Appendix In Children Research Articles

Finding Waldo: Sonographic systematic approach to localize the appendix in children.

To describe a systematic scanning approach using anatomical landmarks followed by an assessment of radiology trainees' ability to identify the normal appendix in healthy children. Uncontrolled pre and post study assessing radiology residents' sonographic skills in detecting the normal appendix in healthy children. Initial questionnaire for the trainees' demographics, perceptions and experiences in detecting the appendix with ultrasound in children followed by a precourse test on healthy volunteers. Hands-on training was conducted by describing a systematic sonographic approach to identify the appendix using anatomical landmarks, and then a postcourse test was carried out. The primary outcome was unprompted ability to identify the appendix. Subjective self-scoring of confidence was also recorded. A three-hour hands-on workshop was conducted. Sixteen radiology trainees participated and were randomly distributed to four stations, each with different ultrasound machines and healthy volunteers. Fifteen had a precourse assessment, and 12 completed the postcourse assessment. Before the course, 3/15 (20%) identified the appendix, while 10/12 (83%) identified the appendix afterward. After the course, participants perceived finding the appendix easier than before. There was no statistically significant difference in the participants' perceived confidence in detecting the appendix. With the described scanning technique, most of the participants were able to identify the normal appendix after receiving short hands-on training. This highlights the importance of targeted training of radiology trainees and nonradiologists.

Appendix: “an appendage to a twelve-meter gut or a storehouse for microbiota”?

Acute appendicitis is the most common surgical pathology in paediatric practice. Surgical interventions in children with acute and complicated appendicitis are performed when urgently indicated at various stages of the disease. Laparoscopic appendectomy has become the current “gold standard” for providing emergency surgery care to children. Improvements in surgical techniques and post-operative protocols have reduced complications in children to 5–7%. The current discussion topics include the issues of argumentation of “incidental appendectomies” to be performed in minimal macroscopic changes in the vermiform appendix in children with nonspecific mesenteric lymphadenitis, intestinal indigitation, appendiceal lithiasis, justifications for indications and timing for surgical interventions in chronic appendicitis. The appendix has long been considered an “unnecessary” organ, just vestigial structures left over in the process of human evolution. Over the past two centuries, much work has been done to study the appendix. The structure of the vermiform appendix is unique. It has a narrow lumen, abundant mucosa-associated lymphoid tissue and valuable microbial composition. It has recently been hypothesized that the appendix has immunomodulatory functions and serves as a “safe house” for the microbiota, providing commensal bacteria that may restore the gut after infections or antibiotic therapy. Some studies suggest that removal of the appendix increases the risk of inflammatory bowel disease, including ulcerative colitis. However, mechanisms underlying such causal relationship remain unclear. This article considers current knowledge when addressing the appendix microbiome and the relationship between the appendix and ulcerative colitis.

Incidence and Management of Appendiceal Neuroendocrine Tumors in Pediatric Population: A Bicentric Experience with 6285 Appendectomies.

Neuroendocrine tumors (NETs) are rare tumors that arise from neuroendocrine cells and are the most common tumors of the appendix. NETs of the appendix usually cause no symptoms and often go unnoticed until they cause acute appendicitis or are discovered during an accidental appendectomy. As the trend towards the conservative treatment of acute appendicitis increases in the pediatric population, the question arises as to whether the majority of NETs go undetected and are only discovered at an advanced stage. The purpose of the proposed study is to review the incidence and outcomes of treatment for NETs of the appendix in children and include the data presented in the data pool for further review. From 1 January 2009 to 1 November 2023, a total of 6285 appendectomies were performed in two large pediatric centers in Croatia. After a retrospective review of the case records and histopathologic findings, a total of 31 children (0.49%) were diagnosed with NET of the appendix and included in the further analysis. The primary outcome of this study was the incidence and treatment outcome of pediatric patients diagnosed with NET of the appendix. Secondary outcomes included the patients' demographic, clinical, and laboratory data and the histopathologic characteristics of tumor species. The overall incidence of NETs of the appendix was stable over the study years, with minor fluctuations. The median age of patients was 14 (interquartile range-IQR: 12, 16) years, with a female predominance (64.5%). The majority of patients (96.8%) presented with acute abdominal pain and underwent appendectomy because acute appendicitis was suspected. Acute appendicitis was confirmed by histopathology in 18 (58%) cases. NETs of the appendix were not detected preoperatively in any of the patients. Among patients with confirmed acute appendicitis, most (n = 14; 77.8%) were found to have non-perforated acute appendicitis. In most children, the tumor was located at the tip of the appendix (n = 18; 58.1%), and the majority of tumors had a diameter of less than 1 cm (n = 21, 67.7%). The mitotic count (n = 25, 80.6%) and Ki-67 proliferation index (n = 23, 74.2%) were low in most patients, so most tumors were classified as NET G1 (n = 25, 80.6%), while NET G2 and NET G3 were found in four (12.9%) and two (6.5%) patients, respectively. All children were treated with appendectomy only. The median follow-up time was 54 (IQR: 24, 95) months. The incidence of appendiceal NET among pediatric patients is very low. NET occurs most frequently in adolescents, with a female predominance. Most tumors are less than 1 cm in diameter, located at the tip, and associated with non-perforated appendicitis. Appendectomy is the treatment of choice, and major surgery was not necessary in our cohort.

