Complications of the "Nuss Procedure" In Pectus Excavatum.

During the pediatric age range, one the most frequent deformities of the chest wall are Pectus Excavatum (PE). Currently the treatment of choice for PE is surgical intervention following the Nuss procedure. In this study, we present a description of the complications associated with surgical treatment of PE with the Nuss technique, in patients with symmetrical or asymmetrical deformity, in different stages of disease severity. The study was conducted in collaboration with the Pediatric Hospital "Istituto G. Gaslini" of Genoa. We analyzed a cohort of 402 patients (334 males and 68 females), who underwent corrective surgery between 2005 and 2018. Within this group of patients, we observed 82 cases with complications (20.39%), 20 of which were intraoperative (4.98%) and 62 post-operative (15.42%). For the evaluation of complications, this group was arbitrarily divided into patients with symmetric and asymmetric Pectus and in patients with mild, moderate and severe Pectus using Haller's index. Although a small group of patients presented complications, overall results from data analysis show that the Nuss technique represents the preferred surgical procedure for the treatment of PE, in agreement with literature. Furthermore, in our results show no correlation between asymmetry or severity of PE with complication related to the surgery.

Papillary Thyroid Carcinoma in Paediatric Age.

In children, differentiated thyroid carcinoma is a rare condition. Early diagnosis is not always easy, because of the lack of clinical symptoms, but it has a pivotal role in performing a correct therapeutic process. The study describes three cases of papillary thyroid carcinoma. None of the three patients had a positive familiarity or exposure to risk factors. In two cases, the tumor occurred as a non-injurious swelling in the anterior cervical region, in the other case it occurred with a latero-cervical lymphadenopathy that had been persistent for a year. In the first two patients we made a certain diagnosis by the needle aspiration of the thyroid nodule; in the other case the diagnosis was made by surgical exeresis and histological analysis of the lymph nodes. We also performed blood chemistry and hormonal tests, neck ultrasound, chest x-ray. The three children underwent total thyroidectomy and two of them also underwent right-sided cervical lymph node exeresis because there was the presence of metastasis. In our experience, the best therapeutic strategy for children with differentiated thyroid carcinoma is the total thyroidectomy, followed or not by latero-cervical lymph node exeresis and radioiodiotherapy. The removal of the whole gland reduces the risk of relapse.

Laparoscopic Repair of Paediatric Indirect Inguinal Hernia: Modified Flip Flap Technique.

In paediatric age, indirect inguinal hernia represents more than 95% of the hernial disease. It is a congenital type, in contrast with adulthood in which acquired forms are more frequently found (1). The laparoscopic correction of indirect inguinal hernia is one of the most common surgeries performed in paediatric age. In recent years, various techniques have been introduced for the videolaparoscopic correction of this disease. The aim of this study is to provide an assessment of the efficacy and safety of the execution of a modified Flip-Flap technique, using tissue glue for filling of Peritoneal-vaginal duct (DPV), performed in order to ensure greater suture tightness and reduce the incidence of postoperative hydrocele. author1, author2, author 2, author1, author1, author 2 The Authors present a retrospective review of their record of cases, considering a total of 187 patients aged between 18 months and 14 years. For the correction of the hernial defect, the modified VLS Flip-Flap technique was carried out. The evaluation of safety, efficacy, operating time, relapse rate and development of short-term complications (such as postoperative hydrocele, scrotal hematoma or ecchymosis, atrophy or iatrogenic testicle ascension) was considered in a mean follow-up of 6 months. The Authors suggest that this variant of the peritoneal Flip-Flap technique is simple to perform; its safety, reproducibility and effectiveness is proven and has a percentage of relapses and complications overlapping with the "open" approach and superior to other laparoscopic techniques.

Surgical VLS Therapy of Oesophageal Achalasia in Pediatric Age: Four Case Reports.

The Authors present a retrospective review of their record of cases, characterized by 4 cases of achalasia in which it was performed a Heller myotomy with front fundoplication (Thall) in laparoscopic approach in the period from 2012 to 2019. In paediatric achalasia, the laparoscopic Heller myotomy seems to be the best treatment because of its multiple advantages offered by the minimally invasive technique. First of all, thanks to the video-technique, which allows a complete and extended myotomy, the accuracy of this operation is maximized; moreover, the post-operative pain is widely reduced, thanks to the minimal dissection and traction of the tissues; finally, but not negligible, this approach ensures a better aesthetic result than the classic open technique. With regard to the front fundoplication, the Authors suggest that it is mandatory because, even if it extends the operating time, it ensures a natural protection to the myotomy herniated mucosa and avoids gastro-oesophageal reflux, which often occurs after the surgical correction, thus obliging to perform a reoperation.

