Laparoscopic robotic-assisted restorative proctocolectomy and ileal J-pouch-anorectal anastomosis in children.

PURPOSE: Total proctocolectomy with ileal J-pouch-anorectal anastomosis (IPAA) remains the preferred surgical treatment for ulcerative colitis (UC) in children. Considering the well-known advantages of minimally invasive approach, and its main application for the deep pelvis, robotic surgery may be used in UC reconstructive procedures. The aim of the study is to report our experience with Robotic IPAA in children. METHODS: Single surgeon experience on Robotic IPAA were prospectively included. Data on patient demographics, surgical details, complications, and length of stay (LOS), were collected. RESULTS: Fifteen patients were included. Median age was 13.2 years, median body weight 45 kg. Median operative time was 240 min. Median LOS was 7 days and mean follow-up time 1 year. No intraoperative complication occurred. Five postoperative complications happened: 3 minors treated conservatively (CD I-II), 2 majors needing reintervention under anesthesia (CD IIIb). No mortality was observed. CONCLUSION: Our preliminary experience reveals that Robotic IPAA is a safe and feasible option for the surgical treatment of UC in children. A bigger patient sample and a long-term follow-up are needed to confirm our findings.

Conservative management in congenital severe bilateral hydronephrosis related to uretero-pelvic junction obstruction.

We report our experience in conservative management of patients with prenatal and neonatal diagnosis of severe bilateral ureteropelvic junction obstruction (UPJO), focusing on the actual predictors of renal function impairment or spontaneous resolution. Between 1996 and 2006, 20 patients with bilateral severe hydronephrosis related to UPJO were included in the study. Indications for surgery were an increased hydronephrosis, decreased renal function, onset of symptoms. Conservatively treated patients were followed up for 3 months to 10 years with renal ultrasound, DTPA diuretic, urine culture. At first renal scan, 22 out of 40 renal units had a poor, 10 an intermediary and 8 a good drainage. Pyeloplasty was required in 10 of the 40 kidneys, while 30 out of 40 kidneys were followed conservatively. At the end of follow up, sieric normalized creatinine and estimated glomerular filtration rate were normal in all patients. Our data showed that bilateral severe hydronephrosis related to UPJO can be safely managed in a similar manner of a unilateral case. A poor drainage could be considered a negative predictive factor in the feasibility of a conservative management.

A long-term follow-up in conservative management of unilateral ureteropelvic junction obstruction with poor drainage and good renal function.

The aim of the study was to retrospectively review the outcome of neonatal ureteropelvic junction obstruction with a good renal function and a poor drainage at a first diuretic renal scan, in cases where surgery was recommended on the basis of a loss of renal function, worsening of hydronephrosis or occurrence of clinical symptoms. Hydronephrosis was graded from 1 to 4 or as ureteral tract dilatation (UTD) P1 to UTD P3. During follow-up, 15 out of 38 patients (34.2%) required surgery while 25 out of 38 (65.8%) could have been managed conservatively. In patients with grade 2, 3, and 4 hydronephrosis, the ureteropelvic junction obstruction resolved or improved spontaneously in 100%, 63%, and 33% of cases (in 100% of UTD P1, 67% of UTD P2, and 50% of UTD P3), respectively. The median of follow-up was 14 years. Chi-square test showed a significant relationship between initial grade of hydronephrosis or UTD and the possibility of an efficient conservative management (p = 0.0088 and p = 0.0460).Conclusion: Conservative management can be safely achieved in ureteropelvic junction obstruction with poor drainage. Scheduled controls are needed for early discovery of functional renal deterioration. High-grade hydronephrosis is unlikely to resolve spontaneously and is often accompanied by a loss of renal function during the first years of life. What is Known: • There is controversy about which management should be adopted in infants with unilateral ureteropelvic junction obstruction with poor drainage but good differential renal function. What is New: • Long-term follow-up suggests that conservative management can be safely achieved also in unilateral ureteropelvic junction obstruction with poor drainage in more than 60% of cases, even if high-grade hydronephrosis is unlikely to resolve spontaneously and it is often accompanied by a loss of renal function during the first years of life. In our experience, surgical intervention was required in more than 50% of cases before 1 year of life and in all cases before 3 years of life.

Different concentration of human cord blood HMGB1 according to delivery and labour: A pilot study.

