Endometrial tuberculosis: a clinical case

Genital tuberculosis is a bacterial infection still frequent in less developed countries where lots of cases are not diagnosed nor treated. In this work we describe a rare case of primary endometrial tuberculosis in a woman of 50 years old. The diagnosis was confirmed by an ultrasonography of the pelvis and an endometrial biopsy followed by a histological examination. The patient after the diagnosis was put under antiturbecular treatment for six months with complete healing.

Thrombosed aneurysm of ductus arteriosus: a case report

Spontaneous aneurysms of the ductus arteriosus are rare complications of a patent ductus arteriosus. It is met at any age but it is most commonly seen in children under two months of age. Echocardiography is the best test to diagnose a ductus arteriosus, but actually the role of thoracoscopy is to help in differential diagnosis of mediastinal masses. Surgery should be recommended without delay, to avoid fatal complications, with the resection of the thrombosed aneurysm of the ductus arteriosus.

Minimally-invasive surgery in paediatric oncology: proposal of recommendations

The Authors report a proposal of recommendations concerning Minimally Invasive Surgery (MIS) in Paediatric Oncology. Since the exact role of MIS in Paediatric Oncology is still not completely defined, a restrict panel of Italian Paediatric Surgeons, some interested in Oncologic Surgery, others in MIS, prepared a schematic document, mainly founded on literature data, to provide Paediatric Surgeons with recommendations useful to approach paediatric tumours with MIS. The final draft was approved by the Italian Group of Paediatric Oncologic Surgeons. The Authors summarize the feasibility of MIS, when performed with different purposes (biopsy / resection) and timing (initial / delayed surgery) for the most common solid tumours in children. The oncologic criteria must be always followed with MIS as well as with "open" surgery.

X-ray magnetic circular dichroism and small angle neutron scattering studies of thiol capped gold nanoparticles

X-ray magnetic circular dichroism (XMCD) and Small Angle Neutron Scattering (SANS) measurements were performed on thiol capped Au nanoparticles (NPs) embedded into polyethylene. An XMCD signal of 0.8 x 10(-4) was found at the Au L3 edge of thiol capped Au NPs embedded in a polyethylene matrix for which Superconducting Quantum Interference Device (SQUID) magnetometry yielded a saturation magnetization, M(S), of 0.06 emu/g(Au). SANS measurements showed that the 3.2 nm average-diameter nanoparticles are 28% polydispersed, but no detectable SANS magnetic signal was found with the resolution and sensitivity accessible with the neutron experiment. A comparison with previous experiments carried out on Au NPs and multilayers, yield to different values between XMCD signals and magnetization measured by SQUID magnetometer. We discuss the origin of those differences.

Evolution of the surgical management of bowel atresia in newborn: laparoscopically assisted treatment

PURPOSE

The jejunal-ileal atresias are the most common cause of intestinal occlusion in neonatal period and the duodenal atresia is the most common cause of high bowel obstruction in newborn. The treatment classically used is performed by a transverse sovraumbilical laparotomy. The first "minimal-invasive" approach was performed at the end of the years '70. Nowadays three clusters of thought are delineated about of mini-invasive treatment of small bowel atresias: the intestinal continuity can be established with a circumbilical incision, a totally laparoscopic technique or a laparoscopically assisted approach. It's presented our initial experience of bowel atresia in newborn treated with laparoscopically assisted approach.

MATERIALS AND METHODS

Three newborns with prenatal diagnosis of suspected bowel obstruction and one with suspected duodenal atresia, confirmed the diagnosis after birth, underwent to laparoscopically-assisted surgery to correct these congenital anomalies. We have treated with this procedure a duodenal atresia, two jejunal atresias and an ileal form. Surgical management was consisted of an explorative laparoscopy that allowed to recognize and isolate the pathological portion. The second step was traditional open surgery: after the exteriorization of the pathological tract through the umbilical wound, we performed the intestinal anastomosis.

