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.

Comparison between two minimally invasive techniques for Hirschsprung disease: transanal endorectal pull-through (TERPT) versus laparoscopic-TERPT.

INTRODUCTION: Surgical treatment for Hirschsprung disease (HD) has recently evolved into different minimally invasive techniques. The aim of the present study is to compare results from two different minimal invasive approaches, transanal endorectal pull-through (TERPT) and laparoscopic-assisted endorectal pull-through (LA-TERPT). METHODS: Patients have been divided into two groups according to surgical technique. Data of HD patients treated by TERPT and those treated by LA-TERPT, respectively, performed at two different centers from January 2007 to December 2017, were retrospectively collected. Patients with aganglionosis confined to the recto-sigmoid colon with a minimum follow-up period of 4 years have been included. Demographic, clinical, surgical and functional outcome data were reviewed for each group using Chi-square and Fisher tests (statistical differences were considered for p < 0.05). RESULTS: Among patients treated for HD in the two centers during the study period, 65 met the inclusion criteria (37 TERPT group and 28 LA-TERPT group). No differences regarding demographic and clinical data were observed between the two groups. Operative time was longer in the LA-TERPT group (p < 0.001). Time to start oral feeding was faster in the TERPT group while hospital stay was similar between the two groups. Three patients of the TERPT group required an additional abdominal approach. The rate of early complications was higher in the TERPT group. Long-term bowel function was assessed in 31 patients for the TERPT group and 24 patients for the LA-TERPT group. Outcomes showed that the bowel functional outcome was good (BFS ≥ 17) in 55% (n = 17) of TERPT group and 54% of LA-TERPT group (p = 0.97), moderate (BFS 12 to 16) in 16% (n = 5) and 33% (n = 8), respectively (p = 0.24), and poor in 29% (n = 9) and 13% (n = 3), respectively (p = 0.23). CONCLUSIONS: Both TERPT and LA-TERPT techniques should be considered safe and feasible for the treatment of HD patients. TERPT patients present faster time to return to normal bowel function while LA-TERPT patients have slightly lower incidence of postoperative complications. Long-term functional outcomes are similar between the two groups. LEVEL OF EVIDENCE: III.

Midazolam premedication in ileocolic intussusception: a retrospective multicenter study.

Ileocolic intussusception is a common cause of bowel obstruction. When spontaneous reduction does not occur, non-operative management through enema reduction is necessary. Despite the evidence indicating that sedatives favor success in the reduction, their use is still not a common practice. To determine if midazolam (MDZ) before enema improves the rate of procedure success, we retrospectively reviewed charts of patients admitted to two Italian pediatric emergency departments. Outcome measures were the success rate of the enema, recurrence, and need for surgery. Patients were grouped according to the use of MDZ or not, before hydrostatic reduction attempt. We included 69 and 37 patients in the MDZ and non-MDZ groups, respectively. The two groups did not differ in demographics, clinical characteristics, and ultrasound findings. Intussusception reduction after the first enema attempt occurred in 75% (MDZ group) and 32.4% (non-MDZ group) of patients (P < .001); 27.9% (MDZ group) and 77.8% (non-MDZ group) of patients underwent surgery (P < .001). Among them, spontaneous reduction of intussusception during the induction of general anesthesia occurred in 31.6% and 42.9% of patients, respectively (P .43). Multivariate logistic regression analysis showed that only MDZ had a positive effect on the result of the enema (OR 7.602, 95%CI 2.669-21.652, P < .001). CONCLUSION: Procedural sedation with MDZ for enema reduction of intussusception can increase the success rate and lead to a better management of patients. WHAT IS KNOWN: • Despite the evidence of the usefulness of sedatives in the reduction of intussusception, their use is still not a common practice. WHAT IS NEW: • Midazolam during enema reduction of intussusception can increase the success rate and consequently lead to better management of patients.

Is It Better to Operate Congenital Lung Malformations when Patients are Still Asymptomatic?