Flow cytometric characterization of cecal appendix lymphocyte subpopulations in children: a pilot study

IntroductionScientific literature regarding the characterization of lymphocyte subpopulations of the cecal appendix is sparse, with few precedents limited to immunohistochemical techniques.MethodsWe conducted a prospective pilot study to characterize lymphocyte subpopulations of the cecal appendix in children. Participants were divided into three groups: (1) patients without histological acute appendiceal inflammation, (2) patients with histological uncomplicated acute appendicitis, and (3) patients with histological complicated acute appendicitis (gangrenous, perforated). A fresh sample of the base of the appendix was taken from all patients and a flow cytometric study was performed. Quantitative variables were compared using Kruskal–Wallis test and Mann–Whitney U test.ResultsThis study included 57 patients divided into Group 1 (n = 5), Group 2 (n = 37), and Group 3 (n = 15). Median values (IQR) of the percentage of B-lymphocytes were 67.8 [66.8–68.1] in group 1, 61.15 [53.74–66.4] in group 2, and 52.1 [33–62.02] in group 3 (p = 0.02). Median values (IQR) of the percentage of NK-lymphocytes were 0.26 [0.2–0.3] in group 1, 0.55 [0.37–0.66] in group 2, and 0.84 [0.35–1.45] in group 3 (p = 0.008). Median values (IQR) of the percentage of T-lymphocytes were 31.9 [31.7–33.1] in group 1, 37.68 [32.15–45.69] in group 2, and 46.9 [37.03–67] in group 3 (p = 0.02). Pair comparisons of groups 2 and 3 also showed significant differences in the percentage of B lymphocytes (p = 0.03) and NK-lymphocytes (p = 0.02).ConclusionsSignificant differences in lymphocyte subpopulations were identified according to the histologic grade of the cecal appendix. More specifically, a lower percentage of B-lymphocytes and a higher percentage of T- and NK-lymphocytes were observed in cases of acute appendicitis. These findings must be confirmed and their etiopathogenic, diagnostic, and prognostic implications elucidated in future studies with larger sample sizes.

Immunocompetent cells of appendix in acute appendicitis in children with COVID-19

