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 [...

Morbo di Hirschsprung: approccio diagnostico differenziato

La diagnosi del morbo di Hirschsprung (MH) si esegue con esami per immagini (clisma opaco), tests funzionali come la Manometria Ano-Rettale (MAR) e studi immunoistochimici su biopsie rettali per suzione (BRS). L’approccio diagnostico più appropriato è ancora discusso dato che tutti i tests producono falsi positivi e falsi negativi ed ognuno presenta vantaggi e svantaggi. Lo scopo di questo lavoro è quello di valutare l’efficacia di un approccio diagnostico differenziato in base all’età per i pazienti con sospetto di MH. Materiali e Metodi: da Gennaio 2005 a Giugno 2007 sono stati esaminati tutti i pazienti giunti all’osservazione chirurgica per sospetto di MH. I pazienti sono stati divisi in due gruppi: A (età inferiore ad 1 anno) e B (età superiore ad 1 anno). I pazienti del gruppo A sono stati sottoposti a BRS e clisma opaco (CO), mentre quelli del gruppo B sono stati sottoposti a MAR per lo studio del tono dello sfintere anale interno e per la ricerca del Riflesso Inibitore Retto-Anale (RIRA), poi in base all’esito della MAR sono stati divisi in 5 sottogruppi ed hanno ricevuto un iter diagnostico-terapeutico diverso: B1, tono normale e RIRA presente (pulizia intestinale con soluzione a base di polietilenglicole (PEG) ad alto peso molecolare poi lassativi orali e clisteri settimanali per 2 mesi); B2, ipertono dello sfintere anale interno e RIRA presente (anestetico locale per 8 settimane associato al lassativo orale e clisteri settimanali per 2 mesi); B3, pazienti non collaboranti (sottoposti a BRS); B4, RIRA assente/dubbio (sottoposti a BRS e CO); B5, RIRA presente, ma scarsi risultati dopo terapia medica al follow up di 6 mesi (sottoposti a BRS e CO). I pazienti con BRS positive (aumentata attività dell’Acetilcolinesterasi associata ad assenza dei gangli) sono stati sottoposti ad intervento chirurgico di Pull-Through ano-rettale per via laparoscopica sec. Georgeson. Tutti i pazienti hanno seguito un follow up a 2 mesi (positivo se evacuazioni settimanali > 5 in corso di trattamento), poi a 6 mesi (positivo se evacuazioni settimanali > 3, senza trattamento). Risultati: I pazienti arruolati per questo studio sono stati 100 (55 maschi, 45 femmine), di cui 14 (età media 2 mesi) sono stati inseriti nel gruppo A, gli altri 86 (età media 6 anni) nel gruppo B. Il CO nei pazienti del gruppo A ha mostrato dilatazione del colon con cono di transizione in due casi, mentre le biopsie rettali per suzione hanno evidenziato assenza di cellule gangliari ed aumento delle fibre colinergiche nel 50% dei pazienti. Nel gruppo B1 sono stati inclusi 40 pazienti, 24 nel gruppo B2, i non collaboranti sono stati 4, mentre 18 sono stati inclusi nel gruppo B4 ed uno solo nel B5. Nel gruppo B sono stati eseguiti 19 CO (gruppi B4 e B5) e BRS in 23 pazienti (gruppi B3, B4 e B5). Al CO sono stati evidenziati dolicolon e megaretto nel 89% dei casi, mentre le BRS hanno evidenziato assenza di gangli ed aumento delle fibre colinergiche in 3 bambini (13%). L’intervento chirurgico è stato eseguito in 6 bambini del gruppo A e 2 del gruppo B, gli altri sono stati trattati altrove. Conclusioni: La MAR è un esame semplice e poco invasivo per studiare il meccanismo della defecazione nei bambini di età superiore ad un anno. L’approccio diagnostico differenziato in base all’età permette di selezionare i casi da sottoporre alle BRS e CO, esami invasivi che possono presentare complicanze. L’esecuzione delle BRS in casi selezionati permette di avere alti valori di positività (50% e 13%) evitando di estendere la procedura a tutti i pazienti con sospetto di MH