Minimally Invasive Treatment of Urolithiasis in Children: Evaluation of the Use of Flexible Ureterorenoscopy and Laser Lithotripsy.

Urolithiasis is a multifactorial disease; in recent years, its incidence has gradually increased in pediatric age. Among the factors involved in urolithiasis pathophysiology, urinary tract anomalies and metabolic diseases are the most relevant, although ethnicity and environmental factors may have an important role. The advances in technology and miniaturization of endoscopic devices have permitted the use of Retrograde Intrarenal Surgery (RIRS) to treat kidney and ureteral stones. Nowadays, flexible ureterorenoscopy and laser lithotripsy, which are techniques that have been applied in the management of adult upper urinary tract disorders, are also used in children as a minimally invasive treatment of urolithiasis with encouraging, effective and safe results. The Authors report a retrospective review of their record of cases considering 21 pediatric urolithiasis treatment procedures performed between October 2017 and April 2019 in a total of 17 patients (10 males and 7 females). Six procedures involved the use of the flexible ureterorenoscope (FURS) while in 15 procedures the application of the laser fiber was used (FURSL). A case of laser lithotripsy for bladder stone was included. The average age of patients was 10.5 years (2-18 years). The renal pelvis dilatation pretreatment was evaluated in post-operative follow-up. From the evaluation of the sample in analysis, the use of RIRS has good results in the treatment of paediatric urolithiasis, emerging as a valid option in the management of the paediatric population in terms of efficacy and safety, with an improvement in patient outcomes.

Laparoscopic Splenectomy: Postero-Lateral Approach.

In paediatric population, the laparoscopic splenectomy has been preferred to the open surgery during the last years. Due to the improvement of the technique and the devices, the indications to the laparoscopic splenectomy have been increased, even though there is still a variety of conditions in which the execution of this technique is arduous. During the preoperative consult there is the need to carefully evaluate the existence of cholecystic lithiasis, the haemoglobin level in patients with SCA, platelet count in children with ITP and the vaccination status. An anterior and a lateral or hanging spleen approach are primarily used for laparoscopic splenectomy. In the last four years, near the Section of Pediatric Surgery of the Department of Pediatrics, Obstetrics and Medicine of the Reproduction of Siena University, 8 cases of splenomegaly have been treated, 7 by lateral videolaparoscopic splenectomy (5 males and 2 females, with medium age of 10,5 years) and 1 by anterior approach (10 years). The advantages shown by these techniques allow the laparoscopic splenectomy to be considered as a valid alternative to the open surgery. In children's laparoscopic splenectomy, the rate of complications is considerably low and the the major problem is the intraoperative hemorrhage. With increasing surgical experience, the minimally invasive approach appears to be superior in terms of faster postoperative recovery, shorter hospital stay, perioperative and postoperative advantages. Therefore, the laparoscopic technique may soon be accepted as the standard method in patients requiring splenectomy.

Pre and Post-Operative Ph-Metry in Videolaparoscopic Surgery for Gastro Oesophageal Reflux Disease.

Gastro-oesophageal reflux is common in children, especially in the first year of life, and it may be regarded as physiological. Good functioning of the lower oesophageal sphincter depends largely on the anatomical relationships between oesophagus, stomach and diaphragm hiatus. Relative immaturity of these structures in newborn babies and young children is a risk factor in reflux disease, which may result in a wide variety of typical and/or atypical symptoms and, sometimes, serious complications such as oesophagitis and stenosis. Reflux disease may be diagnosed and studied, basing on morphological and functional aspects and, since the advent of pH-metry, it is possible to personalise the therapeutic approach to children with reflux. Surgical treatment of reflux disease in children has recently been improved due to a mini-invasive surgical approach. Absolute indications are recurrent pneumonia, intractable pain due to oesophagitis and retarded growth, often in association with neurological impairment. In the last three years, 18 children with reflux disease underwent videolaparoscopic surgery in our department, 14 by the Nissen and 4 by the Toupet technique. Post-operative pH-metry always showed a reduction in exposure of the distal oesophagus to acid (integral of H+) and an improvement in oesophageal clearance (short refluxes percentage) indicative of good functioning of the gastro-oesophageal junction. PH-metry proved to be an invaluable technique for planning therapeutic strategy. In follow-up evaluations, it enabled us to monitor functioning of the gastro-oesophageal junction and to avoid other more difficult and invasive tests in patients with severe neurological impairment.

