Safety of Veress needle for laparoscopic entry in children: Myth or reality?

INTRODUCTION: Recent reports suggested that blind laparoscopic entry techniques, including Veress needle (VN), might increase the risks of potentially fatal complications. MATERIALS AND METHODS: All consecutive patients who underwent laparoscopy in two Pediatric Hospitals with the use of a Veress needle during a 14-year period have been included. In all cases the first trocar was a radially expanding one (STEP). Complications related to the insertion technique are reported as well as those related to the whole laparoscopic technique. RESULTS: A total of 3463 patients younger than 18 years of age underwent laparoscopy between January 2006 and December 2019. Of these, 205 (5.9%) were younger than 6 months of age at surgery. Two-hundred-eighty-four patients (8.2%) previously underwent abdominal surgery. During first trocar insertion no major or minor vascular injuries occurred. Two patients (0.06%) experienced bowel lesions. Nine (0.26%) experienced failed entry. Fourteen patients (0.4%) experienced postoperative issues related to trocars positioning, namely, 9 omental eviscerations through port site insertion and 5 cases of hemoperitoneum owing to epigastric vessels lesion during operative trocar positioning. No other issues strictly related to laparoscopic entry technique have been recorded during the study period. No specific risk factors predisposing to complications have been identified but the presence of a positive history of previous abdominal procedures proved to be significantly related to a higher occurrence of bowel injury during Veress needle insertion (p = 0.0067). DISCUSSION AND CONCLUSIONS: Although with a number of biases and limitations, our study suggests that creation of pneumoperitoneum with VN combined to first trocar entry with STEP technology in children can represent a safe alternative. An exception is represented by patients who underwent previous abdominal surgeries who should be approached with caution, possibly with an open approach. Anyway, given the relatively poor quality of high-quality studies on this regard, we strongly support the implementation of well-designed RCT in children in order to answer this delicate topic. TYPE OF STUDY: Retrospective. LEVEL OF EVIDENCE: IV.

Totally robotic soave pull-through procedure for Hirschsprung's disease: lessons learned from 11 consecutive pediatric patients.

INTRODUCTION: Since Hirschsprung's disease (HSCR) already proved to benefit from robotic surgery, we aimed at describing a wider series of patients with this rare disease who were operated on with a robotic approach. PATIENTS AND METHODS: All consecutive HSCR patients who underwent totally robotic soave pull-through (TRSPT), between October 2015 and June 2019, have been included. Ethical Committee approval was obtained. Data regarding clinical features, technical details, complications, hospital stay, and functional outcome have been prospectively collected for each patient. RESULTS: Eleven patients have been included. Mean age at surgery was 29 months. Median length of surgery was 420 min. Median console time was 180 min. Six patients suffered from rectosigmoid aganglionosis, three from long HSCR (extending up to the hepatic flexure), two from total colonic aganglionosis. No major intraoperative complications occurred. Four patients (three of whom carrying a stoma) experienced minor mucosal tearing during dissection. One anastomotic stricture required dilatation under general anesthesia and two cuff strictures required cuff release (both occurring in patients who experienced intraoperative mucosal tearing). Follow-up lasted a median of 12 months. One patient experienced mild postoperative enterocolitis. Continence scored excellent-to-good in all patients who could be assessed on that regard (7 out of 11). CONCLUSIONS: Provided a number of technical key points are respected, the outcome of TRSPT for HSCR is promising. Younger patients, particularly those carrying a stoma, proved to be technically demanding and deserve a longer learning curve. Accurate preoperative bowel preparation, correct trocar placement and patient positioning proved to be crucial aspects of treatment. To conclude, TRSPT is particularly suitable for older HSCR patients, even those requiring a redo, and represents a valid alternative to available surgical option for this delicate subgroup of HSCR patients.

Autologous fat grafting in the treatment of velopharyngeal insufficiency: Clinical outcomes and treatment tolerability survey in a case series of 21 patients.

INTRODUCTION: Velopharyngeal insufficiency (VPI) is the inability to close the velopharyngeal sphincter during phonation and/or feeding. VPI is clinically characterised by hypernasal speech and nasal regurgitation. In cases of severe VPI, pharyngoplasty is recommended. Cases of mild-to-moderate VPI can be treated with fat grafting of the posterior pharyngeal wall in addition to speech therapy. The lipofilling can also be useful after pharyngoplasty to improve the outcomes. MATERIALS AND METHODS: Twenty-one patients (14 males and 7 females), ages 4-23 affected by mild-to-moderate VPI and treated with lipofilling were included in this retrospective study. The mean injected fat volume was 7.95 cc (median 6 cc, min 4 cc, max 20 cc and range 16 cc). The follow-up ranged from 6 to 60 months. The pre- and post-operative Borel-Maisonny scores were compared using Wilcoxon test. Moreover, we performed a telephone survey with the aim to assess the parental perception on child's speech and quality of life after the surgical treatment. RESULTS: Despite the small sample size, in this case series, we observed a statistically significant Borel-Maisonny score improvement and a parental satisfaction rate of about 85%. CONCLUSIONS: The augmentation of the posterior pharyngeal wall in addition to speech therapy improved the Borel-Maisonny score and the intelligibility of this case series of patients affected by mild-to-moderate VPI. In these patients, evaluated in a multidisciplinary approach, this technique allowed us to avoid major surgical procedures that would modify the anatomy of the velopharyngeal port. However, prospective comparative studies or randomised controlled trials could be useful to compare fat grafting with velopharyngoplasty techniques, with the aim to clarify indications and to define a specific treatment protocol.