Risk Factors of Cholelithiasis Unrelated to Hematological Disorders in Pediatric Patients Undergoing Cholecystectomy

Background: Pediatric cholelithiasis unrelated to hematological disorders is an increasing disease. We analyzed our experience in the surgical treatment of these cases to evaluate risk factors, clinical presentation, intervention and follow-up. Methods: From January 2010 to December 2016, we retrospectively recorded all data (hematological study, familiarity, use of lithogenic drugs and parenteral nutrition) of cholecystectomies for cholelithiasis not related to hematological diseases. The body mass index (BMI) was calculated (obesity if > 25), medical treatment, surgery and follow-up were evaluated. All patients underwent ultrasound for diagnosis and major biliary tract assessment prior to surgery. All patients had a 1-year follow-up. Results: There were twenty-four cases (eight males), with a median age of 11.2 years. Predisposing factors were familiarity in 19, use of lithogenic drugs in 5 and total parental nutrition (TPN) in 3. Median BMI was 19.8 kg/m2, with BMI > 25 kg/m2 in eight cases. Regarding the clinical presentation, 14 had acute pain in the right upper quadrant, 5 had cholecystitis and 5 had non-specific abdominal pain. The medical treatment lasted 6 months in all, except for five (three operated after 2 months and two after 12 months). Preoperative ultrasound did not show stones in the biliary tract. MRI was performed in three cases for suspected malformation of the biliary tract (negative). Laparoscopic cholecystectomy was performed in all cases: mean intervention time was 95 min. A case of postcolecystectomy syndrome was found. At follow-up, all were asymptomatic, except two (recurrent abdominal pain). Conclusion: Main predisposing factors are familiarity and obesity. Preoperative ultrasound in our series replaced the intraoperative study of the biliary tract. Laparoscopic cholecystectomy is the gold standard

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

Transanal protrusion of intussusception can be sign of Waugh syndrome

Intussusception rarely occurs with transanal prolapse of intussusception (TAPI), this presentation may be a sign of Waugh's syndrome (WS), an association between intestinal malrotation and intussusception. The authors present the case of infant with an episode of TAPI, resolved with air enema, who required later diagnostic tests that showed the presence of WS, for which surgery was required after the resolution of the intussusception. At now we found only 72 cases reported of WS and some of them clinically presented with TAPI. In our opinion, patients with this type of presentation require a thorough radiological study of the intestine to rule out intestinal malrotations

Gastric transposition as a valid surgical option for esophageal replacement in pediatric patients: experience from three Italian medical centers

BACKGROUND: Esophageal replacement in children is an option that is confined to very few situations including long-gap esophageal atresia and esophageal strictures unresponsive to other therapies (peptic or caustic ingestion). The purpose of our work was to describe the experience of gastric transposition in three Italian centers. METHODS: This is a retrospective study. The data were extrapolated from a prospective database. We included all patients who had undergone gastric transposition in the last 15 years. RESULTS: In the 15-year period, eight infants and children (3 males and 5 females) underwent gastric transposition for esophageal replacement. Six patients had long-gap esophageal atresia, and two had caustic esophageal stenosis. There were no deaths in the series. Three patients had an early postoperative complication: two had a self-limited salivary fistula at three weeks, and one (a patient with jejunostomy) had a jejunal perforation treated surgically. One late complication, anastomotic stricture, was recorded that required two endoscopic dilatations. The median follow-up was 60 months (range: 18-144 months). At final clinical follow-up, six patients had no eating problems, and two patients had some difficulties with eating (jejunostomy in situ), but they underwent logopedic therapy with improved outcomes. All patients had an increase in body weight and height postoperatively. CONCLUSION: Our small study reports the clinical experience of three Italian centers in which gastric transposition was performed with excellent results, both in terms of surgical technique (simplicity, reproducibility, complication rate) and clinical follow-up (good oral feeding of young patients, normal social life and regular growth curves)

What Is the Correct Way to Manage Children Requiring Gastrostomy? Single Center Experience

