Intramural duodenal hematoma is an uncommon complication of pediatric endoscopic biopsy that occurs mainly in children with bleeding disorders. We report the case of a 5-year-old girl who presented with signs of partial duodenal obstruction and acute pancreatitis due to duodenal hematoma following endoscopic biopsy. The lesion was diagnosed and monitored by sonography and resolved with conservative management.

The main criterion for abdominal aortic aneurysm (AAA) repair is an AAA diameter ≥5.5 cm. However, some AAAs rupture when they are smaller. Size alone may therefore not be a sufficient criterion to determine rupture risk. Fluorodeoxyglucose (FDG) uptake is increased in the presence of inflammation and it was suggested that this may be a better predictor of rupture risk than AAA size. Furthermore, increased FDG uptake following endovascular AAA repair may be an indirect predictor of continuous AAA sac enlargement due to the presence of an endoleak (even if this is not detected by imaging modalities) and/or increased AAA rupture risk. The role of FDG uptake needs to be explored further in the management of AAAs.

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Flondell-Sité et al in this issue of Angiology report that besides abdominal aortic aneurysm (AAA) diameter (P ¼ .0019), endothelin-1 (ET-1) levels (P ¼ .0230) were significant predictors of AAA growth in 178 patients with AAA followed conservatively (mean: 2.9 + 1.6 years).1 In univariate analysis, ET-1 levels also predicted death or need for AAA surgery.1 These results suggest an alternative/additional predictor of AAA growth and rupture risk besides AAA diameter.Currently, the main criterion for AAA repair is an AAA diameter 5.5 cm.2 The 5.5-cm diameter threshold is the size when the AAA rupture rate balances the mortality rates of elective AAA repair (3%).2 However, some AAAs rupture when they are smaller and many are discovered after they have exceeded this critical diameter but have not ruptured.3 It therefore seems that size alone is not sufficient to assess AAA rupture risk. The discovery of alternative predictors of AAA growth and rupture risk holds implications for a more appropriate (earlier/later) surgical management of AAAs.This Editorial discusses potential predictors of AAA growth and rupture risk besides AAA diameter and ET-1. i) 18F-fluorodeoxyglucose (FDG) uptakeMetabolic processes, such as chronic inflammation and proteolysis, play a pivotal role in AAA formation and rupture. [4][5][6] Increased 18F-FDG metabolism measured by positron emission tomography (PET) computed tomography (CT) scans have been described in aortic infection, arteritis, inflammation, as well as symptomatic AAAs. 7,8 A recent study demonstrated increased aortic 18F-FDG metabolism in patients with asymptomatic AAAs compared with healthy controls (mean maximum standard uptake values [SUV max ], 3.5 + 0.6 vs 3.0 + 0.5, respectively; P < .05). Furthermore, patients with symptomatic AAAs had significantly higher focal 18F-FDG metabolism compared with individuals with asymptomatic AAAs (mean SUV max , 7.5 + 0.3 vs 3.5 + 0.6, respectively; P < .05). These findings lead the authors to conclude that ''18F-FDG PET CT imaging might be a new approach to identify AAAs at risk before acute aneurysm onset. '' 9 Although promising, these preliminary results need to be validated in appropriately designed trials. i) Pulse-wave velocity (PWV)Our group recently investigated the prognostic value of the carotid-femoral aortic PWV (a marker of arterial stiffness and cardiovascular risk and a possible predictor of AAA rupture risk)10-12 before and after elective open AAA repair. 13 Patients (n ¼ 24) scheduled for an open AAA repair underwent 2 carotid-femoral aortic PWV measurements; 1 preoperatively and another 6 months later. A polytetrafluoroethylene aortobifurcated graft (aortobi-iliac or aortobi-femoral) was introduced in all patients. Mean aortic PWV increased from 7.84 + 1.85 preoperatively to 10.08 + 1.57 m/s 6 months postoperatively (P < .0001). However, the preprocedural PWV measurement did not correlate with AAA diameter (Spearman rank correlation coefficient r ¼ .12; P ¼ .594). 13In normal aortas, the propagation of the pulse wave i...

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INTRODUCTION: Cholecystectomy in children is not a common surgical procedure. In the past 5 years, we have performed it laparoscopically. There was no difference in insufflated pressure between 2 groups while no drainage catheter was placed. OBJECTIVE: We present a modified laparoscopic technique in children. METHODS: In a 5-year period, 54 children underwent laparoscopic cholecystectomy. Their ages ranged from 14 months to 15 years (mean: 7.6 years). Depending on the applied technique, the patients were separated into 2 groups. The first group comprised 17 patients on whom we performed the conventional 4-port technique. The second group comprised 37 patients on whom a modified technique was performed. We used 3 ports: an umbilical port for the camera, another in the subxifoid region for the dissector, and a third in the right lower quadrant for the grasping clamp and the extraction of the gallbladder. Vessel sealing electrocautery was used for ligation of the cystic artery and detachment of the gallbladder. RESULTS: Reduction of the number of ports had no effect on accessibility and duration of the procedure; however, it simplified access and handling, particularly in the smaller patients. Conversion to open cholecystectomy was performed in 1 case with major deformities of the vertebral column. The duration of hospitalization varied from 1 to 4 days (mean: 2.7 days). CONCLUSIONS: The decreased number of ports and the use of vessel sealing electrocautery make laparoscopic cholecystectomy in children easier and safe, without affecting the perioperative time.

Primary appendiceal Burkitt lymphomas are rare occurring in 0.015% of all gastrointestinal lymphomas. Presentation of such lymphomas with peritonitis and obstructive jaundice owing to its subhepatic location is even more unusual. Burkitt lymphoma is very rare in children below 5 years old. We will present a 3-year-old boy with primary appendiceal lymphoma whose first symptom was obstructive jaundice caused by a ruptured retrocecal subhepatic appendix which in essence is a combination of all 3 mentioned occurrences complicated with acute abdomen.