specificity in patients with febrile UTI was >43.23 mg/l. Furthermore, the area under the receiver operating characteristic curve was significantly greater for LBP than for CRP (p = 0.014), PCT (p < 0.001), ESR (p < 0.001), WBC (p = 0.002) and IL-6 (p = 0.006). CONCLUSIONS: The results of this study suggest that the serum LBP concentration constitutes a reliable biologic marker for the diagnosis of a febrile UTI in children.

(99m)Tc-DMSA scintigraphy diagnosing crossed renal ectopia with fusion in a three years old boy.

A 3 years old boy with a history of surgery for orchidopexy was admitted to our hospital with fever and abdominal pain. Clinical examination and laboratory investigations revealed urinary tract infection with renal involvement. Ultrasonography demonstrated a solitary left kidney and raised the suspicion of a fusion anomaly. Voiding cystography disclosed grade III vesicoureteral reflux and technetium-99m dimercaptosuccinic acid scintigraphy revealed right to left crossed renal ectopia with fusion (L-shaped kidney). The patient is undergoing standard follow-up for the early detection of possible renal complications. In conclusion, L-shaped kidney is a rare entity and the (99m)Tc-DMSA scintigraphy played an important role on timely diagnosis.

Optimal timing for repair of an inguinal hernia in premature infants.

PURPOSE: The aim of this study was to determine the optimal timing for inguinal herniotomy in premature infants treated in the neonatal intensive care unit. METHODS: A two-institutional-center retrospective study was performed including 41 prematures at gestational age 28-35 weeks who underwent herniotomy within 1 week of diagnosis [short-waiting group (SWG), median 5 days, n = 25] or more than 1 week after diagnosis [long-waiting group (LWG), median 30.55 days, n = 16]. Gestational age, birthweight, post-conceptional age at diagnosis, age at diagnosis, post-conceptional age at surgery, age at surgery, weight at surgery, timing of surgery, operative time, and occurrence of incarceration, postoperative apnea, hernia recurrence, testicular atrophy, and hospital stay were compared between the two groups. Statistical analysis was performed using one-way ANOVA. RESULTS: Twelve preoperative episodes of incarceration occurred: three in the SWG and nine in the LWG (P < 0.05). Six infants had apnea postoperatively: four in the SWG and two in the LWG (P > 0.05). Follow-up revealed five hernia recurrences, one in the SWG and four in the LWG (P < 0.05); four testicular atrophies were found, one in the SWG and three in the LWG (P > 0.05). CONCLUSION: Early elective herniotomy should be considered in prematures in order to avoid perioperative morbidity and to reduce the risk of incarceration and subsequent testicular ischemia, and hernia recurrence.

Acute poisoning among children admitted to a regional university hospital in Northern Greece.

OBJECTIVES: The aim of our study was to elucidate the current pattern of acute poisoning among children admitted to a regional University Hospital in the prefecture of Evros in Northern Greece. We also compared the obtained findings with those of two previous studies performed in the same region. METHODS: Demographic and clinical data, management, and outcome of children with acute poisoning were recorded in our region, during the past 5-years (2005-2009, period C) and compared to similar studies carried out in the periods 1985-1989 (period A) and 1995-1999 (period B). RESULTS: Comparison between the three periods showed that in period Athe lower incidence of children's acute poisoning (CAP) was observed. Also this revealed a 20%-reduction in the frequency of poisoning over the past 5-years (period C) compared to period B (p = 0.219), a significant increase in tobacco intoxication over the years (in the order A-C; p < 0.001 for comparisons of periods A and B, and periods B and C), while poisoning from insecticides-pesticides decreased (p < 0.001). The incidence of poisoning via salicylates significantly reduced from 9.7% in period A to 6.2% in period B, and further to 4.7% in period C (p = 0.016), whereas during the same periods poisoning via paracetamol increased from 2.3% to 5.1% and then to 10.4%, respectively (p < 0.001). Atrend toward a higher incidence of suicide attempt via poisoning was found during the three periods (from 3.0% in period A to 4.7% and 6.6%, in periods B and C, respectively; p = 0.049). CONCLUSIONS: The frequency of acute poisoning among children has decreased over the past 5 years. The incidences of poisoning via paracetamol and tobacco, and attempted suicide have increased in recent years. Targeted and continuous educational preventive programs are mandatory.

