Analgesic effects of intravenous flunixin and intrafunicular lidocaine or their combination for castration of lambs.

Abstract Objective: To analyse the effectiveness of intrafunicular lidocaine and intravenous flunixin for reducing pain and signs of stress in lambs undergoing surgical castration. Design: Randomised controlled trial. Setting: One university teaching hospital in Italy. Participants: 30 healthy male lambs, 9-12 weeks old. Intervention: Allocation to five groups: a control group (C), undergoing general anaesthesia but not castration; a surgery group (S), undergoing orchiectomy without analgesic treatment; a surgery-lidocaine group (SL), undergoing orchiectomy and receiving intrafunicular 2 per cent lidocaine solution; a surgery-flunixin group (SF), undergoing orchiectomy and receiving intravenous flunixin; a surgery-flunixin-lidocaine group (SFL), undergoing orchiectomy and receiving both intrafunicular lidocaine and intravenous flunixin. Main outcome measures: Nociception and stress were assessed through intraoperative indicators, serum cortisol concentration, glycaemia, behaviour, immune response and clinical evaluation of the heart rate (HR), respiratory rate and rectal temperature after surgery. Results: Groups S and SL showed increased values of intraoperative HR, mean arterial pressure and postoperative cortisol concentration. In group SFL, cortisol values were similar to those of group C. No other difference could be detected. Conclusions: The combination of intravenous flunixin and intrafunicular lidocaine reduced the pain and discomfort of lambs castrated under general anaesthesia. Intrafunicular lidocaine alone did not prevent pain or discomfort associated with castration

choledochal cyst our experience in a single case by laparoscopic approach

Introduction Choledochal cysts are disproportionate dilatations of the biliary system for the presence of a congenital malformation, the persistence of the common biliary pancreatic channel. Complete excision of the cyst is the best treatment strategy to avoid long-term complications especially malignant transformation, recurrent cholangitis and gallstones. We present a clinical case treated at our center with minimally invasive surgery. Case Report A female patient was admitted to our center at the age of 3 years, with right hypocondrial pain, followed by jaundice, vomiting and recurrent fever. No abdominal mass present. Abdominal ultrasound was performed and also Magnetic resonance cholangiopancreatography. According to the Todani classification modified by Alonso-Lej classification we identified a type I with three gallonstones. She underwent laparoscopic cyst excision and hepatico-jejunostomy Roux-en-Y with perianastomotic drainage positioned. No early and late postoperative complications after 1 year of follow-up. Discussion and Conclusions Choledochal cysts can present at different ages with variable symptoms. Common presentations include abdominal pain, jaundice, and right upper quadrant mass and are most common seen in pediatric patients. Associated congenital anomalies of biliary tract may be present. Most cases of choledochal cyst disease have type I and IV-A cysts. If left untreated, choledochal cysts have an increased risk of malignant transformation. Early surgical excision and restoration of biliary tract continuity is mandatory, whatever the symptom severity to avoid long term complications whenever possible. Currently the gold standard treatment is the mini invasive surgery, in fact the advantages of this technique is the intraoperative visualization of deeper structures, decreased postoperative pain, shorter hospital stay, improved cosmetic result and decreased postoperative ileus. However, these cases remain reserved for highly specialized surgeons with a thorough understanding of hepatobiliary anatomy and minimally invasive techniques. Finally, limited case series of robotic pediatric choledochal cysts resection and reconstruction have been reported with acceptable outcomes, although more studies are needed before widespread acceptance and implementation of this technique in pediatric age

partial congenital bowel obstruction by duodenal atresia windsocks type case report