OBJECTIVE: Oxidative stress is involved in several maternal conditions characterized both by an increase in free radicals synthesis and a parallel decrease in the antioxidant activity. Parturition induces considerable oxidative stress and many inflammatory mediators, among which HMGB1, are involved from the beginning of pregnancy to the birth of the infant. We evaluated serum cord blood HMGB1 levels in a population of neonates to investigate correlation with mode of delivery, as well as the influence of labour. SETTING AND PATIENTS: The study subjects were 325 neonates delivered at University Hospital "G. Martino" of Messina over an 18-month period. Following cord separation, venous blood sampling was performed on umbelical cords. RESULTS: In the cord venous blood, we found HMGB1 values significantly more elevated in spontaneous vaginal group when compared to elective or emergency caesarean section group. Regarding labour, umbilical cord venous blood HMGB1 levels were significantly higher in the spontaneous and induced labour group, compared to non-labouring women. CONCLUSION: These results could highlight a possible role of HMGB1 during birth time related to mode of delivery and labour.

Colonic stenosis post-necrotizing enterocolitis in term newborn with acquired cytomegalovirus infection.

Necrotizing enterocolitis is a gastrointestinal emergency typical of premature infants. Intestinal strictures infrequently complicate medical or surgical treatment of necrotizing enterocolitis. Postnatal cytomegalovirus infection with gastrointestinal linvolvement has occasionally been described in subjects with necrotizing enterocolitis. We report the case of a full term infant presenting necrotizing enterocolitis, acquired cytomegalovirus infection and post necrotizing enterocolitis colonic stricture.List of abbreviations: necrotizing enterocolitis = NEC,cytomegalovirus = CMV.

Paediatric ulcerative colitis surgery: Italian survey.

BACKGROUND AND AIMS: Recent epidemiological studies showed an increase in ulcerative colitis among children, especially in its aggressive form, requiring surgical treatment. Although medical therapeutic strategies are standardized, there is still no consensus regarding indications, timing and kind of surgery. This study aimed to define the surgical management of paediatric ulcerative colitis and describe attitudes to it among paediatric surgeons. METHODS: This was a retrospective cohort study. All national gastroenterology units were invited to participate. From January 2009 to December 2013, data on paediatric patients diagnosed with ulcerative colitis that required surgery were collected. RESULTS: Seven units participated in the study. Seventy-one colectomies were performed (77.3% laparoscopically). Main surgical indications were a severe ulcerative colitis attack (33.8%) and no response to medical therapies (56.3%). A three-stage strategy was chosen in 71% of cases. Straight anastomosis was performed in 14% and J-pouch anastomosis in 86% of cases. A reconstructive laparoscopic approach was used in 58% of patients. Ileo-anal anastomosis was performed by the Knight-Griffen technique in 85.4% and by the pull-through technique in 9.1% of patients. Complications after colectomy, after reconstruction and after stoma closure were reported in 12.7, 19.3 and 35% of cases, respectively. CONCLUSIONS: This study shows that there is general consensus regarding indications for surgery. The ideal surgical technique remains under debate. Laparoscopy is a procedure widely adopted for colectomy but its use in reconstructive surgery remains limited. Longer follow-up must be planned to define the quality of life of these patients.

CO(2) pneumoperitoneum induces in vitro hypoxic response culminating in apoptosis of human neuroblastoma cells.

The ablative role of minimally invasive surgery (MIS) in neuroblastoma (NB) is still controversial due to the possible CO2 pneumoperitoneum side-effects on tumor aggressiveness. It is known that CO2 produces hypoxic condition with changes in tumor microenvironment influencing cell functions. Here we investigated whether CO2 exposure affects the transcription factor HIF-1α and the apoptotic signalling pathway in SH-SY5Y NB cells. SH-SY5Y cells were exposed to a pressure of 15 mmHg CO2 (100%) for 4 h (T0) and then moved to normal condition for 24 h (T24). In control and CO2 -exposed cells, we analyzed the mRNA levels and DNA binding activity of HIF-1α. We also evaluated the proliferative activity and cell viability as well as caspase-9/3 cleavage and nuclear fragmentation. A significant increase in HIF- 1α activation was observed in SH-SY5Y cells exposed to CO2 compared to control cells. CO2 treatment also decreased the proliferation rate and the percentage of viable cells. In addition, the expression and cleavage of caspase-9 and -3 were significantly increased in NB cells exposed to CO2. These data correlated with apoptotic feature observed in CO2 -treated NB cells. Our findings show that CO2 -induced hypoxic condition exerts cytotoxic effects on NB cells by eliciting mitochondrial apoptotic pathway and thereby improving the understanding of the possible clinical impact of CO2 pneumoperitoneum on NB behaviour.

