Pediatr Surg Research Articles

Bronchogenic cyst: An uncommon cause of congenital lobar emphysema

We report a case of a 1-month-old boy who has developed respiratory distress. Chest X-ray and CT scan showed over distension of the left upper lobe and a mediastinal shift in favour of congenital lobar emphysema (CLE) of the left upper lobe. One month after uneventful lobectomy, he was readmitted at hospital for another episode of respiratory distress. Chest radiography revealed relapse of compressive emphysema in the remaining left lobe. Gastro oesophageal transit and MRI were performed, which have shown a mediastinal cystic mass. Accordingly, the patient underwent thoracotomy. Surgical examination found a subcarinal bronchogenic cyst which compressed the main left bronchus, causing the CLE of both upper and lower left lobes. Histological examination of removed cyst confirmed these data. Authors discuss causes of diagnostic delay.

Parenchymal Echo Texture Predicts Testicular Salvage After Torsion: Potential Impact on the Need for Emergent Exploration

In the setting of signs and symptoms of testicular torsion the absence of diastolic flow and/or color flow on Doppler ultrasound has traditionally prompted emergent scrotal exploration. This practice emanates largely from the difficulty on ultrasound of distinguishing salvageable torsed testes from those that are not salvageable. We identified ultrasound findings predictive of testicular viability or the lack thereof. We retrospectively reviewed the charts of all boys who underwent scrotal exploration for signs and symptoms of torsion during a 4-year period. In those who underwent preoperative Doppler ultrasound of the scrotum ultrasound findings were reviewed, as were the operative dictations. In patients who underwent orchiectomy the pathology reports were also reviewed. In patients in whom the torsed testis appeared viable and who underwent orchiopexy followup data were reviewed when available. Emergency room charts were also reviewed to ascertain, when documented, the duration of pain before presentation to the emergency room and the interval between ultrasound and operating room. During this period 55 boys underwent exploration after preoperative scrotal Doppler ultrasound revealed absent diastolic flow and/or color flow Doppler in the symptomatic testis. Assessment of parenchymal echogenicity revealed heterogeneity in 37 testes (67%), of which none were deemed viable at exploration. Orchiectomy was performed in 34 of 37 cases. Pathological examination revealed necrosis in all 34 cases, a finding consistent with late torsion. The remaining 3 testes underwent orchiopexy by parental directive despite nonviability, as confirmed by biopsy and subsequent atrophy. Thus, heterogeneity on preoperative ultrasound was universally predictive of organ loss (chi-square p <0.001). Of the 18 symptomatic testes (33%) demonstrating homogeneity and isoechogenicity on ultrasound 16 (89%) were deemed viable at exploration. Boys in whom the torsed testicle was nonviable on exploration experienced an average of 27.5 hours of pain preoperatively (range 5 to 72), whereas boys in whom the torsed testis was salvaged experienced an average of 20.5 hours of pain (range 2 to 96) (p = 0.073). The nonviable group underwent surgery an average of 49 minutes after ultrasound, whereas the viable group underwent surgery 52 minutes after ultrasound (p = 0.92). None of the 55 patients experienced any surgical or anesthetic complications and no pathological condition was noted intraoperatively in the contralateral asymptomatic testis. In the setting of Doppler proven testicular torsion heterogeneous parenchymal echo texture indicates late torsion and testicular nonviability. Therefore, the case may not require emergent scrotal exploration. On the other hand, homogeneous echo texture portends extremely well for testicular viability. Thus, such testes should be explored emergently.

Successful Repair of a Subtotal Rupture of Distal Tracheobronchial Tree With Complete Abridgment of the Right Bronchus in a 4-Year-Old Child

Accurate diagnosis of tracheobronchial injuries in children is difficult due to the paucity of clinical presentation and the variety of clinical symptoms. They are potentially life threatening in blunt chest trauma. We report here on a clinical case of a boy who was injured during outdoor activity. We describe intraoperative findings of the massive tracheobronchial lesion and its successful repair using a pericardial patch technique and postoperative recovery. Such a serious tracheobronchial injury with a positive outcome has not been reported so far. Clinical and technical steps are described and discussed.