Introduction Duodenal atresia Windsocks type is a rare condition of congenital bowel obstruction. Thanks to recent technological advancements of prenatal diagnosis it is possible to make a diagnosis of duodenal atresia with high degree of certainty through the radiological sign of "double bubble", but up to date it is not yet possible to identify the type of duodenal atresia. We report the case of a patient with prenatal diagnosis of "double bubble". The patient had no other concomitant malformations. Case Report The patient came to our attention after prenatal ultrasound that showed a picture of double bubble. At the 27th week of gestation we performed fetal MRI that confirmed the US pattern of double bubble but it did not identify with certainty the type of duodenal atresia. At birth the patient underwent GI rx examination that showed a picture of partial duodenal obstruction compatible with the Windsocks type. On the following day, we performed endoscopy which showed the presence of duodenal membrane, so the patient underwent surgical treatment with a longitudinal duodenal incision in order to treat the wind-sock membrane. After one month a further Upper-GI rx examination showed a regular transit of the contrast. Four months after the first operation the patient underwent new surgical treatment for bowel obstruction by adhesions. The operation was successful and the patient had a complete recover.Conclusions Patients with prenatal diagnosis of "double bubble" require a multidisciplinary approach for proper clinical management. Unfortunately it is not currently possible to identify with certainty by prenatal ultrasound the type of duodenal atresia, but in case of incomplete bowel occlusion , the possibility of an atresia Windsocks type should always be considered, especially for setting the right surgical approach

mini invasive surgery in the first three years of life

Background: In the last 30 years mini-invasive surgery (MIS) has been widely used becoming an important and irreplaceable method, safe and highly reliable, in both the diagnostic and therapeutic treatment, for a variety of conditions in both the child and the newborn. This has led to a significant increase of the use of this approach in the pediatric population under the age of 3 years, with results similar to the open techniques. Materials and Methods: At the Department of Surgery, Medicine and Neuroscience at the University of Siena we conducted a retrospective study of patients aged less than three years of life underwent minimally invasive procedures. The clinical information was extrapolated from a prospective database. They included all patients treated from June 2003 to October 2014. Were considered for each patient demographics, associated diseases, surgical procedure, MIS approach, the instruments used, the duration of surgery and hospitalization, intraoperative and postoperative complications (early and late). Results: From a total of 933 minimally invasive procedures, 150 (16%) were performed under the age of 3 years. The 76% of patients were males, 24% were females. Twenty-two patients (15%) presented associated diseases. 53 (35%) were diagnostic procedures, 97 (65%) were therapeutic procedures. We treated: 1 3 esophageal atresia, 1 diaphragmatic hernia, 1 congenital cystic adenomatoid malformation (CCAM), 8 stenosis of the ureteropelvic junction , 2 disorders of sexual differentiation (DSD), 20 inguinal hernias, 75 cases of non-palpable testis, 15 cases of Hirschsprung disease, 10 cases of fundoplication, 4 cases of ovarian tumors, 6 cases of nephrectomy, 4 cases of eminefrectomy and 1 case of thymoma. In total we performed 6 (4%) thoracoscopic procedures, 18 (12%) in retroperitoneoscopy and 126 (84%) in laparoscopy. 55 procedures (37%) were performed in "one-trocar" technique. Among the remaining 95 (67%), in 62 (41%) we used a "3 mm" instruments, in 18 (12%) "5 mm" instruments and in 15 (14%) they were mixed (3/5 mm). The duration of the procedure was an average of 59 minutes (range: 20-135 minutes) in diagnostic procedures and 184 minutes (range: 40-370 minutes) in the therapeutic procedures. We converted to an open technique in 14/150 (9%). We reported no postoperative complication and incidentaloma no intraoperative complications. The following is 100% survival. Conclusions:MIS is probably the most important change that has taken place in the field of Pediatric Surgery in the last 30 years. The optimum benefits are to be found in the lesser surgical stress, the lower cavity contamination, the magnification of details, the reduced hospital stay, reduced morbidity or the best aesthetic result

