Ascending septic pylephlebitis with liver abscess development due to appendicitis in an 11-months old infant

The development of septic ascending pylephlebitis secondary to gangrenous appendicitis resulting in the development of liver abscess is a rare complication especially in infancy. In this study we refer to an infant 11 months old with the above clinical entity treated successfully in our clinic. Due to this rare occasion, we reviewed recent literature, aiming at the consolidation of clinical and prognostic parameters

Βilocular cystic ileal duplication

The aim of this study is to present two rare entities: a) a bilocular cystic intestinal duplication and b) the oc­currence of bleeding from the duplication due to lesions associated with chronic hemorrhagic enteritis rather than ectopic gastric mucosa. A 13-year-old male was hospitalized in the Department of Pediatrics for severe lower GI hemorrhage. During neonatal life, the boy had been hospitalized in the Intensive Care Neonatal Unit for necrotizing enterocolitis treated by peritoneal drainage (drains entered into iliac fossae bilaterally). Imaging and scintigraphic exams failed to identify the cause of the current GI hemorrhage. After a second episode of bleeding, pediatricians asked for a pediatric surgical consult and we decided to proceed to an urgent exploratory laparotomy. A diverticular lesion of considerable size and with a wide base was identified 30 cm proximal to the ileocecal valve at the antimesenteric intestinal surface. The lateral wall of the lesion was adhered to the sigmoid colon while its upper surface was adhered to the lateral abdominal wall. Our attempt to mobilize the small bowel from the sigmoid colon revealed the absence of muscular layers in both the small and large bowel walls for a length of 1.5 cm. Segmental intestinal resection including the duplication was performed followed by an end to end anastomosis in two layers. The histopathologic examination showed a bilocular cystic duplication with lesions of active chronic hemorrhagic enteritis; no ectopic gastric mucosa was identified

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Histopathologic changes in the intestinal wall, bacterial translocation and malnutrition in a rat model of Hirschsprung's disease