Congenital Cystic Adenomatoid Malformation of the Lung Tipe II: Three Cases Report.

Congenital cystic adenomatoid malformation (CCAM) is a rare congenital lung lesion. It may appear since birth (30-35%) with difficulty breathing or may have a late onset (60-65%) with recurring pulmonary infections or growth failure; in a small percentage of cases, the lesion can be completely asymptomatic. Fetal or post-natal surgery can be used as surgical treatment of these lesions. Postnatal surgery consists of a lobectomy, bilobectomy or pneumonectomy, based on the size of the lesion. The best age to undergo this surgery is around 2 years, but only if the injury is stable and the child has no complications. The study describes three cases of CCAM, observed at the Pediatric Surgery Section of the University of Siena. We analyzed those 3 cases whose approach was defined by the onset of symptoms, age and clinical condition of patients. In the first case the surgery was performed a few hours after birth due to the worsening of the clinical conditions; in the other two cases it was delayed because the patients were asymptomatic. The purpose of this study is to review the management of patients with CCAM in relation to clinical onset and the type of injury.

Current Espghan Guidelines for Celiac Disease in Pediatric Age, Tertiary Care Center Experience: A Proposal for Further Simplification.

According to the 2012 ESPGHAN criteria for diagnosis of celiac disease (CD), duodenal biopsy (DB) can be avoided in children with a clear malabsorption syndrome, anti-tissue transglutaminase IgA (tTG2) ≥ 10x the cut-off, anti-endomysium IgA (EMA) and HLA DQ2/DQ8 genes. The aim of this study is to report our experience and evaluate the accuracy of the actual guidelines. PATIENTS AND METHODS: This is a retrospective study conducted on all patients diagnosed CD from 2012 to 2018 in our Center. For all patients enrolled were analyzed: data of family history, symptoms, serology, genetics, Marsh grade and follow-up. RESULTS: A total of 481 children [mean age 6,4 yrs; F:M= 1.8:1] were included in the study. The mean age of patients who were not subject to DB was lower (4.51 yrs) comparing with patients that received DB (6.48 yrs). Out of the 256 patients with anti-tTG2 ≥ 10 fold, 121 underwent DB because of mild symptoms (84/121) or no symptoms (37/121). In all cases Marsh type 3 was found and HLA haplotypes was compatible with CD diagnosis. CONCLUSIONS: Our study confirms that the serology has a primary importance to diagnose CD, regardless of the symptoms. These data suggest that biopsy and HLA haplotypes search, in presence of anti-tTG2 IgA ≥ 10x the cut-off, are wasteful and unhelpful for the patients.

Enhanced recovery after surgery efficacy in an older patients and high-risk population affected by colorectal cancer: a more than 1000 patients experience.

AIM: Enhanced recovery after surgery programs aims to standardize care, improving colorectal surgery outcomes. Older patients are a challenge population for these programs. The aim of this manuscript is to explore the effect of application Enhanced recovery after surgery protocol among older patients and high-risk patients undergone colorectal surgery for cancer. METHOD: Since January 2005, until September 2016, 1189 consecutive patients underwent elective Colorectal Surgery and treated according to our Enhanced recovery after surgery protocol. Patients are divided in three groups according to age: Group1 under 69 y-o (control group), Group2 70 to 79 y-o and Group3 over 80 y-o. Primary end point was Time to Readiness to Discharge. RESULTS: Median Time to Readiness to Discharge was 4 days (3-30) in Group 1, 5 (3-47) in Group 2 and 5 (3-19) in Group 3. Length of stay in Group 1 had a median length of 6 days (3-58), in Group 2 of 8 days (3-70) and in Group 3 of 8 days (3-53). CONCLUSIONS: Once more Enhanced recovery after surgery program has showed its efficacy in colorectal surgery field. Moreover, our experience has underlined the need to concentrate efforts mainly on older and high-risk patients.

[Neonatal neuroblastoma and prenatal diagnosis]. / Neuroblastoma neonatale e diagnosi pre-natale.

