Laparoscopic versus open appendectomy in pediatric patients: Operative and postoperative experience

Abstract Objective: Acute appendicitis is very frequently encountered in children. Despite many scientific controversies in supporting classical or laparoscopic appendectomy, there is still no official consensus on this issue. This study aimed to present our experience from the comparison of operative and postoperative effects of laparoscopic and open appendectomy in pediatric patients with acute appendicitis. Materials and methods: The analytical cross-sectional study was conducted at the University Clinic for Pediatric Surgery, Ss. Cyril and Methodius University in Skopje, the Republic of N.Macedonia during the period 2015/2022. The study sample covered 184 hospitalized pediatric patients aged 4-14 years treated with laparoscopic (LA) or open appendectomy (OA). The data of interest included demographic characteristics, and selective operative and postoperative parameters. Results: The average age of the children in LA vs. OA group was 9.63±2.70 with min/max of 4/14 vs. 9.16±2.91 with min/max 2/14 respectively. Postoperative complications were detected in 1 (0.90%) of LA patients and 3 (4.11%) of OA patients with no significant association. Analgesics’ treatment received 57 (51.35%) of the children from LA group and all of the children from OA group.  Conversion from LA to OA happen only in 1 (0.54%) child. The evaluation of parents/guardians related to the satisfaction from the cosmetic appearance of the scar the significantly higher level of satisfaction from the scare after LA compared to OA intervention. Conclusions: Laparoscopic appendectomy was found to be feasible and comparable to open approach in terms of operative time and offers advantages over the latter in terms of postoperative pain, length of hospital stay and earlier return of bowel function to normal. It is a safe approach in all types of appendicitis, with an overall better complication profile than OA

Incarcerated Amyand’s hernia in a 6-week-old infant repaired under spinal anesthesia

Amyand’s hernia is characterized by the presence of the vermiform appendix in an inguinal hernia sac. It occurs in less than 1% of all inguinal hernias in children’s age. As the usual pediatric inguinal hernia, it can present in multiple ways, from uncomplicated to incarcerated and/or strangulated hernia with normal, inflamed or even perforated vermiform appendix within the hernia sac. The repair of all the infant cases we came across in literature involved herniorrhaphy with or without appendectomy and general anesthesia. Herein, we present a case of Amyand’s hernia in an infant with concomitant patent ductus arteriosus (PDA), patent foramen ovale (PFO) and interventricular septum hypertrophy that presented with signs and symptoms suggestive of ordinary right-sided incarcerated inguinoscrotal hernia. Due to the cardiac anomaly the infant underwent spinal anesthesia for the hernia repair, thus contributing to the rarity of the case. By thorough literature review, we could not find any similar case of Amyand’s hernia incarceration in an infant operated on under spinal anesthesia. Furthermore, we discuss the surgical and anesthetic aspects of this condition in children

Diagnostic Value of The Ischemia Modified Albumin and Pentraxin 3 In Pediatric Appendicitis: A Meta Analysis

Objective: In this meta-analysis, we aimed to review the diagnostic value of pentraxin 3 (PTX3) and ischemia-modified albumin (IMA) biomarkers in pediatric appendicitis. Method: Studies focusing on the value of PTX3 and IMA in the diagnosis of appendicitis were searched related to the PubMed database. Only randomized prospective clinical trials were included in this study. Results: After the screening, 6 articles based on the diagnostic value of IMA in appendicitis and 5 articles on the diagnostic value of PTX3 were reviewed. A total of 5 studies were included. The data of the 385 patients were reviewed. Sensitivity of PTX3 was 73-92% and specificity 88-100%, while IMA sensitivity was 89-96.7% and specificity was 26-99.7% in acute appendicitis. Conclusion: Although the results of the present study indicate that PTX3 and IMA can be shown as biomarkers in the differential diagnosis of acute abdomen, further study is needed to determine the cut-off value

Thyroid Stimulating Hormone Receptor Transcripts in Correlation with Clinical Parameters in Thyroid Carcinoma Patients