RESULTS

In all cases the operation was completed successfully, no conversion was necessary. Intraoperatively no complications occurred. The post-operative course was uneventful.

CONCLUSION

The video-assisted technique for the correction of small bowel atresia adds the advantages of the classic laparotomic procedure to the laparoscopic ones.

Congenital colonic stenosis: a case of late-onset

PURPOSE

Colonic atresia and stenosis are rare causes of intestinal obstruction in the infant. Only 1.8%-15% of intestinal atresias occur in the colon. Congenital colonic stenosis is even less common than colonic atresia. Only 10 cases have been reported in Literature since 1966 and only one late-onset case has been reported in Literature until now. We describe the case of a 4-month-old baby coming to our attention because of an intestinal subocclusion due to a congenital colonic stenosis of the ascending colon.

CASE REPORT

A 4-month-old baby came to our attention for persistent abdominal distension, reduction of bowl function and decaying of overall clinical conditions. A plain abdominal radiograph showed distended intestinal loops with air-fluid levels and no gas in the rectum. During the barium enema the contrast medium appeared to completely fill the lumen of the colon up to the ileo-cecal valve and Cecum appearing higher than normal. Beyond the ileo-cecal valve, the contrast medium showed an abnormal hypotonic dilatation of the small intestinal loops. Suspecting an organic intestinal obstruction, an explorative laparotomy was deemed necessary and at halfway in the ascending colon a stenosis was found.

RESULTS

The post-operative course was uneventful and the patient is currently in good clinical conditions, has a normal diet and is thriving.

CONCLUSION

Considering both the Literature and our own experience, it is wise to reckon the congenital colonic stenosis as a rare but possible cause of complete or partial intestinal obstruction not only in the newborn but also throughout the first year of life.

Clinical spectrum and management of congenital pulmonary cystic lesions

INTRODUCTION

Congenital cystic lesions of the lung in children are uncommon but potentially life-threatening and warrant an urgent diagnostic work-up. Pulmonary sequestration (PS), congenital cystic adenomatoid malformation (CCAM), congenital lobar emphysema (CLE), and bronchogenic cyst (BC) are the four major congenital cystic lesions, but they share similar embryologic and clinical characteristics. The purpose of this study is to review our institutional experience with congenital cystic lung disease emphasizing on diagnosis and management.

PATIENTS AND METHODS

Between January 1975 and October 2007, 109 patients have been treated, of which 57 males and 52 females, the age ranged from the birth to 13 years. 104 patients presented solitary lesions: CCAM (47), CLE (16), PS (22), BC (19). The remainders 5 patients presented two simultaneous lesions: intralobar PS and CCAM (2), CLE and CCAM (3).

RESULTS

All the lesions have been treated surgically: in the first cases, only symptomatic patients underwent surgery, while in the last years, patients have systematically been submitted operated.

CONCLUSIONS

A meaningful percentage of CCAM joins to PS and CLE; instead the BC are generally isolated, probably deriving by a more precocious embryogenetic defect. The treatment of these lesions is surgical: CCAM (type I-II) and CLE should be treated promptly in newborns for respiratory distress and pneumothorax; CCAM (type II) and BC generally become symptomatic gradually and expose to degenerative risk; intralobar PS generally becomes symptomatic and surgery prevents the risk of infections. Extralobar PS and the asymptomatic BC are not exempted by surgical approach whenever accidentally described as masses of uncertain nature. Asymptomatic cysts in children should be resected, to avoid later complications of the cysts, which could make operation more difficult. Conservative anatomic resections should be attempted to preserve functional lung tissue. Careful histologic examination of the resection specimen is mandatory to identify occult malignancy. In conclusion a correct embryogenetic organization and a clinical evaluation of the congenital cystic lung diseases allow a precocious and effective surgical timing.