Natural history of non-operative treatment for renal injuries in children.

AIM: Kidney is one of the solid organs injured in blunt abdominal traumas. Conservative management is well recognized in adults, but is still controversial in children. We performed a retrospective review regarding children with renal injuries observed at our Centre, analyzing the importance of a prompt diagnosis and the role of conservative treatment according to the degree of renal injury and natural history. METHODS: We reviewed 15 cases of blunt abdominal trauma with renal injuries observed during a period of 11 years. The diagnosis was confirmed by abdominal computed tomography (CT) scan and ultrasonography (US). Conservative treatment started monitoring the hemodynamic stability, the hematocrit value, the hemoglobin, the red cell count, the urine analysis. If necessary blood transfusion was performed. A follow-up from 1 month to 2 years monitored the lesions healing. RESULTS: Age of patients varied from 3 to 15 years (mean age = 6.3). Nine were males and six females. Two patients had an associated spleen lesion, thirteen had an isolated renal injury. Injury grades were classified as follows: grade I, 5 cases; grade II, 3 cases; grade III, 5 cases and grade IV, 2 cases. Non operative management was successful in 14 out of 15 cases; 1 patient with grade IV required a partial nephrectomy. At follow-up good healing of the lesions was observed. CONCLUSION: Most of renal injury related to abdominal trauma can be successfully and safely managed conservatively. Hemodynamic stability, a prompt clinical and instrumental diagnosis and grading of lesions by CT are necessary to start an effective non operative treatment.

Neonatal intrathoracic gastric volvulus in Marfan's syndrome.

Intrathoracic gastric volvulus is extremely rare in the newborn period. The authors describe the case of a newborn with unusual combination of intrathoracic gastric volvulus and Marfan's Syndrome and discuss its management.

[Crossed renal ectopia. Report of two cases and literature review]. / Ectopia renale crociata. Descrizione di due casi e revisione della letteratura.

Renal ectopia is a malformative uropathy classified as simple and crossed. The authors report two patients with renal ectopia (one case of ERC without fusion and one case of ERC with fusion). The authors review the literature about crossed renal ectopia and discuss the importance of early diagnosis and the advantage of thorough investigation in order to exclude associated anomalies.

Case report of congenital fistula of the penile urethra.

Isolated congenital fistula of the penile urethra is extremely rare. A case of congenital urethral fistula with an intact glandular urethra without chordee is reported with a discussion of the possible etiology and management.

An uncommon case of associate intrinsic and extrinsic stenosis of the duodenum in newborn.

The incidence of congenital combinations of extrinsic and intrinsic compression of duodenum is uncommon. The authors report a rare case of a neonate with a duodenal stenosis due to the contemporary presence of an annular pancreas and wind sock web. The diagnostic strategies and management will be discussed.

Sarcoglycan immunoreactivity is lacking in infantile hypertrophic pyloric stenosis. A confocal laser scanning microscopic study.

OBJECTIVES: The Dystrophin-Glycoprotein Complex (DGC) is a large multisubunit complex that plays a crucial role in maintaining the structural integrity and physiology of muscle fibers. Dystrophin has been reported to be absent in the pyloric muscle of infantile hypertrophic pyloric stenosis (IHPS) patients. The present study was designed to investigate the other two patterns of DGC (dystroglycan and sarcoglycan complexes) in normal pyloric muscle and their possible modifications in IHPS patients. METHODS: Ten pyloric muscle biopsies were obtained from babies operated for IHPS and five control pylorus biopsy taken at autopsy from cases without gastrointestinal disease. The DGC sub-complexes (beta-dystroglican and beta, delta- sarcoglycans) were localized immunohistochemically using specific monoclonal antibodies. The results were evaluated using a confocal laser scanning microscope. RESULTS: Positive immunolocalization of the two DGC sub complexes was demonstrated in the smooth muscle cells (SMCs) of the pyloric region of control patients. Similarly, a positive immune expression of beta-dystroglican was observed in the pyloric SMCs of IHPS patients. On the other hand a negative immunoreaction for sarcoglycans was recorded within the full thickness of the pyloric SMCs of these patients. CONCLUSIONS: The absence of sarcoglycans within the hypertrophied pyloric muscle may be a predisposing factor in the pathogenesis of IHPS since it could alter the normal physiology of SMCs through the modifications of structural integrity of sarcolemma and signaling between the extracellular and intracellular compartment.

