The role of the early video-assisted thoracoscopic surgery in children with pleural empyema.

PURPOSE: Pleural empyema (PE) is a collection of purulent material in the pleural space. PE's management in children is a challenge and an inappropriate diagnostic-therapeutic work up can lead to serious short and long-term complications. The aim of this study is to define the correct timing to approach a pediatric PE by video-assisted thoracoscopic surgery (VATS). METHODS: A retrospective observational study was conducted including pediatric patients who underwent video-assisted thoracoscopy for pleural empyema between May 2005 and September 2022. RESULTS: 62 patients were subjected to VATS for PE (32 in Group Early VATS, 30 in Group Late VATS). It emerged that the elapsed period between the onset of symptoms and surgery correlates in a statistically significant way with the post-operative stay in intensive care (z score 4.3 and p value < 0.0001) and the analysis between early VATS, late VATS and postoperative hospitalization showed a statistically significant reduction of the post-operative hospitalization in the early VATS groups (p value < 0.02). CONCLUSIONS: VATS resulted to be safe and effective for the treatment of PE in children, and an early minimally invasive thoracoscopic intervention (early VATS) correlates with better outcomes, specifically in terms of intensive care hospitalization and overall hospitalization.

Platelet-rich plasma therapy for postoperative esophageal fistula in a pediatric patient.

Postoperative management of esophagocutaneous fistulas in pediatric patients is challenging, often resulting in prolonged hospitalization and increased morbidity. Platelet-rich plasma (PRP) has emerged as a promising adjunctive treatment for such complications. We present the case of a 7-month-old infant who developed an esophago-cutaneous fistula following esophagocoloplasty for esophageal atresia type A. Despite initial conservative management, the fistula persisted, prompting the application of PRP gel derived from umbilical cord blood. After four applications of PRP, complete closure of the fistula was achieved, leading to both functional and aesthetic results. This case highlights the potential of PRP in managing refractory postoperative esophageal fistulas in pediatric patients and underscores the need for further research to optimize treatment protocols and validate its efficacy for this sort of complications.

Ask Doctor Smartphone! An App to Help Physicians Manage Foreign Body Ingestions in Children.

BACKGROUND: Foreign body ingestion (FBI) represents the most common cause of emergent gastrointestinal endoscopy in children. FBI's management can be quite challenging for physicians because of the variability of the clinical presentation, and the decision tree becomes even more intricate because of patient-specific variables that must be considered in the pediatric age range (e.g., age of patients and neuropsychiatric disorders) in addition to the mere characteristics of the foreign body. We present an application for smartphones designed for pediatricians and pediatric surgeons based on the latest guidelines from the official pediatric societies. The app aims to help physicians manage FBI quickly and properly in children. MATERIALS AND METHODS: The latest pediatric FBI management guidelines were reviewed and summarized. The flow chart we obtained guided the development of a smartphone application. A questionnaire was administered to all pediatric surgeon trainees at our institute to test the feasibility and helpfulness of the application. RESULTS: An app for smartphones was obtained and shared for free on the Google Play Store and Apple Store. The app guides the physician step by step in the diagnostic process, analyzing all patient- and foreign body-specific characteristics. The app consultation ends with a suggestion of the most proper decision to make in terms of further radiological investigations and the indication and timing of endoscopy. A questionnaire administered to trainees proved the app to be useful and easy to use. CONCLUSION: We developed an app able to help pediatricians and pediatric surgeons manage FBI in children, providing standardized and updated recommendations in a smart and easily available way.

Intraoperative Ultrasound in Minimally Invasive Laparoscopic and Robotic Pediatric Surgery: Our Experiences and Literature Review.

Ultrasound (US) is a non-invasive imaging technique frequently used to examine internal organs and superficial tissues, and invaluable in pediatric patients. In a surgical setting, intraoperative ultrasound allows to highlight anatomical structures in detail during traditional open and minimally invasive surgery, thanks to the use of specific probes. In fact, laparoscopic and robotic ultrasonography requires the development of specialized transducers that fit through laparoscopic trocars. In adults, laparoscopic ultrasound is used during cholecystectomy before dissection of the triangle of Calot, to guide liver biopsies and ablation procedures and for the staging of patients with pancreas adenocarcinoma. However, the applications in the pediatric field are still limited. This paper aims to share our preliminary experience with ultra-sound in minimally invasive laparoscopic and robotic pediatric surgery, describing two cases in which intra-operative ultrasound was applied, and to present a review of the literature on the state of the art of the actual uses in pediatric surgery.

IL-6 Serum Levels Can Enhance the Diagnostic Power of Standard Blood Tests for Acute Appendicitis.