Sonic Hedgehog Mediator Gli2 Regulates Bladder Mesenchymal Patterning

Congenital bladder anomalies are a major challenge to pediatric urologists. Understanding the mechanism of bladder development is crucial for advancing patient treatment. Current evidence suggests that Shh (R&D Systems) is an epithelial signal regulating bladder development, although the mechanism of the regulation is still unclear. We examined the regulation of bladder mesenchymal development. Mutation analysis, immunohistochemistry, immunoblot, in situ hybridization, and primary cell culture and transfection were performed. The mesenchyma proximal to the epithelium was defined as the inner zone and that distal to the epithelium was defined as the outer zone. We found that the Shh transcriptional factor Gli2 and the Shh target gene Bmp4 (R&D Systems) were expressed in the inner mesenchymal zone of the bladder, where active cell proliferation was observed. In Gli2(-/-) bladder primary mesenchymal cell cultures transfection with adenoviruses expressing DeltaNGli2, a constitutionally active form of Gli2, up-regulated Bmp4 expression and promoted cell proliferation. In the outer mesenchymal zone, where Gli2 and Bmp4 expression was not detectable, smooth muscle alpha-actin was expressed. In Gli2(-/-) embryo bladders Bmp4 expression in the inner zone was lost and ectopic smooth muscle was detected in the inner mesenchymal zone. Exogenous Bmp4 (10 ng/ml) in primary smooth muscle cell culture repressed smooth muscle differentiation and repression was partially rescued by the Bmp4 antagonist Noggin (R&D Systems) (300 ng/ml). Our data suggests that the Shh transcriptional factor Gli2 regulates radial patterning of the bladder mesenchyma.

3-Dimensional Neuroanatomy of the Human Fetal Pelvis: Anatomical Support for Partial Urogenital Mobilization in the Treatment of Urogenital Sinus

Retrospective reviews suggest that the functional outcomes of surgery of the urogenital sinus have often been unsatisfactory and to our knowledge the long-term results of newer surgical techniques have yet to be evaluated. A precise understanding of pelvic fetal neuroanatomy is germane for optimizing surgical correction of the urogenital sinus. The pelves of 10 human female fetuses were serially sectioned. Masson's trichrome staining and immunochemistry for the neuronal marker S100 (Dako Corp., Carpinteria, California) along with anatomical computer reconstruction allowed 3-dimensional analysis of the nerves in relation to the pelvic structures as an animated motion picture. Two types of neuronal structures were identified. 1) A dense perivisceral foil of branching nerves closely surrounded the pelvic organs. The localization of most nerves was on the external faces of the viscera with a limited fraction in the rectovaginal and urethrovaginal septa. This innervation was from the anterior cephalad periurethral area to the posterior caudal perirectal area. 2) A significant amount of nerves surrounded the cephalad urethra on its anterior and posterior faces. Based on these anatomical data during surgical repair of a urogenital sinus we would advocate minimal mobilization of the lateral faces of the vagina, avoiding dissection of the proximal urethra above the pubic bone and electing a vaginal flap in severe cases.

Tissue Engineering a Complete Vaginal Replacement From a Small Biopsy of Autologous Tissue

