Staged imaging pathway for the evaluation of pediatric appendicitis

Purpose

Despite significant radiation exposure involved with computed tomography (CT) in evaluation of pediatric appendicitis, its use is still widespread. The goal of this study was to assess the effect of a staged imaging pathway for appendicitis to significantly decrease CT use while maintaining diagnostic accuracy.

Methods

Chart review was performed for patients evaluated for appendicitis over a 12-month period prior to and after pathway implementation.

Results

There was a significant decrease in CT use as initial imaging after implementation of the pathway; 87.1–13.4 % for evaluations positive for appendicitis (decrease 84.6 %, p < 0.0001) and 82.6–9.2 % for evaluations negative for appendicitis (decrease 88.9 %, p < 0.0001). Use of CT during any point in the evaluation decreased from 91.7 to 25.1 % (decrease 72.6 %, p < 0.0001). The negative appendectomy rate was similar; 5.4 % prior, 4.9 % post (p = 0.955). The missed appendicitis rate did not statistically change; 1.1 % prior, 3.7 % post (p = 0.523). The perforation rate was not statistically altered; 6.5 % prior; 9.8 % post (p = 0.421). 350 less patients underwent CT during the year following the pathway.

Conclusions

The staged imaging pathway resulted in a marked decrease in children exposed to CT without compromising diagnostic accuracy.

     

Deep sedation in pediatric imaging: efficacy and safety of intravenous chlorpromazine

Background

The quality of MRI and CT depends largely on immobility of the patient during the procedure, which is often difficult to achieve without sedation in children below the age of 6 years.

Objective

To assess the efficacy and safety of intravenous chlorpromazine sedation for repeated imaging in young children treated for cancer.

Materials and methods

From July 2003 to January 2007, information on children younger than 6 years of age having MRI or CT was prospectively collected. Forty-five minutes before the scan, a 10-min infusion of chlorpromazine 0.5 mg/kg was administered and managed by non-anesthetic staff. Patient monitoring included continuous measurement of pulse, respiration, oxygen saturation and arterial blood pressure. Procedure-related parameters and adverse events were documented. Sedation was considered successful when the procedure was completed and at least 95% of images were usable.

Results

One-hundred-one procedures (82 MRI, 19 CT) were evaluated in 62 children, 3–74 months old. Adequate sedation was achieved in 96% of cases, with mean induction time, 22 min; mean duration of sleep, 72 min, and mean duration of procedure, 33 min. Mean time spent in the radiology unit was 104 min. Ninety-six percent of imaging procedures were successfully completed. No cardiac, respiratory, neurological or allergic complication occurred.

Conclusion

Intravenous chlorpromazine is safe and effective for procedural sedation in young children with cancer undergoing MRI and CT.

     

Focused CT using a height-adjusted metric and the umbilicus as a landmark for children undergoing evaluation for appendicitis

Background

Confirmation of appendicitis in children often requires CT. A focused CT scan that is limited to the lower abdomen/pelvis might help to reduce radiation exposure.

Objective

To determine the position of the appendix relative to the umbilicus and derive a height-adjusted threshold for a focused CT that would identify most appendices.

Materials and methods

We conducted a retrospective study of children younger than 18 years who underwent a CT scan for suspected appendicitis. A pediatric radiologist determined the distance from the most cephalad portion of the appendix to the center of the umbilicus. This distance was divided by the child’s height to create a ratio for each child. We then assessed the largest of these distance/height ratios (“height constants”) as potential height-adjusted thresholds that, when multiplied by any patient’s height, would yield the superior threshold for the focused CT scan. Radiation reduction was calculated as percentage decrease in scan length compared to a complete abdominopelvic CT.

Results

Of 270 patients whose entire appendix was identified on CT, all were identified within 10.5 cm above the umbilicus. A focused CT using a height constant of 0.07 identified 100% of the appendices visualized on the complete CT scan and resulted in an estimated mean percentage radiation reduction of 27% (standard deviation [SD] +/-4.7). If a height constant of 0.03 was used, 97% of appendices were identified and the estimated radiation reduction was 43% (SD +/-4.3).

