Are the complications after laparo-assisted endo-rectal pull-through for Hirschsprung disease related to the change of the anal tone?

The main advantage of the laparo-assisted transanal endorectal pull-through technique (LA - TERPT) for Hirschsprung Disease (HD) is the respect to the rectal-anal anatomy. Postoperative complications have been observed recently. The present study aims to determine how often these postoperative complications occur in these patients. From January 2009 to December 2018, a retrospective analysis was conducted on 36 children (25 males) with HD who underwent LA-TERPT. Data were collected on the age of diagnosis and surgery, sex, the presence of other pathologies, and cases of enterocolitis. In all cases, anorectal manometry (ARM) was performed to evaluate the anal tone. The median age at diagnosis was 2 months and the mean age at surgery was 5 months. Nine related pathologies were identified: five cases of Down syndrome, one case of hypertrophic stenosis of the pylorus, atresia of the esophagus, polydactyly, and anorectal malformation. A patient with total colonic aganglionosis was identified through laparoscopic serummuscular biopsies. Enterocolitis was diagnosed in 7 cases before and 6 after surgery. At follow-up, the complications recorded were: 5 cases of constipation (treated with fecal softeners), one case of anal stenosis (patient with anorectal malformation), 16 cases of soiling (treated with enemas) and 1 child with fecal incontinence (treated with a transanal irrigation system). The ARM was performed in all 36 cases and showed normal anal tone, except for one case with anal hypotonia. LA-TERPT is an important surgical technique for HD. According to the literature, soiling is the most main complication after HD surgery, probably due to "pseudo-incontinence" with normal anal sphincter tone.

Unusual position of pilonidal sinus in children may explain its malformative etiology: Case report and review of the literature.

INTRODUCTION: Pilonidal sinus is a condition that causes inflammation and abscesses in the sacral region and affects adolescents and young adults. The etiology of this condition remains controversial. CASE PRESENTATION: A six year old boy was observed to have an orifice in the frontonasal region which contained hair. He had two previous infections which were treated with antibiotics. Magnetic Resonance Imaging showed no cranial malformations. Surgery was performed under general anesthesia and the pilonidal sinus was completely excised. At follow-up the child was in good health. CLINICAL DISCUSSION: This case in a child with a frontonasal skin anomaly highlights that skin anomalies may be a cause of pilonidal sinus. CONCLUSION: Skin malformations can be the underlying cause of pilonidal sinus in some cases.

Primary non-refluxing megaureter: Natural history, follow-up and treatment.

Primary non-refluxing megaureter (PMU) is a congenital dilation of the ureter which is not related to vesicoureteral reflux, duplicated collecting systems, ureterocele, ectopic ureter, or posterior urethral valves and accounts for 5 to 10% of all prenatal hydronephrosis (HN) cases. The etiology is a dysfunction or stenosis of the distal ureter. Most often PMU remains asymptomatic with spontaneous resolution allowing for non-operative management. Nevertheless, in selective cases such as the development of febrile urinary tract infections, worsening of the ureteral dilatation, or reduction in relative renal function, surgery should be considered. CONCLUSION: Ureteral replantation with excision of the dysfunctional ureteral segment and often ureteral tapering is the gold-standard procedure for PMU, although endoscopic treatment has been shown to have a fair success rate in many studies. In this review, we discuss the natural history, follow-up, and treatment of PMU. WHAT IS KNOWN: • PMU is the result of an atonic or stenotic segment of the distal ureter, resulting in congenital dilation of the ureter, and is frequently diagnosed on routine antenatal ultrasound. WHAT IS NEW: • Most often, PMU remains asymptomatic and clinically stable, allowing for non-operative management. • Nevertheless, since symptoms can appear even after years of observation, long-term ultrasound follow-up is recommended, even up to young adulthood, if hydroureteronephrosis persists. • Ureteral replantation is the gold standard in case surgery is needed. In selected cases, however, HPBD could be a reasonable alternative.

Unusual location of apocrine hidrocystoma in children: Case series.

INTRODUCTION AND IMPORTANCE: Apocrine Hidrocystoma is a relatively rare benign tumour that begins from the apocrine sweat glands of the head and neck. The Authors present a case series of children with urogenital localization. CASES PRESENTATION: Two boys (15 years and 9 years) presented with a small mass on the glans. Another 15-year-old boy presented with a cystic lesion in the right side of the scrotum where he had a previous surgery. The last case, a 17-year-old boy, presented because of a penile cyst of 8 mm. All four had surgical operations because of aesthetic discomfort or problems during micturition. Histological examination showed a diagnosis of apocrine hidrocystoma in all cases. CLINICAL DISCUSSION: This benign tumour rarely affects the urogenital system in children, but when it happens the child can have discomfort and proper treatment is mandatory. CONCLUSION: Surgery is the preferred treatment with a low risk of recurrence.

