Pediatric cardiac tamponade caused by metallic wire penetration into the heart: A case report and literature review

Thin, metallic wires can easily penetrate the gastrointestinal system if ingested and cause serious cardiac issues in children. We report a pediatric case of such an object that caused cardiac tamponade after lodging in the left ventricle. The wire was extracted without cardiopulmonary bypass and a full recovery was made. Cardiac issues after ingestion of foreign objects are rare but immediate surgery is required for resolution.

Corneal Ulcers (Infectious Keratitis)

Microbial keratitis is an infectious process that occurs due to the proliferation of microorganisms (bacteria, fungi, viruses, and parasites) and associated inflammation and tissue destruction. Smears and cultures are indicated for the isolation of microorganisms and for making the correct diagnosis and immediate initiation of antimicrobial therapy, especially in cases where corneal infiltrate is chronic, large, deep, or atypical. Microbial keratitis is considered a vision-threatening ocular emergency. Therefore, this chapter, which consists of almost all cases studied before and after treatment, highlights the importance of early recognition, isolation of specific microorganisms, and sensitivity-based therapy. Also, the evaluation of these cases helps to show the appearance of the eye after the therapeutic treatment and demonstrates the emergency of immediate surgery to save the eyeball in cases where medical treatment is ineffective. The authors have summarized the treatment options they have used for bacterial, fungal, acanthamoeba, and herpetic keratitis cases.

Imaging versus Intervention in Managing Small Unruptured Intracranial Aneurysms: A Cost-Effectiveness Analysis

<b><i>Objective:</i></b> Current guidelines recommend active surveillance with serial magnetic resonance angiography (MRA) for management of small, asymptomatic unruptured anterior circulation aneurysms (UIAs). We sought to determine the cost-effectiveness of active surveillance compared to immediate surgery. <b><i>Methods:</i></b> We developed a Markov cost-effectiveness model simulating patients with small (&#x3c;7 mm) UIAs managed by active surveillance via MRA, immediate surgery, or watchful waiting. Inputs for the model were abstracted from the literature and used to construct a comprehensive model following persons from diagnosis to death. Outcomes were quality-adjusted life-years (QALYs), lifetime medical costs (2015 USD), and incremental cost-effectiveness ratios (ICERs). Cost-effectiveness, deterministic, and probabilistic sensitivity analyses were performed. <b><i>Results:</i></b> Immediate surgical treatment was the most cost-effective management strategy for small UIAs with ICER of USD 45,772 relative to active surveillance. Sensitivity analysis demonstrated immediate surgery was the preferred strategy, if rupture rate was &#x3e;0.1%/year and if the diagnosis age was &#x3c;70 years, while active surveillance was preferred if surgical complication risk was &#x3e;11%. Probabilistic sensitivity analysis demonstrated that at a willingness-to-pay of USD 100,000/QALY, immediate surgical treatment was the most cost-effective strategy in 64% of iterations. <b><i>Conclusion:</i></b> Immediate surgical treatment is a cost-effective strategy for initial management of small UIAs in patients &#x3c;70 years of age. While more costly than MRA, surgical treatment increased QALY. The cost-effectiveness of immediate surgery is highly sensitive to diagnosis age, rupture rate, and surgical complication risk. Though there are a wide range of rupture rates and complications associated with treatment, this analysis supports the treatment of small, unruptured anterior circulation intracranial aneurysms in patients &#x3c;70 years of age.

Differentiated approach to pancreatic-enteroanastomosis in pancreaticoduodenal resection: a clinical experimental controlled trial

Background. Despite decreasing mortality in pancreaticoduodenal resection, the incidence of postoperative complications in such patients remains high. The choice and formation of “reliable” pancreatic-enteroanastomosis remain relevant.Objectives. The improvement of immediate surgery outcomes in pancreaticoduodenal resection via development of a differentiated algorithm for pancreatic-enteroanastomosis formation.Methods. A prospective non-randomised controlled trial enrolled 90 patients with a pancreaticoduodenal resection surgery. The patients were divided in three cohorts, A (n = 30), B (n = 30) and control C (n = 30). Pancreatic shear wave ultrasound elastography was conducted pre-surgery in main cohorts A and B. Average parenchymal stiffness and intraoperative data decided between the two pancreatico-enteric anastomosis techniques, end-to-side or the original pancreatic-enteroanastomosis. Control cohort C had pancreatico-enteric anastomosis without taking into account the pancreas stiffness and macrocondition.Results. Class A postoperative pancreatic fistula was registered in 2 (6.7%) of 30 patients in cohort B; it was transient, asymptomatic, not requiring additional treatment or a longer postoperative period. No class B and C pancreatic-enteroanastomosis failures or stump pancreonecroses were observed in main cohorts A and B. Clinically significant class B and C postoperative pancreatic fistulae were registered in 5 (16.7%) of 30 patients in control cohort C (inter-cohort comparison statistically significant).Conclusion. The proposed differentiated approach to pancreatic-enteroanastomosis formation associates with a reliably low postoperative complication frequency and lack of clinically significant class B and C postoperative pancreatic fistulae.