PURPOSE: The most common and most severe complication of Hirschsprung's disease is enterocolitis. The pathogenesis of enterocolitis has not been determined and many hypotheses regarding its etiology have been proposed. The aim of this experimental study is to investigate the incidence of bacterial translocation in a rat model of Hirschsprung's disease and to correlate it with histological findings, sepsis and biometric markers. MATERIALS AND METHODS: The animals were randomly assigned to four groups as follows: N (Normal), S (Sham), M20 (Megacolon20), M25 (Megacolon25). The animals of groups M20 (n=23) and M25 (n=23) were injected with 0.1% benzalkonium chloride solution in deionized water. Sham animals (S) (n=8) were subjected to the same procedure using 0.9% NaCl solution instead of benzalkonium chloride solution. There was no intervention in group N (n=8) animals.The animals were sacrificed on the 20th or 25th day after injection and we examined (1) the histopathologic changes in the intestinal wall (2) the presence of bacterial translocation (3) the body biometrics and (4) albumin concentration in blood, white blood cell counts, platelets counts and hemoglobin levels. Results were compared with sham animals. RESULTS: In M20 and M25 rats, severe intestinal injury (atrophy, necrosis) and bacterial translocation of E.coli, Enterococcus spp, Bacillus, Proteus mirabilis and Clostridium spp, proportional to the extent of the intestinal damage and to the time elapsed after the ablation were observed. Were also, observed significant effects on the body weight and height and systematic effects, such as increase in platelets, in WBC and neutrophil counts, decrease in hemoglobin concentration, hypoalbuminemia and restraint of somatic growth. CONCLUSIONS: Chemical rectal ablation of the rat resulted in intestinal mucosa barrier disruption, translocation of intestinal bacteria to organs both nearby and distally located to the intestine, malnutrition and sepsis. Were also, observed gradual deterioration of all parameters in 5 days interval.ΣΚΟΠΟΣ: Η εντεροκολίτιδα είναι η πιο σοβαρή επιπλοκή της νόσου του Hirschsprung. Παρά το γεγονός ότι έχουν προταθεί διάφορες θεωρίες η παθοφυσιολογία της δεν είναι πλήρως διευκρινισμένη. Σκοπός της διδακτορικής διατριβής είναι να καταδείξει πιθανούς παθοφυσιολογικούς μηχανισμούς με τους οποίους η αγγαγλίωση του παχέος εντέρου και η επακόλουθη εντερική στάση, μπορεί να προκαλέσει εντερική βλάβη σε απόσταση από τη στάση, σήψη και υποθρεψία. ΥΛΙΚΟ- ΜΕΘΟΔΟΣ: Για το σκοπό αυτό μελετήθηκαν συνολικά 62 επίµυες φυλής Wistar, ηλικίας 28 ημερών και βάρους 165-170 g. Τα πειραματόζωα χωρίστηκαν µε τυχαιοποιημένο τρόπο σε 4 οµάδες N (Normal), S (Sham), M20 (Megacolon20), M25 (Megacolon25). Στις ομάδες M20 (n = 23) και M25 (n = 23) προκλήθηκε χημικό μεγάκολο με υποβλεννογόνια έγχυση χλωριούχου βενζαλκόνιου 0,1% στο ορθό. Στην ομάδα S (n = 8) πραγματοποιήθηκε υποβλεννογόνια έγχυση NaCl 0,9% στο ορθό. Στην ομάδα N (n = 8) δεν έγινε καμία παρέμβαση. Την 20η και την 25η ημέρα μετά την παρέμβαση αντίστοιχα έγινε ευθανασία των πειραματόζωων και λήψη δειγμάτων ιστών και αίματος. Μελετήθηκαν και βαθμονομήθηκαν τυχόν αλλοιώσεις του τοιχώματος του λεπτού εντέρου (ειλεός). Η ταυτοποιήθηκαν μικρόβια σε έξωεντερικούς ιστούς (πνεύμονες, ήπαρ, σπλήνας, νεφρός, πνεύμονες, πάγκρεας, μεσεντέριοι λεμφαδένες και αίμα) αλλά και στο περιεχόμενο του τυφλού. Καταμετρήθηκε η αλβουμίνη, τα λευκά αιμοσφαίρια, η αιμοσφαιρίνη και τα αιμοπετάλια του αίματος. Επίσης καταγράφηκαν βιομετρικοί δείκτες (βάρος, ύψος, περίμετρος κοιλιάς), η κατανάλωση τροφής και η αποβολή κοπράνων. Όλες οι μετρήσεις έγιναν στην αρχή και στο τέλος του πειράματος. ΑΠΟΤΕΛΕΣΜΑΤΑ: Στις ομάδες Μ20 και Μ25 η εντερική δομή υπέστη σταδιακά σοβαρή βλάβη (ατροφία, νέκρωση) και φλεγμονώδη διήθηση. Επίσης στις ομάδες Μ20 και Μ25 παρατηρήθηκε εντερική βακτηριακή μετακίνηση των E.coli, Enterococcus spp, Bacillus, Proteus mirabilis και Clostridium spp. Το βακτήριο E.coli απομονώθηκε σε υψηλότερη συχνότητα σε σύγκριση με άλλα βακτήρια. Το σωματικό βάρος και ύψος των πειραματοζώων των ομάδων M20 και M25 παρέμεινε σημαντικά χαμηλότερο σε σύγκριση με τις γαγγλιονικές ομάδες Ν και S στο τέλος του πειράματος. Επιπλέον τα πειραματόζωα των ομάδων Μ20 και Μ25 παρουσίασαν σημαντική αύξηση στον αριθμό των αιμοπεταλίων, των λευκών αιμοσφαιρίων όπως και των ουδετερόφιλων (NEU) και μείωση της συγκέντρωσης αιμοσφαιρίνης και της αλβουμίνης σε σύγκριση με τις ομάδες Ν και S στο τέλος του πειράματος. ΣΥΜΠΕΡΑΣΜΑΤΑ: Η μελέτη μας δείχνει ότι η αγαγγλίωση τμήματος του ορθού προκαλεί βαθμιαία επιδεινούμενη βλάβη και φλεγμονή του εντερικού τοιχώματος, καταστροφή του βλεννογόνιου εντερικού φραγμού, εντερική βακτηριακή μετακίνηση, σήψη και υποθρεψία

Intramuscular hemangioma in the anterior scalene muscle in an infant boy: a case report

