Pediatric laparoscopic cholecystectomy with 2.3 mm Percutaneous Surgical System (MiniLap®): A new frontier for pediatric mini laparoscopy?

Abstract Mini-laparoscopy represents an evolving and attractive field both in general and in pediatric surgery, with a pressing and increasing technical demand. Although the advantages of the mini-laparoscopic approach (reduced morbidity, less incisional pain and discomfort, better cosmetic results) are well recognized, its technical difficulties due to the lack of suitable and comfortable instruments brought to a limited use. Moreover, in the pediatric population, the need of ergonomic mini-invasive but efficient devices is the key of a widespread use of mini-laparoscopic surgery performed with an effective and safe technique. We aim to highlight the first case of pediatric laparoscopic cholecystectomy performed with 2.3 mm percutaneous instruments (MiniLap ® Percutaneous Surgical System, Teleflex Incorporated, USA) that represents a significant advance in minimally invasive surgery

Video assisted sclerosis of endoabdominal lymphangiomas with OK432: An effective, safe and minimally invasive choice

Abstract Lymphatic malformations (LM) or lymphangiomas are congenital errors in vascular embryogenesis. Percutaneous sclerosis is considered the best treatment for LM with external localization and yields excellent results. Surgical resection for deep LM is currently the mainstay of therapy, but high recurrence and morbidity rates are reported. Uniform therapeutic protocols are still unavailable. We describe two cases of abdominal LM treated by video-assisted sclerosis with OK432. The first case was a 5-month-old girl with pre-natal diagnosis of a left retroperitoneal LM with vascular encasement. A laparoscopic approach was used to expose the mass and a video-assisted injection of OK-432 in major cysts was performed. A remarkable reduction of the lesion size was observed after 18 months. The second case was a 15-year-old boy who presented at the ER acute abdominal pain. A mesenteric LM was diagnosed and a video-assisted sclerosis of the lesion with OK432 was performed. The LM completely disappeared. Follow-up was of 12 months. In our experience, video-assisted sclerosis of abdominal LM with OK-432 is a valid alternative to surgical resection. The procedure is feasible, safe, effective and minimally invasive; complete resolution may be observed in some cases. Long-term follow-up is required to rule out recurrences

Meconium obstruction in absence of cystic fibrosis in low birth weight infants: an emerging challenge from increasing survival

<p>Abstract</p> <p>Background</p> <p>Meconium abnormalities are characterized by a wide spectrum of severity, from the meconium plug syndrome to the complicated meconium ileus associated with cystic fibrosis. Meconium Related Ileus in absence of Cystic Fibrosis includes a combination of highly viscid meconium and poor intestinal motility, low grade obstruction, benign systemic and abdominal examination, distended loops without air fluid levels. Associated risk factors are severe prematurity and low birth weight, Caesarean delivery, Maternal MgSO4 therapy, maternal diabetes. In the last 20 yrs a new specific type of these meconium related obstructions has been described in premature neonates with low birth weight. Its incidence has shown to increase while its management continues to be challenging and controversial for the risk of complicated obstruction and perforation.</p> <p>Materials and methods</p> <p>Among 55 newborns admitted between 1992-2008 with Meconium Related Ileus as final diagnosis, data about Low Birth Weight infants (LBW < 1500 g) were extracted and compared to those of patients ≥ 1500 g. Hischsprung's Diseases and Cystic Fibrosis were excluded by rectal biopsy and genetic probe before discharge. A softening enema with Gastrografin was the first option whenever overt perforation was not present. Temporary stoma or trans appendiceal bowel irrigation were elected after unsuccessful enema while prompt surgical exploration was performed in perforated cases. NEC was excluded in all operated cases. Data collected were perinatal history and neonatal clinical data, radiological signs, clinical course and complications, management and outcome.</p> <p>Results</p> <p>30 cases with BW ≥ 1500 g had an M/F ratio16/14, Mean B.W. 3052 g, Mean G.A. 37 w Caesarean section rate 40%. There were 10 meconium plug syndrome, 4 small left colon syndromes, and 16 meconium ileus without Cystic Fibrosis. Five cases were born at our institution (inborn) versus 25 referred after a mean of 2, 4 Days (1-7) after birth in another Hospital (outborn). They were managed, after a Gastrografin enema with 90% success rate, by 1 temporary Ileostomy and 2 trans appendiceal irrigation. 25 cases with BW< 1500 g (LBW) had M/F ratio 11/14, Mean B.W. 818 g, Mean G.A. 27 w, Caesarean section rate 70%, assisted ventilation 16/25. There were 8 inborn and 17 outborn. Gastrografin enema was successful in 6 out 8 inborn infants only, all referred within one week from birth. There were 12 perforations mainly among late referred LBW outborn.</p> <p>Conclusions</p> <p>Meconium Related Ileus without Cystic Fibrosis responds to conservative management and softening enema in most of mature infants. In LBW clinical course is initially benign but as any long standing bowel obstruction management may present particular challenges. Clinical and plain radiographic criteria are reliable for making diagnosis and testing for Cystic Fibrosis may not be indicated. Enema may be resolutive when performed in a proper environment. Perforated cases may be confused with NEC which is excluded by clinical history, no signs of sepsis, lab signs missing, abdominal signs missing, typical radiological signs missing. The higher complication rate is recorded among cases delivered and initially managed in Neonatal Units without co-located Surgical Facilities. Early diagnosis and aggressive medical therapy may lead to higher success rate and help avoiding surgical interventions. Surgical therapy in uncomplicated cases, unresponsive to medical management, should be minimally aggressive.</p