Conclusion

A height-adjusted focused abdominopelvic CT scan might reduce radiation exposure without sacrificing the diagnostic accuracy of the complete CT scan.

     

Urinary biomarkers in pediatric appendicitis

Purpose

The diagnosis of pediatric appendicitis is still a challenge, resulting in perforation and negative appendectomies. The aim of this study was to evaluate novel biomarkers in urine and to use the most promising biomarkers in conjunction with the Pediatric Appendicitis Score (PAS), to see whether this could improve the accuracy of diagnosing appendicitis.

Methods

A prospective study of children with suspected appendicitis was conducted with assessment of PAS, routine blood tests, and measurements of four novel urinary biomarkers: leucine-rich α-2-glycoprotein (LRG), calprotectin, interleukin 6 (IL-6), and substance P. The biomarkers were blindly determined with commercial ELISAs. Urine creatinine was used to adjust for dehydration. The diagnosis of appendicitis was based on histopathological analysis.

Results

Forty-four children with suspected appendicitis were included, of which twenty-two (50 %) had confirmed appendicitis. LRG in urine was elevated in children with appendicitis compared to children without (p < 0.001), and was higher in children with gangrenous and perforated appendicitis compared to those with phlegmonous appendicitis (p = 0.003). No statistical significances between groups were found for calprotectin, IL-6 or substance P. LRG had a receiver operating characteristic area under the curve of 0.86 (95 % CI 0.79–0.99), and a better diagnostic performance than all routine blood tests. LRG in conjunction with PAS showed 95 % sensitivity, 90 % specificity, 91 % positive predictive value, and 95 % negative predictive value.

Conclusion

LRG, adjusted for dehydration, is a promising novel urinary biomarker for appendicitis in children. LRG in combination with PAS has a high diagnostic performance.

     

Computed tomography localization of the appendix in the pediatric population relative to the lumbar spine

Background

Computed tomography (CT) is commonly used to evaluate suspected acute appendicitis. Although very effective, CT uses ionizing radiation, exposing patients to an increased risk of cancer.

Objective

This study assessed the potential for decreasing the field of view of the CT (and therefore the dose to the patient) in the evaluation of suspected acute appendicitis in children.

Materials and methods

This study was a retrospective review of prospectively collected data from 212 consecutive patients who underwent CT for suspected acute appendicitis. The most superior aspect of the appendix with respect to vertebral bodies was recorded. Age, gender and diagnosis (negative, acute appendicitis or alternative diagnosis) were noted.

Results

The appendix was visualized in 190 of 212 subjects (89.6%). Overall, all visualized appendixes were located at or below the level of L1. Sixty-three of the subjects (29.7%) were diagnosed with acute appendicitis via CT imaging. All appendixes in patients with acute appendicitis were located at or below the level of the L3 vertebral body, predominating at the level of L5. Six subjects (3.1%) received alternative diagnoses, including pneumonia, pyelonephritis, small bowel obstruction and infected urachal cyst. There were no differences in appendix location with regard to diagnosis, gender, or age (P=0.664, 0.748 and 0.705, respectively).

Conclusion

CT field of view may be decreased to the level of L1 or L3 superiorly, decreasing radiation dose without affecting the rate of appendix visualization.

     

Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and a high risk of perforation

Background

Appendicolith can cause appendiceal obstruction and acute appendicitis. Its high prevalence may be related to the high perforation rate in pediatric appendicitis. This study assessed the characteristics of appendicolith and its clinical significance in pediatric appendicitis.

Methods

A retrospective study was performed among children and adolescents younger than 17 years who were preoperatively diagnosed with appendicitis in the pediatric emergency department (ED). A total of 269 patients with a mean age of 9.98 ± 3.37 years were enrolled. Clinical features and contrast-enhanced computed tomography findings were analyzed.

