Exploratory laparotomy for acute intestinal conditions in children: a review of 10 years of experience with 334 cases

Factors Affecting Survival in Nontraumatic Pediatric Abdominal Surgical Emergencies: A Contemporary Review

Surgically curable illnesses in the pediatric population are a major public health issue with a high prevalence of 10%-33% of all pediatric admissions, and emergency situations account for 50%-78% of surgical cases. Emergency abdominal surgery in children necessitates proper and prompt surgical and perioperative supportive care. When compared to elective operations, emergency surgery has a greater rate of morbidity and fatality. Staffing concerns, access to operating theaters, and access to diagnostic investigations are all possible causes of this high fatality rate, in addition to patient-related factors. Literature from high-income countries (HICs) discusses the problem, and recommendations are available for high-quality setups with good infrastructure. However, surgical care facilities from resource-poor countries have altogether different challenges and bottlenecks when dealing with children requiring emergency surgical operative procedures to save lives. This review aims to discuss factors affecting the survival of children being operated on for abdominal emergencies in resource-poor setups and suggest recommendations.

Outcomes of early relaparotomy in pediatric patients at Tikur Anbessa teaching hospital, Addis Ababa, Ethiopia: a five-year retrospective review

BACKGROUND

Early relaparotomy is defined as relaparotomy within the first 30 days following surgery. The aim of this study is to explore the indications, outcomes and factors associated with relaparotomy in our pediatric population.

METHODS

We performed a retrospective study of pediatric surgical patients (< 13 yrs.) who underwent relaparotomy at Tikur Anbessa Teaching Hospital between September 1, 2011 and August 31, 2016. All children who had relaparotomy within the first 30 days of the initial surgery were included. We collected patient data including demographics, operative indication, and postoperative outcomes. Data analysis was performed using SPSS Version 23. Chi-square and Fisher's exact tests were used to report outcomes stratified by patient characteristics. Multivariable logistic regression was used to identify patient variables associated with relaparotomy and other outcomes.

RESULTS

In our patient population, relaparotomy rate was 17.2%. Patient age ranged from 2 days to 12 years with mean age of 37.5 months. Male to female ratio was 1.2:1. Thirty-one (58.5%) relaparotomies were performed between the 5th and 8th postoperative days. The two most common indications for relaparotomy were postoperative intra-abdominal collection and anastomotic leak, accounting for 18 (34.0%) and 17 (32.1%) respectively. Mortality rate following relaparotomy was 26.4%. The most common cause of mortality was sepsis with multi-system organ failure (90.6%). Neonatal age was found to be the independent risk factors for death following relaparotomy, (AOR = 27.59, 95% CI [2.0-379.9]).

CONCLUSION

Prevalence of relaparotomy in pediatric patients is high (17.2%) in our patient population. Neonatal age was associated with increased mortality following relaparotomy.

A 14-year-old girl presenting with tuberculous intestinal perforation while in a temporary shelter after the 2015 earthquake in Nepal

A 14-year-old Nepalese girl presented with fever, abdominal pain and vomiting. She was living with her family in a temporary settlement camp following the earthquake in Nepal in 2015. She had had abdominal pain for 2 months and fever for 1 month. Abdominal examination suggested acute peritonitis. At laparotomy, three ileal perforations were detected and histopathology demonstrated caseous granulomas. Her father had sputum-positive pulmonary tuberculosis. She was diagnosed with abdominal tuberculosis and responded well to anti-tuberculosis chemotherapy. Intestinal perforation is a rare complication of tuberculosis in children.

Peritonitis in Rwanda: Epidemiology and risk factors for morbidity and mortality

BACKGROUND

Few studies discuss causes and outcomes of peritonitis in low-income settings. This study describes epidemiology of patients with peritonitis at a Rwandan referral hospital. Identification of risk factors associated with mortality and unplanned reoperation could improve management of peritonitis.

METHODS

Data were collected on demographics, clinical presentation, operative findings, and outcomes for all patients with peritonitis. Multivariate regression analysis identified factors associated with in-hospital mortality and unplanned reoperation.