Background. The study of the influence mechanisms of the SARS-CoV-2 virus on human homeostasis is still relevant. Of particular interest is the study of pathomorphological changes in the appendix in children with COVID-19 with the determination of the CD-phenotypic status of immunocompetent cells.
 Aim. Immunohistochemical evaluation of appendix inflammation in children diagnosed with COVID-19.
 Material and methods. The groups were formed on the basis of anamnestic, clinical and morphological data: the first group (n=42; age from 2 to 18 years, mean 10.84.9 years) surgical material of the vermiform processes of children with an established clinical diagnosis of coronavirus infection (COVID-19 based on PCR results); the second group (n=55; age from 2 to 18 years, mean 9.74.2 years) surgical material of the appendix after appendectomy in children with an established clinical diagnosis of acute appendicitis obtained before the onset of the COVID-19 pandemic; the third group (n=38; age from 2 to 18 years, mean 10.33.2 years) control group, autopsy material of appendixes (intact). Histological and immunohistochemical studies were carried out using primary antibodies to CD3, CD4, CD68, CD20, CD138. The number of CD+ cells was determined by computer morphometry in 10 fields of view. Student's t-test was used in quantitative analysis for a significant comparison between groups. Then, the quantitative density of CD+ cells per 1 mm2 was converted into a scoring system for visual presentation by a semi-quantitative method.
 Results. Most samples (n=41) of the first group showed signs of destructive phlegmonous-ulcerative appendicitis. An immunohistochemical study revealed an increase in the number of T-lymphocytes (CD3+, CD4+), macrophages (CD68+), B-lymphocytes (CD20+) and plasma cells (CD138+) in the mucous membrane of the vermiform processes of children of the first group. In children of the second group, all clinical and morphological forms of acute appendicitis were found, the phenotype of immunocompetent cells corresponded to bacterial inflammation.
 Conclusion. In children diagnosed with СOVID-19, confirmed by polymerase chain reaction, predominantly develop destructive forms of acute appendicitis, accompanied by microthrombosis and lymphocytic-plasmacytic infiltration with an increase in the number of immunocompetent cells CD3+, CD4+, CD68+, CD20+, CD138+.

Primary torsion of the appendix in a 10-year-old child

Introduction. Torsion of the appendix is a rare pathology with unclear pathogenesis. The article describes clinical manifestations, diagnostics and surgical management of the distorted appendix in a child. Observation. A 10-year-old boy was admitted to the hospital with pain in the right iliac region and repeated vomiting. During examination, acute appendicitis was diagnosed. At laparoscopy, appendix torsion was revealed; its detorsion and laparoscopic removal were performed. Intraoperatively, it was found out that the mesentery had narrow base , while the process length was about 7 cm; such a combination under developing inflammatory changes in the process could contribute to its torsion. Conclusion. Torsion of the appendix in children has a clinical, laboratory and echographic picture of the destructive appendicitis. Laparoscopy allows to timely clarify the pathology nature and to timely perform appendectomy.

Contemporary Epidemiology of and Risk Factors Associated with Removal of a Pathologically Normal Appendix in Children with Suspected Appendicitis

BackgroundThe goal of this study was to characterize contemporary performance benchmarks and risk factors associated with negative appendectomy (NA) in children with suspected appendicitis. MethodsA multicenter retrospective cohort analysis of children undergoing appendectomy for suspected appendicitis was performed using data from the 2016–2021 NSQIP-Pediatric Appendectomy Targeted Public Use Files. Multivariable regression was used to evaluate the influence of year, age, sex, and WBC count on NA rate, and to generate rate estimates for NA based on different combinations of demographic characteristics and WBC profiles. Results100,322 patients were included from 140 hospitals. The overall NA rate was 2.4%, and rates decreased significantly during the study period (2016: 3.1% vs. 2021: 2.3%, p < 0.001). In adjusted analyses, the highest risk for NA was associated with a normal WBC (<9000/mm3; OR 5.31 [95% CI: 4.87–5.80]), followed by female sex (OR 1.55 [95% CI: 1.42–1.68]) and age <5 years (OR 1.64 [95% CI 1.39, 1.94]). Model-estimated risk for NA varied significantly across demographic and WBC strata, with a 14.4-fold range in rates between subgroups with the lowest and highest predicted risk (males 13–17 years with elevated WBC [1.1%] vs. females 3–4 years with normal WBC [15.8%]). ConclusionsContemporary NA rates have decreased over time, however NA risk remains high in children without a leukocytosis, particularly for girls and children <5 years of age. These data provide contemporary performance benchmarks for NA in children with suspected appendicitis and identify high-risk populations where further efforts to mitigate NA risk should be targeted. Level of EvidenceIII.

Invited Commentary on He K et al.: Contemporary Epidemiology of Risk Factors Associated With Removal of a Pathologically Normal Appendix in Children With Suspected Appendicitis

Invited Commentary on He K et al.: Contemporary Epidemiology of Risk Factors Associated With Removal of a Pathologically Normal Appendix in Children With Suspected Appendicitis

Well-Differentiated Neuroendocrine Tumors of the Appendix in Children and Adolescents: A Clinicopathologic Study.