QRS Complex Separation from Convolutive Mixtures of Biolectrical Signals Acquired by Wearable Systems

Independent component analysis (ICA) has been widely used to remove artefacts from multichannel biomedical signal acquisitions under the hypothesis that there is statistical independence among the original sources. However, the basic ICA model does not take into account the influence on the mixing process of the different paths from the signal sources to the sensors In this study we propose a convolutive mixtures model in order to overcome the limitations of the basic ICA approach. The independent components are estimated in the frequency domain, where the convolutive model can be solved through an instantaneous mixing model. The signals are reconstructed back to the observation space resolving the ICA model ambiguities. Simulations are carried out to optimize of the proposed method for convolutive mixtures of electrocardiographic (ECG) and motion artefacts signals. The algorithm is tested on real ECG signals acquired by wearable systems in order to preserve the QRS complex when the signals are degraded by real life conditions of acquisition

Iatrogenic esophageal perforation in infants: how to avoid thoracotomy? Two case reports

Background: Esophageal perforation is uncommon and often iatrogenic in the neonatal period, and premature and low birth weight infants (<1500 g) are particularly susceptible. Esophageal injury in neonates usually occurs at the pharyngoesophageal junction and can be confused with esophageal atresia due to respiratory signs and excessive salivation. Diagnostic evaluation and treatment are still debated.  Case Presentation: This case report aims to describe two neonatal cases of iatrogenic esophageal perforation. The suspected diagnosis was confirmed only with thoracotomy. Diagnostic difficulties and therapeutic modalities are discussed.  Conclusion: These two cases show the importance of the clinical clues (anamnesis and clinical findings) to suspect the diagnosis of esophageal perforation

Antegrade Sclerotherapy to Treat All Types of Varicoceles in the Pediatric Population: Experience of a Single Center

Objective To analyze our experience with antegrade sclerotherapy for the treatment of Coolsaet types I, II, and III varicoceles in a pediatric and adolescent population. Materials and Methods Between 2005 and 2015, 73 patients who underwent antegrade sclerotherapy were retrospectively evaluated. Patient age, side, clinical and Doppler ultrasound grade, and anatomical variations were collected. Varicoceles were grouped following Coolsaet's classification: all types were sclerosed. Follow-up consisted in clinical examination 3 and 6 months following surgery and testicular Doppler ultrasound 6 and 12 months following surgery. Patients were then telephonically interviewed. Success was defined as varicocele resolution or reduction to a grade not requiring surgery. Results Mean patient age was 14.7 years and mean operating time was 50.8 minutes. Based on phlebographic imaging and following Coolsaet's classification, we identified 57 (78.1%) type I, 3 (4.1%) type II, and 13 (17.8%) type III varicoceles. No intraoperative complications were observed. Three patients (4.1%) presented a short-term complication in the form of pampiniform plexus thrombosis; 1 patient also developed wound dehiscence: all complications occurred in Coolsaet type I varicoceles and during surgeon learning curve. No hydrocele occurred. Out of 59 patients with a satisfactory follow-up (range: 14 months-10 years), 2 recurrences occurred, the success rate thus being 96.6%. Conclusion Tauber's antegrade sclerotherapy is a simple and feasible technique, effective in treating all kinds of varicocele with low complication, recurrence, and persistence rates. Phlebography reveals frequent venous anatomical variations, allows grouping of varicoceles into Coolsaet types, and enables performing of sclerosis safely in all 3 kinds

Antenatal ultrasonographic features associated with segmental small bowel dilatation:an unusual neonatal condition mimicking congenital small bowel obstruction

Segmental dilatation of the intestine (SDI) is an unusual condition presenting during the neonatal period, with symptoms of obstruction. Late diagnosed cases are also reported. The clinical polymorphism, and the lack of specificity of radiological investigations, make diagnosis difficult. Prenatal detection of abdominal cystic lesions or bowel dilatation has occasionally been reported to be associated with SDI. We herein report two cases of SDI, with a prenatal ultrasonographic suspicion of intestinal abnormality. In both infants, a dilatation of the ileum was found at surgery, without any evident site of obstruction or abnormal histology. SDI must be taken into consideration when a prenatal alert of possible bowel obstruction is not followed by postnatal clinical signs

The Fakir Child: Clinical Observation or Invasive Treatment?