CONTEXT: Congenital lung malformation (CLM) is a rare developmental anomaly of the lower respiratory tract. The purposes are to define if the presence of respiratory symptoms, in CLM may affect surgical outcomes and to define optimal timing for surgery in asymptomatic patients. SETTINGS AND DESIGN: Retrospective review of patients with CLM from 2004 to 2018. Asymptomatic and symptomatic patients were compared. Moreover, asymptomatic patients were stratified according to age at surgery (< or >6 months). SUBJECTS AND METHODS: Demographic data, prenatal diagnosis, symptoms, CLM's characteristics, operative and postoperative data were collected. Patients were divided into two groups based on the presence or none of respiratory symptoms. STATISTICAL ANALYSIS: Data were compared using the Fisher's exact test for qualitative values and Mann-Whitney test for quantitative values P < 0.05 was statistically significant. RESULTS: One hundred and eighty-six patients were treated. Asymptomatic were 137 (74%), while symptomatic were 49 (26%). The most common presenting symptoms were respiratory distress (n = 30, 61%) followed by pneumonia (n = 18, 38%). Prenatal diagnosis of CLM was performed in 98% of asymptomatic patients compared to 30% of symptomatic (P = 0.001). Surgical excision was performed in all cases, and in 50% by thoracoscopy, without difference between the two groups. In 97% of all cases, a lung sparing surgery was performed without difference between the groups. Symptoms are significantly associated with older age, location in the upper lobe, and lobar emphysema. Length of stay in intensive care, postoperative complications, and reintervention rate were higher in the symptomatic group. Eighty-one asymptomatic patients underwent surgery <6 months of life; they had a lower rate of surgical complications (2%) compared with those >6 months (7%). CONCLUSIONS: The present study describes a comprehensive picture of CLM. In addition, we emphasize the role of early postnatal management and thoracoscopic surgery, also before 6 months of life, to prevent the onset of symptoms that are associated with worse outcomes.

Fetal lung underdevelopment is rescued by administration of amniotic fluid stem cell extracellular vesicles in rodents.

Fetal lung underdevelopment, also known as pulmonary hypoplasia, is characterized by decreased lung growth and maturation. The most common birth defect found in babies with pulmonary hypoplasia is congenital diaphragmatic hernia (CDH). Despite research and clinical advances, babies with CDH still have high morbidity and mortality rates, which are directly related to the severity of lung underdevelopment. To date, there is no effective treatment that promotes fetal lung growth and maturation. Here, we describe a stem cell-based approach in rodents that enhances fetal lung development via the administration of extracellular vesicles (EVs) derived from amniotic fluid stem cells (AFSCs). Using fetal rodent models of pulmonary hypoplasia (primary epithelial cells, organoids, explants, and in vivo), we demonstrated that AFSC-EV administration promoted branching morphogenesis and alveolarization, rescued tissue homeostasis, and stimulated epithelial cell and fibroblast differentiation. We confirmed this regenerative ability in in vitro models of lung injury using human material, where human AFSC-EVs obtained following good manufacturing practices restored pulmonary epithelial homeostasis. Investigating EV mechanism of action, we found that AFSC-EV beneficial effects were exerted via the release of RNA cargo. MicroRNAs regulating the expression of genes involved in lung development, such as the miR17-92 cluster and its paralogs, were highly enriched in AFSC-EVs and were increased in AFSC-EV-treated primary lung epithelial cells compared to untreated cells. Our findings suggest that AFSC-EVs hold regenerative ability for underdeveloped fetal lungs, demonstrating potential for therapeutic application in patients with pulmonary hypoplasia.

Uretero-Pelvic Junction Stenosis: Considerations on the Appropriate Timing of Correction Based on an Infant Population Treated with a Minimally-Invasive Technique.

