Microsurgical spermatico-epigastric venous anastomosis in the treatment of varicocele in children: assessment of long-term patency.

AIM: To demonstrate the long-term patency of microsurgical anastomoses between the internal spermatic vein and the inferior epigastric vein, constructed in the treatment of essential varicocele in paediatric patients to supplement ligation of the spermatic veins. MATERIALS AND METHODS: We submitted 66 patients to inguinopelvic colour-flow Doppler ultrasonography. The patients had been treated 18 - 36 months earlier for essential varicocele by microsurgical inguinal ligation of the testicular venous pedicle and anastomosis between the internal spermatic vein and the inferior epigastric vein. RESULTS: Preoperatively, the 66 patients operated on at ages ranging from 10 to 16 years (13 +/- 1.4) presented with Dubin and Amelar grade II (14 patients) or grade III (52 patients) left varicocele with ipsilateral testicular hypotrophy. The postoperative follow-up showed 2 cases of persistence of disease and 3 cases of persistence of "medium" spermatic vein reflux without clinical evidence of varicocele. Seven patients developed left hydrocele which resolved spontaneously in 5 cases, whereas in 2 cases it proved necessary to perform an eversion of the tunica vaginalis of the testis. The results obtained in patients treated for Coolsaet type I varicocele (64 patients) were as follows: long-term patency of the anastomosis was observed in 58/64 patients (90.6 %); in 4 patients (6.2 %) the left inferior epigastric vein presented a position in relation to the homologous artery that prevented adequate sampling and thus made it impossible to assess the patency of the anastomosis; in 2 patients (3.1 %) the anastomosis was closed. In the two patients who had submitted to anastomosis for Coolsaet type III varicocele, colour-flow Doppler failed to identify the shunt. CONCLUSIONS: The results of this study demonstrate that microsurgical anastomosis between the internal spermatic vein, and the inferior epigastric vein remains competent in the long term, thus confirming the validity of this technique for the treatment of essential varicocele in children.

Treatment of neonatal chylous ascites using a modified Denver peritoneovenous shunt: a case report.

Chylous ascites is rarely observed in newborns. Its etiology is not always readily identifiable. The authors report a patient with idiopathic chylous ascites resistant both to conservative treatment with total parenteral nutrition plus diuretics and to dietary treatment (milk with a low-fat content and medium-chain triglycerides). Surgical correction of an associated intestinal malrotation and an annular pancreas failed to resolve the ascites and we therefore placed a modified Denver peritoneovenous shunt. Six months after placement of the shunt, the patient was in good general condition, with restoration of normal oral feeding and regular growth in terms of height and weight. Clinical and ultrasonographic follow-up examinations have not revealed the presence of ascitic fluid in the peritoneal cavity.

Complicated total esophagogastric dissociation: case report.

The Authors describe a case of massive haemorragic gastritis in a child who previously underwent total oesophagogastric dissociation without complementary pyloroplasty. The complication was successfully treated by an emergency resection of the fundus. The Authors believe that the complication was probably related to vagal denervation with consequent gastric stagnation and hypergastrinaemia.

Congenital true pancreatic cyst in pediatric age: case report.

Congenital pancreatic cysts are rare lesions in pediatric age. We present a case of congenital true pancreatic cyst in otherwise asymptomatic boy aged 4 years. Clinical history, laboratory, imaging, immunohistological findings and surgical treatment are also described.

Secondary omental torsion in children: report of two cases and review of the literature.

Torsion of the greater omentum (TGO) may be due to a congenital abnormal attachment of its free edge. There are no specific symptoms that allow a preoperative differential diagnosis of this condition from common pathologies such as acute appendicitis. Attachment of the omentum to the large bowel and the absence of concomitant diseases make it possible to distinguish TGO secondary to a congenital attachment anomaly from omental infarction, primary TGO, and TGO secondary to an acquired attachment anomaly (attachment to cysts, tumours, hernias, surgical scars, or perforated bowel segments). Resection of the ischaemic portion of the omentum permits complete resolution of the clinical symptoms. The authors report two cases of TGO in children due to abnormal attachment of the greater omentum to the ascending and transverse colon, respectively.

[The role of continent perineal colostomy in surgical emergencies of the distal bowel]. / Il ruolo della colostomia perineale continente nelle emergenze chirurgiche del grosso intestino.

