Posterior urethral polyp causing haematuria in children.

Posterior urethral hemangioma (PUH) is a rare congenital lesion, included in group of polypoid or papillary lesion of the prostatic urethra. This lesion is responsible for a variety of symptoms in children that may be associated or isolated, sometimes its finding is occasional. The diagnosis is usually made by ultrasonography and cystourethrogram, but the gold standard is represented by the urethrocystoscopy with double possibility: diagnostic and therapeutic. The Authors report a case of 1-year-old boy with persisting haematuria, in whom a previews cystoscopy didn't find any cause of haematuria. An accurate urethrocystoscopy let to make diagnosis of prostatic urethral polyp, a transurethral resection was performed and pathological assessment confirmed the diagnosis of PUH.

Staged laparoscopic-assisted endorectal pull-through for long segment Hirschprung's disease and total colonic aganglionosis.

AIM: Recently laparoscopic endorectal pull-through (LERPT) has been widely performed for treatment of Hirschsprung's disease (HD) as a one stage procedure. In long segment aganglionosis (LSA) and in case of total colonic aganglionosis (TCA) a staged procedure can be preferred. The authors report their experience in the staged LERPT for LSA and TCA. METHODS: In the last five years we treated 4 infants (3 male, 1 female) with LSA and TCA. The mean age at presentation was 40 days (2-110 days). In 3 patients we performed in the first step rectal biopsies, multiple laparoscopic biopsies and stoma. In one case ­ presenting as small bowel obstruction - we performed an emergency laparotomy for ileostomy and biopsies of the bowel. Histology showed 2 left colon aganglionosis (LCA) and 2 TCA. The LERPT was performed at a main age of 10 months. After stoma closure the LERPT was performed according to Georgeson's technique. RESULTS: There were no intraoperative complications. The patient with previous laparotomy needed conversion because of the abdominal adhesions. The two infants with LCA had preoperative and recurrent postoperative enterocolitis. In one case a successful posterior anorectal myectomy was performed. At follow up the children present constipation. The patient with TCA undergoing to LERPT presents a good frequency of defecation. CONCLUSION: Our experience, although on limited series, shows that staged minimally invasive surgical treatment can be safely performed in the LSA and TCA, but conversion can be necessary especially in case of previous laparotomy.

Diagnosis of Hirschsprung's Disease: an age-related approach in children below or above one year.

AIM: The aim of this study was to evaluate the effectiveness of a differential diagnostic approach to Hirshchsprung's Disease (HD) on the basis of age. METHOD: Data on 185 consecutive children with suspected HD were subjected to an age-related diagnostic approach. The patients were divided into two groups according to age (A < 1 year; B > 1 year). Children in Group A had rectal suction biopsy (RSB) and contrast enema (CE), and in Group B anorectal manometry (ARM) was performed. Patients with a normal recto-anal inhibitory reflex (RAIR) underwent bowel disimpaction and medical treatment. Only selected cases in Group B underwent RSB and CE. RESULTS: In Group A (18 patients) CE showed a colonic transitional zone in three patients, whereas RSB led to the diagnosis of HD in nine. In Group B (167 patients) ARM was not possible in seven patients and it was normal in 140 (normal anal sphincter pressure: 83; hypertonia of the internal anal sphincter: 57). The RAIR was negative in 20 patients. RSB performed in 31 children in Group B confirmed HD in three patients. CONCLUSIONS: For patients with a neonatal onset of constipation RSB is the best diagnostic technique. Chronic constipation is rarely due to HD and ARM is a useful non-invasive screening tool.

Frailty, disability and survival in the elderly over the age of seventy: Evidence from "The Treviso Longeva (TRELONG) Study".

Frailty is a biological syndrome of decreased reserves and lower resistance to stressors, deriving from cumulative declines across multiple physiological systems and causing adverse outcomes. Physical frailty is easy to assess, strongly correlated to disability and to survival, considering the comorbidities, too. This working definition of frailty is inexpensive to apply, and provides a basis for standardized screening for risk of disability in older adults.

Physical activity, socialization and reading in the elderly over the age of seventy: what is the relation with cognitive decline? Evidence from "The Treviso Longeva (TRELONG) study".