There is no univocal consensus about timing of intervention and best surgical approach for infants with asymptomatic uretero-pelvic junction obstruction (UPJO). We conducted a retrospective analysis of patients undergoing one-trocar-assisted pyeloplasty (OTAP) in a 13 year range period by creating two homogenous groups (indications for surgery were the same for all patients): patients operated on in the first 90 days of life (34 patients; Group 1) and patients operated on between 3 and 12 months of life (34 patients; Group 2). We observed no statistically significant differences between groups in regard to mean operative time, conversion rate to open surgery, mean hospital stay, early complications (urinary leakage) rate and mean antero-posterior diameter (APD) reduction rate. Moreover, no statistical improvement was seen between groups in regard to separate renal function (SRF) at 1-year-follow-up renogram. Thanks to the HSS calculated before and 1 year after surgery, we registered an important improvement in Group I patients (p = 0.023). In our study, there was no significant evidence, in terms of intraoperative data and early postoperative outcomes, between patients who underwent an early pyeloplasty and those who underwent a delayed correction. Nevertheless, we registered a significant improvement in those patients with an impaired SRF that underwent an early surgical correction, especially in terms of urinary flow. Even though this study cannot definitely establish the superiority of early timing of correction, it is evident that further research is needed to clarify this aspect.

Laparoscopy-Assisted Versus Open Surgery in Treating Intestinal Atresia: Single Center Experience.

INTRODUCTION: Surgical management of jejuno-ileal atresia/stenosis (JIA) is shifting to a minimally invasive approach. Our purpose is to evaluate the safety and feasibility of laparoscopy-assisted surgery (LAS) in JIA by comparing outcomes with a control group of open surgery (OS). METHODS: A retrospective review of JIA cases was performed. Demographic, surgical, and outcomes data were extracted. LAS cases were compared with OS. Fisher's exact-test for qualitative and Mann-Whitney-test for quantitative values were used. p values <0.05 were considered significant. RESULTS: Forty-seven patients (24/23, F/M) were included. In 19 (40%), the LAS technique was successfully performed, while 3 (17%) required conversion to OS. No differences were observed between the LAS and OS (n = 28) groups concerning demographic data (sex, mean gestational age, mean weight, associated anomalies) and type of JIA. Operative time was shorter in LAS (112 ± 46 min) compared to OS (138 ± 40 min), p = 0.04. Time to start enteral feeding and time to full enteral was shorter in LAS compared to OS, p = 0.04. No difference was observed between the two groups concerning duration of parenteral nutrition, length of hospitalization and weight at discharge. Overall rate of postoperative complications was 14% (n = 7), with a slightly prevalence in OS (18%) compared to LAS (10%), p = 0.68. CONCLUSIONS: The LAS technique in the treatment of neonatal JIA is safe and feasible. LAS is associated with shorter operative and restoration of enteral feeding times. The post-operative outcomes in LAS are similar with OS, with a lower rate of postoperative complications.

Preliminary Study on the Echo-Assisted Intersphincteric Autologous Microfragmented Adipose Tissue Injection to Control Fecal Incontinence in Children Operated for Anorectal Malformations.

AIM OF THE STUDY: To assess the efficacy of a novel technique (echo-assisted intersphincteric autologous microfragmented adipose tissue injection, also called "anal-lipofilling") in the management of non-responsive fecal incontinence in children born with anorectal malformations (ARMs). METHODS: Following ethical committee approval (CHPED-MAR-18-02), anal-lipofilling was proposed to patients with fecal incontinence not responsive to medications or bowel management (bowel enema and/or transanal irrigation automatic systems), then a prospective study was conducted. Anal-lipofilling consisted of three phases: lipoaspiration from the abdominal wall, processing of the lipoaspirate with a Lipogems system and intersphincteric injection of the processed fat tissue via endosonographic assistance. A questionnaire based on Krickenbeck's scale (KS) was administered to the patients to evaluate the clinical outcome. MAIN RESULTS: Four male patients (three recto-urethral fistula, and one recto-perineal fistula) underwent the anal-lipofilling procedure at a mean age of 13.0 ± 4.2 yrs. There were no complications during or after the procedure. From an initial assessment of the patients there was an improvement in the bowel function at a median follow up of 6 months, with better scores at KS (100% Soiling grade three pre-treatment vs. 75% grade one post-treatment). CONCLUSIONS: Even if our Study is preliminary, echo-assisted anal-lipofilling could be considered as a feasible and safe alternative technique in the management of the fecal incontinence in non-responding ARMs patients. More studies are still necessary to support the validity of the implant of autologous adipose tissue in the anal sphincter as a therapy for fecal incontinence in children born with ARMs.