RESULTS

A total of 280 patients presented with peritonitis over a 6-month period. Causes of peritonitis were complications of intestinal obstruction (39%) and appendicitis (17%). Thirty-six (13%) patients required unplanned reoperation, and in-hospital mortality was 17%. Factors associated with increased odds of in-hospital mortality were unplanned reoperation (adjusted odds ratio 34.12), vasopressor use (adjusted odds ratio 24.91), abnormal white blood cell count (adjusted odds ratio 12.6), intensive care unit admission (adjusted odds ratio 9.06), and American Society of Anesthesiologist score ≥3 (adjusted odds ratio 7.80). Factors associated with increased odds of unplanned reoperation included typhoid perforation (adjusted odds ratio 5.92) and hypoxia on admission (adjusted odds ratio 3.82).

CONCLUSION

Peritonitis in Rwanda presents with high morbidity and mortality. Minimizing delays in care is important, as many patients with intestinal obstruction present with features of peritonitis. A better understanding of patient care and management prior to arrival at the referral hospital is needed to identify areas for improvement at the health center and district hospital.

Single-incision laparoscopic appendectomy for treating appendicitis in a patient with gastrointestinal malrotation

INTRODUCTION

Intestinal malrotation is a rare congenital anomaly, and acute appendicitis associated with intestinal malrotation is extremely rare. PRESENTATION OF CASE We report a rare case of a 47-year-old Japanese woman diagnosed with barium-related perforated appendicitis associated with intestinal malrotation. We used a transumbilical single-incision laparoscopic approach to resect the appendix, and the procedure was completed successfully without perioperative complications.

DISCUSSION

To our knowledge, single-incision laparoscopic surgery for appendicitis associated with intestinal malrotation has not been reported yet. In cases with mobile cecum such as this one, mobilization from inflammatory adhesion of the surrounding structures is easy.

CONCLUSION

We conclude that transumbilical single-incision laparoscopic appendectomy is a simple and less invasive method for treating appendicitis associated with intestinal malrotation.

Intestinal obstruction from congenital bands at the proximal jejunum: a case report and literature review

Congenital anomalous bands at the proximal jejunum resulting in obstruction have been described sporadically in the literature and are otherwise rare. We present a case of an 8 year-old girl with a nine-month history of intermittent vomiting and no history of prior surgery. The imaging workup includes an abdominal ultrasound, a single contrast upper gastrointestinal series, and a dual contrast computed tomography of the abdomen and pelvis. Surgical intervention revealed the presence of dense bands at the proximal jejunum without evidence of malrotation. Our report reviews the embryology and radiologic findings of this entity using different imaging modalities.

Prevention, diagnosis, and treatment of tuberculosis in children and mothers: evidence for action for maternal, neonatal, and child health services

Tuberculosis affected an estimated 8.8 million people and caused 1.4 million deaths globally in 2010, including a half-million women and at least 64 000 children. It also results in nearly 10 million cumulative orphans due to parental deaths. Moreover, it causes 6%-15% of all maternal mortality, which increases to 15%-34% if only indirect causes are considered. Increasingly, more women with tuberculosis are notified than men in settings with a high prevalence of human immunodeficiency virus (HIV), and maternal tuberculosis increases the vertical transmission of HIV. Tuberculosis prevention, diagnosis, and treatment services should be included as key interventions in the integrated management of pregnancy and child health. Tuberculosis screening using a simple clinical algorithm that relies on the absence of current cough, fever, weight loss, and night sweats should be used to identify eligible pregnant women living with HIV for isoniazid preventive therapy or for further investigation for tuberculosis disease as part of services for prevention of vertical HIV transmission. While implementing these simple, low-cost, effective interventions as part of maternal, neonatal, and child health services, the unmet basic and operational tuberculosis research needs of children, pregnant, and breastfeeding women should be addressed. National policy makers, program managers, and international stakeholders (eg, United Nations bodies, donors, and implementers) working on maternal, neonatal, and child health, especially in HIV-prevalent settings, should give due attention and include tuberculosis prevention, diagnosis, and treatment services as part of their core functions and address the public health impacts of tuberculosis in their programs and services.