BACKGROUND: The diagnosis of acute appendicitis (AA) remains challenging, especially in pediatrics, because early symptoms are not specific, and the younger the patient the more difficult their interpretation is. There is a large degree of agreement between pediatric surgeons on the importance of an early diagnosis to avoid complicated acute appendicitis (CAA) and its consequences. The aim of this study is to assess if Interleukin 6 (IL-6) could enhance the sensitivity (Sn) and specificity (Sp) of the currently available and routinely performed diagnostic tools in case of suspected AA in pediatric patients. MATERIALS AND METHODS: A prospective observational study was conducted including patients who underwent appendectomy between November 2020 and March 2022. We divided patients into three groups: not inflamed appendix (group NA), not complicated AA (group NCAA), and complicated AA (group CAA). We compared the mean values of white blood cells (WBC), neutrophils, fibrinogen, ferritin, aPTT, INR, C-reactive protein (CRP), IL-6, and CRP between the three groups. Then we evaluated Sn, Sp, and odds ratio (OR) of IL-6 and CRP alone and combined. RESULTS: We enrolled 107 patients operated on for AA (22 in Group NA, 63 in Group NCAA, and 21 in group CAA). CRP levels resulted in a significant increase when comparing CAA with NA (p = 0.01) and CAA with NCAA (p = 0.01), whereas no significance was found between NA and NCAA (p = 0.38). A statistically significant increase in average IL-6 levels was found when comparing NCAA with NA (p = 0.04), CAA with NA (p = 0.04), and CAA with NCAA (p = 0.02). Considering CRP alone, its Sn, Sp, and OR in distinguishing NA from AA (both NCAA and CAA together) are 86%, 35%, and 33,17, respectively. Similarly, Sn, Sp, and OR of IL-6 alone are 82%, 54%, and 56, respectively. Combining CRP and IL-6 serum levels together, the Sn increases drastically to 100% with an Sp of 40% and OR of 77. CONCLUSIONS: Our study may suggest an important role of IL-6 in the detection of AA in its early stage, especially when coupled with CRP.

Characterization of bone homeostasis in individuals affected by cardio-facio-cutaneous syndrome.

Cardio-facio-cutaneous syndrome (CFCS) is a rare disorder characterized by distinctive craniofacial appearance, cardiac, neurologic, cutaneous, and musculoskeletal abnormalities. It is due to heterozygous mutations in BRAF, MAP2K1, MAP2K2, and KRAS genes, belonging to the RAS/MAPK pathway. The role of RAS signaling in bone homeostasis is highly recognized, but data on bone mineral density (BMD) in CFCS are lacking. In the present study we evaluated bone parameters, serum and urinary bone metabolites in 14 individuals with a molecularly confirmed diagnosis of CFCS. Bone assessment was performed through dual X-ray absorptiometry (DXA); height-adjusted results were compared to age- and sex-matched controls. Blood and urinary bone metabolites were also analyzed and compared to the reference range. Despite vitamin D supplementation and almost normal bone metabolism biomarkers, CFCS patients showed significantly decreased absolute values of DXA-assessed subtotal and lumbar BMD (p ≤ 0.05), compared to controls. BMD z-scores and t-scores (respectively collected for children and adults) were below the reference range in CFCS, while normal in healthy controls. These findings confirmed a reduction in BMD in CFCS and highlighted the importance of monitoring bone health in these affected individuals.

Bone tissue homeostasis and risk of fractures in Costello syndrome: A 4-year follow-up study.

Costello syndrome (CS) is a neurodevelopmental disorder with a distinctive musculoskeletal phenotype and reduced bone mineral density (BMD) caused by activating de novo mutations in the HRAS gene. Herein, we report the results of a prospective study evaluating the efficacy of a 4-year vitamin D supplementation on BMD and bone health. A cohort of 16 individuals ranging from pediatric to adult age with molecularly confirmed CS underwent dosages of bone metabolism biomarkers (serum/urine) and dual-energy X-ray absorptiometry (DXA) scans to assess bone and body composition parameters. Results were compared to age-matched control groups. At baseline evaluation, BMD was significantly reduced (p ≤ 0.05) compared to controls, as were the 25(OH)vitD levels. Following the 4-year time interval, despite vitamin D supplementation therapy at adequate dosages, no significant improvement in BMD was observed. The present data confirm that 25(OH)vitD and BMD parameters are reduced in CS, and vitamin D supplementation is not sufficient to restore proper BMD values. Based on this evidence, routine monitoring of bone homeostasis to prevent bone deterioration and possible fractures in adult patients with CS is highly recommended.