Peritoneal dialysis catheters in pediatric patients: 10 years of experience in a single centre.

Peritoneal Dialysis (PD) is one of the numerous options for chronic dialysis and in many cases when access for acute dialysis is required early in a hospital course, at any age. PD catheter can be inserted with an open or laparoscopic approach. The complication rate after catheter insertion is still high, as reported in published literature. We present the experience matured at our Centre in the last 10 years on implantation of peritoneal dialysis catheters in children, emphasising surgical complications. We conducted a retrospective study on patients who underwent PD at our Centre in a range period of 10 years. We analysed patients 'demographic data, past and present medical, perioperative and post-operative data, permanence of the catheter, duration of dialysis, the gap between placement and use, outcomes and complications. We compared the data, dividing patients in 2 groups: patients operated with a traditional open technique and patients operated laparoscopically. We retrospectively reviewed 29 children with an average age of 3years and 6 months. Mean age was 42 months (1 month; 8 years) for the VLS group, 18 months (11 days, 4 years) for the OT group. Mean operative time was 106 min for the VLS group; 44 min for the OT group. The Catheter permanence period was 17 days (12h-64 days). Duration of dialysis was between 48 hours and 23 days (average 8 days). In the total population, we registered 8 complications (5 minor, 3 major), the overall complication rate being 33 % (minor complication rate 21%, major complication rate 12,5 %). 6 complications occurred in patients operated laparoscopically (6/14 = 36 %); 2 complications in the OT group (2/10 = 20 %). The complication rate after PD catheter insertion is still high. Advantages and disadvantages of the open and laparoscopic approach must be known. Both minor and major complications, such as bowel perforations and occlusions, must be understood and differentiated.

Experimental necrotizing enterocolitis induces neuroinflammation in the neonatal brain.

BACKGROUND: Necrotizing enterocolitis (NEC) is an inflammatory gastrointestinal disease primarily affecting preterm neonates. Neonates with NEC suffer from a degree of neurodevelopmental delay that is not explained by prematurity alone. There is a need to understand the pathogenesis of neurodevelopmental delay in NEC. In this study, we assessed the macroscopic and microscopic changes that occur to brain cell populations in specific brain regions in a neonatal mouse model of NEC. Moreover, we investigated the role of intestinal inflammation as part of the mechanism responsible for the changes observed in the brain of pups with NEC. METHODS: Brains of mice were assessed for gross morphology and cerebral cortex thickness (using histology). Markers for mature neurons, oligodendrocytes, neural progenitor cells, microglia, and astrocytes were used to quantify their cell populations in different regions of the brain. Levels of cell apoptosis in the brain were measured by Western blotting and immunohistochemistry. Endoplasmic reticulum (ER) stress markers and levels of pro-inflammatory cytokines (in the ileum and brain) were measured by RT-qPCR and Western blotting. A Pearson test was used to correlate the levels of cytokines (ELISA) in the brain and ileum and to correlate activated microglia and astrocyte populations to the severity of NEC. RESULTS: NEC pups had smaller brain weights, higher brain-to-body weight ratios, and thinner cortices compared to control pups. NEC pups had increased levels of apoptosis and ER stress. In addition, NEC was associated with a reduction in the number of neurons, oligodendrocytes, and neural progenitors in specific regions of the brain. Levels of pro-inflammatory cytokines and the density of activated microglia and astrocytes were increased in the brain and positively correlated with the increase in the levels pro-inflammatory cytokines in the gut and the severity of NEC damage respectively. CONCLUSIONS: NEC is associated with severe changes in brain morphology, a pro-inflammatory response in the brain that alters cell homeostasis and density of brain cell populations in specific cerebral regions. We show that the severity of neuroinflammation is associated with the severity of NEC. Our findings suggest that early intervention during NEC may reduce the chance of acute neuroinflammation and cerebral damage.