Evidence in the literature suggests that physical activity, social contacts and cognitively stimulating activity, such as reading, often considered individually, may improve cognitive performance. Our work examines their interactions and confirms their positive effects on cognitive functions. The correlations between physical activity, socialization, reading and improved cognitive performance remained significant after adjusting for confounding factors, such as comorbidity and hearing function. Our work suggests that these factors are important for the prevention of cognitive decline in the elderly.

Role of anorectal manometry in children with severe constipation.

OBJECTIVE: Constipation is one of the most frequent disorders of the digestive tract in children and it can be an important problem in paediatric and surgical practice. Most of the time, the cause is psychological or because of a slowing of colonic transit, but it can be a sign of organic gastrointestinal outlet obstruction. Some patients with chronic constipation are resistant to a medical approach and they present with a severe form of constipation that needs recurrent hospital admission. Anorectal manometry (ARM) is a noninvasive procedure and it helps to explain the mechanisms of defecation disorders. The aim of the present study was to evaluate the role of ARM in children with severe constipation. METHOD: From October 2003 to October 2006, in the Paediatric Surgery Unit, 85 children - aged more than 1 year - with severe constipation were seen. The mean age was 5 years (range, 1-13). At presentation, every child had abdominal and rectal examination in order to identify abdominal distension or faecal masses. Bowel preparation with enemas was performed before ARM in patient with a rectal faecaloma. Myoelectric activity of the internal anal sphincter and resting anal tone was recorded; recto-anal inhibitory reflex (RAIR) was tested to exclude Hirschsprung's disease (HD). Anal tone was considered normal until 50 cm H(2)O. When the RAIR was absent, the patient underwent rectal suction biopsies (RSB) for histology and acetylcholinesterase histochemistry. In cases of normal or high anal tone with the RAIR present, the child had bowel cleaning, medical treatment, 2- and 6-month follow-up. Children with ineffective treatment at follow-up underwent RSB. In case of HD, a laparoscopic-assisted endorectal pull-through (ERPT) according to Georgeson's technique was performed. RESULTS: Seventy per cent of the patients had bowel preparation before ARM. In four patients the ARM was impossible to assess because of crying. In 28 patients, the anal tone result was higher than 50 cm H(2)O and local treatment with anaesthetic agents was used for 8 weeks. Seventeen patients underwent RSB: 11 patients with RAIR absent/unclear, 4 noncooperative children and 2 patients with ineffective medical treatment at follow-up. HD was diagnosed in 2 patients and laparoscopic-assisted ERPT was performed. The remaining patients had good results at 6-month follow-up. CONCLUSION: ARM is a noninvasive diagnostic tool to study the mechanism of defecation in children with constipation in order to prescribe the appropriate treatment. This procedure can be used in every child - aged more than 1 year - with severe constipation and assessment of the RAIR can select the cases for RSB.

One-trocar transumbilical laparoscopic-assisted management of Meckel's diverticulum in children.

PURPOSE: Transumbilical laparoscopic-assisted intestinal surgery using only "one trocar" is a very minimal invasive procedure. The authors present their experience for the management of Meckel's diverticulum. MATERIALS AND METHODS: Between January 2001 and December 2004, 9 transumbilical laparoscopic-assisted procedures were performed for Meckel's diverticulum. The median age of the patients was 6.1 years (range, 6 months-13.6 years). Six patients were admitted for intestinal bleeding and technetium-99m pertechnetate scan was positive in 3. Three patients had recurrent abdominal pain and abdominal ultrasound scan showed a cystlike structure. An intraumbilical Hasson 10-mm trocar was inserted in an open fashion. Using a 10-mm operative laparoscope, the terminal ileum was grasped with an atraumatic instrument and exteriorized through the umbilicus. Ileal exploration and treatment were performed extracorporeally. RESULTS: Meckel's diverticulum was identified in 8 patients and ileal duplication in 1 patient: intestinal resection/anastomosis (n = 7) or excision of diverticulum (n = 2) was performed. There were no operative complications. Median hospital stay was 4 days (range, 3-7 days). At a median followup of 24 months (range, 3-51 months), all patients are asymptomatic. CONCLUSION: Our results indicate that the one trocar transumbilical laparoscopic-assisted procedure is safe and effective for the diagnosis and treatment of Meckel's diverticulum, with excellent cosmetic results.

Neonatal adrenal hemorrhage presenting as contralateral scrotal ematoma.

