Non-operative treatment of children with simple appendicitis: long-term follow-up (5 years) in a prospective cohort study

Long-term results after non-operative treatment for children with simple appendicitis seem promising, possibly avoiding appendicectomy in 70 per cent of children after a median follow-up of 5 years. The need for delayed appendicectomy more than 2 years after the initial treatment is rare (0–5 per cent) and no complications occurred past 1 year, including children who underwent delayed appendicectomy.

Malignant recurrence after mature Sacrococcygeal teratoma: A meta-analysis and review of the literature

BACKGROUND AND AIMS

Sacrococcygeal teratoma (SCT) is a rare extragonadal germ cell tumour mostly diagnosed during infancy and early childhood. Neonatal SCTs are mostly mature, but can also contain immature and/or malignant components. Recurrence of an SCT alters prognosis, especially when it is malignant, of which its mechanism is not yet fully understood. This study is a review and meta-analysis of the literature on malignant recurrences after an initially mature SCT.

METHODS

A literature search was performed to identify studies describing children with SCT and presenting specific information on histology of the initial tumour as well as the recurrence. Random effect models for mature recurrence and malignant recurrence after an initially mature SCT were employed to pool study-specific percentages in order to estimate an overall percentage and its associated 95 % confidence intervals (CI). Inverse variance method, which gives more weight to larger studies, was used to pool outcomes for the different studies.

RESULTS

A total of 22 articles, comprising 1516 patients with SCT, were included in the meta-analysis. The pooled proportions of mature and malignant recurrences after mature SCT were 3 % (95 % CI 1-4 %) and 5% (95 % CI 3-6 %), respectively. Fifty-seven (56 %) of a total of 102 recurrences after resection of an initially mature SCT were malignant, mostly yolk sac tumour (YST). Many recurrences occurred within 1-6 years, however some occurred as long as 20 years after initial diagnosis.

CONCLUSIONS

A substantial number of recurrences of mature SCT present as a malignant tumour. Overlooking malignant components on initial pathological evaluation and the progression of mature SCT cells to malignant cells may play a role. Treatment of mature SCTs with resection alone requires thorough follow-up of at least 6 years. Future research is needed to determine whether SCTs with malignant microfoci should be treated or followed-up differently from mature or immature SCTs. In addition, the value of serum biomarkers in follow-up after SCT needs to be further evaluated.

Neurological symptoms in children with intussusception

AIM

The classical combination of abdominal pain, vomiting, rectal blood loss and a palpable abdominal mass is only present in a minority of children with intussusception. Neurological signs and symptoms have been described, but are not a well understood phenomenon. We performed a retrospective study to ascertain the frequency and nature of these symptoms and to describe the characteristics of the patients presenting in this atypical way.

METHODS

The records of 58 children presenting with intussusception from 2003 to 2008 were reviewed for abdominal and neurological signs and symptoms, duration of symptoms and effectiveness of treatment.

RESULTS

In 10 out of 58 patients (17%), one or more neurological symptoms were recorded at presentation, with lethargy being the most frequent, followed by hypotonia and fluctuating consciousness. The patients with neurological abnormalities were significantly younger and presented with a shorter duration of symptoms. Therapy was more invasive, although not statistically significant, in this patient category.

CONCLUSION

Intussusception should be considered in the differential diagnosis in young children presenting with lethargy, hypotonia and/or sudden alterations of consciousness even in the absence of the classical symptoms of intussusception.

Depth of the thoracic epidural space in children

Thoracic epidural anaesthesia in anaesthetized children requires a meticulous technique and may have an increased success rate when the distance between skin and epidural space is known. The objective of this observational study was to measure the skin to epidural distance (SED) during thoracic epidural puncture in 61 children. The epidural puncture was performed using the loss of resistance technique with saline 0.9%. The distance from the needle tip to the point where the needle emerged from the skin was measured. The post-operative analgesia parameters were also measured. Skin to epidural distance correlated significantly with the age and weight of the children. The equation for the relation between SED (cm) and age was 2.15 + (0.01 x months) and for SED vs weight was 1.95 + (0.045 x kg). Despite considerable variability among individuals, the observed correlation of SED with both age and weight shows that this parameter may be helpful to guide thoracic epidural puncture in anaesthetized children.