The APpendicitis PEdiatric (APPE) score: a new diagnostic tool in suspected pediatric acute appendicitis.

Our aim was to develop an APpendictis-PEdiatric score (APPE score) in quantifying risk of acute appendicitis based on combination of clinical and laboratory markers. 1025 patients were classified in: acute appendicitis (AA) and non-appendicitis. Demographic/clinical features, and laboratory were collected. They were compared for quantitative-variables and categorical-variables. Significant predictors (P=<0,05) were included in logistic regression model. Based on regression-coefficients, a diagnostic score was tested by calculating the area under the ROC curve. Two cut-offs were established to define classes of risk of AA. 9 variables were identified as potentially predictors for AA. Those underwent logistic regression and a score was assigned, for maximum 21-points. The score showed an area under the curve: 0.831 and a linear proportion with the state of appendicular inflammation (R20.85). Patients with a score ≤8 were at low risk of AA (sensitivity 94%); those with a score ≥15 were at high risk for AA (specificity 93%). Those between 8 and 15 were defined at intermediate risk class. APPE-score guides clinicians in classifying patients with suspected-AA according to clinical and laboratory findings in order to improve their management.

Risk Factors for Surgical Site Infection in Neonates: A Systematic Review of the Literature and Meta-Analysis.

Purpose: Surgical site infections (SSI) contribute to postoperative morbidity and mortality in children. Our aim was to evaluate the prevalence and identify risk factors for SSI in neonates. Methods: Using a defined strategy, three investigators searched articles on neonatal SSI published since 2000. Studies on neonates and/or patients admitted to neonatal intensive care unit following cervical/thoracic/abdominal surgery were included. Risk factors were identified from comparative studies. Meta-analysis was conducted according to PRISMA guidelines using RevMan 5.3. Data are (mean ± SD) prevalence. Results: Systematic review-of 885 abstracts screened, 48 studies (27,760 neonates) were included. The incidence of SSI was 5.6% (1,564 patients). SSI was more frequent in males (61.8%), premature babies (77.4%), and following gastrointestinal surgery (95.4%). Meta-analysis-10 comparative studies (16,442 neonates; 946 SSI 5.7%) showed that predictive factors for SSI development were gestational age, birth weight, age at surgery, length of surgical procedure, number of procedure per patient, length of preoperative hospital stay, and preoperative sepsis. Conversely, preoperative antibiotic use was not significantly associated with development of SSI. Conclusions: Younger neonates and those undergoing abdominal procedures are at higher risk for SSI. Given the lack of evidence-based literature, prospective studies may help determine the risk factors for SSI in neonates.

The Regenerative Potential of Amniotic Fluid Stem Cell Extracellular Vesicles: Lessons Learned by Comparing Different Isolation Techniques.

Extracellular vesicles (EVs) derived from amniotic fluid stem cells (AFSCs) mediate anti-apoptotic, pro-angiogenic, and immune-modulatory effects in multiple disease models, such as skeletal muscle atrophy and Alport syndrome. A source of potential variability in EV biological functions is how EV are isolated from parent cells. Currently, a comparative study of different EV isolation strategies using conditioned medium from AFSCs is lacking. Herein, we examined different isolation strategies for AFSC-EVs, using common techniques based on differential sedimentation (ultracentrifugation), solubility (ExoQuick, Total Exosome Isolation Reagent, Exo-PREP), or size-exclusion chromatography (qEV). All techniques isolated AFSC-EVs with typical EV morphology and protein markers. In contrast, AFSC-EV size, protein content, and yield varied depending on the method of isolation. When equal volumes of the different AFSC-EV preparations were used as treatment in a model of lung epithelial injury, we observed a significant variation in how AFSC-EVs were able to protect against cell death. AFSC-EV enhancement of cell survival appeared to be dose dependent, and largely uninfluenced by variation in EV-size distributions, relative EV-purity, or their total protein content. The variation in EV-mediated cell survival obtained with different isolation strategies emphasizes the importance of testing alternative isolation techniques in order to maximize EV regenerative capacity.

Open Versus Laparoscopic Approach for Morgagni's Hernia in Infants and Children: A Systematic Review and Meta-Analysis.

