Congenital lung malformations: a nationwide survey on management aspects by the Italian Society of Pediatric Surgery

INTRODUCTION

Over the years, congenital lung malformations (CLM) management remains a controversial topic in pediatric thoracic surgery. The Italian Society of Pediatric Surgery performed a national survey to study the current management variability among centers, trying to define national guidelines and a standardized approach of children with congenital lung malformations.

METHODS

Following a National Society approval, an electronic survey including 35 items on post-natal management was designed, focusing on surgical, anesthesiology, radiology and pneumology aspects. The survey was conducted contacting all pediatric surgical units performing thoracic surgery.

RESULTS

39 pediatric surgery units (97.5%) participated in the study. 13 centers (33.3%) were classified as high-volume (Group A), while 26 centers (66.7%) were low volume (Group B). Variances in diagnostic imaging protocols were observed, with Group A performing fewer CT scans compared to Group B (p = 0.012). Surgical indications favored operative approaches for asymptomatic CLM and pulmonary sequestrations in both groups, while a wait-and-see approach was common for congenital lobar emphysema. Surgical timing for asymptomatic CLM differed significantly, with most high-volume centers operating on patients younger than 12 months (p = 0.02). Thoracoscopy was the preferred approach for asymptomatic CLM in most of centers, while postoperative long-term follow-up was not performed in most of the centers.

CONCLUSION

Thoracoscopic approach seems uniform in asymptomatic CLM patients and variable in symptomatic children. Lack of uniformity in surgical timing and preoperative imaging assessment has been identified as key areas to establish a common national pattern of care for CLM.

Early laparoscopic-assisted surgery is associated with decreased post-operative inflammation and intestinal strictures in infants with necrotizing enterocolitis

INTRODUCTION

In 2015, a protocol including early laparoscopy-assisted surgery in the treatment of necrotizing enterocolitis (NEC) was implemented at our institution. Carbon dioxide insufflation during laparoscopy may have an anti-inflammatory effect. We aimed to compare post-operative outcome after early laparoscopy-assisted surgery and classical laparotomy for NEC.

MATERIAL AND METHODS

Charts of premature infants undergoing surgery for NEC (2012-2021) were reviewed. Cases operated by early laparoscopy-assisted surgery (2015-2021) were compared to infants operated for NEC between 2012 and 2015 (laparotomy-NEC). Outcomes were post-operative CRP, need for reintervention, mortality, and the occurrence of post-NEC intestinal strictures. CRP was measured on the day of surgery (POD-0), 2 days (POD-2), and 7 days after surgery (POD-7). Data were compared using contingency tables for categorical variables and Student t-test or Mann-Whitney test for continuous variables.

RESULTS

Infants with NEC operated by early laparoscopy (n = 48) and laparotomy (n = 29) were similar in terms of perforation (60% vs 58%, p = 0.99) and POD-0 CRP (139 vs 124 mg/L, p = 0.94). Delay between first signs of NEC and surgery was shorter in the laparoscopy group (3 vs 6 days, p = 0.004). Early laparoscopy was associated with a lower CRP on POD-2 (108 vs 170, p = 0.005) and POD-7 (37 vs 68, p = 0.002), as well as a lower rate of post-operative intestinal stricture (34% vs 61%, p = 0.04).

CONCLUSIONS

In addition to being safe and feasible in premature infants, early laparoscopic-assisted surgery was associated with decreased NEC-related post-operative inflammation and strictures. A prospective, randomized study is needed in order to evaluate short and long-term effects of laparoscopy in infants with NEC.

LEVEL OF EVIDENCE

Level III.

Midazolam premedication in ileocolic intussusception: a retrospective multicenter study

Ileocolic intussusception is a common cause of bowel obstruction. When spontaneous reduction does not occur, non-operative management through enema reduction is necessary. Despite the evidence indicating that sedatives favor success in the reduction, their use is still not a common practice. To determine if midazolam (MDZ) before enema improves the rate of procedure success, we retrospectively reviewed charts of patients admitted to two Italian pediatric emergency departments. Outcome measures were the success rate of the enema, recurrence, and need for surgery. Patients were grouped according to the use of MDZ or not, before hydrostatic reduction attempt. We included 69 and 37 patients in the MDZ and non-MDZ groups, respectively. The two groups did not differ in demographics, clinical characteristics, and ultrasound findings. Intussusception reduction after the first enema attempt occurred in 75% (MDZ group) and 32.4% (non-MDZ group) of patients (P < .001); 27.9% (MDZ group) and 77.8% (non-MDZ group) of patients underwent surgery (P < .001). Among them, spontaneous reduction of intussusception during the induction of general anesthesia occurred in 31.6% and 42.9% of patients, respectively (P .43). Multivariate logistic regression analysis showed that only MDZ had a positive effect on the result of the enema (OR 7.602, 95%CI 2.669-21.652, P < .001).