Delayed-onset peripheral blood cytopenia after rituximab: frequency and risk factor assessment in a consecutive series of 77 treatments

The occurrence of unexplained peripheral blood cytopenia, particularly neutropenia, has been recently reported after rituximab. Its prevalence may be underestimated since it may occur late after treatment. This study analysed all cases of unexplained delayed-onset peripheral blood cytopenia of WHO grade II - IV occurring in an unselected series of patients treated with rituximab in order to evaluate its prevalence and clinical significance. Seventy-seven courses of rituximab (corresponding to 317 rituximab infusions) given to 72 consecutive patients affected by non-Hodgkin's Lymphoma and treated at a single Center with rituximab, alone (nine cases), associated with chemotherapy (50) or with chemotherapy and autologous stem cell transplantation (18) were evaluated. Twenty-three cases of cytopenia (29.8%) were observed. Neutropenia developed in 21 cases (27.3%), thrombocytopenia in eight (10.4%), anemia in four (5.2%). Multiple cytopenias were observed in nine cases. Neutropenia developed after a median of 10 weeks, anemia of 5 weeks and thrombocytopenia of 4 weeks after the last rituximab dose. Severe infections occurred in four of 21 neutropenic patients (19%), compared to two of 56 controls (3.6%) (p = 0.043). Cytopenia eventually resolved in nine of 18 evaluable cases after a median of 10 weeks (range 1 - 23). Age, sex, histology, bone marrow infiltration, hypogammaglobulinemia, previous chemotherapy, autologous stem cell transplant, rituximab schedule and timing, rituximab doses were analysed as predictors for cytopenia; by multivariate analysis only a previous treatment with chemotherapy and more than four rituximab doses were significantly associated with a higher risk of post-rituximab delayed cytopenia. Delayed-onset cytopenia, particularly neutropenia, is a clinically significant complication of rituximab treatment, which merits further investigation.

[Thoracoscopic treatment of oesophageal atresia]

BACKGROUND

Advancements in minimally invasive surgery in newborns have allowed even the most complex neonatal procedures to be approached using these techniques. Other authors have demonstrated its efficacy in the treatment of the esophageal atresia with distal fistula.

METHODS

We report our experience based on the thoracoscopic repair of esophageal atresia with distal fistula in two newborns. Birth weights were 2.800 g and 2.300 g respectively. The patients were intubated endotracheally and placed in a left prone position. Four trocars were inserted: the first one of 5 mm was positioned in the fifth intercostal space for the camera, the other two of 3 mm were positioned in the fourth intercostal space on the anterior and posterior axillary line respectively for the operative instruments. The last trocar of 3 mm was inserted in the third intercostal space on the anterior axillary line for the lung retractor. CO2 was insufflated at a pressure of 8 mm Hg and a flow of 0.5 L/min. The fistula was first isolated then ligated and cut with scissors. The proximal esophagus was opened and an anastomosis was made over a 6F or 8F nasogastric tube with interrupted 4-0 Vicryl sutures. A tube chest was placed through the lower trocar site with the tip near the anastomosis.

RESULTS

These two procedures were free of neither intraoperative nor post-operative complications. Feeding by nasogastric tube was started after a mean of 4 days. Barium swallow made on day 7 demonstrated no leakage and no stenosis of the anastomosis. Total oral feeding was possible after 8 days. Mean hospitalization was 14 days.

CONCLUSION

This initial report shows, as demonstrated by the experience since 1999 by other authors, that the thoracoscopic esophageal repair in the newborns is technically feasible and, thanks to a magnified vision, it allows to abtain a good isolation of the esophagus and of the tracheo-esophageal fistula respecting the anatomical structures. Moreover the advantages are in terms of exposure and esophageal length, avoiding the significant short and long-term morbidity associated with thoracotomy.

[Video-assisted treatment for biliary atresia]

BACKGROUND

The surgical treatment of biliary atresia is still a great challenge for pediatric surgeons. Kasai's operation usually needs a wide, painful, muscle-cutting laparotomies that quite often are followed by pain and peritoneal adhesion. These possible complications may disturb the post-operative course and humper liver transplantation. Advancements in minimally invasive surgery have allowed even the most complex procedures to be approached using these techniques.

