Esophagogastric dissociation reduces the re-operation rate for persistent gastroesophageal reflux in severely neurologically impaired children

Purpose: In this study we want to demonstrate the effectiveness of the esophagogastric dissociation as a first level operation in treatment of the gastroesophageal reflux in severe neurologically impaired children, in term of a reduction of reoperation rate.Methods: We divided patients operated from 1998 to 2005 in a group A, composed by children treated with fundoplication, and in a group AR, composed by the patients of group A who had a recurrence of reflux and that was treated with esophagogastric dissociation. Patients operated from 2005 to 2013 were selected on the basis of the severity of the neurological impairment and were divided in a group B, treated with fundoplication, and in a group C of more severe impaired children, treated with esophagogastric dissociation. Data regarding the complications of the A and C groups were analyzed with Fisher’s test.Results: We evaluated 63 patients: 34 (54 %) in group A, 11 in group AR, 15 (23.6 %) in group B, 14 (22.4 %) in group C. The Fisher’s test showed a non significant difference with a p value of 0.2.Conclusion: Despite of statistic result we believe that TOGD is a useful procedure as the first choice of surgical management in severe neurological impaired children affected by gastroesophageal reflux

Cervical Lymphadenitis by Mycobacterium triplex in an Immunocompetent Child: Case Report and Review

Mycobacterium triplex was first described in 1996. This nontuberculous Mycobacterium causes a severe pulmonary disease in immunocompromised patients but it can involve also healthy patients. A literature search was made on the PubMed database and it produced only few cases of children with cervical lymphadenitis due to this Mycobacterium Triplex. We are describing a case of M. triplex cervical lymphadenitis in an immunocompetent child

Herlyn–Werner–Wunderlich syndrome: An “early” onset case report and review of Literature

AbstractHerlyn–Werner–Wunderlich syndrome (HWWS) is a rare congenital mullerian anomaly consisting of uterus didelphys, hemivaginal septum, and unilateral renal agenesis [1,2]. Most authors reported cases of Herlyn–Werner–Wunderlich syndrome with prepuberal or postpuberal onset with cyclical abdominal pain and a vaginal mass (3–8). Only six cases are reported in Literature with early onset of this syndrome under 5 years (9–14). Our case is about 3 years old girl, with all the features of this syndrome who came to our attention for lower abdominal mass. The aim of this article is to share our experience and focus the attention on the importance of high level of suspicion of HWWS in neonatal period to early diagnosis and treatment. The possible early presentation of this syndrome should be suspected in all neonates (females) with renal agenesia confirmed postnatally or with prenatal diagnosis. It is common, in fact, an error of evaluation with planning of removal of mass, that can damage patients in term of chance for a successful reproductive outcome. For all these reasons, our team consider HWWS as differential diagnosis in newborn with prenatal ultrasonography of a cystic mass behind the urinary bladder in the absence of a kidney and plan a pelvic ultrasound (with aim to identify an uterus, normal or dydhelfus, and presence or absence of pelvic mass), an examination under anesthesia and cystoscopy and vaginoscopy, if it is necessary. A high level of suspicion, indeed, is the key to early diagnosis

HYPERPLASIA OF THYMIC GLAND: LEFT VIDEO-ASSISTED THORACOSCOPIC APPROACH

Hyperplasia of thymic gland is a rare benign entity that should be considered in the differential diagnosis of anterior mediastinal masses in children and young adolescents. We report a case of a patient with a thymic mass, diagnosed occasionally for respiratory symptoms and treated by video-assisted thoracoscopic surgery. A previously healthy 10 years-old boy presented to our hospital for retrosternal pain and dyspnea with restriction to daily activities from four months. Diagnostic imaging was performed, including a chest x-ray and a magnetic resonance imaging, showing a large homogeneous anterosuperior mediastinal mass, more extended on the left side. The additional laboratory analysis, considered essential for differential diagnosis with myasthenia gravis and lymphoma, resulted negative. In view of these findings, our patient underwent to video assisted thoracoscopy with left-sided approach for a total resection of thymus and perithymic fat. The patient made an excellent recovery without postoperative complications and was discharged from the hospital four days later. Histopathological examination showed a normal thymic architecture like a true thymic hyperplasia. At follow up, chest x-ray was normal in absence of pleural and parenchimal alterations. Thoracoscopic thymectomy is a safe technique that allows to achieve the goal of early thymectomy with the advantages of less invasive procedure

Color Doppler imaging of the superior ophthalmic vein in patients with Graves' orbitopathy before and after treatment of congestive disease