Neonatal adrenal hemorrhage may rarely present as scrotal hematoma. This condition can simulate a torsion of the testis requiring an immediate surgical exploration of the scrotum. Ultrasonographic study of the abdomen can find out intraperitoneal or retroperitoneal bleeding in order to avoid unnecessary surgical intervention. The case of a newborn with right adrenal hemorrhage presenting as left scrotal hematoma is reported.

[Antimicrobial agents for preventing peritonitis in peritoneal dialysis: guideline from the Italian Society of Nephrology]. / Strategie antimicrobiche per la prevenzione delle peritoniti in dialisi peritoneale: Linea Guida.

BACKGROUND: The current 3rd edition of the Italian Society of Nephrology guidelines has been drawn up to summarize evidence of key intervention issues on the basis of systematic reviews (SR) of randomized trials (RCT) or RCT data only. The present guideline reports evidence of the use of antimicrobial agents for preventing peritonitis in peritoneal dialysis (PD). METHODS: SR of RCT and RCT on treatments aiming at preventing peritoneal dialysis peritonitis were identified referring to a Cochrane Library and Renal Health Library search (2005 update). Quality of SR and RCT was assessed according to current methodological standards. RESULTS: One SR and 19 RCT were found addressing this issue. Staphylococcus Aureus nasal carriage treatment with mupirocin reduces exit-site and tunnel infections but not peritonitis. Topical gentamicin treatment on the exit site reduces Staphylococcus Aureus infection and peritonitis incidence. Intravenous antibiotics administration prior to catheter placement significantly reduces the risk of early peritonitis but not exit-site and tunnel infections. Oral nistatin associated with antibiotic treatment significantly reduces the incidence of Candida peritonitis. No other prophylaxis measure seems to be effective based on available evidence. CONCLUSION: In patients on peritoneal dialysis current evidence supports the hypothesis that topical mupirocin reduces the risk of Staphylococcus Aureus peritonitis, intravenous antibiotics prior to catheter placement prevent the risk of early peritonitis, and oral nistatin reduces the risk of Candida peritonitis. Further studies are necessary to test the effectiveness of other interventions.

The Treviso Longeva (Trelong) study: a biomedical, demographic, economic and social investigation on people 70 years and over in a typical town of North-East of Italy.

Longevity is a complex process resulting from genetic and environmental factors, as well as their interaction. These factors are poorly understood, and the comparison among health status, socio-economics, demographic and other characteristics of the elderly people can help in understanding these complex interactions. Such an interdisciplinary approach is necessary to allow an appropriate evaluation of longevity. Here we report the methodology and the first results of a representative study performed in 2003-2004 on people of 70 years and over, living in a typical town of North-East of Italy. In the research we collected biomedical, demographic, socio-economic and quality of life (QoL) data.

Associations of the plasma interleukin 6 (IL-6) levels with disability and mortality in the elderly in the Treviso Longeva (Trelong) study.

IL-6 expression is regulated by the interplay of several transcriptional and hormonal factors, including sex steroids and glucocorticoids. In late life IL-6 expression increases as a result from loss of the normally inhibiting sex steroids. IL-6 is one of several proinflammatory cytokines. It has been proposed that many chronic inflammatory diseases are the result of a dysregulation of IL-6 expression. In this work we demonstrate that increased IL-6 levels in elderly are associated with higher disability and mortality, also independently of age and comorbidity.

Laparoscopic Fowler-Stephens procedure is contraindicated for intraabdominal testicular major duct anomalies.

The laparoscopic one- and two-stage Fowler-Stephens procedure has gained large popularity in the treatment of the child with a high intraabdominal testis. It is largely debated which technique (e.g., testicular autotransplant or Fowler-Stephens procedure) offers the best results for high intraabdominal testes. We describe a case of a 3-year-old boy for whom previous bilateral inguinal exploration results were negative for testes or testicular remnants. The diagnostic laparoscopy showed two iliac intraabdominal testes with short spermatic vessels, closed inguinal rings, and complete dissociation of didime-epididime. A left open orchidopexy was perfomed, and testicular autotransplant was proposed for the right testes located 4 cm from the internal inguinal ring. Long-term follow-up evaluation (1.8 years) of the left testis showed it in the scrotum with good testicular size (1.5 cm). We believe that there are two main reasons to contraindicate the Fowler-Stephens technique: associated malformation that does not permit the development of the collateral blood flow via the vasal artery necessary for a viable testis, and previous surgery that represents a risk factor for testicular atrophy. The laparoscopic anatomic classification for the intraabdominal testis is reliable and can disclose the most suitable surgical technique. Laparoscopy is a valuable tool in the diagnosis and treatment of the nonpalpable testicle.

