The American Academy of Pediatrics recently released its new Technical Report and Policy Statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the 8 task force members reflect what these individual physicians perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report’s conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a different view is presented by non–US-based physicians and representatives of general medical associations and societies for pediatrics, pediatric surgery, and pediatric urology in Northern Europe. To these authors, only 1 of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.

Purpose: Nonparasitic splenic cysts (NPSCs) are uncommon in children. The aim of this multinational and multicentric study was to present the authors' experience as well as the changing trends in the management of NPSCs over the last 25 years. Material and Methods: From 1981 to 2005, 50 children or adolescents were surgically treated for NPSCs in 6 paediatric surgical centres in four European countries. The medical records of these 50 patients with NPSCs were reviewed retrospectively. Results: Twenty-six male and 24 female patients were operated on. Age at surgery ranged from 1 to 17 years (mean 11.9). Seventeen patients were symptomatic. Six total (4 open and 2 laparoscopic) and 26 partial (22 open and 4 laparoscopic) splenectomies were performed. Laparoscopic fenestration or deroofing and open cystectomy was carried out in 9 patients, respectively. Histological findings revealed the lesion to be an epidermoid cyst (n = 28), a pseudocyst (n = 15) or a mesothelial cyst (n = 2). In 5 patients haemangioma or lymphangioma was the pathological diagnosis. At a mean follow-up of 2.9 years, residual cysts were found in 8 laparoscopically treated patients, 4 of whom required re-do laparoscopy or open surgery. Conclusions: Over the last two decades, the surgical treatment of NPSCs has changed from a formerly customary total splenectomy to spleen-conserving procedures, such as total cystectomy with or without partial splenectomy or partial cystectomy. These therapeutic modalities can be performed laparoscopically, if technically possible. Fenestration or deroofing of the cyst resulted in a high recurrence rate (7/9).

Biliary atresia (BA) is a rare but potentially devastating disease. The European Biliary Atresia Registry (EBAR) was set up to improve data collection and to develop a pan-national and interdisciplinary strategy to improve clinical outcomes. From 2001 to 2005, 100 centers from 22 countries registered with EBAR via its website (www.biliary-atresia.com). In June 2006, the first meeting was held to evaluate results and launch further initiatives. During a 5-year period, 60 centers from 19 European countries and Israel sent completed registration forms for a total of 514 BA patients. Assuming the estimated incidence of BA in Europe is 1 : 18 000 live births, 35 % of the expected 1488 patients from all EBAR participating countries were captured, suggesting that reporting arrangements need improvement. At the meeting, the cumulative evaluation of 928 BA patients including patients from other registries with variable follow-up revealed an overall survival of 78 % (range from 41 % to 92 %), of whom 342 patients (37 %) have had liver transplants. Survival with native liver ranged from 14 % to 75 %. There was a marked variance in reported management and outcome by country (e.g., referral patterns, timing of surgery, centralization of surgery). In conclusion, EBAR represents the first attempt at an overall evaluation of the outcome of BA from a pan-European perspective. The natural history and outcome of biliary atresia is of considerable relevance to a European population. It is essential that there is further support for a pan-European registry with coordination of clinical standards, further participation of parent support groups, and implementation of online data entry and multidisciplinary clinical and basic research projects.

Purpose: This prospective, single-center cohort study analyzes the potential of inflammatory protein mediator leucine-rich alpha-2 glycoprotein 1 (LRG1) for the early and accurate diagnosis of acute appendicitis (AA), and differentiation of acute complicated (AcA) from uncomplicated appendicitis (AuA). Methods: Participants were divided into the AcA, AuA, and control groups, and their serum (s-LRG1) and urine LRG1 (u-LRG1) levels were assayed preoperatively on the second and fifth postoperative days. Results: 153 patients participated, 97 had AA. Preoperative u-LRG1 with a cut-off value of 0.18 μg/mL generated an area under the receiver operated characteristic (AUC) curve of 0.70 (95% CI 0.62–0.79) for AA versus control (p < 0.001), while the results for AcA versus AuA were not significant (AUC 0.60, 95% CI 0.49–0.71, p = 0.089). The s-LRG1 levels of AA versus the control with a cut-off value of 51.69 μg/mL generated an AUC of 0.94 (95% CI 0.91–0.99, p < 0.001). The cut-off value of s-LRG1 was 84.06 μg/mL for diagnosis of AcA from AuA, and therefore, significant (AUC 0.69, 95% CI 0.59–0.80, p = 0.001). Conclusions: LRG1 exhibited excellent diagnostic performance as an inexpensive, non-invasive, rapid, and accurate biomarker able to reflect the pathogenesis of AA. LRG1 has the potential to replace advanced imaging to diagnose clinically ambiguous AA cases.