INTRODUCTION: The laparoscopic repair of Morgagni's hernia (MH) has been reported to be safe and feasible. However, it is still unclear whether laparoscopy is superior to open surgery in repairing MH. MATERIALS AND METHODS: Using a defined search strategy, three investigators independently identified all comparative studies reporting data on open and laparoscopic MH repair in patients <18 years of age. Case reports and opinion articles were excluded. Meta-analysis was conducted according to PRISMA guidelines and using RevMan 5.3. Data are expressed as mean ± SD. RESULTS: Systematic review - Of 774 titles/abstracts screened, 51 full-text articles were analyzed. Three studies were included (92 patients), with 53 (58%) open approaches and 39 (42%) laparoscopy. Meta-analysis - The length of surgery was shorter in laparoscopy (50.5 ± 17.0 min) than in open procedure (90.0 ± 15.0 min; P < .00001). Laparoscopy shortened the length of hospital stay (2.1 ± 1.4 days) versus open surgery (4.5 ± 2.1 days; P < .00001). There was no difference with regards to complications (laparoscopy: 8.8% ± 5.5%, open: 9.4% ± 1.6%; P = .087) and recurrences (laparoscopy: 2.9% ± 5.0%, open: 5.7% ± 1.8%; P = .84). DISCUSSION: Comparative studies indicate that laparoscopic MH repair can be performed in infants and children. Laparoscopy is associated with shortened length of surgery and hospital stay in comparison to open procedure. Prospective randomized studies would be needed to confirm present data.

Prenatal detection of megacystis: not always an adverse prognostic factor. Experience in 25 consecutive cases in a tertiary referral center, with complete neonatal outcome and follow-up.

INTRODUCTION: Megacystis is a condition of abnormal enlarged fetal bladder for gestational age, which is usually associated with urological malformations that may constitute a life-threatening condition for the baby. OBJECTIVE: The purpose of this study was to assess the prognostic and etiological criteria of fetal megacystis and to describe the neonatal outcome in a large series collected in a single tertiary center. STUDY DESIGN: A retrospective observational study was conducted between 2008 and 2012. We reviewed all consecutive cases of fetal megacystis diagnosed during routine ultrasound (US) screening. The following data were collected and analyzed: maternal age, gestational age at diagnosis, prenatal ultrasonographic details of the urinary system, extra-urinary ultrasonographic anomalies, fetal karyotype, pregnancy outcome, postnatal diagnosis, and medical/surgical follow-up. RESULTS: Of the 25 fetuses included in this study, 76% were males. The mean gestational age (GA) at diagnosis was 23.1 ± 7.5 weeks (range 12-34), among them only four (16%) were diagnosed during the first trimester. Associated urological malformations were detected in 92% (n = 23) of the cases, while other malformations were detected in 36% (n = 9). Oligohydramnios or anyhydramnios were observed in 52% (n = 13) of the cases. Twelve (48%) fetuses were considered as having poor prognosis for renal function. Vesicocentesis with or without vesico-amniotic infusion were performed in 28% (n = 7) of the cases. Pregnancy outcome was surprisingly good, with only one case of prenatal death and survival rate of 96% (n = 24) of liveborn babies. Posterior urethral valve (PUV) (n = 9, 36%) was the most common etiology of the fetal megacystis, followed by persistent urogenital sinus (n = 2, 8%), Prune belly syndrome (n = 2, 8%) and bilateral vescico-ureteral reflux (VUR) (n = 2, 8%). Surgical or endoscopic procedures were performed in 75% (n = 18) of the cases. Six (24%) newborns presented with moderate/severe respiratory distress that requested invasive assisted ventilation. Three cases (n = 3, 12%) of perinatal death were observed due to severe impaired renal function. After a median follow-up of 29 months renal function was good in 79% (n = 19) of the cases. CONCLUSIONS: Fetal megacystis may underline a wide range of associated pathologies with the highest prevalence of urinary malformation. Optimal counseling of the involved parents requires a multidisciplinary approach to allow the best management during the pregnancy and the perinatal period. Despite the high risk of renal failure, lung hypoplasia, and severe associated anomalies, the outcome of fetuses with megacystis could be improved thanks to an appropriate perinatal diagnosis and neonatal management.