Pediatric neuroendocrine tumors (NET) of the GI tract are rare and appendiceal NET are typically incidental. Few studies have been done in the pediatric population and practice guidelines are mainly based on adult data. There are currently no diagnostic studies specific for NET. Our study aimed to identify clinical, radiological, and pathological findings in pediatric appendiceal NET, test criteria for follow up surgical treatment, review potential prognostic pathological findings, and possible pre-operative diagnostic radiological studies. A retrospective data search was conducted for well-differentiated NET of the appendix in patients ≤21 years between 1/1/2003 and 7/1/2022. Available clinical, radiologic, pathological, and follow-up information was recorded. Thirty-seven patients with appendiceal NET were identified. No masses were reported in the patients who underwent presurgical imaging. Appendectomy samples showed NET (0.2->4 cm), most located in the tip. Most cases were WHO G1 (34/37), with negative margins (n = 25). Sixteen cases extended to the subserosa/mesoappendix (pT3). Lymphovascular (6), perineural (2), and both lymphovascular and perineural invasion were also noted (2). The specified tumor stages were pT1 (10/37), pT3 (16/37), and pT4 (4/37). Patients who underwent laboratory testing for chromogranin A (20) and urine 5HIAA (11) had normal limits. Subsequent surgical resection was recommended in 13 cases and performed in 11. To date, all patients have no recurrent or additional metastatic disease. Our study showed that all pediatric well-differentiated appendiceal NET were incidentally found as part of acute appendicitis management. Most NET were localized with low-grade histology. Our small cohort support the previously suggested management guidelines with follow up resection in certain cases. Our radiologic review didn't identify a best modality for NET. Comparing cases with and without metastatic disease, no tumors under 1 cm had metastasis, but serosal and perineural invasion along with G2 status were associated with metastasis in our limited study.

Angiotensin-Converting Enzyme 2 and Furin Expression in the Appendix of Children with COVID-19.

Background: The sudden outbreak of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has resulted in more than 261 million infections and an estimated 5.1 million deaths. Some vital organs such as the kidneys, heart, intestines, and lungs could be damaged by SARS-CoV-2. Questions remain regarding the effect of SARS-CoV-2 on the mucous membrane of the appendix in children. The aim of this study was to evaluate the knowledge of cytologic processes in appendix tissue in children with coronavirus disease 2019 (COVID-19). Patients and Methods: Fragments of the appendices of children with confirmed COVID-19 (n = 42) were studied by real-time polymerase chain reaction (PCR) to determine the expression of SARS-CoV-2 RNA and genes encoding protein complexes: ACE-2 and Furin. Results: We found traces of coronavirus genetic material in the appendices of children with COVID-19. We also found increased expression of ACE-2 and Furin in the tissue, which indicates favorable conditions for coronavirus infection. Conclusions: Viral load in the appendices of children can be reported based on the results of real-time PCR for SARS-CoV-2 and the expression of ACE-2 and Furin.

A new approach to laparoscopic appendectomy in children-clipless/sutureless Harmonic scalpel laparoscopic appendectomy.

The aim of this study was to investigate Harmonic scalpel performance in laparoscopic appendectomy for sealing the base of the appendix in children. During the study period, a total of 312 patients who underwent laparoscopic appendectomy were included in prospective bicenter clinical trial. The patients were divided in two study groups in regard to technique used for appendiceal base closure. In the first group (n = 197) the appendiceal base was secured using a polymeric clip while in the second group (n = 115) the Harmonic scalpel was used for sealing the base in a stepwise manner, without placing any clip or suture. Outcomes of treatment, including complication rates, duration of surgery and length of hospital stay were compared between the groups. A total of 312 patients with a median age of 11years (IQR 8, 15) were included in study. Of these, 191 were males (61.2%). Both groups were symmetric in regard to baseline characteristics of the patients. A total of 10 (5.1%) postoperative complications (postoperative abscess n = 7 and ileus n = 3) were recorded in the polymeric clip group while none of the patients from the clipless group had postoperative complications (P = 0.015). In the group who received a polymeric clip appendectomy, fever lasting 0-72h and > 72h was recorded in 16 (8.1%) and 12 (6.1%) children, respectively, while in the clipless group, it was observed in 2 (1.7%) and 5 (4.3%) children, respectively (P = 0.048). Significantly shorter surgical times were found in the clipless group compared to the polymeric clip group (21min (IQR 18, 25) vs. 30min (IQR 22, 40), P < 0.0001). Also, length of hospital stay was significantly shorter in the clipless group of the patients (2days (IQR 2, 3) vs. 3days (IQR 2, 4), P < 0.0001). Clipless harmonic scalpel laparoscopic appendectomy is a safe and effective method in children for treatment of acute appendicitis with lesser number of complications and shorter duration of surgery compared to laparoscopic appendectomy in which the appendiceal base is secured with clip.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum.