Lipoblastoma on the posterior side of the neck.

Lipoblastoma is a rare benign pediatric tumor derived from embryonic fat, and only two cases of lipoblastoma located on the posterior side of the neck have been reported in the literature. Here, we present the third case of posterior neck lipoblastoma in a 13-month-old healthy girl, who presented with a firm, posterior cervical mass. The tumor was completely resected following ultrasonography, computerized tomography, and magnetic resonance imaging evaluations. Histological examination of the resected tissue showed the typical characteristics of lipoblastoma. The child's postoperative progress was uneventful and no recurrence was observed 27 months after the operation. The clinical manifestations, radiologic and histopathologic findings, and treatment of this lesion are discussed.

Acute abdomen in children due to extra-abdominal causes.

BACKGROUND: Acute abdominal pain in children is a common cause for referral to the emergency room and for subsequent hospitalization to pediatric medical or surgical departments. There are rare occasions when the abdominal pain is derived from extra-abdominal organs or systems. The aim of the present study was to establish the most common extra-abdominal causes of acute abdominal pain. METHODS: The notes of all children (1 month-14 years of age) examined for acute abdominal pain in the Accident and Emergency (A&E) Department of Alexandroupolis District University Hospital in January 2001-December 2005 were analyzed retrospectively. Demographic data, clinical signs and symptoms, and laboratory findings were recorded, as well as the final diagnosis and outcome. RESULTS: Of a total number of 28 124 children who were brought to the A&E department, in 1731 the main complaint was acute abdominal pain. In 51 children their symptoms had an extra-abdominal cause, the most frequent being pneumonia (n = 15), tonsillitis (n = 10), otitis media (n = 9), and acute leukemia (n = 5). CONCLUSION: Both abdominal and extra-abdominal causes should be considered by a pediatrician who is confronted with a child with acute abdominal pain.

Late onset of spontaneous pneumothorax complicating acute bronchiolitis in a 5-month-old infant: case report and literature review.

The literature contains only a few reported cases of spontaneous pneumothorax complicating acute bronchiolitis in infants. We present a case of a 5-month-old infant with a presentation of spontaneous pneumothorax 7 days after hospitalization for acute bronchiolitis. The characteristics of this particular manifestation are discussed.

Second-look Flexible Nephroscopy Combined With Holmium: Yttrium-Aluminum-Garnet Laser Lithotripsy Under Local Anesthesia: A Prospective Study.

OBJECTIVE: To present a prospectively studied series of patients who underwent second-look flexible nephroscopy combined with holmium:yttrium-aluminum-garnet (Ho:YAG) laser lithotripsy under local anesthesia for residual stone removal after percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: Thirty consecutive eligible patients who underwent a PCNL procedure in the previous 48-96 hours were included. The inclusion criteria were the following: (1) 1 or 2 residual stones 0.8-1.5 cm in diameter and (2) age >18 years. Approximately 15 mL of a 2% solution of lidocaine hydrochloride was injected through the nephrostomy tube, which was then clamped for 15 minutes. Flexible nephroscopy was combined with Ho:YAG laser lithotripsy set at 0.8 Joules and 8 Hz. Patients were asked to rate their pain intensity using the numeric rating scale (NRS). RESULTS: There were 14 (46.7%) men and 16 (53.3%) women in the study, with a mean age of 45.2 ± 17.5 years. Twenty-one (70%) patients had 1 stone and 9 (30%) had 2 stones needing fragmentation. Twenty-eight (93.3%) patients successfully underwent the procedure under local anesthesia. The mean NRS value was 1.39 ± 1.08 (range 0-5). For the entire group, there was a statistically significant difference between those patients with 1 stone vs 2 stones needing fragmentation (NRS scores of 1.1 ± 0.77 vs 2.1 ± 1.36, respectively, P = .033). Operative time >30 minutes was associated with higher NRS score. The stone-free rate under local anesthesia was 86.7%. CONCLUSION: For patients with a minimal to moderate residual stone burden after PCNL, second-look flexible nephroscopy can be combined with Ho:YAG laser lithotripsy using only local anesthesia.