Diverting colostomy is commonly required in surgical emergencies of the distal colon, especially if the patient is in poor condition. This paper shows that the colostomy could be unnecessary in most cases. In the last 10 years, 6 patients (4 with high-risk or postoperative complicated Hirschsprung disease, 1 with intestinal neuronal dysplasia and 1 with iatrogenic rectal stenosis obstruction) have been submitted to primary continent perineal colostomy-modified Duhamel's procedure. The modified technique consists of the exteriorization of the normal colon or ileum by a retrorectal and trans-anal way, while the excision of redundant tissue and rectal spur section are postponed at least for 10 days. In personal experience this peculiar surgical approach allows to avoid not only the complications due to the fashioning of a contraindicated primary anastomosis, but even those due to stomy performance and its closure, promoting good anatomo-functional results in all patients. The advantages of modified Duhamel's operation compared to other procedures (Swenson-Pellerin or Soave pull-through) depend on the rapidity of execution and on the quality of short and long term outcome.

[Idiopathic varicocele in children. Epidemiological study and surgical approach]. / Varicocele idiopatico in età pediatrica. Studio epidemiologico e approccio chirurgico.

BACKGROUND: Idiopathic varicocele is one of the most frequent conditions capable of reducing male fertility. Early detection and adequate therapy make it possible to prevent the infertility related to this disease. METHODS: The results of a clinical and instrumental (Doppler) epidemiological study conducted in 766 subjects of peripuberal age are reported. The clinical and functional results in those subjects undergoing surgery for varicocele. The technical options adopted for varicocele correction were either microsurgical venous bypass between the internal spermatic vein and the inferior epigastric vein or laparoscopic ligation of the internal spermatic vein in a retroperitoneal site. RESULTS: The epidemiological investigation conducted by the authors showed a high incidence (48.5% including the subclinical forms) of idiopathic varicocele in the male population. The clinical and instrumental (Doppler) follow-up carried out at 3, 6 and 18 months postoperatively showed satisfactory results, particularly in patients submitted to microsurgical venous bypass, with a relapse rate of only 2.6%. CONCLUSIONS: On the basis of the results obtained, the authors advocate an early surgical approach to varicocele. Among the corrective techniques available, microsurgical treatment is, in the authors' opinion, capable of yielding the best clinical and functional results.

[Reconstruction of the vas deferens: an experimental study on the rat]. / Ricostruzione deferenziale. Studio sperimentale sul ratto.

BACKGROUND: A microsurgical technique for reconstruction of the vas deferens on an absorbable transanastomotic stent in the rat is described. METHODS: A microsurgical end-to-end anastomosis of the vas deferens was performed in a group of 10 rats (group A) by suturing with Nylon 10-0 interrupted stitches. In another 10 rats (group B) the same microsurgical anastomosis was performed after insertion of a 0.5 cm long intraluminal chromic catgut 4.0 stent. RESULTS: Sixty days postoperatively all 20 animals were submitted to roentgenography of the vas deferens. The vas deferens proved radiographically undetectable in 8/10 rats in the unstented group A (80%), whereas the entire course of the vas could be traced in 9/10 rats in group B (90%). CONCLUSIONS: The encouraging results obtained with this alternative technique, even on structures of limited diameter, suggests that it may be possible to use this procedure in children.

[Cryptohypospadias: Surgical approach and long-term results]. / Cripto-ipospadia: Approccio chirurgico e risultati a distanza.

BACKGROUND: Chordee without hypospadias is a rare morphological abnormality of the penis capable of interfering with sexual function. Usually, cases of chordee without hypospadias require surgical correction, and the aim of this study is to assess the efficacy of the techniques normally used in this pathology. METHODS: The authors analyze the surgical outcomes achieved in 34 patients presenting various degrees of ventral or lateral curvature of the erect penis and operated on in our department over the past 22 years. Twenty-nine subjects attended for follow-up, including 13 who have now reached adulthood. RESULTS: The milder forms of chordee without hypospadias (Horton and Devine type III and lateral deviations of the penis) all benefited from minor surgery (dermal grafts and Nesbit dorsal plication of the contralateral penile tunica albuginea) and were corrected with a single operation. The most serious forms of chordee without hypospadias where the hypoplasia variously affected the corpus spongiosum, Buck's fascia and the dartos fascia (Horton and Devine types I and II), were submitted to a supplementary extensive urethral mobilization or occasionally a urethroplasty and one-third of them presented persistent residual curvature. CONCLUSIONS: The authors advocate a more aggressive surgical approach (urethroplasty and/or patches on the ventral tunica albuginea as an alternative to urethral mobilisation) in subjects with more pronounced defects.