Results

Among the 269 patients, 147 (54.6%) had appendicoliths, with a mean maximal diameter of 5.21 ± 2.34 mm. Compared to the no appendicolith group, the appendicolith group demonstrated more prolonged abdominal pain (≥ 48 hours) before the ED visit (23.1% vs. 11.5%; P = 0.013), clinical features of severe appendicitis (presence of fever, vomiting, positive urine ketone, and increased C-reactive protein), and higher rate of perforation (43.5% vs. 9.8%; P < 0.001). Multivariate risk factor analysis for perforated appendicitis in the appendicolith group revealed that maximal diameter of 5 mm or more in the appendicolith (adjusted odds ratio [aOR] 2.919; 95% CI 1.325–6.428, P = 0.008) and proximal collapse adjacent to the appendicolith (aOR 2.943; 95% CI 1.344–6.443, P = 0.007) were significant.

Conclusions

Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and severe clinical conditions with a high risk of perforation.

     

Clinical safety of 3-T brain magnetic resonance imaging in newborns

Background

The effects and potential hazards of brain magnetic resonance imaging (MRI) at 3 T in newborns are debated.

Objective

Assess the impact of 3-T MRI in newborns on body temperature and physiological parameters.

Material and methods

Forty-nine newborns, born preterm and at term, underwent 3-T brain MRI at term-corrected age. Rectal and skin temperature, oxygen saturation and heart rate were recorded before, during and after the scan.

Results

A statistically significant increase in skin temperature of 0.6 °C was observed at the end of the MRI scan (P<0.01). There was no significant changes in rectal temperature, heart rate or oxygen saturation.

Conclusion

Core temperature, heart rate and oxygen saturation in newborns were not affected by 3-T brain MR scanning.

     

Dose optimisation for intraoperative cone-beam flat-detector CT in paediatric spinal surgery

Background

During surgery for spinal deformities, accurate placement of pedicle screws may be guided by intraoperative cone-beam flat-detector CT.

Objective

The purpose of this study was to identify appropriate paediatric imaging protocols aiming to reduce the radiation dose in line with the ALARA principle.

Materials and methods

Using O-arm® (Medtronic, Inc.), three paediatric phantoms were employed to measure CTDI_w doses with default and lowered exposure settings. Images from 126 scans were evaluated by two spinal surgeons and scores were compared (Kappa statistics). Effective doses were calculated. The recommended new low-dose 3-D spine protocols were then used in 15 children.

Results

The lowest acceptable exposure as judged by image quality for intraoperative use was 70 kVp/40 mAs, 70 kVp/80 mAs and 80 kVp/40 mAs for the 1-, 5- and 12-year-old-equivalent phantoms respectively (kappa = 0,70). Optimised dose settings reduced CTDI_w doses 89–93%. The effective dose was 0.5 mSv (91–94,5% reduction). The optimised protocols were used clinically without problems.

Conclusions

Radiation doses for intraoperative 3-D CT using a cone-beam flat-detector scanner could be reduced at least 89% compared to manufacturer settings and still be used to safely navigate pedicle screws.

     

Structural and perfusion magnetic resonance imaging of the lung in cystic fibrosis

Background

Because of its absence of ionising radiation and possibility for obtaining functional information, MRI is promising for assessing lung disease in children who require repetitive imaging for long-term follow-up.

Objective

To describe MRI findings in children with cystic fibrosis and evaluate semi-quantitative dynamic contrast-enhanced lung perfusion.

Materials and methods

We retrospectively compared lung MRI in 25 children and young adults with cystic fibrosis (median age 3.7 years) to 12 children (median age 2 years) imaged for other pathologies. MRI at 1.5 T included respiratory-gated sequences and contrast-enhanced lung perfusion imaging. We described and graded any morphologic change. Signal enhancement and time to peak values of perfusion abnormalities were compared to those of normally enhancing lung parenchyma.