hypospadias long term follow up in a single center

Introduction: Hypospadias is one of the most common birth defects that affect the male urogenital tract. It can present as isolated anomaly, but sometimes can arise in the context of complex disorders of sex development (DSD). These malformations are characterized by a great variety of clinical manifestations and compromise the aesthetic appearance, but also functional and psychological impact that the malformation can determine the patient. Materials and Methods: We conducted a retrospective study of patients undergoing surgery for hypospadias from March 2000 to January 2015. The data was extrapolated from a prospective database. It was considered for each patient: demographics; type of hypospadias; surgical technique; average age for surgery; intraoperative and postoperative complications (early and late). Duckett's classification was used. Results: 343 urethroplasties were performed. 320 (93%) were primary urethroplasties and 23 (7%) reoperations in patients who had performed many other surgical procedures. 7 patients with megameatus were excluded. The hypospadias have been ranked according to Duckett's classification, 35 patients had associated diseases. In total were performed: 186 (55%) Snodgrass, 71(21%) Duckett,10 (3%) augmented Duckett, 42 (13%) Magpi, 16 (5%) Duplay, 1 (0,3%) Bracka, 1 (0,3%) was a Bianchi'technique and 5 (1,4%) were Standoli. In 4 patients (1%) were used mixed technique. There were no intraoperative complications. The mean age at surgery was 15 months (range 12-22 months). Postoperative complications were 12%. Long term follow up was done with uroflussimetrie at 3 and 6 months in those who had reached the continence and possible urethral calibrations in those who had submitted a stenosis in post-op.Conclusions: The improvement of surgical techniques, the use of optical amplification tools, the use of suture material (PDS) and the experience gained in recent years have enabled us to optimized the results. Though aware of the potential and actual complications that this type of microsurgical correction can lead to the results we have obtained are comparable to those of major international series and can be considered satisfactory, both from an aesthetic and functional

a case of ileoileal intussusceptions caused by burkitt s lymphoma

Introduction Burkitt's lymphoma is a high grade B-cell tumor described for the first time by the Irish surgeon Dennis Burkitt in 1958 in Africa. The most frequent of the clinical variants, in which it is classified by the World Health Organization (sporadic, endemic, HIV-associated), is the sporadic one, which usually involves the abdomen, in particular the ileocecal tract. Thus, a common clinical presentation is that of a child suffering from abdominal pain with nausea and vomit, until the dramatic case of an intestinal occlusion by an intussusceptions. According to this, the surgeon is the first who diagnoses and treats this tumor, playing an important role for the treatment, in terms of reduction of the metabolic complications of the medical therapy and of improvement of survival rate. In this work we present a case of a child operated for intestinal occlusion by ileoileal intussusception, caused by a Burkitt's lymphoma, as it was diagnosed by histological examination few days after surgical intervention. Case report A 12-years boy reached the emergency department for abdominal pain and vomit. Two weeks before he had a surgical intervention for a suspected appendicitis at another hospital. An ultrasound examination was performed and it revealed the presence of a complex mass in the right iliac fossa. The day after the patient felt worse and he had an episode of bilious vomit. An x-ray examination of the abdomen was performed and showed the presence of an intestinal obstruction. The patient underwent to surgical intervention. The obstruction was caused by an ileoileal intussusceptions, and it needed to perform a resection followed by anastomosis. Few day after surgical intervention, the result of histological examination indicated the presence of a Burkitt's lymphoma within the tract resected. A CT scan was performed and showed the involvement of mesenteric lymph nodes. The bone marrow aspirate and the lumbar puncture showed no neoplastic presence. Then the patient started therapy according to protocol. Discussion and Conclusions Burkitt's lymphoma represents 3-5% of all non-Hodgkin lymphomas, and 40% in pediatric population. Children have an excellent prognosis with contemporary treatment regardless of the disease stage. Patients with limited stage disease are curable with limited treatment, avoiding complications associated with more intensive therapies. Nevertheless surgery is important in the management of this disease, the role of the surgeon has usually been controversial. A surgical intervention can be resolving in case of limited disease, or, in case of a high stage disease, it can be diagnostic or helpful, through the debulking of the mass. However, apart in case of intussusception, the diagnoses of Burkitt can be challenging and the presence of disease can revealed after a story of recurrent abdominal pain or after surgical interventions for appendicitis. In this work we show how a timely diagnosis can be difficult and how it can be an obstacle for treatment. In this case the sudden worsening of clinical conditions permitted an early diagnosis with a complete resection of the ileum involved by Burkitt's lymphoma has improved the prognosis and reduced therapy's complications