METHODS

The authors present a case of successful Roux-en-Y laparoscopic portoenterostomy for the treatment of biliary atresia. We report a case of a 3-month-old patient with biliary atresia who weighted Kg 5,300 at the operation. The patient was placed in supine position. The procedure was performed with 4 trocars of 3 mm and 1 of 10 mm. The umbilical site was used for extracorporeal Roux-en-Y enteroenterostomy. CO2 was insufflated at a pressure of 8 mmHg and a flow of 0.5 L/min. A drain was placed through the lower trocar site with the tip near the anastomosis.

RESULTS

The procedure was free of neither intraoperative nor post-operative complications. Feeding by nasogastric tube was started after 2 days. Total oral feeding was possible after 8 days.

CONCLUSION

Laparoscopic approach to perform Kasai's operation is technically feasible and thanks to a magnified vision, it allows to abtain a good visualization of the portal structures with an adequate retraction of the liver. This procedure can avoid or decrease the post-operative complications such as pain, breathing difficulty, adhesions and resulting in very small scars. Anyway laparoscopic Kasaiportoenterostomy should be done by a surgeon with a good experience in laparoscopic hand-suturing and neonatal experience and with the support of an experienced in neonatal and infantile videosurgery anaesthesiologist.

CXCR4/SDF-1 expression in early breast cancer (BC) is not influenced by circulating estrogens serum levels

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Background: The chemokine SDF-1 and its receptor CXCR4 have been found to enhance the metastatic potential of BC cells and correlate with a poorer prognosis of BC patients. Estradiol is a known mitogenic factor for BC cells. SDF-1 has been reported to be an estradiol (E2)-inducible autocrine growth factor that supports the growth of breast cancer cell lines in vitro. The aim of this study was to verify whether estrogens serum levels may influence SDF-1 and CXCR4 expression in vivo, in a series of patients with early stage BC. Methods: 68 patients sequentially observed at the Spedali Civili di Brescia from 2001 to 2002, with a diagnosis of T1a,b,c, N0 breast cancer were retrospectively analysed. CXCR4 and SDF-1 expression was determined by immunohistochemistry with anti-human CXCR4 (Clone 44716) and anti-human SDF-1 (Clone 79018) monoclonal antibodies (R&D Systems, Minneapolis, USA) followed by incubation with the EnVision peroxidase kit (Dakocytomation, Glostrup, Denmark). A serum sample was obtained from all patients at baseline before surgery. Serum estrone (E1) and estradiol (E2) were measured by radioimmunoassay by using commercial kits (Alifax, Padua, IT and Ortho-Clinical Diagnostics, Amersham, UK, respectively). Results: Estrogens serum levels analysis revealed elevated levels of E1 in 9/54 (16%) post-menopausal patients, while E2 levels were in the normal ranges. SDF-1 was expressed in 68/68 (100%) patients with a diffuse and intense cytoplasmatic pattern of staining and CXCR4 was coexpressed in 15/68 (22%) patients with a predominant faint nuclear distibution (p 0,06). No significant correlations were found between CXCR4, SDF-1 and E1 or E2, respectively, as well as with other clinico-pathological characteristics. After a median follow-up of 48 months, 3/68 (4%) patients which all resulted CXC4/SDF1-positive, relapsed and are dead for metastatic disease. Conclusions: This study demonstrates that in T1N0 BC patients: 1) SDF-1 is high levels in the majority of cases; 2) CXCR4 is expressed in approximately 20% of cases with restriction to the nucleus and 3) serum levels of circulating E2 and E1 in pre- or post-menopausal patients, respectively, do not influence CXCR4/SDF-1 expression on breast cancer cells.

No significant financial relationships to disclose.