Surgical treatment of chordee without hypospadias.

OBJECTIVE: The aim of this study was to retrospectively assess the efficacy of the surgical techniques commonly used in three types of chordee without hypospadias (Devine and Horton classification). METHODS: Twenty-six patients, ranging in age from 3 to 14 years, had chordee without hypospadias and underwent Nesbit dorsal plication (9 cases out of 12, type III), associated extensive mobilization of the urethra (10 cases out of 10, type II), and vascularized neourethra (3 cases out of 4, type I). RESULTS: Eleven subjects undergoing follow-up investigation for the milder forms of chordee were satisfied with the outcome achieved; there was no impediment of any kind in the sex lives of 5 adult subjects. Of the 11 patients undergoing follow-up after more complex surgery for Devine and Horton type I-II chordee without hypospadias, a residual abnormal curvature was present in 4 subjects. These patients were submitted to one or more reoperations with outcomes defined as satisfactory. CONCLUSION: To avoid the risks of persistent chordee, the authors suggest more radical and accurate operations for the treatment of type I and II pseudohypospadias.

[Unusual anorectal anomalies. A clinical contribution]. / Anomalie anorettali rare. Contributo clinico.

Anorectal malformations (ARM) include a spectrum of anomalies which have been subdivided as "high", "intermediate" and "low"; a fourth group, defined as "miscellaneous", collects the forms which are most rarely observed. It is important, for a specialist, to know the last ones under the diagnostic and/or therapeutic profile. In this paper, the various problems observed in five cases of ARM considered particularly rare are analysed: a case of anorectal agenesia with recto-cloacal fistula and short uro-genital sinus; a rectal atresia with normal anal canal; a case of anorectal stenosis; an incomplete anal membrane; an anal agenesia with scrotal fistula.

Cellular subsets and epithelial ICAM-1 and HLA-DR expression in human papillomavirus infection of the vulva.

Cryostat sections of 20 clinical condylomata of the vulva induced by human papillomavirus and 5 normal control biopsies were examined using immunohistochemistry. The results indicated that in vulvar papillomavirus infection the intraepithelial Langerhans' cells showed abnormal morphology and a significantly lower density than controls. CD1a positive Langerhans' cells were also observed in dermis of condylomata, suggesting an abnormal epithelial traffic of dendritic cells. T lymphocytes with a mean CD4/CD8 ratio of 0.25 and a mean density of 267 +/- 59 cells/mm2 of epithelial section were the main cellular infiltrate in vulvar papillomavirus infection. Most of the T cells were HLA-DR negative. Those condylomata with moderate to severe mononuclear infiltrate showed leucocyte function antigen 1 positive T cells forming small clusters in the lower epithelial half around the ICAM-1 positive keratinocytes. Vulvar warts also showed epithelial areas with overlapped ICAM-1 and HLA-DR expression. Scattered T gamma-delta and B lymphocytes, macrophages and NK cells were observed among the cells of the dermal infiltrate of vulvar condylomata.

Postoperative staging of vulvar carcinoma: a retrospective study.

The clinical staging of malignant disease is necessary before initiating nonsurgical therapy. Unfortunately, such staging does not help answer critical questions about the course and natural history of the cancerous process. Answers to these questions are crucial to the planning of future therapeutic programs. A postoperative staging system, amenable to computer analysis, that can be retrospectively applied to a large series of invasive squamous cell carcinomas of the vulva is presented. A review of the experience of a large oncologic service at the University of Buenos Aires, which used this new classification system, shows the system's applicability. Such a system could, in time, provide answers to many questions concerning invasive squamous cell carcinoma of the vulva.

Relevance of microinvasion in carcinoma of the vulva.

Retrospective analysis of 22 cases of Stage I invasive carcinoma of the vulva showed 11 cases in which the depth of tumor invasion was 5 mm or less. All of these patients were treated with radical vulvectomy and lymphadenectomy. In 3 cases positive groin node metastases were discovered. A fourth patient with minimal stromal invasion (less than 5 mm) was prospectively managed with vulvectomy alone and subsequently developed groin node metastasis leading to death from disseminated tumor. Depth of the invasion alone, therefore, is not a reliable indicator of the likelihood of groin node involvement, and lymphadenectomy should continue to be considered for all patients with invasive squamous cell carcinoma of the vulva.