management and outcome of herlyn werner wunderlich syndrome conservative treatment in pediatric age

Herlyn–Werner–Wunderlich syndrome (HWWS) is a rare congenital mullerian anomaly consisting of uterus didelphys, hemivaginal septum, and unilateral renal agenesis. Reported data in pediatric age are rare. We report our case of HWWS

RECTAL DUPLICATION CYST IN PREVIOUS ANORECTAL MALFORMATION AND DOWN SYNDROME

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PRELIMARY EXPERIENCE IN ROBOTIC PYELOPLASTY IN OUR CENTRE

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prenatal diagnosis and surgical innovations in congenital diaphragmatic hernia evaluation of pre and post operative management

Introduction. Congenital diaphragmatic hernia (CDH) is still today considered a challenge from surgeons. Considerable progress in prenatal diagnosis, intensive care unit of neonates and surgical techniques, with the possibility to perform minimally access surgery, widely increased survival rates. The aim of this study is to analyze our series about long and short-term outcomes, also considering the progress made by minimally invasive techniques. Methods. The study was performed at Pediatric Surgery of Siena. It is a retrospective study that analyzed all patients with CDH (Bochdalek) treated in the last 14 years, from 2000 to 2013. Sex, side of the defect, presence of prenatal diagnosis, age of onset and symptoms, associate malformation, herniated organs, surgical technique and site of surgery, complications, recurrences, survival and followup were analyzed. Results. We included 23 patients. Five of them, were ruled out because of affected by diaphragmatic eventration or acquired diaphragmatic hernia. Forteen patients (77%) presented left CDH and 4 patients (23%) a right one. The male female ratio were 14:4. Prenatal diagnosis was performed in 5 patients (27,5%) at a mean gestational age of 29 weeks. Forteen patients (77%) had an early onset of symptoms (first day of life). Most common symptoms were respiratory distress and cyanosis; 4 patients (23%) had a late onset of symptoms, at a mean age of 9 months, and most common symptoms were failure to thrive and vomiting. Seven patients (39%) had associated malformation: common mesenterium (5 pts-71%). The colon was the most commonly herniated organ, present in 15 patients (83%), followed by small intestine in 13 patients (72%), stomach in 11 patients (61%), spleen in 9 patients (50%) and liver in 4 patients (23%). Seventeen patients (94,5%) underwent open surgery: 10 of them (59%) underwent a subcostal laparotomy approach, 7 of them (41%) underwent a supraumbelical laparotomy approach; 1 patient (5%) underwent minimally access surgery with thoracoscopy access. We performed performed surgery in the intensive care unit in 3 patients (16,5%). Six patients (33%) developed minor postoperatory complications. No patient had recurrence. Four patients died so we report a mortality rate of 23%. A follow-up investigation, with an average duration of 87 months, it is still going on in 5 patients (27,5%). Conclusions. The our survival rate was 77% and it reflects the encouraging reported data in the recent literature. These results are due to the reliability of the new resuscitation strategies, such as high-frequency oscillatory ventilation and the use of NO, the ability to perform surgery in the neonatal intensive care unit and, especially, to successfully perform minimally invasive surgery in newborn. The improvement of the survival showed the increasing of long-term morbidity end the requirement of a multidisciplinary followup. For these reasons, a multidisciplinary pathway for the management of young patients has been created, to follow them in a standardized way as early as the prenatal diagnosis