OBJECTIVE: To compare superior ophthalmic vein blood flow parameters measured with color Doppler imaging in patients with congestive Graves' orbitopathy before and after treatment and in normal controls. METHODS: Twenty-two orbits from 12 patients with Graves' orbitopathy in the congestive stage and 32 orbits from 16 normal controls underwent color Doppler imaging studies. Color Doppler imaging was repeated after treatment in the group of patients with Graves' orbitopathy, which included orbital decompression in 16 orbits and corticosteroids in six orbits. The findings for each group were compared. RESULTS: In the group of orbits with congestive disease, superior ophthalmic vein flow was detected in 17 orbits (anteroposteriorally in 13 and in the opposite direction in four) and was undetectable in five. After treatment, superior ophthalmic vein flow was detected and anteroposterior in 21 and undetected in one orbit. In normals, superior ophthalmic vein flow was detected anteroposterior in 29 orbits and undetectable in three orbits, indicating a significant difference between groups. There was also a significant difference between controls and congestive Graves' orbits and between congestive orbits before and after treatment, but not between controls and patients after treatment. A comparison of superior ophthalmic vein flow parameters revealed a significant difference between the groups. The superior ophthalmic vein flow was significantly reduced in the congestive stage compared with the flow parameters following treatment and in the untreated controls. CONCLUSIONS: Superior ophthalmic vein flow was significantly reduced in the orbits affected with congestive Graves' orbitopathy and returned to normal following treatment. Congestion appears to be a contributing pathogenic factor in the active inflammatory stage of Graves' orbitopathy.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

Preoperative distraction in children: hand-held videogames vs clown therapy.

Anxiety in children undergoing surgery is characterized by feelings of tension, apprehension, nervousness and fear which may manifest differently. Postoperative behavioural changes such as nocturnal enuresis, feeding disorders, apathy, and sleep disturbances may stem from postoperative anxiety. Some Authors pointed out that over 60% of children undergoing surgery are prone to developing behavioural alterations 2 weeks after surgery. Variables such as age, temperament and anxiety both in children and parents are considered predictors of such changes.1 Studies were published describing how psycho-behavioural interventions based on play, learning and entertainment in preparing children for surgery, may reduce preoperative anxiety. Clown-therapy is applied in the most important paediatric facilities and has proved to diminish children's emotional distress and sufferance, as well as consumption of both analgesics and sedatives and to facilitate the achievement of therapeutic goals. The aim of our study was to evaluate the efficacy of clown-therapy during the child's hospital stay, with a view to optimizing treatment and care, preventing behavioural alterations and enhancing the child's overall life quality

URACHAL CYST: AN UNSPECTED COMPLICATION

The urachus is the remnant of the allantois, which usually becomes obliterated shortly after birth. Urachal remnants due to an incomplete obliteration of different portion of the urachus are rare, but they need to be treated surgically because of their potential for infectious complications and malignant degeneration. We present a case report with an unespected postoperative complication. M.E., a 10 years old boy, came to the Accident and Emergency Department for an acute abdominal pain, without other symptoms, twice in one year. The blood tests, urine sample and voiding cystourethrogram were normal. The ultrasound scan showed a thickened urachal duct. After antibiotic and anti-inflammatory therapy for two weeks, we performed laparoscopic surgery. In the second postoperative day the patient showed abdominal pain and hematuria. An ultrasound scan and a voiding cystourethrogram showed a leak from the dome of bladder. We performed an open surgery to close the defect on the bladder’s dome. The patient was discharged in 10th postoperative day. Now he is healthy. Clinically manifest persistent urachal anomalies are rare, but they carry a risk of recurrent infection and subsequent malignant degeneration. For these reasons the radical excision of the remnant is suggested. Today, due to the large laparoscopic experience, all the reports showed that this technique can be used safely, but we have to pay attention to all steps of the procedure. This case is a paradigmatic situation and it illustrates the importance of a meticulous technique during the excision of urachal remnant. Indeed even if laparoscopic excision could be safe and effective, it is not free of complication

Caudal 'duplication' or 'split' syndrome: Is there a misnomer?

Abstract'Caudal duplication syndrome' was coined to describe the apparent duplication of organs derived from the hindgut, the neural tube and the adjacent mesoderm. Review of the anatomy suggests that the word 'duplication' may be a misnomer. This paper describes the management of 2 girls with caudal duplication syndrome who underwent multistage reconstructive surgery. Both had a large omphalocele and a severe diastasis of the pubic symphysis. The first patient also had an apparent duplication of the vulva, the perineum and the anus to either side of a wide midline. Each vulva contained a urethra, a hemi-clitoris with ipsilateral labium minor, and a hemi-vagina with hemi-uterus. The second child had an infrapubic sequestrated appendico-cecal duplication lying between two hemi-bladders each with ipsilateral ureter and urethra. The everted duplication split the single vulva longitudinally in the midline as far as the fourchette. To each side were a hemi-clitoris, and a hemi-vagina with hemi-uterus and ipsilateral fallopian tube. Analysis of our patients' anatomy and a literature review indicates for the most part 'hemi' organs on either side and suggests that the term 'duplication' is a misnomer such that caudal 'split' syndrome may be a more appropriate title