In Which Patients and Why Is Laparoscopy Helpful for the Impalpable Testis?

Since laparoscopy has been proposed in the management of the nonpalpable testis (NPT), this technique has been widely diffused among pediatric surgeons and urologists, but its application is still debated. We conducted a retrospective review to highlight how diagnostic and surgical indications for laparoscopy are selective and should be targeted to individual patients. From 2015 to 2019, 135 patients with NPT were admitted to our surgical division. Of these, 35 were palpable on clinical examination under anesthesia and 95 underwent laparoscopy. The main laparoscopic findings considered were: intra-abdominal testis (IAT), cord structures that are blind-ending, completely absent, or entering the abdominal ring. The patients' mean age was 22 months. In 48 cases, an IAT was found, and 42 of these underwent primary orchidopexy while 6 had the Fowler-Stephens (FS) laparoscopic procedure. Of the first group one patient experienced a testicular atrophy while two a reascent of the testis. In the FS orchidopexy group, one patient had testicular atrophy. Cord structures entering the internal inguinal ring were observed in 35 children, and all were surgically open explored. In 3 cases of these, a hypotrophic testis was revealed and an open orchidopexy was executed. In the remaining the histological examination revealed viable testicular cells in four patients and fibrosis, calcifications, and hemosiderin deposits in the others. Eleven patients presented with intrabdominal blind-ending vessels and one a testicular agenesia. A careful clinical examination is important to select patients to submit to laparoscopy. Diagnostic laparoscopy, and therefore, the anatomical observation of the testis and cord structures are strictly related to develop a treatment plan. In IAT, many surgical strategies can be applied with good results. Laparoscopy offers a concrete benefit to the patient.

Can Infant Dyschezia Be a Suspect of Rectosigmoid Redundancy?

Infant dyschezia is a functional gastrointestinal disorder that occurs in children less than nine months of age. This disorder causes much anxiety among parents who consult different physicians when suspecting major intestinal problems. The aim of this study is to verify whether infant dyschezia involves an anatomic abnormality (redundancy) of the colon. In this retrospective study (48 months) we analyzed all the children younger than 9 months who came to our attention through the suspicion of gastrointestinal abnormality (Hirschsprung's disease, anorectal malformations, colonic disorders or constipation). They all had a complete medical history, clinical examination and diagnostic tests, such as blood samples, suction rectal biopsy, a study of stool characteristics and, finally, a contrast enema. In cases with infant dyschezia, different colonic sizes and rectosigmoid length were measured, which created a ratio with the diameter of the second lumbar vertebra. These values were compared with those reported in the literature as normal for the age of one year. Of the 24 patients evaluated (mean age 4 months), 9 were excluded for different diagnoses (aganglionic megacolon, hypothyroidism, constipation). The comparison of the ratios obtained in the remaining 15 cases showed a significantly higher rectosigmoid length (redundancy) in children with dyschezia, 18.47 vs. 9.75 (p < 0.001). The rectosigmoid redundancy, a congenital anomaly already reported as a cause of refractory constipation, may be present in children with infant dyschezia.

Esophageal impedance baseline in infants with bronchopulmonary dysplasia: A pilot study.

BACKGROUND: Bronchopulmonary dysplasia (BPD) may induce gastroesophageal reflux (GER). Esophageal impedance baseline values (BI) reflect mucosal inflammation. Our aim was to evaluate BI levels in preterm infants with BPD compared with those without BPD and to identify BI predictors. METHODS: This is a retrospective pilot study including infants born <32 weeks' gestational age (GA) who underwent esophageal multichannel intraluminal impedance (MII)-pH. Univariate/multivariate analysis were performed to compare data between BPD and non-BPD infants and to identify BI predictors. A subgroup analysis was performed in infants born <29 weeks' GA, at highest risk for BPD. RESULTS: Ninety-seven patients (median GA 285/7 weeks, mean postnatal age 49 days, 29 with BPD), were studied. BPD infants had significantly lower birth weight compared with non-BPD infants (750 vs. 1275 g), were more immature (274/7 vs. 290/7 weeks GA), were older at MII-pH (79 vs. 38 days) and received less fluids during MII-pH (147 vs. 161 ml/kg/day). The same findings were found in the group of 53 infants born <29 weeks. BPD versus non-BPD infants had significantly lower BI (2050 vs. 2574 ohm, p = 0.007) (<1000 ohm in five BPD infants vs. one non-BPD) whereas the other MII-pH parameters were not significantly different. Multiple regression analysis found that increasing chronological age was positively associated with BI (B = 9.3, p = 0.013) whereas BPD was associated with lower BI (B = -793.4, p < 0.001). CONCLUSIONS: BPD versus non-BPD infants had significantly lower BI despite similar MII-pH data. BPD and chronological age predicted BI, whereas only BPD predicted BI in the most immature infants.

