Cryopreserved Thyroid Tissue Autotransplant in Pediatric Age Patients: A Feasibility Study and Literature Review.

BACKGROUND AND AIMS: This paper aims to study an alternative solution to hormonal replacement therapy in specific groups of patients who underwent thyroidectomy during childhood or adulthood. After cryopreservation, thyroid autotransplantation could be an alternative solution which would allow us to use the ability of the thyroid tissue of producing hormones according to the physiological needs of the body. MATERIALS AND METHODS: A feasibility study about the effects of the most modern cryopreservation techniques on the structural and functional integrity of the follicular cells of the thyroid tissue has been carried out. Patients who could benefit from the treatment have been found for both autotransplant techniques. Additionally, a literature review has been conducted. RESULTS: The histological analysis has shown that cryopreservation does not alter the original architecture, and the culture examination that cell viability is successfully preserved. Moreover, both thyroid autotransplantation studies on animals and those on humans that were found in the literature have shown good results regarding the viability and functionality of the transplant. CONCLUSIONS: The viability of cryopreserved thyroid tissue found in this study is encouraging. Further studies to evaluate the levels of FT3, FT4 and thyroglobulin in thyroid tissue after cryopreservation are needed to verify that the secretory properties of the thyrocytes have been maintained intact. Furthermore, autotransplanted cases found in the literature do not have a long-term follow-up.

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.

Training minimally invasive surgery's basic skills: is expensive always better?

INTRODUCTION: Not all hospitals have a MIS training facility because often training is not a main corporate objective and could require lots of money. We tried to build a laparoscopic simulator that was effective and that would allow to carry out an adequate laparoscopic training similar to that obtained with the models normally used in MIS training programs. To construct a box trainer that would achieve the equivalent results than those usually used. A validation study was carried out by evaluating the content validity and construct validity of our simulator in addition a comparison study of our homemade trainer vs Karl Storz box trainer was performed. MATERIAL AND METHODS: The HM laparoscopic trainer was assembled using a wood frame. Two LED lights were positioned on the inside roof of the trainer and a webcam was positioned through a special support as operative optic. The webcam was then connected to a PC and the latter was used as a monitor for the operator. Participants were 20 students and a group of 6 surgeons. Students were prospectively randomized to perform 4 of the 5 tasks of the fundamental laparoscopic surgery (FLS) program on both the HM trainer and the KS trainer (pegboard transfer, pattern cut, placement of ligating loop and intracorporeal knot suture). Simple paired t test was performed to compare times between the trainers. Then students performed two more sets of exercises on the HM. The group of surgeons performed three sets of the same exercises performed by the students on the HM. The time taken by surgeons and students to complete the exercises was compared using t test. At the end, all the participants carried out a questionnaire to evaluate their experience with the HM box trainer. For the questionnaire it was chosen to use a Linkert 1-5 scale (1 = strongly disagree; 2 = disagree; 3 = undecided; 4 = agree; 5 = strongly agree). RESULTS: HM vs KS BT: Comparing time to complete the 4 tasks performed by students on both the BT, for the first task the p value was 0.30, for the second task 0.48, for the third task 0.80, for the fourth task 0.93, and for the total time 0.86. The comparison between the mean time of the first set of tasks of the participants who started with the HM BT and one of the participants who started on the KS p value was 1 p = 0.09; task 2 p = 0.32; task 3 p = 0.62; task 4 p = 0.32; total time p = 0.81. The comparison between the meantime of the second set of tasks of the participants who switched to the HM BT with the one of those who switched to the KS BT showed a p value of: p = 0.20 tasks 1 p = 0.53 task 2; p = 0.39 task 3; p = 0.30 task 4; p = 0.56 total time. Construct validity: The mean experts and students time of every single task and the total one showed a p value of: p < 0.01 for task 1; p < 0.01 task 2; p < 0.01 task 3; p < 0.01 task 4; p < 0.01 total time. Content validity: Both experts and students indicated the HM BT as a useful training tool and appreciated its easy use. Both groups would use it at home if it were available. CONCLUSION: Valid MIS trainer can be easily built at home with few low-cost materials. Our study shows how training programs can be structured even with few resources in a creative and innovative way.