[Conservative treatment of pediatric spleen trauma. Twenty years of experience]. / Trattamento conservativo dei traumi splenici in età pediatrica. Venti anni di esperienza.

OBJECTIVE: The spleen is the most frequently involved organ in abdominal blunt traumas. In the last decade the treatment has changed from an exclusive surgical approach to a conservative approach. We report our experience in the last twenty years. METHODS: Between 1983-2003, 54 patients with blunt abdominal traumas and isolated injury have been treated. The age at the time of diagnosis was 3 to 16 years (mean, 6.5). The diagnosis was made clinically and with imaging techniques (radiographic assessment, scintigraphy, US, CT). In all cases, a conservative treatment was started with continuous vital parameters monitoring, blood red cells count, hemoglobin, hematocrit; volume infusion and when necessary hemo-transfusion. Clinical follow-up and US monitoring were performed for six months after the trauma. RESULTS: In the period 1983-1993 a conservative treatment was tried in 23 patients; in 15 cases it was successfully, in 8 cases a laparotomy with splenectomy was necessary due to hemodinamic instability. In the second decade we observed 31 patients, all had been treated conservatively. The mean hospital stay was of 12 days with no deaths. CONCLUSIONS: Conservative treatment for splenic injuries in patients with hemodinamic stability is nowadays the treatment choice. Constantly monitoring of clinical, laboratory parameters and use of modern imaging techniques allows to follow the evolution of the lesion and to avoid, in most cases, a surgical treatment.

[Acute abdomen caused by Salmonella typhi acute appendicitis]. / Addome acuto da appendicite acuta secondaria a Salmonella typhi.

Salmonella infections can manifest themselves as acute abdominal problems and lead to emergency surgery. Some examples are: salmonella-related intestinal perforations, gallbladder involments, salpingitis, and peritonitis. Mesenteric lymphadenitis associated with salmonella mimics acute appendicitis and it is often difficult to establish a timely and tempestive diagnosis in children with right lower abdominal pain. Because of the difficult diagnostic process, a significant number of patients with salmonella infections present acute abdomen and undergo needless operations. Instead, in our case of salmonella-related acute abdomen, laparotomy was the right therapeutic choice. The conclusion is drawn that, even if there is not a precise diagnosis, in salmonella-related acute abdomen the surgical approach is the right choice, considering the high morbidity and mortality associated with untreated appendicitis and intestinal perforations.

[Preputioplasty in the treatment of phimosis in pediatric age. Indications and results]. / La prepuzioplastica nel trattamento della fimosi in età pediatrica. Indicazioni e risultati.

AIM: Phimosis is a common condition in the pediatric age. Circumcision has been the technique of choice for the surgical correction of this condition. As an alternative to circumcision different techniques of preputioplasty have been described in the last years. The aim of this paper was to report our experience with the preputioplasty technique in the treatment of phimosis in pediatric age. METHODS: A preputioplasty is performed for phimosis correction in 109 patients aged between 4 and 16 years. Patients with a sclerotic phimosis were not treated with preputioplasty. All the patients underwent frenulotomy with dorsal preputial plasty using a single dorsal incision. Only in 3 patients a double lateral incision was necessary. Patients were operated under general anesthesia with an average time of 8 min. RESULTS: Patients were followed-up at 8 days, 30 and 90 days postoperatively. The cosmetic result has been excellent in 90% of cases and good in 10%. The functional result has been excellent in all the patients. We observed 3 cases of infection and 8 cases of edema of the prepuce. These postoperative complications were all resolved with medical therapy. No recurrences have been observed. CONCLUSIONS: Preputioplasty is a safe and rapid technique that allows to obtain excellent cosmetic and functional results. In our opinion, preputioplasty should be the first choice technique for the treatment of phimosis in pediatric and adolescent age.

Varicocele and sport in the adolescent age. Preliminary report on the effects of physical training.