COVID-19 Can Cause Severe Intussusception in Infants: Case Report and Literature Review.

COVID-19 may cause intussusception in infants. We report on a case of severe ileo-colic intussusception in an infant with COVID-19 who required an ileo-colic resection. A literature review revealed 9 other cases with COVID-19 and intussusception. In this article, we will discuss the management and treatment of the first reported case of intussusception associated with COVID-19 in Italy.

Thoracoscopic excision of asymptomatic antenatally diagnosed mediastinal bronchogenic cysts: A case report.

Bronchogenic Cysts (BCs) are benign congenital malformations commonly located in the mediastinum. In recent years the development of antenatal diagnosis has changed the BCs management allowing an earlier minimally invasive approach. We report a case of an asymptomatic 8-months-old girl with antenatal diagnosis of subcarinal posterior mediastinal BC. Thoracoscopic excision of the cyst was successfully performed. The management of antenatally diagnosed BCs is discussed. Thoracoscopic treatment of BCs is safe and effective with the advantage of a reduced morbidity compared to thoracotomy.

The "Dark Side" of Pneumoperitoneum and Laparoscopy.

Laparoscopic surgery has been one of the most common procedures for abdominal surgery at pediatric age during the last few decades as it has several advantages compared to laparotomy, such as shorter hospital stays, less pain, and better cosmetic results. However, it is associated with both local and systemic modifications. Recent evidence demonstrated that carbon dioxide pneumoperitoneum might be modulated in terms of pressure, duration, temperature, and humidity to mitigate and modulate these changes. The aim of this study is to review the current knowledge about animal and human models investigating pneumoperitoneum-related biological and histological impairment. In particular, pneumoperitoneum is associated with local and systemic inflammation, acidosis, oxidative stress, mesothelium lining abnormalities, and adhesion development. Animal studies reported that an increase in pressure and time and a decrease in humidity and temperature might enhance the rate of comorbidities. However, to date, few studies were conducted on humans; therefore, this research field should be further investigated to confirm in experimental models and humans how to improve laparoscopic procedures in the spirit of minimally invasive surgeries.

New Surgical Frontiers for Nutrition in Children.

Nutrition in pediatric age, if properly adapted to the various developmental phases, can be considered the first prevention tool for the most common pathologies of this age [...].

Laparoscopic Fowler-Stephens orchidopexy for intra-abdominal cryptorchid testis: a single institution experience.

Fowler-Stephens Laparoscopic Orchiopexy (FSLO) permits the mobilization of Intra-Abdominal Testis (IAT) to the scrotal position after spermatic vessel ligation. We reported our experience of FSLO for IAT. The charts of all boys who underwent a FSLO were retrospectively reviewed. Data were analysed for demographic data, procedure, complications and follow-up results. From January 2008 to June 2016, 160 laparoscopies for Non Palpable Testis (NPT) were performed at a mean age of 3,2 years. 61% of patients had a right NPT, while 6% were bilateral. In 64 cases, an IAT was found: 20 were managed by FSLO with a two-stage procedure in 11 patients. There were no differences in hospitalisations; one patient had a prolonged ileus. Follow-up ranged from 1 to 8 years. Of the 20 patients who underwent FSLO, testicular atrophy developed in three; the remaining testes were in the scrotal position, with normal consistency. FSLO was applied in 31% of IAT. The overall success rate of the technique was 85 %. The percentage of atrophy associated after spermatic vessels interruption appears to provide a good chance of testicular survival.

Nuck cyst: a rare cause of inguinal swelling in infancy.