Hyperechogenic Bowel: Etiologies, Management, and Outcome according to Gestational Age at Diagnosis in 279 Consecutive Cases in a Single Center.

Introduction The aim of the study was to investigate perinatal outcome of fetuses with hyperechogenic bowel (HB) in relation to gestational age at diagnosis. Materials and Methods This is a retrospective observational study of fetal HB cases from 2002 to 2012. Patients were divided into three groups according to trimester at diagnosis. For each group, data from fetal ultrasound examination, fetal medicine investigations, intrapartum cares, and neonatal outcome were obtained. Results A diagnosis of HB was made in 279 fetuses among them 17 (6%) during the first trimester, 186 (67%) during the second trimester, and 75 (27%) during the third trimester. A significant prevalence of maternal comorbidities was noticed in group 1 (12%: p = 0.02). A chromosomal defect was identified in 13% of the fetuses without difference among the three groups. HB was associated with prenatal infection in 11.5% (n = 32) of the cases, with an equal distribution between groups 2 and 3. Intrauterine growth retardation was noticed in 23% (n = 64) of the cases with a slightly high prevalence in groups 1 (35%). HB was the only ultrasonographic intestinal soft marker in 80% (n = 223) of the fetuses, two-third of them were detected during the first and the second trimesters (p = 0.001). However, HB was associated with bowel dilation in 33% of the cases diagnosed during the third trimester (p = 001). Ultrasonographic extraintestinal anomalies were identified in 30% of the fetuses with a higher prevalence in group 1 (59%). HB resolved spontaneously in 55 (19.7%) cases-without difference among the three groups. In group 1 we recorded a significant prevalence of intrauterine demise (23.5%, p = 0.004). Two hundred twenty-seven (81.3%) pregnancies resulted in live-born neonates; among them gastrointestinal anomalies were noticed in 12.5% with a significant prevalence in group 3 (36%) compared with 6 and 5.4% in groups 1 and 2, respectively (p = 0.001). Extraintestinal anomalies were confirmed in 27% of the cases, whereas postnatal mortality rate was of 7% without differences between the three groups. Conclusion Detection of HB during the first trimester is associated with an increased risk for maternal comorbidities, intrauterine growth retardation, and adverse pregnancy outcome. Moreover, if HB is detected during the second trimester, it is associated with a favorable prognosis. Otherwise, HB detected during the third trimester is associated with a significant risk of gastrointestinal anomaly.

Isolated Fetal Ascites, Neonatal Outcome in 51 Cases Observed in a Tertiary Referral Center.

Introduction Prenatal detection of isolated ascites is a rare finding on ultrasound, usually suggestive of an underlying pathology that may negatively impact on the pregnancy and neonatal outcome. The purpose of the present study was to evaluate the outcome of primary isolated ascites in relation to gestational age (GA) at diagnosis. Materials and Methods Data were prospectively collected for fetuses with ascites that have been followed in our center of prenatal diagnosis and therapy from 2004 to 2014. Patients have been divided in group I when ascites was detected before the 24th week of GA and group II if it was noticed later. Prenatal workup included detailed ultrasound, maternal blood group and presence of antibodies, maternal infection screening, fetal karyotyping, and if needed fetal paracentesis. Postnatal data included GA at birth, mode of delivery, weight at birth, neonatal and surgical outcome. Results During the study period, 51 fetuses were included. Among them, 28 in group I and 23 in group II. An associated anomaly was prenatally identified in 84% of the fetuses. Prenatal demise occurred only in patients belonging to group I for an overall incidence of 10%. An associated disease was confirmed after birth in 61% of cases in group I and in 74% in group II (p = ns). There was a higher incidence of gastrointestinal pathology in group II than in group I (47 vs. 10%, p = 0.004); with a significant prevalence of meconium peritonitis (32 vs. 4%, p = 0.016). Nine patients (17.6%) died after birth, all in group I, because of major systemic malformations. Overall, the postnatal outcome was good in 63% (n = 32) of the cases, and more than half of them belonged to group II (p = 0.003). Conclusion A wide range of etiologies have been found to be associated with isolated fetal ascites. A systematic diagnostic workup and multidisciplinary prenatal counseling can improve the accuracy of prenatal identification of associated pathologies. The early detection of fetal ascites, before the 24th week of GA, is associated with a significant risk of perinatal death; otherwise, a late diagnosis of fetal ascites is associated with an increased risk of gastrointestinal diseases, especially with meconium peritonitis.