Children with complex medical issues often present different comorbidities that cause feeding difficulties. Gastrostomy is often helpful, and should be performed when nutritional supplementation is necessary for longer than 6 weeks. Recently, different techniques have been used for gastrostomy in children. The authors report on their experiences regarding the diagnostic and therapeutic management of children requiring gastrostomy. All patients managed in the last 10 years were reviewed, retrospectively. Everyone underwent investigation to exclude gastroesophageal reflux disease (GERD). A total of 148 patients: 111 cases (75%) were neurologically impaired patients, 18 (12%) had complex heart disease, 10 (6%) had metabolic diseases, 4 (3%) had fibrosis cystic, 4 (3%) had muscle disease, and one had chromosomopathy. After investigation, 49 patients had GERD. PEG was performed in 101 cases (68%), laparo-assisted gastrostomy was performed in 44 cases (29.7%), open gastrostomy was performed in three cases. At follow-up, all patients reported weight gain, but 13 cases had major complications. Currently, the surgeon has the possibility of choosing between several safe techniques for gastrostomy. In our experience, PEG is the most useful technique for patients without GERD, while a laparo-assisted technique is better for patients who require laparoscopic fundoplicatio

Clinical Study Transumbilical Laparoscopic-Assisted Appendectomy in the Treatment of Acute Uncomplicated Appendicitis in Children

Transumbilical laparoscopic-assisted appendectomy (TULAA) is increasingly being performed worldwide. The authors report their experience in the treatment of acute uncomplicated appendicitis in children with TULAA. From January 2008 to December 2012 all types of acute appendicitis were divided, according to the clinical and ultrasonographic findings, into complicated (appendiceal mass/abscess, diffuse peritonitis) and uncomplicated. Complicated appendicitis was treated by open appendectomy (OA). All patients with the suspicion of uncomplicated appendicitis were offered TULAA by all surgeons of the team. Conversion to open or laparoscopic appendectomy (LA) was performed in case of impossibility to complete TULAA, depending on the choice of surgeon. The histopathologic examination of appendix was always performed. 444 children (252 males) with acute appendicitis were treated. The mean age was 9.2 years (range, 2 to 14 years). Primary OA was performed in 144 cases. In 300 patients a transumbilical laparoscopic-assisted approach was performed. TULAA was completed in 252 patients. Conversion to OA was performed in 45 patients and to LA in 3. Conversion was related to the impossibility to adequately expose the appendix in 47 patients and bleeding in 1. The mean operative time for TULAA was 42 minutes. Histopathologic examination of the appendix removed by TULAA showed a phlegmonous/gangrenous type in 92.8% of cases. Among the 252 TULAA there were 11 cases of umbilical wound infection. TULAA is a feasible and effective procedure for uncomplicated appendicitis in children. It combines the advantages of open and laparoscopic technique (low operative time, low complications rate, and excellent cosmetic results)

Transscrotal orchidopexy for palpable cryptorchid testis: follow-up and outcomes.

We retrospectively reviewed the results of transscrotal orchidopexy in the surgical management of palpable testis. From January 2014 to June 2017, 130 male children with a total of 140 palpable undescended testes (UDT) underwent transscrotal orchidopexy. The charts were retrospectively reviewed for demographic data, preoperative position and mobility of the testis, patency of the peritoneal vaginal duct (PVD), and post-operative complications. The resting position of the testis and its traction towards the scrotum were assessed before surgery and under anaesthesia. The mean age of the patients was 4.6 years. The position of the testis assessed at surgery was in most cases at the external inguinal ring (62.8%), at the neck of the scrotum (15.7%), in the inguinal canal (12.8%), or in an ectopic position (8,5%). A PVD was found in 66 testes (47.1%). Two surgical cases required an inguinal incision. In each patient, the postoperative course was unremarkable. The testicle at 1-year follow-up was in a scrotal position in 134 cases, but 6 patients required a second surgical intervention for re-ascent of the testis. No testicular atrophy or inguinal hernias were observed. Transscrotal orchidopexy is a simple and effective procedure for the treatment of palpable UDT. The incidence of complications is low and manageable, with rapid postoperative recovery and early resumption of normal activities