The improvement of the imaging has considerably increased the number of cases of neuoroblastoma, diagnosed in preborn age. The authors present a case of neonatal neuroblastoma diagnosed in prenatal age and managed with a multidisciplinary approach. The authors report the case of R.T., born from a scheduled Caesarean delivery. The echographic morphological prenatal diagnosis showed an abdominal mass of 3x2 cm located on the upper side of the kidney, which was not apparently involved. Postnatal ultrasound evaluations confirmed that diagnosis. The diagnostic programme included nuclear magnetic resonance and a renogramm with metaiodobenzylguanidine. These exams confirmed the presence of a mass, probably due to a neuroblastoma. Due to the increasing of the mass, the patient underwent surgical excision of the neoplastic mass. The histological examination confirmed the diagnosis of neuroblastoma Stage I without medullary involvement. During the operation, a medullary biopsy was performed. The FISH exam did not show the amplification of N-myc or a delection of p36 chromosome. For patients younger than 18 months there is no therapeutic gold standard for the treatment of suprarenal masses of neoplastic origin, and the approach is still controversial. The complete excision of the mass should be taken in consideration in presence of an increasing neoformation, and should not include any chemotherapeutical or radiation therapy for stage I, II, IVs (INSS) or L1, MS (INGRSS) neoformations. In conclusion, the effectiveness of a multidisciplinary approach of neonatal neuroblastoma is higher in the early diagnosis and in an accurate staging of the disease, which is fundamental for the favourable prognosis.

Italian multicentric survey on laparoscopic spleen surgery in the pediatric population.

BACKGROUND: Some technical aspects of laparoscopic spleen surgery still are debated, although efforts have been made to standardize them. The position of the patient, the approach to the spleen, vessel identification and division, and spleen extraction can vary from center to center. METHODS: This retrospective muticentric study led by the Società Italiana di Videochirurgia Infantile (SIVI) examined indications, surgical details, and complications of laparoscopic spleen surgery in the pediatric population during a 5-year period. RESULTS: The study period from January 1999 to December 2003 (5 years) involved nine centers and included 85 patients with a mean age of 10 years (range, 2-17 years). Hypersplenism or severe hemolysis in cases of hematologic disorders represented the most important indications. More than 90% of the patients underwent total laparoscopic splenectomy. Specific technical details from each center were collected. Intraoperative complications occurred in 19% of the patients (hemorrhage in 8% and technical problems in 14%), and 6% of the patients required conversion to the open approach. No deaths occurred, and no reoperations were required. Postoperative complications were experienced by 2% of the patients. CONCLUSION: Laparoscopic spleen surgery is safe, reliable, and effective in the pediatric population. On the basis of the results, some technical details for laparoscopic spleen surgery can be suggested. The patient is preferably kept supine or lateral, approaching the spleen anteriorly. Moreover, the ilar vessels should be identified selectively and individually, with initial artery division performed to achieve spleen shrinking. Any hemostatic device proved to be effective in experienced hands. Once freed, the spleen is preferably extracted via a suprapubic cosmetic transverse incision (faster, easier, and safer), although a bag can be used. Finally, the size of the spleen does not represent a contraindication for a trained and experienced surgeon. Nevertheless, this parameter must be considered when laparoscopic spleen surgery is planned.

[Treatment of varicocele in pediatric age with retroperitoneoscopic ''one trochar'' technique. Long term follow-up]. / Trattamento del varicocele in etá pediatrica in retroperitoneoscopia, con tecnica ''one trocar'' follow-up a lungo termine.

AIM: The incidence of varicocele varies from 6% to 16.2% in male children and adolescents. Various techniques were proposed to treat it. In the last years there was an increasing interest in the use of laparoscopy in pediatric urology. The authors reports their experience in the treatment of varicocele by retroperitoneoscopy with one trocar technique and the long-term follow-up in pediatric patients. METHODS: Fourty patients were treated for idiopathic Horner's degree III or less, but symptomatic, and type 1 according to Coolsaet varicocele. All patients underwent a clinical examination and echo-color Doppler before treatment and during the follow-up. RESULTS: The following parameters were evaluated: duration of the operation, intra and postoperative complications, duration of hospitalization and of antalgic therapy. Follow-up was at 6, 12, 24 and 36 months (mean 23.4 months). Testicles diameters, persistence/recurrence of varicocele and hydroceles were estimated. CONCLUSIONS: The retroperitoneoscopic approach in the treatment of varicocele is an effective technique because it implies a minor surgical trauma, a rapid postoperative recovery and a good cosmetic result.

Experimental internal anal sphincter replacement with demucosated colonic plication.