Antioxidants reduce oxidative stress in claudicants

BACKGROUND

Low-grade ischemia-reperfusion in claudicants leads to damage of local tissues and remote organs. Since this damage is partly caused by oxygen-derived free radicals (ODFR), scavenging these ODFR could reduce the local and remote injury.

METHODS

Using a new method by which a free radical reaction product (ortho-APOH) of the exogenous marker antipyrine is measured to quantify the oxidative stress, 16 stable claudicants performed a standard walking test before and after administration of vitamin E (200 mg) and vitamin C (500 mg) daily for 4 weeks.

FINDINGS

Ortho-APOH was significantly increased during the reperfusion period (P = 0.026) before administration of the vitamins. After 4 weeks of vitamin supplementation no rise was found in the reperfusion period. Malondialdehyde showed no changes in either group.

INTERPRETATION

These findings indicate that administering extra antioxidants to claudicants reduces oxidative stress in these patients. This may also have an effect on the remote ischemia-reperfusion damage and reduce cardiovascular morbidity in this group.

Differences in renal response between endovascular and open repair of abdominal aortic aneurysms

OBJECTIVES

to determine the difference in renal and systemic response between open and endovascular aneurysm repair.

MATERIALS AND METHODS

we studied prospectively 22 patients undergoing open repair (OR) and 15 patients undergoing endovascular repair (ER). Blood and urine samples were taken preoperatively (T0) and before clamping of the aorta or femoral artery (T1) and 5 min (T2), 1 h (T3), 6 h (T4), 24 h (Day 1) and 48 h (Day 2) after declamping. Albumin/creatinin ratio (AC ratio) in urine, serum albumin, serum creatinin, serum C-reactive protein and serum lactate were determined.

RESULTS

the urinary AC ratio in ER was significantly lower than in OR (p<0.001). In both groups the rise in urine albumin/creatinin ratio after declamping (T2, T3) was significant (p<0.001). C-reactive protein was raised significantly at day 1 and 2 in both groups (p<0.001) with no difference between the groups. Serum lactate values were significantly higher in OR. There was a significant increase in serum lactate 6 h after declamping in the ER group.

CONCLUSIONS

after endovascular repair renal damage is less compared to open repair. There is a significant systemic reaction to the endovascular repair causing mild, short-lasting damage to the kidney. This systemic response is most probably induced by a combination of ischaemia reperfusion injury and the surgical trauma of the procedure. Other possible explanations are discussed.

"Dog ear" formation after double-stapled low anterior resection as a risk factor for anastomotic disruption

PURPOSE

The aim of this study was to investigate the possible deleterious effect of the lateral intersecting margins (so-called dog ears) on anastomotic disruption after experimentally performed double-stapled anastomoses.

METHODS

Two groups of double-stapled side-to-end anastomoses were performed using pig small intestines. Group A consisted of 35 circular anastomoses and Group B of 32 double-stapled anastomoses with a bilateral dog ear. In both groups bursting pressures were tested using a water-filled, pressure-controlled automatic pumping system (Hamou Endomat), and special attention was paid to the location(s) in the anastomoses were the disruption(s) occurred.

RESULTS

In Group A bursting pressures were significantly higher than in Group B (median pressure, 90 vs. 60 mmHg; P < 0.001, Mann-Whitney U test). Remarkably, in Group B in 13 cases (42 percent) the first disruption occurred at the corner of a dog ear.

CONCLUSIONS

We conclude that the lateral intersections of double-stapled anastomoses are a structural weak spot and that the currently most often applied double-stapled anastomosis is a less effective type of anastomosis than a complete circular one. Resolving this technical problem might help to reduce the number of anastomotic disruptions after low anterior resections.

[Endometriosis in the round ligament of the uterus as a cause of inguinal pain]

Within one year three patients, women aged 31, 28 and 26 years, presented with a cyclic painful small mass in the inguinal region. Histopathological examination of the resected specimen showed a pattern consistent with an extra-abdominal localization of endometriosis in the round ligament. The patients' complaints disappeared after surgical resection. It is concluded that in case of a painful mass in the inguinal region in a fertile woman endometriosis of the round ligament should be considered.