The Roux-en-Y procedure in congenital hepato-biliary disorders.

BACKGROUND: The use of the Roux-en-Y procedure is limited in paediatric surgery practice, and is performed mainly in congenital hepatobiliary disorders either as an initial or permanent treatment. In this 18-year retrospective study, we present our experience of the Roux-en-Y procedure in childhood cases of biliary atresia (BA) and congenital choledochal cyst (CCC). METHODS: Twenty-eight children (18 females and 10 males; age 25 days-12 years) with hepatobiliary disorders were treated in our clinics between 1986-2004. Twenty patients suffered from BA (11 females, 9 males) and eight from CCC (seven females, one male). The surgical approach in the patients with BA (mean age 2.1 months) was Roux-en-Y hepatic portoenterostomy (Kasai procedure) and in the patients with CCC (mean age 7.2 years) was cyst excision with Roux-en-Y hepaticojejunostomy. The mean follow up period was 9.3 years. RESULTS: The children with BA developed the follow postoperative complications: 12 cholangitis, 6 portal hypertension and 5 hepatic cirrhosis. Among the children with CCC, two presented post-operative cholangitis, which was treated conservatively, and one developed anastomotic stricture and underwent reoperative reconstruction. At the end of the follow-up period among the children with BA 6 had died, 3 had undergone liver transplantation, and 5 were on a waiting list for transplantation. All children with CCC were alive without sequelae. CONCLUSIONS: Roux-en-Y in BA, with timely diagnosis, is preferred as an initial procedure, followed by liver transplantation in cases with no bile drainage and is the only possible reconstruction in cases of CCC after excision of the biliary cyst.

Treatment of hemangiomas in children using a Nd:YAG laser in conjunction with ice cooling of the epidermis: techniques and results.

BACKGROUND: Hemangiomas are the most common type of congenital anomaly in childhood. Although many resolve spontaneously, intervention is required when their growth could damage vital adjacent structures. Various therapeutic approaches to childhood hemangiomas with different types of laser have been described previously. The objective of this study was to determine whether the cooling of the epidermis during irradiation of hemangiomas with a Nd:YAG laser prevents thermal damage and decreases the number of sessions required to treat these lesions. METHODS: Between 1993 and 2001, 110 patients aged 3 months to 4 years, with cutaneous hemangiomas were treated with a Nd:YAG laser. The lesion was cooled with ice prior to, during, and after the irradiation. During each session the laser beam passed through the pieces of ice. The laser power was between 35-45 W with a pulse length of 2-10 seconds. RESULTS: After 6 months of follow-up, from the first session of laser treatment, total resolution was obtained in 72 (65.5%) patients. A second or third session followed in 30 out of 38 patients in which, the initial results were good, moderate, or poor. The parents of the remaining eight children refused this second session and these patients excluded from the study Complications were seen in nine (8.8%) patients. One patient had postoperative bleeding which stopped spontaneously, while atrophic scars occurred in six (5.8%) patients, and hypertrophic scars in two (1.9%) patients. CONCLUSIONS: Nd:YAG laser irradiation in conjunction with ice protection of the epidermis produces good cosmetic results for the treatment of cutaneous hemangiomas in children, and decreases the number of sessions for treatment of these lesions.

Urological symptoms of acute appendicitis in childhood and early adolescence.

We present 15 cases of acute appendicitis in ten boys and five girls (age 3-15 years) with cardinal symptomatology coming from the urogenital tract, who were treated in our departments. All the patients presented with right renal colic, dysuria, frequency and urinary retention. The symptoms were attributed to an ongoing appendix inflammatory process in close proximity to the right distal ureter and urinary bladder. All the patients were successfully operated, and postoperative courses were uneventful. As the present patient group is the largest reported to date, a classification of the pathophysiology in relation to the clinical presentation is proposed.