The extremely rare localization of an intramuscular hemangioma (IMH) into the anterior scalene muscle was the motive for the present case report, aiming to highlight major, atypical characteristics. An 11-month-old boy with free medical history presented with a painless and progressively growing lesion 4.5 × 4 cm in diameter, located in the left supraclavicular region over the last 4 months. During physical examination, the presence of a painless, non-pulsating, non-adhesive to the overlying skin lesion was documented. Color Doppler flow ultrasonographic examination demonstrated the increased blood supply to the aforementioned lesion. Thus, we planned an elective surgical excision of the lesion in healthy limits. The postoperative course was uneventful, and the patient was discharged on the second postoperative day in good general condition. Histopathologic examination revealed the presence of hemangioma surrounded by connective tissue bundles and striated muscle fibers. IMHs do not follow the general rule of regression, beyond the age of 6–12 months, with no trend to increase over time. Accurate preoperative diagnosis is challenging. Color Doppler flow ultrasonographic examination is the imaging modality of choice during the preoperative assessment. Surgical excision of the IMH in healthy limits is the most appropriate treatment option

Early diagnosis and surgical intervention untie the Gordian knot in newborns with colonic atresia: report of two cases and review of the literature

Incidence of colonic atresia in living infants ranges from 1:5,000 to 1:60,000 (average 1:20,000). It constitutes 1.8 to 15% of all cases of atresia of the gastrointestinal tract. In 58.56–75% of all cases is right-sided. We aim, through the presentation of two cases of colonic atresia which we encountered and after systematic research of the current literature, at addressing three major issues: diagnostic approach, operative strategy and management of the prognostic parameters of the colonic atresia. The common parameter in these two cases was the early diagnosis, which played a significant role in the uncomplicated postoperative course. The first case was a type I sigmoid atresia. Contrast’s escape during contrast enema examination due to accidental rupture of the distal part of the colon led to diagnosis. Side-to-side anastomosis, restoration of the rupture and a central loop sigmoidostomy were urgently performed. The second case was a type III atresia at the level of the ascending colon, which was early diagnosed via pregenital ultrasonography, in which colonic dilation was depicted. Restoration of the intestinal continuity early after birth was performed at a time. In conclusion, we believe that early diagnosis, selection of the appropriate operative strategy and prompt recognition of potential post-operative complications, especially rupture of the anastomosis, contribute to the optimization of the prognosis in patients with colonic atresia

Fusiform Cervical Mass in a 6-Year Old Boy; Do not Forget the Thymic Cyst

Cervical thymic cyst is a rare clinical entity, with approximately one hundred cases reported in the literature so far. The purpose of this case report is to highlight some certain features, along with an extensive research of the relevant literature. A 6-year-old boy was admitted to the Otorhinolaryngology Department due to the presence of a left-sided, painless, latero-cervical swelling, first observed by his parents 2 weeks ago. Physical examination revealed a painless, well-delineated mass, with no signs of inflammation. No enlarged cervical nodes were present. The mass extended from the mandibular angle, under the sternocleidomastoid muscle, in proximity with the ipsilateral neurovascular bundle. Ultrasound transverse gray-scale panoramic view detected a wellcircumscribed lesion, with fine echogenic foci, appearing in close proximity with the upper pole of the left thyroid lobe and the ipsilateral common carotid artery. Elective surgical intervention with complete mass excision was performed. Histopathological examination confirmed the diagnosis of a cervical thymic cyst. Cervical thymic remnants represent a group of neck masses that pediatricians and pediatric surgeons should consider in differential diagnosis of both cystic and solid neck masses. Most cystic cervical thymic masses are found in the lower third of the anterior neck, extending deep to the sternocleidomastoid muscle, featuring close anatomic relationship with the composites of the ipsilateral carotid sheath. Elective surgery is kept as the treatment of choice, after ruling out the possibility of subject immunologic disturbance.</jats:p

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

Background: This study assessed the potential cost-effectiveness of high (80–100%) vs low (21–35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was$216 compared with $222 for low FiO2 leading to a −$6 (95% confidence interval [CI]: −$13 to −$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with$195 for low FiO2 leading to a −$11 (95$15 to −$6) difference in costs. In South Africa, the average cost for high FiO2 was$1164 compared with $1257 for low FiO2 leading to a −$93 (95% CI: −$132 to −$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a −1.05 (95% CI: −1.14 to −0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this