BACKGROUND: Inguinal and/or inguino-scrotal swellings, such as hernia and hydrocele, are among the commonest anomalies in childhood. Hydrocele of the canal of Nuck is an uncommon diagnosis and a rare cause of swelling in women that occurs due to a patent vaginal process. METHODS: From January 2001 to January 2016, 353 female patients 1-14 years of age were admitted to our university hospital division for inguinal swelling. We have performed 403 inguinal approaches, and of these, 399 (99%) had inguinal hernias, 3 (0.74%) had a cyst of the canal of Nuck, and 1 (0.24%) had a lipoma. All of the patients with Nuck cysts underwent surgical exploration of the swelling through a right inguinal skin crease incision. RESULTS: The patients were between the ages of 1 and 8 years. The cyst sizes varied between 25 and 40 mm. All the patients exhibited right, tender, painless, non-reducible masses. In all patients, ultrasound confirmed the suspected diagnosis. The histological findings revealed fibrous-walled cystic formations with mild chronic inflammatory infiltrate that were covered by mesothelial epithelium. The patients' postoperative follow-ups at 1, 6 and 12 months revealed normally healed incisions with no recurrences. CONCLUSIONS: The surgical findings and the histological demonstrations of serous epithelium seemed to validate the hypothesis that the patency of the inguinal canal combined with fluid secretion of the peritoneal serosa participated in the formation of the cysts. Surgery with high ligature of the vaginal process is considered the therapy of choice for this pathology.

Response to therapy among neonates with gastro-esophageal reflux is associated with esophageal clearance.

BACKGROUND: Few studies evaluated the efficacy of pharmacological therapy for gastro-esophageal reflux disease (GERD) in newborns, whose safety has been questioned. Esophageal basal impedance (BI) is a marker of mucosal integrity, and treatment with proton pump inhibitors significantly increases BI in infants; however, no correlation with clinical improvement was reported. AIMS: To evaluate the relationship between BI and other esophageal pH-impedance parameters and clinical response to therapy in newborns with GERD. STUDY DESIGN: Multicenter retrospective study. SUBJECTS: Infants who received omeprazole or ranitidine for GERD. OUTCOME MEASURES: Complete response to therapy was defined as symptom decrease by ≥50% compared to baseline, partial response as symptom decrease <50%, no response as no symptom decrease based on chart analysis. Response to therapy was assessed 2 and 4 weeks after the onset of therapy. Univariate and multivariate statistics were performed to assess associations between response to therapy and clinical/pH-impedance parameters. RESULTS: We studied 60 infants (51 born preterm): 47 received omeprazole, 13 ranitidine. Response to therapy was associated with decreasing esophageal clearance time: odds ratio 0.308, 95%CI 0.126-0.753, p = 0.010 at 2 weeks, odds ratio 0.461, 95%CI 0.223-0.955, p = 0.037 at 4 weeks. CONCLUSIONS: Clinical response to therapy among infants with GERD was associated with esophageal clearance but not with esophageal BI level.

Pneumoperitoneum Modifies Serum and Tissue CCL2-CCL5 Expression in Mice.

BACKGROUND AND OBJECTIVES: Laparoscopy is the preferred method when operating in the abdomen. In this study, we evaluated systemic and morphological peritoneal cytokine modifications (RANTES/CCL5 and MCP-1/CCL2) due to CO2 pneumoperitoneum in rats. METHODS: Twenty-five prepubertal Sprague-Dawley rats were randomized into three groups. Pneumoperitoneum lasting 30 minutes, was induced with a flow of 0.5 L/min, in two groups (S1 and S2, n = 20), at a P/CO2 of 6 and 10 mm Hg, respectively. In the control group (C, n = 5), only anesthesia was carried out. All animals were sacrificed after 24 hours. The serum of the rats was collected for ELISA, and the levels of the cytokines RANTES and MCP-1 were investigated. An immunohistochemical analysis of RANTES and MCP-1 was performed on samples of the peritoneum, and the morphological evaluation was conducted with a blinded evaluation by two independent, experienced pathologists by using a grading system (0, 1+, 2+, 3+: no, faint, moderate, and strong reactivity, respectively). RESULTS: RANTES mean levels were significantly different in the S1, S2, and C groups (70.3 ± 2.26, 58.23 ± 4.32, 29.66 ± 4.03, respectively, P = .0001). The levels of MCP-1 were 32.1 ± 1.63 in the S1 group, 27.0 ± 9.26 in the S2 group, and 16.4 ± 9.55 in the C group (P = .159). Normal control peritoneum showed little reactivity, whereas a moderate to strong cytoplasmic reaction to anti-CCL5/CCL2 antibodies was observed in mesothelial and inflammatory cells in the S1 and S2 groups. CONCLUSION: CO2 pneumoperitoneum evokes an inflammatory response by modifying plasma RANTES levels and peritoneal CCL5/CCL2 expression.

Functional constipation or redundancy of the colon?