In women, a healthy, patent vagina is important for the maintenance of a good quality of life. Apart from congenital abnormalities, such as cloacal exstrophy, intersex disorders, and an absence of the posterior two thirds of the organ, individuals may also suffer from cancer, trauma, infection, inflammation, or iatrogenic injuries leading to tissue damage and loss -- all of which require vaginal repair or replacement. Of necessity, reconstruction is often performed with nonvaginal tissue substitutes, such as segments of large intestine or skin, which are not anatomically or functionally ideal (Hendren and Atala, J Urol 1994; 152: 752; Hendren and Atala, J Pediatr Surg 1995; 30: 91). Whenever such tissue is used additional complications often ensue, such as strictures, infection, hair growth, graft shrinkage, diverticuli, and even malignancy (Filipas et al., BJU Int 2000; 85: 715; Lai and Chang, Changgeng Yi Xue Za Zhi 1999; 22: 253; Parsons et al., J Pediatr Surg 2002; 37: 629; Seccia et al., Ann Plast Surg 2002; 49: 379; Filipas, Curr Opin Urol 2001; 11: 267). Using a rabbit model, we report here the construction of a functional vagina using autologous cells expanded from a small vaginal biopsy. RESULTS.: Six months after total vaginal replacement, radiographic analysis of rabbits implanted with the neovagina demonstrated wide, patent vaginal calibers without strictures. Histologic analysis revealed well-organized epithelial and muscle cell layers. Physiologic studies showed normal-range responses to electrical stimulation or to an adrenergic agonist. These data indicate that a tissue engineering approach to clinical vaginal reconstruction in women is now a realistic possibility.

Discriminating acute appendicitis from other causes of acute abdominal pain in children

Goldman et al have taken an important step in evaluating the usefulness of a clinical score for discriminating acute appendicitis from other causes of abdominal pain in children. They have applied the Samuel score (J Pediatr Surg 2002;37:877-881) prospectively to a different population (ie, broader age, different continent, Emergency Department of a provencial tertiary medical center) than that in which it was defined. The reader should note the caveats and limitations of the Toronto study. However, a low cutoff score supports the safe discharge from the Emergency Department of almost two-thirds of children evaluated without imaging studies, and a high cutoff score supports surgical intervention of almost 10% without imaging studies because they will almost certainly have acute appendicitis. Additional clinical observation, imaging studies, and clinical research can be focused on the more difficult quarter of children who have middling, non-discriminating scores.

Abdominal cocoon complicated with early postoperative small bowel obstruction

Abdominal cocoon complicated with early postoperative small bowel obstruction

Congenital Bochdalek hernia presenting with acute pancreatitis in an adult

Posterolateral diaphragmatic hernias (Bochdalek) are a common congenital anomaly usually presenting in the neonatal period or infancy. Although well documented, their presentation in adulthood is uncommon. 1-3 We describe the case of an adult Bochdalek hernia presenting with acute pancreatitis and intermittent gastric volvulus.

EFirst - European Journal of Pediatric Surgery Articles Published ahead of Print

See also: Improvement of Renal Split Function in Hydronephrosis with less than 10 % FunctionEur J Pediatr Surg 2008; 18(03): 156-159DOI: 10.1055/s-2008-1038445

Sympathetic (Adrenergic) Innervation Modulates But Does Not Generate Basal Tone in the Internal Anal Sphincter Smooth Muscle

Sympathetic (Adrenergic) Innervation Modulates But Does Not Generate Basal Tone in the Internal Anal Sphincter Smooth Muscle

Mechanical Occlusion of the Inferior Vena Cava: An Unusual Complication After Repair of Pectus Excavatum Using the Nuss Procedure

We describe the case of a 13-year-old girl with a pectus excavatum in whom acute occlusion of the inferior vena cava developed after a nuss repair. In this hemodynamically unstable patient, we evaluated the possibility of a penetrating injury to the thoracic and abdominal structures before confirming the diagnosis of inferior vena cava obstruction with a venogram. Removal of the nuss bar relieved the unexpected problem.