One trocar assisted pyeloplasty (OTAP): initial experience and codification of a technique

BACKGROUND

The Anderson-Hynes pyeloplasty is still the gold standard for the surgical treatment of the ureteropelvic junction obstruction (UPJO) in children. To reduce the surgical invasivity, laparoscopic (RPSc) and retroperitoneoscopic (RPSc) pyeloplasty have been proposed but concerns have been expressed. In the RPSc approach, the small operative space and the technical difficulties have limited the application and diffusion of this techinique while in case of laparoscopy, a transperitoneal technique is used to treat a retroperitoneal disease. We report our initial experience with the "one trocar assisted pyeloplasty" (OTAP) in the treatment of UPJO in children.

METHODS

From January 2005 to December 2006 sixteen children (13 males--3 females) from 2 to 18 months of age (mean age 5.6 months), with impaired monolateral renal function underwent surgical treatment for UPJO. In 11 cases the obstruction was on the left side and in one case a crossing vessel was found. The renal pelvis was anteriorly reached using a 10 mm operative telescope via a flank 12 mm incision. The UPJ was exteriorized and a dismembered pyeloplasty performed also for the crossing vessel. In two cases a 6 Fr uretero-pyelo-nephrostomy catheter was used.

RESULTS

The patients were discharged after four days without complications. The cosmetic results are excellent. In one case, a small perianastomotic leakage was seen. The ultrasonographic follow-up demonstrated the spontaneous resolution of the leakage. The post operative US follow-up showed the reduction of the dilatation in all cases.

DISCUSSION

This is an initial experience and a longer follow-up is needed. However, in our opinion the OTAP could be considered as a safe and feasible alternative to the laparoscopic or retroperitoneoscopic pyeloplasty, especially in very small children and also in presence of crossing vessels.

[Laparoscopic surgery in Hirschsprung's disease]

The laparoscopic treatment of benign conditions of the colon represents only one of the numerous application fields of the modern laparoscopic techniques in pediatric surgery. Until the half of the 1990's, the surgical treatment of choice for Hirschsprung's disease has been the procedure ideated by Soave in the early 1960's. Nowadays, the optimal treatment in the classic forms of aganglionic megacolon consists in performing, in neonatal age or in the first months of life, a transanal extramucous pull-through. This approach can be integrated by a laparoscopic step. From September 2000, at the Department of Pediatric Surgery, Bologna University, we have operated 21 cases of congenital aganglionic megacolon with this technique.

Molecular adsorbent recirculating system (MARS) application in liver failure: clinical and hemodepurative results in 22 patients

PURPOSE

Acute liver failure (ALF) and acute on chronic liver failure (ACLF) still show a poor prognosis. MARS was used in 22 patients with ALF or ACLF to prolong patient survival for liver function recovery or as a bridge to transplantation.

DESIGN

Evaluation of depurative efficiency, biocompatibility, hemodynamics, encephalopathy (HE) and clinical outcome.

PROCEDURES

During 71 five-hour sessions we evaluated (0', 60', 120', 180', 240', 300'): bilirubin, ammonia, cholic acid (CCA), chenodeoxycholic acid (CCDCA), leukocytes, platelets, hemoglobin and mean arterial pressure (MAP). Serum creatinine, electrolytes, cardiac output, cardiac index (bioimpedence) and HE (West Haven Criteria score) were evaluated at 0' and 300'. STATISTICAL METHODS AND OUTCOME MEASURES: Student's t-test for pre- vs. end-session values was used. For bilirubin and ammonia the correlation test was made between pre- and end-session values and between pre-session values and removal rates (RRS).