Results

Frequent findings in patients with cystic fibrosis were bronchial wall thickening (24/25, 96%), areas of consolidation (22/25, 88%), enlarged lymph nodes (20/25, 80%), bronchiectasis (5/25, 20%) and mucus plugging (3/25, 12%). Compared to normally enhancing lung, perfusion defects (21/25, 84%), characterised by decreased enhancement, showed prolonged time to peak. Areas of consolidation showed increased enhancement. While time to peak of procedure-related atelectasis was not significantly different from that of normal lung, disease-related consolidation showed prolonged time to peak (P=0.01).

Conclusion

Lung MRI demonstrates structural and perfusion abnormalities in children and young people with cystic fibrosis. Semi-quantitative assessment of dynamic contrast-enhanced perfusion imaging might allow differentiation between procedure-related atelectasis and disease-related consolidation.

     

The non-visualized appendix and secondary signs on ultrasound for pediatric appendicitis in the community hospital setting

Background

Secondary signs of appendicitis on ultrasound may aid with diagnosis in the setting of a non-visualized appendix (NVA). This role has not been shown in the community hospital setting.

Materials and methods

All right lower quadrant ultrasounds performed in children for clinical suspicion of appendicitis over a 5-year period in a single community hospital were evaluated. Secondary signs of inflammation including free fluid, ileus, fat stranding, abscess, and lymphadenopathy were documented. Patients were followed for 1 year for the primary outcome of appendicitis. These data were analyzed to determine the utility of secondary signs in the diagnosis of acute appendicitis when an NVA is reported.

Results

Six hundred and seventeen ultrasounds were reviewed; 470 of these had an NVA. Of NVAs, 47 (10%) of patients were diagnosed with appendicitis. Sensitivity and specificity of having at least one secondary were 38.3% and 80%, respectively. The positive and negative predictive values of having at least one secondary sign were 17.3% and 92%, respectively.

Conclusion

These data suggest that the absence of secondary signs has a strong negative predictive value for appendicitis in the community hospital setting; however, the full utility of secondary signs may be limited in this setting.

     

Maturation of pelvic ossification centers on computed tomography in normal children

Background

The pelvis is composed of three paired primary ossification centers: the pubis, the ischium and the ilium. During maturation, multiple secondary ossification centers can be seen in the synchondroses between these bones and in the pelvic apophyses. The fragmented appearance of these centers can be confused with pathology.

Objective

To examine development of pelvic ossification centers by CT and determine normal appearance throughout childhood.

Materials and methods

Three pediatric radiologists reviewed 325 pelvic CT scans in children and young adults 5–18 years old and graded 6 pelvic ossification centers to evaluate maturational changes in critical structures.

Results

Rate and progression of ossification and age at complete fusion vary with gender at the different ossification centers in the growing pelvis.

Conclusion

Knowledge of the normal CT appearance of ossification centers throughout childhood is important to differentiate the normal appearance from pathology.

     

Multimodality imaging findings of massive ovarian edema in children

Background

Massive ovarian edema is a rare benign condition that predominantly affects childbearing women as well as preadolescent girls. It is thought to result from intermittent or partial torsion of the ovary compromising the venous and lymphatic drainage but with preserved arterial supply. The clinical features of massive ovarian edema are nonspecific and can simulate tumors, leading to unnecessary oophorectomy.

Objective

To demonstrate imaging features that should alert radiologists to consider the diagnosis of massive ovarian edema preoperatively so that fertility-sparing surgery may be considered.

Materials and methods

We identified five girls diagnosed with massive ovarian edema at pathology. Presenting symptoms, sidedness, imaging appearance, preoperative diagnosis, and operative and histopathological findings were reviewed.

Results

Age range was 9.6–14.3 years (mean age: 12.5 years). Common imaging findings included ovarian enlargement with edema of the stroma, peripherally placed follicles, isointense signal on T1-W MRI and markedly hyperintense signal on T2-W MRI, preservation of color Doppler flow by US, and CT Hounsfield units below 40. The uterus was deviated to the affected side in all patients. Two of the five patients had small to moderate amounts of free pelvic fluid. Mean ovarian volume on imaging was 560 mL (range: 108-1,361 mL).