Suprapubic catheter knotting: an unusual complication.

We describe a case of true knotting of a suprapubic catheter in a 25-month-old boy who underwent surgery for urethrocutaneous fistula as a complication of a distal penile hypospadias repair. This unusual complication was probably attributable to an excessive length of catheter being inserted into the bladder, thereby allowing it to bend onto itself.

The use of a perimeatal-based penile skin flap to cover the repair of a tubularized incised plate urethroplasty: from experimental surgery to clinical practice.

OBJECTIVE: To prospectively evaluate the efficacy and safety of a perimeatal-based penile skin flap for neourethral coverage after repair of distal hypospadias with tubularized incised plate urethroplasty (TIPU). METHODS: In 12 New Zealand white rabbits a ventral urethral defect was created and reconstruction was accomplished with continuous suture. An epithelialized defect-based flap was harvested from the penile skin to cover the repaired defect. The animals were euthanized on the 28th postoperative day and their penises were processed for microscopic examination. In 32 children with distal hypospadias a TIPU was performed. A penile skin flap was created immediately below the distal end of the neourethra and used to cover the urethroplasty. RESULTS: Histological examinations revealed complete restoration of continuity of the stratified squamous epithelium without evidence of inflammation or fistula formation with full consistency with the underlying papillary reticular and corium. There were no cases of fistula formation. One patient developed meatal stenosis. All patients had a satisfactory cosmetic appearance and excellent functional results. CONCLUSION: The formation of a perimeatal-based skin flap is a simple and safe method of providing additional cover for the constructed neourethra after TIPU, minimizing the fistula rate.

Identification of children and adolescents at risk for renal scarring after a first urinary tract infection: a meta-analysis with individual patient data.

IMPORTANCE: No studies have systematically examined the accuracy of clinical, laboratory, and imaging variables in detecting renal scarring in children and adolescents with a first urinary tract infection. OBJECTIVES: To identify independent prognostic factors for the development of renal scarring and to combine these factors in prediction models that could be useful in clinical practice. DATA SOURCES: MEDLINE and EMBASE. STUDY SELECTION: We included patients aged 0 to 18 years with a first urinary tract infection who underwent follow-up renal scanning with technetium Tc 99m succimer at least 5 months later. DATA EXTRACTION AND SYNTHESIS: We pooled individual patient data from 9 cohort studies. MAIN OUTCOMES AND MEASURES: We examined the association between predictor variables assessed at the time of the first urinary tract infection and the development of renal scarring. Renal scarring was defined by the presence of photopenia on the renal scan. We assessed the following 3 models: clinical (demographic information, fever, and etiologic organism) and ultrasonographic findings (model 1); model 1 plus serum levels of inflammatory markers (model 2); and model 2 plus voiding cystourethrogram findings (model 3). RESULTS: Of the 1280 included participants, 199 (15.5%) had renal scarring. A temperature of at least 39°C, an etiologic organism other than Escherichia coli, an abnormal ultrasonographic finding, polymorphonuclear cell count of greater than 60%, C-reactive protein level of greater than 40 mg/L, and presence of vesicoureteral reflux were all associated with the development of renal scars (P ≤ .01 for all). Although the presence of grade IV or V vesicoureteral reflux was the strongest predictor of renal scarring, this degree of reflux was present in only 4.1% of patients. The overall predictive ability of model 1 with 3 variables (temperature, ultrasonographic findings, and etiologic organism) was only 3% to 5% less than the predictive ability of models requiring a blood draw and/or a voiding cystourethrogram. Patients with a model 1 score of 2 or more (21.7% of the sample) represent a particularly high-risk group in whom the risk for renal scarring was 30.7%. At this cutoff, model 1 identified 44.9% of patients with eventual renal scarring. CONCLUSIONS AND RELEVANCE: Children and adolescents with an abnormal renal ultrasonographic finding or with a combination of high fever (≥39°C) and an etiologic organism other than E coli are at high risk for the development of renal scarring.