Short Stay Pyeloplasty: Variables Affecting Pain and Length of Stay

Pyeloplasty is increasingly performed on a short stay basis. We sought to determine what patient and treatment variables affect postoperative pain and length of stay, and whether an open approach could be considered "minimally invasive." We performed a retrospective review of patients younger than 10 years who underwent open pyeloplasty between 2001 and 2007. All patients received ketorolac every 6 hours and acetaminophen with codeine as needed. Data extracted from the medical records included morphine and codeine usage, patient age and gender, incision type, operative time, stent usage and outcome data (pain scores and length of stay). Multiple regression analyses were used to determine the association between variables and outcomes. A total of 51 patients met the inclusion criteria. Patient age and gender, operative time and stent usage had no significant correlation with mean or median pain scores. Children who received morphine had significantly higher mean, median and maximum pain scores and length of stay (33 vs 23 hours) than those who did not receive morphine. Multiple regression analyses revealed that morphine usage and dorsal lumbotomy incision were independently associated with higher mean, median and maximum pain scores, and a nephroureteral catheter was correlated with a higher maximum pain score. The only variable associated with length of stay was morphine usage. Morphine usage was the most significant variable associated with increased pain scores and increased length of stay. Ketorolac and acetaminophen/codeine provide better pain control, and allow children to return home within 24 hours. With mean pain scores less than 1 this series demonstrates that open pyeloplasty can be "minimally invasive."

Abdominal Ultrasound in Pediatric Trauma Patients

Source: Holmes JF, Gladman A, Chang C. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg. 2007;42(9)1588–1594; doi:10.1016/j.jpedsurg.2007.04.023According to the CDC Vital Statistics Reports, blunt trauma remains the leading cause of death and disability in children.1Because pathognomic physical examination findings may not be present in many children with blunt abdominal injury, abdominal computed tomographic (CT) scanning has become the standard for identifying intra-abdominal injuries.Increasing awareness of the risk of radiation-induced malignancy has led to the search for alternative diagnostic strategies.2 Consequently, the use of abdominal ultrasound (US) in adult patients with blunt abdominal trauma has increased, and the Focused Assessment with Sonography for Trauma (FAST) exam has become routine in many major trauma centers across the country as a ready means of identifying adult patients with hemoperitoneum.The use of the FAST exam in children with blunt trauma remains controversial. Studies on the use of abdominal US in pediatric trauma patients have yielded conflicting results, and variability in study methods and protocols has led to confusion and disagreement about the usefulness of US in this setting.3The authors, from the University of California at Davis, performed a systematic review of the literature and meta-analysis to assess the test performance of abdominal US in children with blunt traumatic injury. Both prospective and retrospective studies were included if they used abdominal US for the detection of intraperitoneal fluid or intra-abdominal injury in blunt trauma patients less than 18 years of age.Data was then abstracted from the articles and the methodological quality of the articles was graded. Raw data related to US detection of intra-abdominal injury was abstracted from each study and used to generate conservative estimates of sensitivity, specificity, and likelihood ratios. The search yielded more than 1,000 abstracts for initial review. Of those, 25 studies (all cohort studies) involving a total of 3,838 children met all inclusion criteria and were included in the meta-analysis.For identifying children with hemoperitoneum, abdominal US had a sensitivity of 80% and specificity of 96%. When only the most methodologically stringent articles were used (six studies), the combined sensitivity of the FAST exam for identifying children with hemoperitoneum was 66% with a negative likelihood ratio of 0.36 (95% CI, 0.27–0.47). (For a discussion of likelihood ratios, see AAP Grand Rounds Weighing the Evidence, January 2007;17:9.)Sensitivity for detection of all children with intra-abdominal injuries (including those without hemoperitoneum) was even lower at 50%. The authors conclude that ultrasonography has questionable utility as the sole diagnostic test to rule out the presence of intra-abdominal injury in children with blunt trauma.Dr. Cavett has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.FAST examination in children with blunt abdominal trauma has only a modest degree of sensitivity for detection of hemoperitoneum. As stated above, the FAST exam will correctly identify only 66–80% of children with blood in their abdomen following blunt trauma. This 20–34% false negative rate is unacceptably high. This low sensitivity may reflect the difficulty of recognizing the small amounts of fluid in the abdominal cavity sometimes seen in children with intra-abdominal injury.A negative FAST exam cannot rule out an intra-abdominal injury. The greatest limitation of the FAST exam is in the child with intra-abdominal injury with no hemoperitoneum, which can include up to 34% of children with intra-abdominal injury.4–6Addition of solid organ imaging added little to the sensitivity of the exam, and then only when a radiologist interpreted the images. A hemodynamically stable child with a positive FAST exam following blunt abdominal trauma should immediately undergo abdominal CT scan for further evaluation of intra-abdominal injury.It remains challenging for the clinician at the bedside to determine whether abdominal CT remains indicated after FAST. My personal view is that abdominal US can provide helpful reassurance when evaluating the child who is alert and cooperative and has a benign abdomen on clinical examination without other distracting injury, but whose mechanism of trauma is concerning.The study reported here illustrates the utility of the accumulation of case series and the rigorous scientific analysis of such data.