The Histopathology of the Appendix in Children at Interval Appendectomy.

Whilst most surgeons agree that conservative treatment of appendiceal abscess in children is an adequate treatment, the need for subsequent interval appendectomy is still controversial. We analyzed the histopathology in interval appendectomy in search of signs of inflammation. All patients admitted between 2010 and 2017 with appendiceal abscess and scheduled for interval appendectomy were reviewed. The specimens were evaluated for grade of inflammation, type and distribution of cellular infiltrate, presence of necrosis or hemorrhage and infiltrate in the serosa. Forty-two patients had appendiceal abscess and were treated conservatively. Seven underwent emergent appendectomy. Thirty-three out of 35 patients underwent elective interval appendectomy. Thirty-two specimens were revised. Carcinoid tumor or other malignant lesions were not found. All of them presented some amount of inflammation, grade 1 to 2 in 53%, grade 3 to 4 in 47%. Twenty-five percent of the specimens had signs of necrosis accompanied by hemorrhage and in more than the half (53%) the infiltrate extended to the serosa. Conclusions: Although the appendix was mostly found not macroscopically inflamed intraoperatively, histology confirmed a certain grade of inflammation even months after the conservative treatment. No correlation was found between histopathologic findings and lapse of time between abscess treatment and interval appendectomy.

Radical surgical treatment of neuroendocrine tumors of the appendix in children - a Polish multicenter study.

IntroductionThe aim of the study was to examine management of pediatric appendiceal neuroendocrine tumors (ANETs) in Poland.MethodsRecords of 27 patients with ANET diagnosed incidentally after appendectomy in the last decade.ResultsWell-differentiated NET G1/G2 was diagnosed in 25 and well-differentiated neuroendocrine carcinoma G3 in 2 patients. Extended surgery was performed primarily in one instance and secondarily in 10 patients (right hemicolectomy in 9, ileocecal resection in 1) without adjuvant chemotherapy. Follow-up range was 1–121 months. Recurrence after secondary surgery was observed in 1 (3.7%) patient.ConclusionsApplying ENETS guidelines resulted in 100% overall survival of patients with NET.

Levels of C-Reactive Protein and Sodium May Differentiate a Perforated Appendix from a Nonperforated Appendix in Children.

Background Acute appendicitis (AA) might be amenable to conservative antibiotic treatment, whereas a perforated appendix (PA) necessitates surgery. We investigated the value of clinical–laboratory markers in distinguishing AA from a PA. Methods Retrospectively obtained preoperative parameters for 306 consecutive patients (<18 years) with histologically confirmed appendicitis (AA (n = 237) vs. PA (n = 69)), treated at our institution between January 2014 and December 2017. Results A PA was associated with male preponderance, younger age, decreased sodium level and increased white blood cell count, Tzanakis score, C-reactive protein (CRP) level, and CRP-to-lymphocyte ratio (CLR). Upon discrimination analysis, CLR and CRP displayed the highest accuracy in differentiating a PA from AA. Regression analysis identified levels of CRP, sodium, and the Tzanakis score as independent predictors for a PA. Conclusion Levels of CLR, CRP, sodium, and Tzanakis score might support decision-making regarding treatment options for pediatric appendicitis.