Pediatric thalamic incidentalomas: an international retrospective multicenter study

OBJECTIVE Widespread use of modern neuroimaging has led to a surge in diagnosing pediatric brain incidentalomas. Thalamic lesions have unique characteristics such as deep location, surgical complexity, and proximity to eloquent neuronal structures. Currently, the natural course of incidental thalamic lesions is unknown. Therefore, the authors present their experience in treating such lesions. METHODS A retrospective, international multicenter study was carried out in 8 tertiary pediatric centers from 5 countries. Patients were included if they had an incidental thalamic lesion suspected of being a tumor and were diagnosed before the age of 20 years. Treatment strategy, imaging characteristics, pathology, and the outcome of operated and unoperated cases were analyzed. RESULTS Overall, 58 children (23 females and 35 males) with a mean age of 10.8 ± 4.0 years were included. The two most common indications for imaging were nonspecific reasons (n = 19; e.g., research and developmental delay) and headache unrelated to small thalamic lesions (n = 14). Eleven patients (19%) underwent early surgery and 47 were followed, of whom 10 underwent surgery due to radiological changes at a mean of 11.4 ± 9.5 months after diagnosis. Of the 21 patients who underwent surgery, 9 patients underwent resection and 12 underwent biopsy. The two most frequent pathologies were pilocytic astrocytoma and WHO grade II astrocytoma (n = 6 and n = 5, respectively). Three lesions were high-grade gliomas. CONCLUSIONS The results of this study indicate that pediatric incidental thalamic lesions include both low- and high-grade tumors. Close and long-term radiological follow-up is warranted in patients who do not undergo immediate surgery, as tumor progression may occur.

EP.FRI.758 Management of Small Bowel Obstruction: A Retrospective Audit

Aims How does management of small bowel obstruction (SBO) at a district general hospital in London compare with current recommendations from the BMJ Best Practice algorithm and the National Audit for Small Bowel Obstruction (NASBO)? Methods This retrospective audit captured patients admitted with SBO over a four-month period. Two authors searched the general surgery admission lists and extracted hospital numbers. A total of 59 patients were identified initially but nineteen of these patients were subsequently excluded, leaving 40 to be analysed. Inclusion criteria involved age 18 or over and SBO proven on imaging. Results The majority of the obstructions were secondary to adhesions (65%), with 10% due to hernia, 7% due to inflammatory bowel disease and 5% due cancer. All but one patient underwent computed tomography (CT) and in 90% of cases this was performed within 12 hours of initial assessment. For those who underwent a period of conservative management, 64% received a water-soluble study. Seven patients had immediate surgery within 12 hours of admission, and 5 patients proceeded to surgery after failed conservative management. Of the patients who failed conservative management, only one was operated on after the 72 hours. Conclusions Access to CT was excellent, as was time to theatre when the decision was made for immediate surgery. There was not a difference in access to imaging or theatre given the time or day of the week. Use of water-soluble studies in conservative management could be increased and the time to this study could be formalised.

Partial Renal Transplant Torsion as a Cause of Abdominal Pain

Allograft torsion is a rare but potentially devastating outcome of renal transplantation. Patients typically present with an acute onset of abdominal pain, though symptoms are non-specific and can easily be missed in favor of more common diagnoses. Imaging, in particular ultrasound and computed tomography, can aid in the diagnosis of renal transplant torsion by demonstrating characteristic features, and once recognized immediate surgery is typically performed in an attempt to salvage the allograft. However, renal transplant torsion needs not be an acute event; patients can instead present with chronic, waxing, and waning symptoms if the allograft undergoes partial or intermittent torsion. The aforementioned characteristic imaging findings may not be present in this situation. It is essential to recognize partial, intermittent torsion as well, for which imaging can again play a role.