Preliminary report on endoscopic pilonidal sinus treatment in children: results of a multicentric series.

BACKGROUND: Pilonidal disease is a troublesome acquired condition for whom various surgical treatments have been proposed with relatively high recurrence and complication rates. Since EPSiT technique has been described in 2013, it became an alternative treatment in adult practice. Our study reports the results of a multicentre series of pediatric patients who underwent EPSiT procedure over a 21-month period. METHODS: Between July 2015 and March 2017, all consecutive patients undergoing EPSiT in four different pediatric surgical units have been enrolled. Details regarding demographic data, detailed surgical procedure, outcome and complications have been recorded. RESULTS: A total of 43 patients underwent EPSiT procedure. Mean age was 15 years. There was a slight female preponderance. Mean weight and height at surgery were 67 kg and 168 cm, respectively. In 14% of cases a previous ineffective procedure was performed. Mean length of procedure was 34 min and median hospital stay was 24 h (12-72 h). Median length of follow-up was 4 months (range 3-18 months). Complications leading to reoperation were reported in 9% of cases with an overall resolution rate of 88%. DISCUSSION: EPSiT proved to be feasible and safe even in the pediatric population. The effectiveness and safety of the procedure suggest that this technique can represent a valid alternative for the treatment of pilonidal disease in children.

Perioperative management of hypertensive neuroblastoma: A study from the Italian Group of Pediatric Surgical Oncologists (GICOP).

BACKGROUND: Hypertension (HT) is rarely reported in patients affected by Neuroblastoma (NB), and management guidelines are lacking. Clinical features and perioperative medical treatment in such patients were reviewed to 1) ascertain whether a shared treatment strategy exists among centers and 2) if possible, propose some recommendations for the perioperative management of HT in NB patients. METHODS: A retrospective multicenter survey was conducted on patients affected by NB who presented HT symptoms. RESULTS: From 2006 to 2014, 1126 children were registered in the Italian Registry of Neuroblastoma (RINB). Of these, 21 with HT (1.8%) were included in our analysis. Pre- and intraoperative HT management was somewhat dissimilar among the participating centers, apart from a certain consistency in the intraoperative use of the alpha-1 blocker urapidil. Six of the 21 patients (28%) needed persistent antihypertensive treatment at a median follow-up of 36months (range 4-96months) despite tumor removal. Involvement of the renal pedicle was the only risk factor constantly associated to HT persistency following surgery. A correlation between the presence of HT and the secretion of specific catecholamines and/or compression of the renal vascular pedicle could not be demonstrated. CONCLUSION: Based on this retrospective review of NB patients with HT, no definite therapeutic protocol can be recommended owing to heterogeneity of adopted treatments in different centers. A proposal of perioperative HT management in NB patients is however presented. LEVEL OF EVIDENCE: IV.

Massive bleeding after rectal suction biopsy: uncommon and unexpected delayed onset.

BACKGROUND: rectal suction biopsy is a safe and painless procedure commonly performed in pediatric surgical practice for the diagnosis of intestinal dysganglionosis. METHODS: we report a 3.5-year-old boy who experienced massive delayed bleeding after a rectal suction biopsy. Detailed information regarding clinical features, onset, management, and outcome are provided. RESULTS: acute onset of massive bleeding occurred 4 days after a rectal suction biopsy was performed to rule out possible intestinal dysganglionosis. The complication was managed conservatively, but blood transfusion and hospitalization were required. No predisposing abnormalities were detected. CONCLUSIONS: massive bleeding after rectal suction biopsy is a well-known life-threatening complication. Nonetheless, such a delayed bleeding (up to 4 days after a rectal suction biopsy) has never been reported before. Parents should be made aware of this possibility and surgeons should be aware of this complication which can be scarcely predicted based on patient's and familial history.

A single institution observational study of early mechanical complications in central venous catheters (valved and open-ended) in children with cancer.

The use of indwelling central venous catheters (CVCs) has become essential for managing children undergoing cancer treatment. Various types of CVCs are available, but reports on complications observed in pediatric series are scarce. We describe our experience concerning early mechanical complications at our institute by providing a prospective evaluation of three types of CVCs that were inserted over a 39-month period. Between January 1, 2000, and March 31, 2003, double-lumen (DL) or single-lumen (SL) Hickman-Broviac (HB) and single-lumen pressure-activated safety-valved (PASV) catheters were inserted and prospectively evaluated. Five groups of possible mechanical complications were defined a priori: dislodgement, migration, rupture, accidental removal, and blockage. We took into consideration complications occurring only within the first 30 days of insertion. A total of 272 CVCs (118 PASV, 57 DL-HB, and 97 SL-HB) were inserted in 232 children. A total of 29 early mechanical complications (10.7% of all CVCs) were diagnosed: 15.2% of the PASV, 10.5% of the DL-HB, and 4.1% of the SL-HB. Elective removal of the catheter due to complications was required in eight patients. SL-HB catheters had fewer complications, while the complication rate and the number of devices that were removed were significantly higher in patients with PASV catheters. We conclude that catheter type correlates with the risk of early mechanical complications and removal.