Closure of a large tracheoesophageal fistula using AlloDerm

Tracheoesophageal fistula (TEF) is an uncommon but devastating complication of prolonged intubation. Pressure exerted from the cuff of an endotracheal tube against a rigid nasogastric tube causes tissue necrosis and breakdown.1Dartevelle P. Macchiarini P. Management of acquired tracheo-esophageal fistula.Chest Surg Clin N Am. 1996; 6: 819-836PubMed Google Scholar Patients typically present with recurrent aspiration pneumonia. Urgent repair of the fistula with tissue interposition is warranted, although this can be challenging in the ventilated patient because of the need for continued positive pressure ventilation and the paucity of healthy, local tissue to fashion the repair. The present study is a case report of a 65-year-old woman in whom a large TEF developed after bilobectomy and who was successfully treated with AlloDerm (LifeCell Corporation, Branchburg, NJ), a commercially available biologic tissue. In this case, AlloDerm was used as a tissue scaffold to reconstruct the defect in the trachea to serve and enhance the integrity of the repair.2Sinha U.K. Chang K.E. Shih C.W. Reconstruction of pharyngeal defect with AlloDerm and sternocleidomastoid muscle flap.Laryngoscope. 2001; 111: 1910-1916Crossref PubMed Scopus (25) Google Scholar, 3Isch J.A. Engum S.A. Ruble C.A. Davis M.M. Grosfeld J.L. Patch esophagoplasty using AlloDerm as a tissue scaffold.J Pediatr Surg. 2001; 36: 266-268Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar A 65-year-old woman underwent right middle and lower lobectomy for non–small cell lung carcinoma at an outside hospital. Her postoperative course was marked by adult respiratory distress syndrome and prolonged mechanical ventilation that required tracheostomy. Six weeks post-tracheostomy, recurrent pneumonia and sepsis developed in the patient. Subsequently, the patient underwent bronchoscopy and was diagnosed with TEF. She was transferred to the Cleveland Clinic Foundation for management. In the operating room, fiberoptic bronchoscopy was performed transnasally and through the patient's tracheal stoma. A 4-cm defect involved the entire width of the membranous airway directly posterior to the stoma. The nasogastric tube was clearly visible along this length and confirmed the diagnosis of TEF. The region of the fistula was 3 tracheal rings distal to the cricoid cartilage on the airway side and 15 cm from the gums on the esophageal side. An extended length tracheostomy was reinserted. Given the size of the TEF, primary repair of the trachea was not possible. We elected to use AlloDerm to reconstruct the membranous trachea, close the esophageal defect primarily, and interpose a muscle flap. The airway and esophagus were approached through an oblique left neck incision anterior to the border of the sternocleidomastoid muscle. The esophagus was dissected out, encircled, and separated from the airway. The entire tracheal and esophageal defects were carefully delineated (Figure 1). The esophagus was repaired using interrupted 3-0 Vicryl sutures. A 4 × 2.5-cm AlloDerm patch was then parachuted down to reconstruct the membranous trachea and secured to the edges of the cartilaginous airway using 3-0 Vicryl sutures. A pectoralis major muscle flap was then mobilized and interposed between the 2 repairs. Postoperatively, the patient had an uneventful recovery and was weaned from the ventilator. On the fifth postoperative day, a flexible bronchoscopy was performed through the stoma. This revealed an intact, well-approximated AlloDerm graft with no evidence of airway narrowing. The patient was discharged on the 18th postoperative day and decannulated 7 weeks postoperatively in the clinic. Currently, she is tolerating a normal oral diet and doing well at 4 months' follow-up. A follow-up computed tomography scan was performed that demonstrated a widely patent trachea with no residual tracheal defect or fistula (Figure 2).Figure 2A, Computed tomographic image of a large TEF. B, Follow-up computed tomographic image shows intact tracheal repair with AlloDerm (LifeCell Corporation, Branchburg, NJ) graft. There is no evidence of recurrence of TEF. TEF, tracheoesophageal fistula.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Secure closure of postintubation TEF is a challenge because of global patient debilitation, inadequacy of local tissue for reconstruction, and an inflamed, infected operative field.4Daniel Knott P. Lorenz R.R. Eliachar I. Murthy S.C. Reconstruction of a tracheobronchial tree disruption with bovine pericardium.Interact Cardiovasc Thorac Surg. 2004; 3: 554-556Crossref PubMed Scopus (12) Google Scholar AlloDerm, an acellular dermal matrix derived from donated human skin tissue, has been used in a broad range of tissue reconstruction. Its rigidity and substantial ability to resist infection allowed this repair of a large TEF. Tissue ingrowth appears to prevent shrinkage and stricture. AlloDerm is a useful tool for complex airway reconstructions when options are limited.