Pyelonephritis in Pediatric Uropathic Patients: Differences from Community-Acquired Ones and Therapeutic Protocol Considerations. A 10-Year Single-Center Retrospective Study.

Pyelonephritis (PN) represents an important cause of morbidity in the pediatric population, especially in uropathic patients. The aim of the study is to demonstrate differences between PNs of uropathic patients and PNs acquired in community in terms of uropathogens involved and antibiotic sensitivity; moreover, to identify a proper empiric therapeutic strategy. A retrospective study was conducted on antibiograms on urine cultures from PNs in vesicoureteral reflux (VUR) patients admitted to pediatric surgery department and from PNs in not VUR patients admitted to Pediatric Emergency Unit between 2010 and 2020. We recorded 58 PNs in 33 patients affected by VUR and 112 PNs in the not VUR group. The mean age of not VUR patients at the PN episode was 1.3 ± 2.6 years (range: 20 days of life-3 years), and almost all the urine cultures, 111 (99.1%), isolated Gram-negative bacteria and rarely, 1 (0.9%), Gram-positive bacteria. The Gram-negative uropathogens isolated were Escherichia coli (97%), Proteus mirabilis (2%), and Klebsiella spp. (1%). The only Gram-positive bacteria isolated was an Enterococcus faecalis. As regards the antibiograms, 96% of not VUR PNs responded to beta-lactams, 99% to aminoglycosides, and 80% to sulfonamides. For the VUR group, mean age was 3.0 years ± 3.0 years (range: 9 days of life-11 years) and mean number of episodes per patient was 2.0 ± 1.0 (range: 1-5); 83% of PNs were by Gram-negatives bacteria vs. 17% by Gram-positive: the most important Gram-negative bacteria were Pseudomonas aeruginosa (44%), Escherichia coli (27%), and Klebsiella spp. (12%), while Enterococcus spp. determined 90% of Gram-positive UTIs. Regimen ampicillin/ceftazidime (success rate: 72.0%) was compared to ampicillin/amikacin (success rate of 83.0%): no statistically significant difference was found (p = 0.09). The pathogens of PNs in uropathic patients are different from those of community-acquired PNs, and clinicians should be aware of their peculiar antibiotic susceptibility. An empiric therapy based on the association ampicillin + ceftazidime is therefore suggested.

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.

Latent tuberculosis in childhood: tolerability of two different therapeutic approaches.

BACKGROUND: Isoniazid monotherapy for six or nine months and the combination of isoniazid and rifampicin for three or four months are the most used regimens for treating latent tuberculosis. The main aim of this retrospective study is to evaluate the safety of latent tuberculosis treatment by analysing side effects in both regimens. RESEARCH DESIGN AND METHODS: Children with latent tuberculosis and treated with isoniazid or isoniazid and rifampicin were included. Periodic evaluations with clinical assessment and blood exams were carried out to detect any adverse reaction, including elevated serum transaminases. RESULTS: 441 children were included, 14.5% treated with isoniazid and 85.5% with isoniazid and rifampicin. Five patients under combined treatment developed hepatotoxicity within the first month. None of the patients under isoniazid monotherapy presented hepatotoxicity. A slight increase of transaminases level was found in both groups (18.7% in isoniazid and 10.3% in isoniazid/rifampicin groups, respectively) without causing discontinuation of treatment, with values normalization at the subsequent checks. CONCLUSIONS: Both regimens resulted safe. Hepatotoxicity occurred rarely and within the first month. For this reason, it may be appropriate to perform liver function tests after about one month from the beginning of therapy to avoid diagnostic delays.