Detection of crossing vessels at the ureteropelvic junction with fast MRI.

OBJECTIVE: Minimally invasive surgery is an alternative to open surgery in the treatment of ureteropelvic junction obstruction (UPJO) in selected pediatric patients. Anomalous crossing vessels represent a contraindication to endopyelotomy and may also interfere with the videosurgical pyeloplasty. We investigated the usefulness of magnetic resonance imaging (MRI) without contrast in the preoperative evaluation of anomalous crossing vessels in children. MATERIALS AND METHODS: From January 1999 to December 1999, 14 patients with diagnosis of hydronephrosis were prospectively evaluated with the aim of accurately plan the operative approach. The children underwent MRI study with HASTE sequences, heavily T2 weighted. Diagnosis was made without IV contrast material. No sedation was used. RESULTS: 4 out of the 14 patients studied were diagnosed as having anomalous crossing vessels at the ureteropelvic junction. They underwent open dismembered pyeloplasty and the diagnosis was confirmed at the operation. There was 1 false negative. CONCLUSIONS: The fast T2 weighted MRI allows a non invasive preoperative assessment of crossing vessels at the UPJO which is of paramount importance in the choice of the appropriate surgical approach. Nevertheless, the high cost and the low sensitivity (80%, 4/5) make this technique still not routinely applicable in the preoperative work-up of children with UPJO.

Italian multicenter survey on laparoscopic treatment of gastro-esophageal reflux disease in children.

BACKGROUND: Skepticism is still present today about the laparoscopic treatment of gastro-esophageal reflux (GER) in children. We present the prospective experience and short-term results of eight Italian pediatric surgical units. METHODS: We included all the children with complicated GER, operated after January 1998 by single surgeons from eight different centers. Diagnostic aspects, type of fundoplication, and complications were considered. All the patients were followed for a minimum period of 6 months in order to detect complications or recurrences. RESULTS: 288 children were prospectively included. Mean age was 4.8 years (3 m-14 y). Nissen fundoplication was done in 25%, floppy Nissen in 63%, Toupet in 1.7%, and anterior procedures (Lortat Jacob, Thal) in 10%. Gastrostomy was associated, if neurological impairment or feeding disorders were present. Mean follow-up was 15 months and reoperation was necessary in 3.8% of cases. CONCLUSIONS: This experience underlines that minimal invasive access surgery in children is safe and that the laparoscopic approach is considered in eight centers the golden standard for surgical repair of gastro-esophageal reflux disease maintaining the same indications and techniques of the open approach.

Hyperinsulinism reduction associated with icodextrin treatment in continuous ambulatory peritoneal dialysis patients.

Glucose absorption from peritoneal dialysis solutions causes a chronic stimulation of insulin secretion, which leads to hyperinsulinism. The use of solutions without glucose should correct this metabolic derangement together with the associated cardiovascular risk. To verify this hypothesis, we studied the entire non diabetic continuous ambulatory peritoneal dialysis (CAPD) population of our center: 27 patients with a mean age of 62 +/- 15 years, and a median 17 months on treatment. Morning fasting serum insulin was 32.8 +/- 9.3 microU/mL; glucose, 104.4 +/- 21.8 mg/dL; triglycerides, 162.4 +/- 125.7 mg/dL; cholesterol, 221.9 +/- 54.7 mg/dL; intact parathyroid hormone (iPTH), 212 +/- 189 pg/mL; fibrinogen, 519 +/- 112 mg/dL; body mass index, 24.1 +/- 4.1; and daily erythropoietin subcutaneous therapy dose, 17 +/- 6 U/kg. Insulin sensitivity, measured as ISI-HOMA (insulin sensitivity index, derived from the homeostasis model assessment) was 2.4 +/- 0.7. Daily glucose load, calculated from dialytic schedules, was 135 +/- 38 g. Of the 27 patients, 12 were treated with standard glucose solutions during the day and with one icodextrin dwell during the night for a median of 9 months (range: 1-28). The remaining 15 patients were treated with standard glucose solutions. The icodextrin group showed significantly lower serum insulin levels (28.6 +/- 6.0 microU/mL vs 36.1 +/- 10.2 microU/mL, p = 0.021) and significantly higher ISI-HOMA values (2.7 +/- 0.5 vs 2.2 +/- 0.7, p = 0.041) than the control group. The two groups showed no significant differences for glucose, triglycerides, cholesterol, iPTH, fibrinogen, body mass index, or erythropoietin therapy dose. Daily glucose load was lower in the icodextrin group, but without reaching statistical significance (128 +/- 31 g vs 142 +/- 43 g). This study shows, in a preliminary way, that the chronic use of icodextrin in the long nighttime dwell can reduce serum insulin levels and increase insulin sensitivity in CAPD patients.