Accidental swallowing of foreign bodies is a common problem among the pediatric population (6 months to 3 years), especially if the foreign body (FB) presents a sharp end that could potentially lead to perforation of the gastrointestinal (GI) tract, resulting in infection and complications. We report the case of a 2-year-old, admitted to the Emergency Department of our hospital after ingesting two FBs classifiable as sharp objects, specifically two metal nails, both approximately 4-cm long, which had been swallowed in one go, as reported by the parents. The patient had been previously admitted to another hospital in the same region, where the Emergency Department (ED) doctors took an X-ray to confirm the ingestion. The foreign bodies ingestion was thus confirmed, and they were, according to their report, located in the GI tract over the stomach. The patient has been monitored through all of his stay in the hospital and the progression of the foreign bodies has been documented with serial X-rays. Since neither clinical nor radiological signs of perforation were present, putting the FBs in the small bowel, a non-operative expectant management was followed. After 4 days of admission, the patient had passed one of the two FBS and later on the second one, without any complication. Thereafter the patient was discharged. The management of sharp gastrointestinal foreign objects ingestion is still debated, and the data of the current literature are poor. A number of case reports and small case series describe successful conservative management for the majority of ingested sharp objects. According to the literature data, our report confirms that the ingestion of sharp objects and relatively big objects in a baby can be successfully non-operatively managed, even despite the age of the patient and though the FBs are multiple

Predictors of Gastrointestinal Involvement in Children with IgA Vasculitis: Results from a Single-Center Cohort Observational Study

Background and objective: IgA vasculitis (IgAV), a predominantly pediatric leukocytoclastic disease, has an unpredictable, though largely benign, evolution. The aim of this study was to retrospectively investigate any potential clinical or laboratory predictors of gastrointestinal involvement in a single-center cohort of children with IgAV. Patients and methods: A total of 195 children with a history of IgAV, regularly followed-up for an average period of 1 ± 2.6 years via outpatients clinics of the pediatric rheumatology unit in our University, were assessed, analyzing their clinical and laboratory variables in relationship with their disease evolution and outcome. Results: Univariate analysis showed that a higher neutrophil granulocyte count and lower lymphocyte count (expressed as a percentage of the total white blood cells) were significantly associated with the presence of gastrointestinal involvement at the first examination (65.2 ± 13% versus 58.8 ± 12%, p = 0.02, and 26.4 ± 11% versus 32.1 ± 11%, p = 0.02, respectively). A positive pharyngeal swab for Streptococcus pyogenes, a deficiency of 25-hydroxyvitamin D, a persistence of purpuric rash for more than 1 month, and purpuric lesions in the genital area were also associated with gastrointestinal involvement (p = 0.0001, p = 0.0001, p = 0.007 and p = 0.001, respectively). However, multiple logistic regressions with correction for the patients’ sex and age showed that lower 25-hydroxyvitamin D levels, persistent rash, and genital lesions were independently and significantly associated with signs of gastrointestinal involvement. We then performed a secondary analysis (both univariate and multivariate) to investigate whether vitamin D deficiency was associated with other IgAV manifestations: we found that only 25-hydroxyvitamin D deficiency remained significantly associated with gastrointestinal involvement in IgAV. Conclusions: Patients with IgAV and vitamin D deficiency might be more prone to developing gastrointestinal manifestations of variable severity

Incidental Diagnosis of Giant Cell Tumor After Urachal Remnant Removal in a Thalassemic Child

Urachal anomalies are relatively uncommon; they usually present in childhood as urachal cysts, urachal sinuses, diverticula, and patent urachus. The malignant involvement of the urachus, although rare in children, is commonly found in adulthood when adenocarcinoma accounts for the majority of the cases, representing up to 20-30% of all adenocarcinomas of the bladder. Urachal tumors of variable histology have been reported in children and adolescents as single case report. We present the first case of a 4-year-old thalassemic boy, with an incidental finding of giant cell tumor arising in an urachal remnant