Bleeding Stomal Varices: Case Series and Systematic Review of the Literature

Bleeding stomal varices are a common problem in patients with surgical stomas and portal hypertension, and remain difficult to diagnose and manage. We identified all patients at our institution with bleeding stomal varices from 1989 to 2004. We surveyed all patients undergoing ileal pouch-anal anastomosis from 1997 to 2007 for bleeding anastomotic varices. Finally, we performed a systematic review of the literature focusing on diagnosis and treatment of bleeding stomal varices that included 74 English language studies of 234 patients. We identified 8 patients with bleeding stomal varices. Recognition of stomal varices typically was delayed, particularly when failing to examine the ostomy without the appliance. Stomal variceal bleeding was confirmed by Doppler ultrasound or angiographic imaging. Simple local therapy usually stopped bleeding, albeit temporarily. Sclerotherapy was effective, but at the expense of unacceptable stomal damage. Decompressive therapy was required for secondary prophylaxis, including transjugular intravascular transhepatic shunts (2 patients), surgical portosystemic shunts (2 patients), and liver transplantation (1 patient). No patient with an ileal pouch-anal anastomosis developed anastomotic bleeding from varices. Primary prevention of bleeding stomal varices requires avoidance of creating enterocutaneous stomas in patients with portal hypertension. Careful inspection of the uncovered ostomy is essential for bleeding stomal varices diagnosis. Once identified, conservative measures will stop bleeding temporarily with definitive therapy required, including transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation.

Reply to Letter to the Editor #D-07-00415 regarding "The use of preoperative chemotherapy in Wilms' tumor with contained retroperitoneal rupture"

We appreciate the thoughtful response to our article on the management of contained preoperative rupture of Wilms' tumors (J Pediatr Surg. 2007 Sep;42[9]:1595-1599) by the Renal Tumor Committee of the Children's Oncology Group. We agree that sweeping conclusions regarding therapy for childhood malignancies should not be made based on single institutional series or case reports and that the Renal Tumor Committee and its predecessor, the National Wilms' Tumor Study Group, have made great progress in Wilms' tumor management. We are very familiar with the articles cited in this letter. However, most therapeutic interventions evaluated by large cooperative group trials are based on small pilot experiences. Neither the Renal Tumor Committee nor the previous National Wilms' Tumor Study Group has ever specifically addressed the problem of a patient who presents with a large, loculated, perinephric fluid collection around a renal tumor that by all imaging criteria is contained within the Gerota fascia. It is rightly pointed out that spill is a significant predictor of outcome in these children, and we strongly agree with this. Our therapeutic approach was based on avoiding diffuse peritoneal contamination. With a sizeable fluid collection around the involved kidney, this would be unavoidable with immediate surgery and result in massive peritoneal contamination.

Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy

Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy

Magnet Ingestion

A 6-year-old boy presented to the emergency room with a 3-week history of abdominal pain described as colicky and diffuse. He admitted that he had eaten several magnetic toys before the occurrence of symptoms. An abdominal flat plate revealed multiple radio-opaque objects throughout the abdomen (Figure 1). The patient underwent emergency exploratory laparotomy, which revealed a volvulus of the small bowel and four jejunal enterotomies caused by pressure necrosis of attaching magnets (Figure 2). In total, 11 1.5-cm magnetic toy bars and 7 ball bearings were removed through the jejunal enterotomies and a surgically indicated cecal colostomy (Figure 3).Figure 2Spontaneous enterotomy from pressure necrosis (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Removed magnetic objects.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Significant morbidity and even mortality have been associated with magnet ingestion in children due to magnetic attraction, which can lead to volvulus, perforation, and fistula formation.1Centers for Disease Control and PreventionGastrointestinal injuries from magnet ingestion in children, United States, 2003-2006.MMWR Morb Mortal Wkly Rep. 2006; 55: 1296-1300PubMed Google Scholar, 2Cauchi J.A. Shawis R.N. Multiple magnet ingestion and gastrointestinal morbidity.Arch Dis Child. 2002; 87: 539-540Crossref PubMed Scopus (81) Google Scholar Early surgical intervention is essential in any child with a history of ingesting multiple magnets, especially in the presence of abdominal pain.3Uchida K. Otake K. Iwata T. Watanabe H. Inoue M. Hatada T. et al.Ingestion of multiple magnets: hazardous foreign bodies for children.Pediatr Radiol. 2006; 36: 263-264Crossref PubMed Scopus (24) Google Scholar Surgical intervention also likely will be necessary in any child who has ingested a magnet along with other metallic objects, which can lead to magnetic attraction and bowel perforation.Underlying psychosocial, psychiatric, and developmental risk factors have been noted in many children with a history of foreign body ingestion, and such risk factors should be screened for at presentation.4Binder L. Anderson W. Pediatric gastrointestinal foreign body ingestions.Ann Emerg Med. 1984; 13: 112-117Abstract Full Text PDF PubMed Scopus (86) Google Scholar In addition, clinicians should make patients and their families aware of the risks associated with ingesting multiple magnets or magnets along with metallic objects.5Lee S. Beck N. Kim H. Mischievous magnets: unexpected health hazard in children.J Pediatr Surg. 1996; 31: 1694-1695Abstract Full Text PDF PubMed Scopus (59) Google Scholar This patient had no history of psychiatric disorder, and he and his parents were counseled regarding the dangers of magnet ingestion.References available atwww.jpeds.com. A 6-year-old boy presented to the emergency room with a 3-week history of abdominal pain described as colicky and diffuse. He admitted that he had eaten several magnetic toys before the occurrence of symptoms. An abdominal flat plate revealed multiple radio-opaque objects throughout the abdomen (Figure 1). The patient underwent emergency exploratory laparotomy, which revealed a volvulus of the small bowel and four jejunal enterotomies caused by pressure necrosis of attaching magnets (Figure 2). In total, 11 1.5-cm magnetic toy bars and 7 ball bearings were removed through the jejunal enterotomies and a surgically indicated cecal colostomy (Figure 3). Significant morbidity and even mortality have been associated with magnet ingestion in children due to magnetic attraction, which can lead to volvulus, perforation, and fistula formation.1Centers for Disease Control and PreventionGastrointestinal injuries from magnet ingestion in children, United States, 2003-2006.MMWR Morb Mortal Wkly Rep. 2006; 55: 1296-1300PubMed Google Scholar, 2Cauchi J.A. Shawis R.N. Multiple magnet ingestion and gastrointestinal morbidity.Arch Dis Child. 2002; 87: 539-540Crossref PubMed Scopus (81) Google Scholar Early surgical intervention is essential in any child with a history of ingesting multiple magnets, especially in the presence of abdominal pain.3Uchida K. Otake K. Iwata T. Watanabe H. Inoue M. Hatada T. et al.Ingestion of multiple magnets: hazardous foreign bodies for children.Pediatr Radiol. 2006; 36: 263-264Crossref PubMed Scopus (24) Google Scholar Surgical intervention also likely will be necessary in any child who has ingested a magnet along with other metallic objects, which can lead to magnetic attraction and bowel perforation. Underlying psychosocial, psychiatric, and developmental risk factors have been noted in many children with a history of foreign body ingestion, and such risk factors should be screened for at presentation.4Binder L. Anderson W. Pediatric gastrointestinal foreign body ingestions.Ann Emerg Med. 1984; 13: 112-117Abstract Full Text PDF PubMed Scopus (86) Google Scholar In addition, clinicians should make patients and their families aware of the risks associated with ingesting multiple magnets or magnets along with metallic objects.5Lee S. Beck N. Kim H. Mischievous magnets: unexpected health hazard in children.J Pediatr Surg. 1996; 31: 1694-1695Abstract Full Text PDF PubMed Scopus (59) Google Scholar This patient had no history of psychiatric disorder, and he and his parents were counseled regarding the dangers of magnet ingestion. References available atwww.jpeds.com.