Conclusion

While the clinical presentation of massive ovarian edema is nonspecific, an enlarged ovary with stromal edema, peripherally placed follicles and preservation of blood flow may be suggestive and wedge biopsy should be considered intraoperatively to avoid unnecessary removal of the ovary.

     

Intravoxel incoherent motion magnetic resonance imaging of the knee joint in children with juvenile idiopathic arthritis

Background

MRI of synovitis relies on use of a gadolinium-based contrast agent. Diffusion-weighted MRI (DWI) visualises thickened synovium but is of limited use in the presence of joint effusion.

Objective

To investigate the feasibility and diagnostic accuracy of diffusion-weighted MRI with intravoxel incoherent motion (IVIM) for diagnosing synovitis in the knee joint of children with juvenile idiopathic arthritis.

Materials and methods

Twelve consecutive children with confirmed or suspected juvenile idiopathic arthritis (10 girls, median age 11 years) underwent MRI with contrast-enhanced T1-weighted imaging and DWI at 1.5 T. Read-out segmented multi-shot DWI was acquired at b values of 0 s/mm², 200 s/mm², 400 s/mm² and 800 s/mm². We calculated the IVIM parameters perfusion fraction (f) and tissue diffusion coefficient (D). Diffusion-weighted images at b=800 s/mm², f parameter maps and post-contrast T1-weighted images were retrospectively assessed by two independent readers for synovitis using the Juvenile Arthritis MRI Scoring system.

Results

Seven (58%) children showed synovial hypertrophy on contrast-enhanced imaging. Diagnostic ratings for synovitis on DWI and on f maps were fully consistent with contrast-enhanced imaging, the diagnostic reference. Two children had equivocal low-confidence assessments on DWI. Median f was 6.7±2.0% for synovitis, 2.1±1.2% for effusion, 5.0±1.0% for muscle and 10.6±5.7% for popliteal lymph nodes. Diagnostic confidence was higher based on f maps in three (25%) children and lower in one child (8%), as compared to DWI.

Conclusion

DWI with IVIM reliably visualises synovitis of the knee joint. Perfusion fraction maps differentiate thickened synovium from joint effusion and hence increase diagnostic confidence.

     

Neonatal gastrointestinal perforation in Japan: a nationwide survey

Purpose

The purpose of this study is to identify the current clinical features of neonatal gastrointestinal perforation in Japan.

Methods

A questionnaire about cases of neonatal gastrointestinal perforation treated in recent 5 years was sent to participating institutions of the Japanese Society of Pediatric Surgeons (JSPS).

Results

Five hundred and thirty-six neonates with gastrointestinal perforation were treated. They consisted of 42 patients with gastric rupture/perforation (GR), 33 patients with intestinal atresia/stenosis (IA), 3 patients with malrotation (ML), 118 patients with necrotizing enterocolitis (NEC), 160 patients with focal intestinal perforation (FIP), 46 patients with meconium-related ileus (MRI), 77 patients with meconium peritonitis (MP), and 57 patients with other conditions. The total mortality rate was 20.5 %. The mortality rates of the patients with GR, IA, ML, NEC, FIP, MRI, and MP were 9.5, 9.1, 0, 33.1, 20.6, 28.2, and 9.1 %, respectively. In 263 cases involving extremely low-birth-weight neonates (ELBW), 108 died (mortality rate 41.1 %). The mortality rates for ELBW with GR, NEC, FIP, MRI, MP, and other conditions were 27.3 % (3/11), 58.5 % (48/82), 21.6 % (24/111), 70.6 % (24/34), 57.1 % (4/7), and 27.8 % (5/18), respectively.

Conclusions

The mortality rates for ELBW decreased from 62.8 % in the previous survey to 41.1 % by the time of this survey.

     

Understanding parental refusal of permission for child participation in surgical prospective trials

Purpose

The success of prospective randomized trials relies on voluntary participation, which has been perceived as a barrier for successful trials in children who rely on parental permission. We sought to identify the reasons parents decline child participation to understand potential limitations in the consent process.