Results and complications of laparoscopic surgery for pediatric varicocele.

BACKGROUND: The aim of this study was to evaluate the results and complications of laparoscopic varicocelectomy in children. METHODS: Over a 36-month period, 211 children underwent laparoscopic treatment of varicocele. Their ages ranged between 6 and 17 years; the varicocele was located on the left side in 209 cases (99.1%) and was bilateral in 2 (0.9%). In 195 patients the laparoscopic transperitoneal approach was used and in 16 retroperitoneoscopy was used. Thirty children (14.2%) underwent ligation of the veins alone, and 181 (85.8%) underwent ligation of testicular veins and artery. In 15 (7.1%) cases an additional procedure was applied during the same operation. RESULTS: Average operating time was 30 minutes and hospitalization about 24 hours. At an average follow-up of 26 months, there were 19 (9%) postoperative complications: 14 children had a left hydrocele, 3 children a scrotal emphysema, and 2 an umbilical granuloma. There were 5 recurrences of varicocele in our series: 2 (2 of 30, 6.6%) after the Ivanissevitch procedure, and 3 (3 of 181, 1.6%) after Palomo's. Testicular atrophy did not occur in any patient of this series. CONCLUSIONS: This preliminary experience shows that the results of the laparoscopic approach are comparable to those of the open approach. The ligation of testicular veins and artery is preferable to the ligation of the testicular veins alone. Hydrocele seems to be the most frequent postoperative complication and a potential problem, especially in children operated on with the Palomo procedure.

One-trocar surgery: a less invasive videosurgical approach in childhood.

BACKGROUND/PURPOSE: Laparoscopic techniques and instruments are evolving to lessen the invasiveness of this surgical approach. The authors present their experience with the videosurgical approach using only 1 trocar. METHODS: Between October 1997 and January 2000 the authors performed 59 videosurgical procedures using a 1-trocar approach (mean age, 11.5 years; range, 4 to 18 years). A 10-mm Hasson trocar was inserted in an "open" fashion either through the umbilicus (laparoscopy) or below the apex of the 12th rib (retroperitoneoscopy). An operative laparoscope was used in all cases. The operations were 18 retroperitoneoscopic Palomo varicocelectomies, 1 retroperitoneoscopic renal biopsy, 38 appendectomies, and 2 ileal resections (Meckel's diverticulum, duplication cyst). For appendectomies and ileal resections, the corresponding intestinal loop was grasped and exteriorized through the umbilicus to perform conventional surgery. RESULTS: Mean operating time was 50.9 minutes (range, 30 to 120) for laparoscopies and 44 minutes (range, 15 to 80) for retroperitoneoscopy. There were 11 conversions (8 appendectomies, 3 varicocelectomies) and no postoperative complications. CONCLUSIONS: "One-trocar surgery" is safe, effective, and fast with a low complication rate and excellent cosmetic results. The authors believe it is the least invasive as well as the most effective approach in the treatment of varicocele, appendicitis, and selected intestinal diseases.

Unusual clinical presentation of a rare case of phyllodes tumor of the breast in an adolescent girl.

Phyllodes tumor of the breast is a very rare neoplasm, particularly in adolescent girls and young women. It usually presents as unilateral palpable mass. The authors report the case of an adolescent girl who presented at the Emergency Department with bloody nipple discharge. Although the clinical signs suggested an intraductal tumor, the histologic examination showed a phyllodes tumor. The management and the biologic behavior of this uncommon tumor are discussed with particular regard to the very unusual clinical presentation in this patient. J Pediatr Surg 36:941-943.