BACKGROUND: Selective re-creation of a new internal anal sphincter could be indicated when the natural one is irreversibly damaged or excised. METHODS: In this preliminary experimental work, surgical techniques of internal anal sphincter replacement in pigs were investigated. After preoperative anorectal manometry, surgical procedure was done in two phases: abdominal, mobilization of the colon-rectum to the pelvic floor; and perianal, dissection of the anal canal from the external anal sphincter through the intersphincteric space. The fully mobilized anorectal segment, including the internal anal sphincter, was pulled down through the anus and resected. The distal colonic stump was then demucosated and two types of plications of the demucosated segment were accomplished, each type in three animals. The plicated segment was then returned into the anal canal, inside the external sphincter. Short-term follow-up with clinical and manometric evaluations was performed and, subsequently, histological analysis of the plicated segment, after the animals were sacrificed. RESULTS: None of the animals became incontinent. Anal manometry identified a high-pressure zone and relaxation reflex in the new anal canal. Histologic studies showed hypertrophy of smooth muscle layers without degenerative changes. CONCLUSION: This study indicates that a plication of colonic smooth muscle wall can re-create a high-pressure zone in the anal canal after the internal anal sphincter has been excised.

Italian multicenter survey on laparoscopic treatment of gastro-esophageal reflux disease in children.

BACKGROUND: Skepticism is still present today about the laparoscopic treatment of gastro-esophageal reflux (GER) in children. We present the prospective experience and short-term results of eight Italian pediatric surgical units. METHODS: We included all the children with complicated GER, operated after January 1998 by single surgeons from eight different centers. Diagnostic aspects, type of fundoplication, and complications were considered. All the patients were followed for a minimum period of 6 months in order to detect complications or recurrences. RESULTS: 288 children were prospectively included. Mean age was 4.8 years (3 m-14 y). Nissen fundoplication was done in 25%, floppy Nissen in 63%, Toupet in 1.7%, and anterior procedures (Lortat Jacob, Thal) in 10%. Gastrostomy was associated, if neurological impairment or feeding disorders were present. Mean follow-up was 15 months and reoperation was necessary in 3.8% of cases. CONCLUSIONS: This experience underlines that minimal invasive access surgery in children is safe and that the laparoscopic approach is considered in eight centers the golden standard for surgical repair of gastro-esophageal reflux disease maintaining the same indications and techniques of the open approach.

An extensively hydrolysed cow's milk formula improves clinical symptoms of gastroesophageal reflux and reduces the gastric emptying time in infants.

BACKGROUND: About 20 % of infants fed with breast-milk substitutes suffer from Gastro Esophageal Reflux (GER) and 1/3 of them also show Cow's Milk Allergy (CMA) symptoms. METHODS: We planned this study to assess by dynamic echography the usefulness of an Extensively Hydrolysed Cow's Milk Formula (eHF) in infants suffering from GER. Ten infants showing GER symptoms and 10 normal babies, all fed with breast-milk substitutes, were enrolled. Clinical symptom scores related to GER were assessed for one week. The Gastric Emptying Time (GET) was determined by means of dynamic echography after feeding with cow's milk-derived formulae and again after a week feeding with eHF in subjects previously showing GER symptoms. RESULTS: All infants with a clinical diagnosis for GER showed an abnormally high average GET in comparison to normal subjects (205 vs 124 min, p = 0.000). Switching to the eHF led to a significant clinical improvement (p = 0.0039) especially in babies skin-test and RAST positive to cow's milk, and to a significant decrease toward the normal value of the GET (167 min, p < 0.001). CONCLUSIONS: The eHF tested improves GER symptoms in infants suffering from this disease. Our experience confirms and supports the use of dynamic echography as a reliable, simple, and non-invasive diagnostic method for infants with an increased GET associated with clinical symptoms of GER.

Laparoscopic diagnostic exploration of the vaginal processus in the pediatric age. Preliminary experiences.

BACKGROUND: Laparoscopic surgical procedures, employed even in the paediatric age, bearing both diagnostic and therapeutic value, are currently used in the evaluation of peritoneal-vaginal duct patency during surgery for controlateral inguinal hernia or other diseases requiring opening of abdominal wall. METHODS: From January 1996 to December 2000, at the Department of Pediatric Surgery of the University of Siena a prospective study protocol has been performed to evaluate the effectiveness of laparoscopy versus traditional surgery in showing patency of peritoneal-vaginal duct. RESULTS: From our study we have been able to see how this laparoscopic procedure is well tolerated by children and parents, and is lacking in clinical complications. Patency of peritoneal-vaginal duct has been pointed out in 21.73% of cases. This result is in line with the international literature; in fact, the majority of authors have found a negative controlateral exploration in 50-80% of patients examined, thus confirming the uselessness of routine surgical controlateral inguinal exploration in hernia cases. CONCLUSIONS: The use of diagnostic laparoscopy in the study of peritoneal duct patency is a rapid and relatively easy technique, practically without intra- and peri operative risks. It allows an easy solution of the diagnostic doubt, without the need to necessarily perform a traditional explorative surgical procedure.