BACKGROUND: Differentiated thyroid carcinomas (DTC) preserve expression of thyroid stimulating hormone receptor (TSHR). AIM: The aim of our study was to evaluate the expression of mRNA-TSHR in peripheral blood of DTC patients, then to correlate the expression with clinical features: Serum thyroglobulin (sTg) value, initial staging and findings from the whole body scan (WBS), neck ultrasound (US), and total received dose of radioiodine therapy. MATERIALS AND METHODS: Forty patients were divided into three groups according to the treatment response: Patients with incomplete structural response (TCs), incomplete biochemical response (TCb), and excellent responders (TCr). Total RNA was isolated from peripheral blood and used for two-step reverse transcriptase-PCR with appropriate primers. Relative quantification using the ΔCt and 2–ΔΔCt and method was applied. sTg levels were evaluated with chemiluminescent assay. The statistical analysis was performed with Spearman Rank Order Correlation. RESULTS: We found that TCs patients expressed mRNA-TSHR by a 5.37-fold higher level than TCr patients, TCb patients expressed TSHR by an 8.88-fold higher level than TCr patients. A significant negative correlation was detected between sTg and ΔCt (CtTSHR - CtGAPDH) value (R = −0.475; p < 0.05), and between WBS/US findings and ΔCt (R= −0.321; p < 0.05). CONCLUSION: Our data revealed higher expression of mRNA-TSHR in peripheral blood of TCs and TCb compared to TCr patients and analysis revealed a significant correlation between mRNA-TSHR and sTg and US/WBS findings. Further studies with larger number of subjects and absolute quantification are needed for understanding the real meaning of mRNA-TSHR as a biomarker in DTC

Споредба на лапаро- ÑкопÑка херниоплаÑтика Ñо конвенционална техника кај женÑки деца Ñо индиректна ингвинална хернија

The study aims to compare the conventional open technique for treating inguinal hernia versus laparoscopic assisted technique of percutaneous closure of the internal inguinal ring in female children with clinically diagnosed indirect inguinal hernia. Materials and methods: The study is a prospective analytical (case control) study performed at the University Clinic for Pediatric Surgery in Skopje in the period 2015-16. Twenty  female children aged 1-14 years with clinically diagnosed indirect inguinal hernia were analyzed. Children from the experimental group were treated with laparoscopic hernia repair, and those from the control group with conventional techniques. Results: The average duration of the intervention in the experimental and control group was 27.6 ± 6.1 vs.64.8 ± 7.2 minutes. The length of hospital stay in the two groups was 10.8 ± 3.1 vs. 27.2 ± 4.2 hours. The shortest stay was 8 vs. 24 hours and the longest 18 vs. 36 hours. Fifty percent of the children in the experimental group took up a normal position in bed for less than 4 hours compared to the control group in which it happened in 9 hours. The average time to recovery from bed in the two groups was 4.1 ± 0.9 vs. 9.9 ± 1.8 hours with a minimum of 3 vs. 7 and maximum of 6 vs. 12 hours. The average length of the mark was 1.9 ± 0.9 mm in the experimental and 34.8 ± 17.4 mm in the control group. Analgesia because of pain was given to 2 (20%) children in the experimental group and to 8 (80%) in the control group. Easy impressive scar have 8 (80%) patients in the control group and no patient in the experimental group. The mark does not disturb the esthetics in 9 (90%) of patients in the experimental group and in 2 (20%) in the control group. Conclusion: Laparoscopic assisted technique of percutaneous closure of the internal inguinal ring with one port represents a minimally invasive method and ultimate achievement in this field for treatment of inguinal hernias in children, with special advantage in females.ИÑтражувањето има за цел да ги Ñпореди отворената конвенционална техника за третман на ингви- налните хернии наÑпроти лапароÑкопÑки аÑиÑтирана техника на перкутано затворање на внатреш- ниот ингвинален прÑтен кај женÑки деца Ñо клинички дијагноÑтицирана индиректна ингвинална хернија. Матерјал и методи: ИÑтражувањето претÑтавува проÑпективна аналитичка (case control) Ñтудија, Ñпроведенa на УниверзитетÑката клиника за детÑка хирургија во Скопје во периодот 2015-16. Опфатени Ñе 20 женÑки деца на возраÑÑ‚ од 1-14 години Ñо клинички дијагноÑтицирана индирекна ингвинална хернија. ИÑпитаниците од иÑпитуваната група Ñе третирани Ñо лапароÑкопÑка херни- оплаÑтика, а оние од контролната група Ñо конвенционална техника. Резултати: ПроÑечното време- трање на интервенцијата во иÑпитуваната, одноÑно контролната група изнеÑува 27,6±6,1 vs. 64,8±7,2 минути. Должината  на преÑтојот во болница во двете групи  Ð¸Ð·Ð½ÐµÑува  10,8±3,1 vs. 27,2±4,2 чаÑови. Ðајкраткиот преÑтој изнеÑува 8 vs. 24 чаÑа, а најдолгиот 18 vs. 36 чаÑа. ПедеÑет проценти од децата во иÑпитуваната група заземале нормална положба во кревет за помалку од 4 чаÑа Ñпоредено Ñо оние од контролната група кај кои тоа изнеÑувало 9 чаÑа. ПроÑечното време до вертикализација во кревет во двете групи изнеÑува 4,1±0,9 vs. 9,9±1,8 чаÑови Ñо минимум 3 vs. 7 и макÑимум 6 vs. 12 чаÑови. ПроÑечната должина на белегот изнеÑува 1,9±0,9 мм во иÑпитуваната и 34,8±17,4 мм во контролната група. Ðналгезија поради болка е дадена кај 2 (20%) од децата во иÑпитуваната и 8 (80%) од оние во контролната група. ЛеÑно впечатлив белег имаат 8 (80%) од пациентите во контролната група и ние- ден пациент од иÑпитуваната група. Белегот не ја нарушува еÑтетиката кај 9 (90%) од пациентите во иÑпитуваната група, и кај 2 (20%) од оние во контролната група. Заклучок: ЛапароÑкопÑки аÑиÑтирана техника на перкутано затворање на внатрешниот ингвинален канал Ñо еден порт претÑтавува мини- мално инвазивна метода за третман на ингвинални хернии во детÑка возраÑÑ‚ и врвно доÑтигнување во оваа проблематика, Ñо поÑебни предноÑти кај женÑките деца