Comparison of Alvarado score and pediatric appendicitis score for clinical diagnosis of acute appendicitis in children\u2014a prospective study

BackgroundAcute appendicitis is the most common surgical condition of children. Differential diagnosis of an acutely inflamed appendix in children includes a vast variety of diseases which can present with the same symptoms and signs as acute appendicitis. It is an important factor for delay in diagnosis. Many scoring systems are being used to reach a diagnosis within time and to reduce the rate of negative appendectomies.The purpose of this study was to compare both scoring systems (Alvarado and pediatric appendicitis scoring system) and to know which one is better to establish an early correct diagnosis of acute appendicitis in pediatrics, thus decreasing the morbidity and burden on hospital resources. Although many studies had been completed at the international level for comparing both of these scoring systems, the pediatric population in our region was still awaiting such an effort.So a prospective cohort study was designed. A total of 180 patients were recruited with 95% confidence level and 5% margin of error. Every enrolled patient was awarded clinical scores according to both the Alvarado scoring system and the pediatric appendicitis scoring system. Patients having a score of 7 or more by both scoring systems were considered “seven or more than seven group” and their appendectomies were performed and histopathology reports were reviewed. Patients having a score of 7 in one system and less than 7 in the other/both were considered “less than seven group” and were admitted in the ward for further clinical evaluation and observation.ResultsAt cutoff 7, the Alvarado score showed a sensitivity of 85.5%, specificity of 70%, PPV of 96.5%, NPV of 33.3%, and diagnostic accuracy of 84.11% while the pediatric appendicitis score showed a sensitivity of 93.8%, specificity of 70%, PPV of 96.8%, NPV of 53.8, and diagnostic accuracy of 91.59%.ConclusionThe pediatric appendicitis score (PAS) is superior in diagnosing acute appendicitis in the pediatric population than the Alvarado score as indicated by the values of diagnostic accuracy. So it can be a good diagnostic tool for pediatric patients presenting with clinical symptoms and signs of appendicitis.

Nowadays treatment of testicular appendix torsion in children

Introduction. Currently, a modern tactics as to the treatment of testicular appendix torsion in children is not an indisputable axiom but it is a subject of discussion in domestic and foreign literature. Modern diagnostic tools, wide implementation of expert-class equipment as well as gaining more experience have reduced, to a minimum , the risk of diagnostic error with fatal consequences for the gonad. So, it impels to revise the existing algorithms and to consider the conservative treatment as the method of choice in uncomplicated testicular appendix torsion.Objective. To analyze the gained experience in treating testicular appendix torsion and to suggest reasonable algorithms which correspond to modern diagnostic techniques and treatment options. Material and methods. 2875 cases with testicular appendix torsion have been analyzed. Of these, 2 069 (71.96%) patients were operated on; 755 (26.26%) patients had conservative treatment and 51 (1.78%) had to be operated on despite conservative treatment.Results. The material obtained in three statistically homogeneous groups has been аnalyzed. When comparing clinical and ultrasound criteria, it was found out that the incidence of orchalgia in the surgical group is slightly higher than in the conservative one. It may indicate that the adhesive process in the scrotal cavity after surgical trauma is more frequent than after a possible aseptic inflammation. Asymmetry of gonad volumes with smaller diseased testicle was seen in all groups. The decrease in testicular volume is minimal in all cases and is not statistically significant. The incidence of heterogeneity in the testicular and appendage echo structure, which indicates sclerotic changes in the parenchyma, is also not statistically significant in the analyzed groups. Patients who were operated despite their conservative care do not have much worse outcomes after long-lasting follow-up period than groups with other curative options.Conclusion. Torsion of the testicular appendix in children is a challenging problem that is far from being solved. There is no consensus as to the indications for surgical treatment and to the assessment of postoperative outcomes. Modern diagnostic and monitoring techniques allow to dynamically monitor the scrotal organs in conservative treatment. The conservative treatment of testicular appendix torsion is an effective and safe method. The conservative tactics which was changed for surgical one does not lead to gonad deterioration.

Not only appendicitis: rare appendix disorders manifesting as surgical emergencies in children.