MAIN FINDINGS

Survival was 90.9% at 7 days, 40.9% at 30 days. Pre- vs. end-session: bilirubin from 37.2 +/- 12.5 mg/dL to 24.9 +/- 8.9 mg/dL (p < 0.01), ammonia from 88.0 +/- 60.4 micromol/L to 43.6 +/- 32.9 micromol/L (p < 0.01), CCA from 42.8 +/- 21.0 micromol/L 18.2 +/- 9.8 micromol/L (p < 0.01), CCDCA from 26.3 +/- 6.3 micromol/L to 15.7+/-7.6 micromol/L (p<0.01). The correlation test between pre-session values of bilirubin and ammonia vs. RR S was respectively 0.32 (p = 0.01) and 0.30 (p = 0.04). Leukocytes, platelets and hemoglobin remained stable. MAP increased from 82.0 +/- 12.0 mmHg to 87.0 +/- 13.0 mmHg (p < 0.05), West Haven Criteria score decreased from 2.7 +/- 0.7 to 0.7 +/- 0.7 (p < 0.001).

CONCLUSION

MARS treatment led in all patients to an improvement of clinical, hemodynamic and neurological conditions, with significant reduction in the hepatic toxins blood level. Treatment biocompatibility and tolerance were satisfactory.

[Psychopathology in epilepsy and pseudoepilepsy: preliminary results in our experience]

PURPOSE

Pseudoseizures or nonepileptic seizures (NES) are termed "nonepileptic psychogenic seizures" and account for approximately 20% of all intractable seizure disorders. These seizures are often misdiagnosed as true epilepsy, resulting in inappropriate, ineffective and costly treatment of many patients. Nowadays video-EEG monitoring have greatly improved the ability of specialists to correctly distinguish NES from epilepsy. Nevertheless, patients with NES do not always demonstrate obvious psychopathology. The aim of this study is to examine the complexity and severity of psychopathological features of patients with NES, in order to optimize strategies of intervention and appropriate long-term psychological and psychopharmacological treatment for these patients.

MATERIALS AND METHODS

We evaluated three samples: patients with NES, patients with epilepsy and a control sample. Subjects with pseudoseizures and epileptic seizures have been randomly recruited from the Epilepsy Centre at the Neurology Institute of Catholic University of Sacred Heart of Rome. Seizures have been documented by the recording of spontaneous events with video-EEG, EEG, clinical observation and ictal examination. Each sample of patients has been tested using the Hamilton Rating Scale for Depression (HDRS), Dissociative Experience Scale (DES), Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and Short Form Health Survey 36 (SF-36).

RESULTS

17 (4 M; 13 F) patients with NES, 13 (3 M; 10 F) patients with epilepsy and 16 (4 M; 12 F) control subjects were recruited. Our preliminary results confirm previous researches showing that NES typically manifest between 20 and 30 years of age and that approximately a three-quarters of all patients are women. Besides, they confirm that psychosocial, environmental and intrapsychic mechanisms interact in the aetiology of NES: in particular, our preliminary results are consistent with the hypothesis that traumatic experiences are important precursors to the development and expression of NES.

CONCLUSIONS

This study has yielded promising results and confirm the necessity to improve our knowledge about psychopathology of patients with NES. Psychiatrists and neurologists should work in equipe to guarantee an adequate treatment for a pathology too long set aside and almost ignored from clinical research.

[Laparoscopic surgical treatment of anorectal malformations]

Anorectal Malformations (ARM) include a wide spectrum of anomalies, ranging from anal and rectal agenesis (usually associated with a recto-urethral, rectovaginal or recto-vestibular fistula) to ano-cutaneous fistula. On the basis of studies on the anatomy of the muscular structures contained in the pelvic cavity and on the physiology of the mechanisms which regulate the continence, many different techniques have been performed to allow a surgical treatment for the ARMs and to obtain post-operative results as nearer as possible to normality, that is to an adequate colic motility and a defecation control. In 2000, a new surgical technique for high and intermediate ARMs has been introduced, the laparoscopically assisted ano-rectal pull-through (LAARP) according to Georgeson. At the Department of Pediatric Surgery, Bologna University, from 2000 to nowadays, we have treated with LAARP 7 cases of high ARMs, all male patients and with colostomy. The average age at operation was between 2 and 10 months.