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Tретман на венски малформации кај педијатриска популација – три-годишно искуство

Venous malformations (VMs) are a type of vascular malformations that result in abnormal development of veins that become extensible over time due to an error in vascular morphogenesis. They usually appear in newborns or in early adulthood as a bluish, soft, swollen and eventually painful skin formation. Treatment includes conservative therapy, sclerotherapy and surgical excision. Aim of the paper is to evaluate the therapeutic effect of scleraotherapy in pediatric patients with venous malformations. Material and methods: In a three-year period, from 2019 to 2021, venous malformation was found in 33 patients aged 4 to 14 years (average age: 8 years). Pain as a symptom occurred in 8 patients. Two patients had lesions measuring up to 5 cm and 5 cm respectively, while in the remaining subjects the lesion was over 5 cm. Ultrasound was performed routinely in all subjects, and MRI in two patients. Conservative treatment was instituted in 13 patients with venous malformations of the extremities, surgical excision with local reconstruction was performed in 11 patients, and sclerotherapy with bleomycin under general anesthesia was performed in 8 patients. Combined treatment was used in one patient that presented with venous malformation of the upper arm that underwent partial sclerotherapy with subsequent operative excision due to a phlebolith. Follow-up examinations revealed regression of the change not only from functional but from aesthetic aspect as well. Conclusion: Sclerotherapy is the established golden standard, first-line treatment for venous malformations. Excellent results were achieved as the reduction of the lesions was below 50% of the initial size. However, the modality of treatment should be individualized to each patient as it can sometimes require a combination of more than one treatment option. Venous malformations are best treated early, but they usually recur over time. Treatment helps relieve symptoms and control the growth of vascular malformations.Венските малформации се тип на васкуларни малформации што резултираат со  патолошки развој на вените, кои стануваат проширени со тек на време како резултат на нарушување во морфогенезата. Обично се манифестираат во новороденечка или рана адултна возраст како сини, меки, отечени и болни на палпација кожни формации. Третманот вклучува: конзервативна терапија, склеротерапија и хируршка ексцизија. Цел на трудот е да се евалуираат терапевтските ефекти од склеротерапијата кај педијатриски пациенти со венски малформации. Материјали и методи: Во 3-годишен период (2019-2021), венските малформации беа дијагностицирани кај 33 пациенти на возраст од 4 до 14 години (средна возраст: 8 години). Болка како симптом се јавила кај 8 пациенти. Кај двајца пациенти лезијата била поголема од 5 цм и еднаква на 5цм соодветно, додека кај  останатите пациенти лезиите биле под 5цм. Ултрасонографија била ординирана рутински кај сите пациенти и МРИ кај два пациенти. Конзервативниот третман беше ординиран кај 13 пациенти со венски малформации на екстремитетите, хируршка ексцизија со локална реконструкција кај 11 пациенти, додека кај 8 пациенти беше изведена склеротерапија со блеомицин во услови на општа анестезија. Комбинирана терапија се употреби кај еден пациент со клиничка слика на венска малформација на надлактица кај кого третманот вклучуваше парцијална склеротерапија со последователна оперативна ексцизија заради флеболит. Контролните прегледи покажаа регресија на промената, не само од функционален туку и од естетски аспект. Заклучок: Склеротерапијата е воспоставен „златен стандард“ и прва линија на третман на венските малформации. Одлични резултати се постигнаа со оглед на редукција на лезијата под 50% од иницијалната големина. Сепак овој тип на третман потребно е да се индивидуализира за секој пациент, со оглед на тоа што побарува комбинација на повеќе од еден тераписки модалитет. Венските малформации најоптимално се лекуваат рано со оглед на тенденцијата за рекурентност. Со помош на третманот се подобруваат симптомите и се контролира растот на венските малформации