Re: Predictive value of white cell count and C-reactive protein in children with appendicitis.

We have read with interest the article concerning the predictive value of white blood cell count and C-reactive protein in children with appendicitis by Betràn et al [ [1] Betràn M.A. Almonacid J. Vicencio A. Guitièrrez J. Cruces K.S. Cumsille M.A. Predictive value of white cell count and C-reactive protein in children with appendicitis. J Pediatr Surg. 2007; 42: 1208-1214 Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar ] that was recently published in your journal. Although the article was of interest, we have some comments about how the study was performed and the conclusions drawn from it. The authors undertook the task of defining a possible relationship between raised inflammatory markers and acute appendicitis, hoping to be able to use it as an aid in diagnosing the condition. The cohort group consisted of patients who underwent appendicectomy, with histology providing the gold standard of diagnosis. No mention is made of patients who were admitted with the presumptive diagnosis of appendicitis and were not operated on for whatever reason, more specifically what their inflammatory markers were. Conditions such as urinary tract infections, gastroenteritis, and acute mesenteric lymphadenitis may cause these biochemical values to be elevated in the absence of appendicitis. Had these factors been considered, a sensitivity of 1.0 at 0 to 12 hours for white cell count would probably not have been achieved. Other important information not mentioned was the proportion of patients who were treated with antibiotics before admission and before surgery and how this affected their blood results, as well as time from admission to surgery, more factors that could affect inflammatory marker levels. Their conclusion that inflammatory markers can support the clinical diagnosis of appendicitis has been proven in history [ [2] Stefanuti G. Ghirardo V. Gamba P. Inflammatory markers for acute appendicitis in children: are they helpful?. J Pediatr Surg. 2007; 42: 773-776 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar ]. However, it cannot be used to empirically differentiate patients with or without appendicitis because several other factors need to be assessed to rule out common differentials such as urinary tract infection, gastroenteritis, mesenteric lymphadenitis, and others. This is a well-presented article. We wonder whether its value could not be increased by calculating the negative predictive value of inflammatory markers in patients presenting with acute right iliac fossa pain suspicious of acute appendicitis and who are consequently discharged with another diagnosis.