CONCLUSION

Procedural sedation with MDZ for enema reduction of intussusception can increase the success rate and lead to a better management of patients.

WHAT IS KNOWN

• Despite the evidence of the usefulness of sedatives in the reduction of intussusception, their use is still not a common practice.

WHAT IS NEW

• Midazolam during enema reduction of intussusception can increase the success rate and consequently lead to better management of patients.

Telemedicine system for improving maternal and neonatal health: an interventional trial in Tanzania

Background

In Tanzania, maternal and neonatal mortality is still high, mainly due to poor quality of Antenatal Care (ANC) and Post Natal Care (PNC) services. PANDA (Pregnancy And Newborn Diagnostic Assessment) is a telemedicine system that uses mobile technology to perform adequate ANC/PNC visits according to WHO recommendations. Two pilot studies showed that PANDA is efficient in providing high-quality ANC and facilitating the continuity of care for underserved communities.

This project aims at testing the impact of PANDA in Tanzania for improving the adherence to both ANC and PNC WHO protocols.

Methods

This case-control study is conducted in two different areas of the Mufindi district, Tanzania. The PANDA system includes: - solar backpack containing instrumentation for communicable and non-communicable diseases screening; smartphone with an icon-based application, including 5 modules: socio-demographic information, medical history, clinical screening, health education and birth plan, postnatal care;hospital database with the data collected during the visits.

Results

At present, 405 women (1,066 ANC visits) were recruited in the implementation site and 200 in the control site. The preliminary results show that 60% of women attended ≥ 2 ANC visits in the implementation site. In this area, 52 women were found positive for HIV and 4 for syphilis. Data collection in both the sites is ongoing.

Conclusions

PANDA system allows the creation of electronic patient records and the identification of the high-risk pregnancies. The collection of population data is useful for health planning policies. The easy-to-use and easy-to-understand graphic interface overcomes language and literacy barriers and facilitates comprehension of women and compliance to visits. This can improve the quality of ANC/PNC services with an expected reduction in maternal and neonatal mortality.

Key messages

PANDA system increases access to high-quality ANC for pregnant women in low-income countries, improving the adherence to WHO recommendations. The telemedicine system PANDA is a useful tool for public health policy-makers, as it allows the collection of previously unavailable population data.

Esophageal Stricture as a Complication After Scald Injury in Children

Burn injuries are distressful and shocking events, which can lead to noteworthy sequelae on metabolic markers and organs. Such traumatic accidents do occur every so often in both adult and pediatric populations, requiring prompt and adequate treatments. Notably, scald injuries occur due to direct contact with hot liquids and these are the most common cause of burns in early childhood. Herein, we report on an 18-month-old boy admitted to our pediatric surgery unit for an extensive scald injury, who has experienced an unusual esophageal stricture following the traumatic event.

Surgical approach to giant ovarian masses in adolescents: technical considerations

Ovarian neoplasms arising from the surface epithelium are rare in the pediatric population; their knowledge is therefore limited and the appropriate management is poorly defined. We describe our experience and suggest our surgical approach to adolescents affected by voluminous ovarian masses. Two 15-year-old adolescents were admitted to our institution in 2017 for multilobulated, fluid-filled masses measuring over 30 cm arising from the ovaries. The cystic component was drained intraoperatively with a spillage-free technique, consisting in the application of a sterile autoadhesive transparent drape on the cyst and the insertion of a 12 Ch pleural drain, secured with a purse-string suture. Unilateral salpingo-oophorectomy was then carried out. Histology revealed mucinous cystadenoma in both patients. Surgical treatment of ovarian masses should aim at both radically excising the tumor and preserving the fertility of the patients. Decompression with spillage-free techniques can be useful to achieve radical therapy with limited manipulation of tissues.

Ultrasound-Guided Bar Edge Labeling in the Perioperative Assessment of Nuss Bar Removal

INTRODUCTION

Nuss bar removal after minimally invasive repair of pectus excavatum in patients where bar ends are not palpable, can be a challenging procedure for the surgeon; a blind dissection toward the bar edges may lead to intercostal vessels or deep intercostal muscle injuries. In this article, we describe a fast, repeatable, low-cost technique to detect bar edge and stabilizers.

METHODS

A perioperative scan is performed by means of a portable ultrasonograph a few minutes before the operation. The bar edge stabilizer is detected as a hyperechogenic image with a concentric crescent while the bar edge is detected as a hyperechogenic dashed line with net edges. The scan is performed, and the actual projection on the skin of the metal plaque bulk is then labeled on the patient's chest by an ink marker.

CONCLUSIONS

We believe that this method may improve morbidity, operative time, and consequently, hospitalization length and costs.