Methods

A prospective observational study was conducted in 92 patients asked to participate in prospective randomized trials between 2012 and 2015. Parental reasons for refusal were documented.

Results

The 92 refusals were distributed between studies investigating the management of circumcision, gastroschisis, pectus excavatum, appendicitis, pyloric stenosis, undescended testicles, abdominal abscess and gastroesophageal reflux. Reasons for refusal included preference of treatment path (37 %), inability to follow up (21 %), unspecified resistance to participate in research (18 %), preference to maintain independent surgeon decision (16 %), and desire for historically standard treatment (8 %). Of the families who opted to pursue a specific treatment arm rather than randomization, 35 % had prior experience with that treatment, 32 % had researched the procedure, 18 % wished to pursue the minimal intervention and 15 % did not specify.

Conclusions

Parental preference of therapy is the most common reason for refusal of study participation. This variable could be influenced with more effective explanation of study rationale and existing equipoise.

     

Subjective and objective image differences in pediatric computed tomography cardiac angiography using lower iodine concentration

Background

Several recent studies showed the optimal contrast enhancement with a low-concentration and iso-osmolar contrast media in both adult and pediatric patients. However, low contrast media concentrations are not routinely used due to concerns of suboptimal enhancement of cardiac structures and small vessels.

Objective

To evaluate the feasibility of using iso-osmolar contrast media containing a low iodine dose for CT cardiac angiography at 80 kilovolts (kVp) in neonates and infants.

Materials and methods

The iodixanol 270 group consisted of 79 CT scans and the iopromide 370 group of 62 CT scans in patients ≤1 year old. Objective measurement of the contrast enhancement was analyzed and contrast-to-noise ratios of the ascending aorta and left ventricle were calculated. Regarding subjective measurement, a four-point scale system was devised to evaluate degrees of contrast enhancement, image noise, motion artifact and overall image quality of each image set. Reader performance for correctly differentiating iodixanol 270 and iopromide 370 by visual assessment was evaluated.

Results

Group objective and subjective measurements were nonsignificantly different. Overall sensitivity, specificity and diagnostic accuracy for correctly differentiating iodixanol 270 and iopromide 370 by visual assessment were 42.8%, 59%, and 50%, respectively.

Conclusion

The application of iodixanol 270 achieved optimal enhancement for performing pediatric cardiac CT angiography at 80 kVp in neonates and infants. Objective measurements of contrast enhancement and subjective image quality assessments were not statistically different in the iodixanol 270 and iopromide 370 groups.

     

Correlation among Magnetic Resonance Imaging Parameters of Brain in Preterm Neonates at Term Equivalent Age

Objectives

To assess the spectrum of Magnetic Resonance Imaging (MRI) abnormalities among preterm babies at term equivalent age using objective scoring and to study the association among MRI variables.

Methods

Ninety-four preterm babies born at ≤32 wk of gestation and / or birth weight ≤ 1500 g at term equivalent age who underwent cranial MRI between April 2011 and August 2012 and the MRI interpreted by experienced radiologists were studied. In 2014, the MRI was retrospectively re-interpreted by the same radiologists using an objective scoring system described by Kidokoro. Spectrum of MRI abnormalities, their association with perinatal variables and correlation among white matter (WM), grey matter and cerebellar scores were analyzed.

Results

MRI abnormalities observed were WM signal abnormality (24 %), lateral ventricular dilatation (16 %), WM cystic abnormality (13 %), deep grey matter signal abnormality (9 %), cerebellar volume reduction (9 %) and deep grey matter volume reduction (8 %). Sepsis was significantly associated with occurrence of WM and cerebellar abnormalities (p < 0.05). WM scores did not show significant correlation with cortical grey matter and deep grey matter scores while cerebellar scores showed a weak positive correlation with WM (r = 0.33), cortical grey matter (r = 0.27) and deep grey matter scores (r = 0.22).