The register of Latvian children with portal hypertension (PH) includes 34 patients from 2 to 16 years old. In 26 children the PH is caused by a prehepatic obstruction. The most widespread symptoms of PH are variceal bleeding and hypersplenism. The traditional management of hypersplenism has been splenectomy. We have used partial splenic embolization (PSE) as an alternative to splenectomy. From 1998 to 2000 we carried out PSE in 8 patients with PH. A percutaneous femoral artery approach to the splenic artery was used to deliver microspheres with a diameter of 0.3 mm into the spleen, minimizing blood circulation to the organ by 60 - 70 %. In 7 patients symptoms of hypersplenism disappeared and blood tests returned to normal status. In one patient we carried out PSE twice. In one case PSE was not successful and the patient underwent partial resection. Abdominal pain and subfebrility were observed on average 2 weeks after PSE. In 7 patients the 4 - 20 months follow-up period demonstrated the efficiency of the non-operative hypersplenism management method. We conclude that PSE is the method of choice to treat hypersplenism. Le registre des patients porteurs d'une hypertension portale (PH) en Lettonie inclus 34 enfants âgés de 2 à 16 ans. HP de 26 patients est en rapport avec une obstruction pré-hépatique. Les symptômes typiques de la maladie sont l'hémorragie en rapport avec les varices œsophagiennes et l'hypersplénisme. La splénectomie est la méthode traditionnelle de traitement de l'hypersplénisme. Nous avons réalisé une embolisation partielle de la rate (EPR) comme alternative à la splénectomie. Nous avons réalisé une EPR chez 8 patients de 1998 à 2000. Un cathétérisme de l'artère fémorale a été réalisé. L'embolisation est faite en introduisant des microsphères de 0,3 de mm dans les branches de l'artère splénique. Ainsi, la circulation sanguine splénique est réduite de 60 à 70 %. Après l'embolisation, les symptômes de l'hypersplénisme ont disparus chez 7 patients, et les examens biologiques sanguins se sont améliorés dans les limites de la normale pour l'âge. Nous avons réalisé 2 EPR à l'un des patients. Une EPR a été sans résultat et une résection partielle de la rate a été faite secondairement. Un décalage thermique et des douleurs abdominales ont été observés 2 semaines après l'embolisation. Le suivi des patients 4 à 20 mois après l'EPR a permis de constater que les symptômes de l'hypersplénisme avaient disparus. Nous concluons que l'EPR est une méthode de choix pour le traitement de l'hypersplénisme. El registro de niños en Letonia con hipertensión portal (HP) es de 34 pacientes, con edades comprendidas entre los 2 y 16 años. En 26 niños la hipertensión portal está causada por la obstrucción prehepática. Los síntomas más comunes de hipertensión portal son el sangrado varicoso y el hiperesplenismo. El tratamiento tradicional del hiperesplenismo ha sido la esplenectomía. Hemos realizado una embolización parcial del bazo (EPB) como alternativa a la esplenectomía en ocho pacientes con hipertensión portal entre los años 1998 y 2000. Se abordó percutáneamente la arteria esplénica a través de la femoral y distribuimos microesferas de 0,3 mm de diámetro dentro del bazo, minimizando la circulación sanguínea al órgano en un 60 - 70 %. En 7 pacientes los síntomas de hiperesplenismo desaparecieron y los análisis de sangre volvieron a su estado normal. En un paciente realizamos una embolización parcial del bazo dos veces. En un caso la embolización parcial del bazo no tuvo éxito y el paciente fué sometido a una esplenectomía parcial. Dolor abdominal y fiebre fueron observados en un periodo de 2 semanas, aproximadamente, después de haber sido realizada la embolización parcial del bazo. En 7 pacientes un seguimiento entre 4 y 7 meses demuestra la eficacia del tratamiento no quirúrgico del hiperesplenismo. Concluimos que la embolización parcial del bazo es un método alternativo para tratar el hiperesplenismo. 34 lettische Kinder im Alter von 2 bis 16 Jahren werden mit portaler Hypertension (PH) vorgestellt. Bei 26 Patienten war die PH durch den prähepatischen Block bedingt. Das Krankheitsbild geht mit Blutungen aus den varikös veränderten Ösophagusvenen und dem Hypersplenismus einher. Als traditionelle Behandlungsmethode des Hypersplenismus gilt die Splenektomie. Zur Alternative gehört die partielle Embolisation der Milz (PEM), die von uns eingesetzt wird. Von 1998 bis 2000 unterzogen sich 8 Patienten der Embolisation. Der Zugang erfolgte durch die Arteria femoralis. Die Embolisation wird durchgeführt, indem man in die Verzweigungen der Milzarterie die Mikrosphären im Kaliber von 0,3 mm einbringt. Dadurch wird der Milzkreislauf um 60 - 70 % vermindert. Nach der Embolisation der Milz kam es bei 7 Patienten zum Verschwinden von Hypersplenismuserscheinungen, d.h., das Blutbild besserte sich und entsprach der Altersnorm. Bei einem der Kinder musste die Embolisation wiederholt werden, bei einem weiteren misslang sie, und es wurde später eine partielle Milzresektion vorgenommen. Als Folgeerscheinungen ließen sich Bauchschmerzen und subfebrile Temperaturen beobachten. Bei der Nachuntersuchung - 4 bis 20 Monate nach der Embolisation - konnten keine Hypersplenismusphänomene mehr nachgewiesen werden. Die PEM kann als Methode der Wahl in der Behandlung von Hypersplenismus angesehen werden. 1 Paper read at the 4th European Congress of Pediatric Surgery, Budapest, May 3 - 5, 2001