Aim of the study: Postoperative intra-abdominal abscess (PIAA) is a frequent and severe complication of acute appendicitis (AA) with peritonitis. The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory marker that has been related to the development of peritonitis; however, its diagnostic role in predicting PIAA has not been evaluated. This is the first study that analyzes the usefulness of NLR as a predictor of PIAA in children operated for AA.Material and Methods: Retrospective observational study in children operated for AA in our institution during 2017–2018. Patients aged under 5 years or with incomplete laboratory determinations at hospital admission (blood count, C-reactive protein, and fibrinogen) were excluded. Demographic and laboratory parameters and the development of PIAA were analyzed. NLR was calculated by dividing the absolute number of neutrophils by the absolute number of lymphocytes. By means of ROC curves, we determined the sensitivity and specificity of the different laboratory parameters to predict the development of PIAA.Results: A total of 388 patients aged 10.5 ± 2.9 year were included. Twenty (5.2%) developed PIAA. NLR presented an area under the curve (AUC) of 0.85, significantly higher than the determination of leukocytes (AUC 0.69, p < 0.001), neutrophils (AUC 0.74, p < 0.001), fibrinogen (AUC 0.68, p < 0.001) and C-reactive protein (AUC 0.73, p < 0.001). We estimated the optimal cut-off point of NLR > 10.5, with a sensitivity of 85% and a specificity of 75.2%.Conclusions: NLR is the laboratory parameter with the highest sensitivity and specificity for predicting the development of PIAA in children operated for AA. It can be useful as a predictor of worse postoperative course.

Background  Kaposiform hemangioendothelioma (KHE) is a vascular tumor frequently associated with Kasabach–Merritt phenomenon (KMP), characterized by severe thrombocytopenia and consumptive coagulopathy. Visceral involvement in KHE is rare. In our recent experience, sirolimus has shown to be an effective treatment in cutaneous KHE, becoming indeed the treatment of choice in KMP. We report a case of pancreatic KHE associated with KMP and refractory to sirolimus. Case Report  A 4-month-old infant is referred for obstructive jaundice (10 mg/dL conjugated bilirubin) secondary to vascular pancreatic tumor. Magnetic resonance (MR) and immunohistochemistry were compatible with KHE, but the tumor was considered unresectable. We initiated sirolimus (0.8 mg/m 2 /12 h) to treat KMP, and interventional radiology was performed for percutaneous biliary diversion. This procedure prompted KMP (platelets: 51,000/µL). Sirolimus treatment for 7 days showed no effect; therefore, we started our VAT protocol (vincristine/aspirine/ticlopidin) with great response after 10 days (platelets: 3,70,000/µL). Three months later, percutaneous biliary diversion was replaced by a biliary stent. The tumor disappeared leaving fibrosis and dilatation of biliary tract needing hepaticojejunostomy 6 months later. Discussion  It is difficult to establish protocols for an unusual presentation of a tumor with different targets. This is a reason collaborative multicenter studies should be performed. Management of obstructive jaundice secondary to a tumor that usually regresses in 10 years is an added challenge; therefore, the management should be led by a multidisciplinary team. Sirolimus treatment in cutaneous KHE has been described as successful in the literature, as well as in our own experience; however, it failed in our first patient with visceral KHE. We need to investigate the different response to pharmacological agents in tumors with similar histopathology, but with visceral involvement.