Conclusions

MRI abnormalities are common in preterm infants, with 60 % showing some abnormality at term equivalent age. Among perinatal characteristics, sepsis was identified as risk factor for WM and cerebellar injury. Grey matter abnormality occurs independent of WM abnormality. Cerebellar abnormalities appear to coexist with either WM or grey matter changes.

     

Re-evaluation of liver transaminase cutoff for CT after pediatric blunt abdominal trauma

Purpose

Current guidelines for computed tomography (CT) after blunt trauma were developed to capture all intra-abdominal injuries (IAI). We hypothesize that current AST/ALT guidelines are too low leading to unnecessary CT scans for children after blunt abdominal trauma (BAT).

Methods

Patients who received CT of the abdomen after blunt trauma at our Level I Pediatric Trauma Center were stratified into a high risk (HR) (liver/spleen/kidney grade ≥III, hollow viscous, or pancreatic injuries) and low risk (LR) (liver/kidney/spleen injuries grade ≤II, or no IAI) groups.

Results

247 patients were included. Of the 18 patients in the HR group, two required surgery (splenectomy and sigmoidectomy). Transfusion was required in 30% of grade III and 50% of grade IV injuries. Eleven (5%) patients in LR group were transfused for indications other than IAI, and none were explored surgically. Both AST (r = 0.44, p < 0.001) and ALT (r = 0.43, p < 0.001) correlated with grade of liver injury. Using an increased threshold of AST/ALT, 400/200 had a negative predictive value of 96% in predicting the presence of HR liver injuries.

Conclusion

The current cutoff of liver enzymes leads to over-identification of LR injuries. Consideration should be given to an approach that aims to utilize CT in pediatric BAT that identifies clinically HR injury.

     

Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children

Background

Fundoplication is considered a mainstay in the treatment of gastro-esophageal reflux. However, the literature reports significant recurrences and limited data on long-term outcome.

Aims

To evaluate our long-term outcomes of antireflux surgery in children and to assess the results of redo surgery.

Methods

We retrospectively analyzed all patients who underwent Nissen fundoplication in 8 consecutive years. Reiterative surgery was indicated only in case of symptoms and anatomical alterations. A follow-up study was carried out to analyzed outcome and patients’ Visick score assessed parents’ perspective.

Results

Overall 162 children were included for 179 procedures in total. Median age at first intervention was 43 months. Comorbidities were 119 (73 %), particularly neurological impairments (73 %). Redo surgery is equal to 14 % (25/179). Comorbidities were risk factors to Nissen failure (p = 0.04), especially children suffering neurological impairment with seizures (p = 0.034). Follow-up datasets were obtained for 111/162 = 69 % (median time: 51 months). Parents’ perspectives were excellent or good in 85 %.

Conclusions

A significant positive impact of redo Nissen intervention on the patient’s outcome was highlighted; antireflux surgery is useful and advantageous in children and their caregivers. Children with neurological impairment affected by seizures represent significant risk factors.

     

A systematic review and individual patient data meta-analysis of published randomized clinical trials comparing early versus interval appendectomy for children with perforated appendicitis

Purpose

Our objective was to perform a meta-analysis on RCTs that compared outcomes in children with perforated appendicitis (PA) who underwent either early appendectomy (EA) or interval appendectomy (IA). We also sought to determine if the presence of an intra-abdominal abscess (IAA) at admission impacted treatment strategy and outcomes.

Methods

We identified two RCTs comparing EA versus IA in children with PA. A meta-analysis was performed using regression models and the overall adverse event rate was analyzed. The treatment effect variation depending on the presence of IAA at admission was also evaluated.

Results

EA significantly reduced the odds of an adverse event (OR 0.28, 95 % CI 0.1–0.77) and an unplanned readmission (OR 0.08, 95 % CI 0.01–0.67), as well as the total charges (79 % of the IA, 95 % CI 63–100) for those who did not have an IAA at admission. In children with an IAA, there was no difference between EA and IA. However, heterogeneity of treatment effect was present regarding IAA at presentation.

Conclusions

While EA appears to improve outcomes in patients without an abscess, the published data support no significant difference in outcomes between EA and IA in patients with an abscess.