Open versus laparoscopic approach for intestinal malrotation in infants and children: a systematic review and meta-analysis.

PURPOSE: Although the principles of the Ladd's procedure for intestinal malrotation in children have remained unchanged since its first description, in the era of minimally invasive surgery it is controversial whether laparoscopy is advantageous over open surgery. The aim of our study was to determine whether the surgical approach for the treatment of malrotation had an impact on patient outcome. METHODS: Using a defined strategy (PubMed, Cochrane, Embase and Web of Science MeSH headings), two investigators independently searched for studies comparing open versus laparoscopic Ladd's procedure in children. Case reports and opinion articles were excluded. Outcome measures included age at operation, time to full enteral feeding, length of hospital stay, and post-operative complications. Maneuvers were compared using Fisher's exact test and meta-analysis was conducted using RevMan 5.3. Data are expressed as mean ± SD. RESULTS: Of 308 abstracts screened, 49 full-text articles were analyzed and nine (all retrospective) met our search criteria. Selected articles included 1003 patients, of whom 744 (74 %) underwent open surgery and 259 (26 %) laparoscopy. Patients who had open surgery were younger (0.9 ± 1.2 years) than those who underwent laparoscopy (2.6 ± 3 years; p < 0.0001). Laparoscopy was converted to open Ladd's in 25.3 % patients. Laparoscopy was associated with faster full enteral feeding (1.5 ± 0.3 days) in comparison to open surgery (4.6 ± 0.1 days, p < 0.0001). Length of hospital stay was shorter in the laparoscopic group (5.9 ± 4.3 days) than in the open group (11.2 ± 6.7 days; p < 0.0001). Open surgery was associated with higher overall post-operative complication rate (21 %) than laparoscopy (8 %; p < 0.0001). Although there was no difference in the prevalence of post-operative bowel obstruction (open, n = 10 %; laparoscopy, n = 0 % p = 0.07), post-operative volvulus was more frequent in the laparoscopy group (3.5 %) than in the open group (1.4 %, p = 0.04). CONCLUSION: Comparative but non-randomized studies indicate that laparoscopic Ladd's procedure is not commonly performed in young children. Although one third of laparoscopic procedures is converted to open surgery, laparoscopy is associated with shorter time to full enteral feeds and length of hospital stay. However, laparoscopic Ladd's procedure seems to have higher incidence of post-operative volvulus. Prospective randomized studies with long follow-up are needed to confirm present outcome data and determine the safety and effectiveness of the laparoscopic approach.

Gastrostomy Placement in Children: Percutaneous Endoscopic Gastrostomy or Laparoscopic Gastrostomy?

The aim of this study is to compare the outcomes and the complications between the 2 most adopted procedures for gastrostomy placement: percutaneous endoscopic gastrostomy (PEG) and laparoscopic gastrostomy (LG) in children. We present our study on 69 patients (male: 46/female: 23): group 1 (37 patients, 54%) undergoing PEG, group 2 (32 patients, 46%) undergoing LG. A total of 5 major complications were observed all in the PEG group (13.5%), no major complication was observed in the LG group (P-value<0.05). A total of 12 minor complications were observed: 4 occurred in the PEG group (10.8%) and 8 (25%) in the laparoscopic gastrostmoy group, not statistically relevant. We suggest that the LG should be considered the preferred technique for gastrostomy placement in pediatric patients, particularly in newborns, children with significant skeletal malformations, and patients who underwent previous abdominal surgery.