OBJECTIVES: Constipation is a common problem in children, and most of the time, the cause is defined as functional. Our hypothesis is that children with functional refractory constipation had anatomic alterations of the colon. METHODS: All children with chronic refractory constipation who visited our centre underwent accurate clinical examination, contrast enema (CE), anorectal manometry (ARM) and rectal suction biopsies (RSB). In case of functional constipation, three operators measured the size of the colon using radiograms and calculated the ratio based on the width of the second lumbar vertebra. The measurements carried out were compared with those reported in the literature on patients of the same age without constipation. RESULTS: Over a period of 24 months, 69 patients with chronic refractory constipation, aged between 1 and 14 years, visited our department. A CE was performed on 67, and 2 were excluded because of anal stenosis. Sixty-five underwent anorectal manometry. Rectal suction biopsies were needed in 14 children, and 2 of them were found to have colonic aganglionosis. After a complete evaluation, 57 (82.61%) patients were diagnosed having functional constipation. By comparing the data of the patients with those of normal children reported by the other authors, we found that none of the measurements was statistically significant except for the rectosigmoid length: the mean value in one-year-old patients was 19.03 vs. 9.75, and in older children, it was 19.46 vs. 9.59. CONCLUSIONS: Recognizing an anatomic anomaly in patients suffering from functional constipation is important for specific treatment, especially when the ratio (rectosigmoid length/L2) is higher than 15.

Isolated fallopian tube torsion in pediatric age: An Italian multicenter retrospective study.

PURPOSE: The purpose of this study was to quantify the experience of five Italian centers on the diagnosis and management of isolated fallopian tube torsion (IFTT) in children. METHODS: We retrospectively reviewed the data of 20 patients aged 1-16 years of age with surgically diagnosed IFTT between 1991 and 2017 from five Italian centers of pediatric surgery. We analyzed common presenting signs, symptoms, and radiographic findings, as well as surgical interventions to describe management offering further insight into the diagnosis and treatment of this rare entity. RESULTS: Twenty cases of IFTT were collected. Median age was 13.1 years. Menarche was present in 14 cases. A clinical history of abdominal pain was present in 13 patients, whereas in 7 patients the clinical picture was an acute abdomen. Ultrasonography was the first diagnostic examination in 16 cases. Surgical approach was by laparoscopy in 16 cases and laparotomy in 4 cases. In 11 patients IFTT was associated with another pathologic condition. In 7 of the remaining 9 IFTT without pathologic association, the girls played sports. Salpingectomy was performed in 13 patients and de-torsion in 7. CONCLUSIONS: IFTT is a rare condition that seems to occur in younger adolescents. Vague clinical presentation contributes to low preoperative suspicion. IFTT should be considered in girls with abdominal pain who practice sports with sudden body movements. Preoperative suspicion may be increased based on radiographic findings of an enlarged tubular/cystic structure with adjacent normal ovary. Conservative management is controversial but could be preferred in order to provide the best option for future fertility of these girls. TYPE OF STUDY: Treatment Study (Retrospective Study) - Level IV.

How replace the gastrostomy tube in children with extremely compromised general conditions.

The percutaneous endoscopic gastrostomy is the best technique to use in case of children requiring long-time enteral nutrition. The first replacement of the tube is easy in most of the patient, but this step can be extremely problematic in patients with compromised general conditions. The authors report their experience in some cases. Two boys with endoscopic gastrostomy had a deterioration in the general conditions, when replacing the probe, these conditions contraindicated anaesthesia for which the "cut-and-push" technique was adopted in a patient with heart malformation and a local anaesthetic in a neuropathic patient. Both the boys died a few days after this procedure. In our opinion, in children who are not using anaesthesia to reposition the gastrostomy probe, it is best to continue feeding through the nasogastric probe.

The isolated tubal torsion: an insidious pediatric and adolescent pelvic urgency.

Isolated tubal torsion (ITT) is a rare cause of acute abdominal pain. Preoperative diagnosis is difficult because of a lack of specific signs. Surgery is recommended to preserve the integrity of the tube. Seven patients of median age of 13 years (range 9 to 15) came to our observation for worsening abdominal pain, nausea and vomiting. On admission, all girls had blood tests and ultrasound. Laparoscopy was performed for diagnosis in all cases. The girls had one-month and one-year ultrasound and clinic follow up. In all cases diagnosis was delayed, median 66 hours after the onset of symptoms and laparoscopy showed necrosis of the Fallopian tube. In five girls a laparoscopic salpingectomy was performed. In the other two, an open salpingectomy was necessary because of pelvic adhesions. Histology showed a hemorrhagic infarction of the Fallopian tubes. At follow up all patients were asymptomatic with normal ovaries, but one ovarian cyst. In the differential diagnosis of acute abdominal pain in children or female adolescents the possibility of ITT should be considered for a conservative treatment. Laparoscopy allows for definitive diagnosis and treatment.