The effect of physical training on the natural history of varicocele has received little attention. The aim of the present pilot study was to evaluate the prevalence of idiopathic varicocele in young athletes, in the attempt to find a correlation between the training workload and the clinical grade of varicocele. We evaluated 150 adolescents with an age of 10-16 yr (median age: 13 yr). All these subjects were athletes practicing different sport at agonistic level. One hundred and fifty non-athlete adolescents of matched age (median: 13.5 yr) were used as controls. All underwent physical examination, and if a varicocele was suspected, the diagnosis was confirmed or excluded by echo-color-Doppler examination. The young athletes were stratified into two groups according to the different time spent for training: Group 1-6 h training per week; Group 2-7 to 12 h per week. Statistical analysis was performed. A p<0.05 was considered significant. The physical examination revealed a clinical varicocele on the left side in 20 athletes. A significant positive correlation was observed between the Group 2 and the highest grade of varicocele (r2=0.9918, p=0.0041). In the adolescent group used as control we observed a varicocele in 16 cases. A positive correlation was observed between the number of athletes with varicocele and the highest grade of varicocele (r2=0.96, p=0.02). Sport training does not modify the prevalence of varicocele compared to the general population, but physical activity has to be considered as an aggravating factor in the natural history of varicocele. In countries where sport eligibility is necessary for agonistic sport practice, varicocele should be then considered as a conditioning factor.

Melatonin reduces oxidative stress in surgical neonates.

BACKGROUND/PURPOSE: Cytokines are inflammatory mediators found in the circulation after surgery. Newborns have less protection against oxidation and are very susceptible to free radical oxidative damage. Melatonin has been reported recently to reduce oxidative stress in neonates with sepsis, asphyxia, and respiratory distress. The aim of this study has been to determine if melatonin would lower interleukin (IL)-6, IL-8, tumor necrosis factor alpha (TNF-alpha) and nitrite/nitrate (NOx) levels and modify serum inflammation parameters, improving the clinical course of surgical neonates. METHODS: Ten newborns (group 1), 5 with surgical malformations and respiratory distress (group 1a) and 5 with isolated abdominal surgical malformations (group 1b) received a total of 10 doses of melatonin (10 mg/kg) at defined times interval for 72 hours. The treatment was started within 3 hours after the end of surgery. Ten surgical neonates (group 2), did not receive melatonin. Twenty healthy neonates (group 3) served as control. Blood samples were collected at the end of operation; before treatment with the antioxidant; and 24 hours 72 hours, and 7 days after start of treatment with melatonin or placebo, respectively. RESULTS: Postoperative value of cytokines and NOx levels of groups 1 and 2 were significantly higher than group 3. Compared with group 1b, group 2 displayed significantly higher cytokines and NOx levels at 24 hours, 72 hours, and at 7 days. In group 1a the immediate postoperative values of cytokines were significantly higher than group 1b and group 2, but a significant improvement was observed after administration of melatonin with significantly lower levels of IL-6 and IL-8 with respect to group 2. An improvement of clinical outcome was observed by progressive reduction of clinical parameters of inflammation. CONCLUSIONS: Melatonin reduces cytokines and NOx levels showing potent antioxidant properties with improvement in clinical outcome. Further studies are warranted to define, on larger numbers, the role of melatonin in surgical patients.

Preliminary report on nitric oxide-mediated oxidative damage in adolescent varicocele.

BACKGROUND: The current study was designed to characterize the process of nitric oxide (NO) and peroxynitrite generation through the determination of nitrotyrosine concentration in the dilated veins of varicoceles in adolescents. METHODS: Ten adolescents with a median age of 13 years (range 12-17) affected by a left idiopathic varicocele (grade II and III) were studied. Whole blood samples were withdrawn from a peripheral vein at time of induction of anaesthesia, and from a dilated spermatic vein before ligation. Peripheral blood samples from five adolescents undergoing minor surgical procedures were used as controls. The nitrotyrosine concentration was evaluated by a sandwich enzyme-linked immunosorbent assay (ELISA), using a monoclonal anti-nitrotyrosine antibody and Western blot analysis. RESULTS: Plasma nitrotyrosine concentrations were significantly greater in the spermatic vein when compared with the peripheral vein (P = 0.031). Nitrotyrosine in plasma of controls did not show any significant difference in comparison with peripheral samples from varicocele patients. Western blot analysis confirmed the above data. CONCLUSIONS: In adolescents with a varicocele, there is an increase in nitrotyrosine concentration within the spermatic vein that can cause protein nitration and cytotoxicity via its reaction with various molecular targets. This could have repercussions on both sperm and testis function. We conclude that an oxidative stress status is present and should be considered as an indication for varicocele treatment in the adolescent.