Acute appendicitis is the most common cause of acute abdominal pathology in children. However, other rare non-inflammatory non-neoplastic disorders involving the appendix may manifest as surgical emergencies. This study aimed to describe these atypical entities and present representative cases. The database of a tertiary children's medical center was reviewed for all the patients aged 0-18years who underwent urgent appendectomy between June 2014 and December 2019, for rare disorders of the appendix unrelated to inflammatory or neoplastic processes. Of 1367 patients who underwent appendectomy, 1345 were operated urgently or emergently. Of these, six, all males, mean age 32.6months (range 0.7-76), underwent appendectomy for rare surgical complications that involved the appendix. These included torsion of the appendix (2), a strangulated internal hernia through an appendicular ring (1) or through a mesoappendix gap (1), an incarcerated appendix in an acute hernia sac (1), and appendiceal intussusception (1). In all cases, the role of the appendix in the pathologic process was unexpected and came as a surprise to the surgeon. During a median follow-up of 4.2months (range 1-8months), one patient underwent relaparotomy for small bowel obstruction 4weeks after the original procedure.Conclusion: The appendix in children can be the source of rare pathological disorders that present as surgical emergencies. Familiarity with these entities may aid in achieving accurate preoperative diagnosis and contribute to surgical team orientation on exploratory laparotomy. However, correct diagnosis is often only established during timely surgical intervention.

Prevalence of organ-space surgical site infections after appendectomy for ruptured appendix in children

Introduction: Appendicitis can be classified as non-perforated and perforated; based on such classification, the reported organ-space surgical site infection (OS-SSI) rate is 0.8% and 18%, respectively.Objective: To establish the prevalence of OS-SSI in patients with perforated appendicitis treated in a pediatric hospital in 2012.Materials and methods: Retrospective, observational and descriptive study conducted at Fundación Hospital Pediátrico La Misericordia, with a random sample of 200 patients, of which 160 met the inclusion criteria.Results: 20 patients (12.5%) presented with OS-SSI and all of them received antibiotic treatment; 70% did not require abscess drainage. Patients ≥8 years of age had 5 times more abscesses than younger ones (17.6% vs. 3.4%). OS-SSI was found in 33% of patients with free fecalith and in 50% of the patients who required postoperative management at the ICU vs. 9.5% of the patients who received management in the intermediate care unit and the inpatient hospital floors. The total rate of surgical site infection was 24.3% (11.8% superficial, 0% deep and 12.5% organ-space).Conclusions: The prevalence of OS-SSI found here is lower than what has been reported in the literature. Being 8 years or older and having free fecalith are risk factors to develop this type of infection. The higher frequency of OS-SSI in patients treated at the ICU during the post-operative period observed here suggests that this condition may be associated with septic shock.

Hidden hazard in appendix in children: Carcinoid tumors

Introduction: Carcinoid tumors (CT) are the most common tumors of the appendix. The incidence of CT of the appendix is generally 1–2 in every 1000 appendectomy material. Objectives: The objectives of the study were to discuss the follow-up and treatment of CT of the appendix in the specimen of patients who underwent an appendectomy. Materials and Methods: This retrospective study enrolled the patients who were diagnosed with CT of the appendix as a result of an examination of the appendix specimen after the patients underwent an appendectomy. All the patients, who underwent appendectomy in the pediatric surgery clinic of our hospital between November 2015 and November 2018, were included in the study. Patients’ demographic characteristics, clinical findings, pre-operative laboratory and imaging results, location, diameter and size of the tumor, mesoappendix invasion status, mitotic index and Ki-67 elevation, hospital stay duration, surgical types and complications, and results of laboratory and imaging tests were evaluated. Findings: Eight of the 621 patients (1.2%) who underwent an appendectomy were diagnosed with CT of the appendix. The median age of the patients was 13 years (range, 11–16 years). Of the eight patients, five (62.5%) were female and three (37.5%) were male. All patients presented to our clinic with abdominal pain. No surgical complications were observed during the operation and in the early post-operative period. The mean hospital stay was 2.7 days (2–5 days). In all the patients, the tumor size was &lt;2 cm, the surgical margins were clean, the mitotic index was &lt;2%, the Ki-67 index was below 1%, and the tumor had not spread to the mesoappendix. Only in one of the patients, the CT was located in the appendix radix; in the other seven patients, the tumor was in the middle and end of the appendix. Conclusion: CT of the appendix are clinically similar to acute appendicitis but may be found incidentally during other surgical procedures other than an appendectomy. Diagnosis is made after the pathological specimen diagnosed with CT is histopathologically evaluated. The size, diameter, and depth of the tumor, mesoappendix invasion, mitotic index, and Ki-67 elevation are used in the evaluation and treatment of the tumor.