Non-standard approach to infants and children with megacolon: laparotomy and endorectal pull-through for diagnosis and treatment in difficult countries with low resources in a non-profit setting: return to the past Soave's ERPT

BACKGROUND

Hirschsprung's disease is an important cause of pediatric constipation with high risk of bacterial enterocolitis. Its diagnosis is histological and the suction biopsy is the gold standard. In resource-limited countries, the main diagnostic exam is the contrast enema and mini-invasive surgery lacks. We present the management of a cohort of patients with megacolon in Haiti, a low-resource country.

METHODS

Children with megacolon and fecal impaction admitted at St Damien Children Hospital in Port-Au-Prince in June, August and December 2017 were included. We considered only patients with an evident transition zone on contrast enema who underwent endorectal pull-through (ERPT). Short term complications were recorded.

RESULTS

Twenty children with clinical megacolon were admitted, eleven were included in the study. No suction rectal biopsy and intraoperative histological evaluation were performed. In ten children a Soave ERPT with anastomosis at 5POD was performed, in the other case a Boley primary anastomosis was preferred. One patient complicated with a peritonitis. No major complications were recorded. Colostomy was not considered a good option.

CONCLUSIONS

In developing countries, Soave ERPT with definitive anastomosis after few days could be considered a valid option. Colostomy is suggested only in case of scant general conditions or bad colon appearance.

Pathways and microbiome modifications related to surgery and enterocolitis in Hirschsprung disease

BACKGROUND

Hirschsprung disease (HSCR) is a congenital anomaly of the enteric nervous system. Abnormal microbiome composition was reported in HSCR patients. In this study, we addressed and analyzed microbiome modifications with relation tosurgery and HSCR associated enterocolitis (HAEC).

METHODS

The faecal microbiome of 31 HSCR patients (overall 64 samples) was analyzed. HAEC was diagnosed and classified according to a combination of Pastor's and Elhalabi's criteria. Stool samples were analyzed by 16S sequencing (7 out of 9 polymorphic regions). Compositional and relative abundance profiles, as well as the functional potentials of the microbial community, were analyzed with the marker gene sequencing profiles using PICRUSt.

RESULTS

The relative abundance of Bacteroidetes showed a severe decrease with slow recovery after surgery. Conversely, Proteobacteria transiently increased their abundance. Noteworthy, a strong linkage has been found between Proteobacteria descendants and HAEC occurrences. The inferred functional analysis indicated that virulence factors and fimbriae or pili might be associated with HAEC.

CONCLUSIONS

Our study, addressing microbiome dynamics, demonstrated relevant changes after surgical manipulation. Alpha-diversity analyses indicated that surgery deeply affects microbiome composition. Proteobacteria and Enterobacteriaceae seem to play a pivotal role in HAEC occurrences. Several virulence factors, such as fimbriae or pili, might explain the HAEC-predisposing potential of selected microbiomes. These results suggest some innovative therapeutic approaches that deserve to be tested in appropriate clinical trials.

Skipped aganglionic lengthening transposition (SALT) for short bowel syndrome in patients with total intestinal aganglionosis: technical report and feasibility

Extended aganglionosis (TIA) is the presence of some viable aganglionic gut distal to the levelling jejunostomy. Different surgical procedures (including transplantation) have been proposed with inconclusive results. We conceived a new procedure named skipped aganglionic lengthening transposition (SALT) consisting of multiple pedicled isoperistaltic transpositions of aganglionic ileal loops interposed to normoganglionic jejunum. The innovative aspect consists of taking advantage of the propulsive effect of normoganglionated bowel to progress enteric content throughout interposed aganglionic loops down to the stoma. The procedure was adopted in a male patient who was born with 30 cm of normoganglionated jejunum. SALT was performed when the baby was 18 months. Three 5-cm pedicled isoperistaltic aganglionic loops of small bowel were interposed each 10 cm of normoganglionic jejunum with an overall 36% length gain (from 42 to 57 cm). Postoperative course was uneventful. 6 months postoperatively, an upper gastrointestinal series showed normal progression without dilatations. A laparoscopic gastrostomy was performed due to food aversion 6 months postoperatively, demonstrating impressive anatomic and functional postoperative results. The procedure provides promising and unique opportunity for patients with TIA with encouraging outlook for the near future.

Minimally Invasive Redo Pull-Throughs in Hirschsprung Disease

Introduction: To reoperate a patient with Hirschsprung disease (HSCR) can be technically demanding and most surgeons would resort to conventional laparotomy. This article describes a series of patients with postoperative obstructive symptoms who underwent minimally invasive redo pull-throughs (MIRPT) (either laparoscopic or robotic) to assess the role of minimally invasive surgery (MIS) in complicated HSCR patients. Patients and Methods: All consecutive HSCR patients with postoperative obstructive symptoms, who underwent MIRPT with fast track concepts of care between January 2012 and January 2020, have been included. Data regarding indications, surgical details, complications, and outcome have been compared to those of a series of patients who underwent conventional laparotomic redo. Results: Sixteen patients were included. Male to female ratio was 4.3:1. Median age at surgery was 78 months. Eleven patients underwent laparoscopic redo and 5 underwent robotic redo. Median length of follow-up was 49 months. Reasons for redoing were transition zone pull-through, residual aganglionosis, anastomotic retraction or leak, rectal diverticulum, and refractory anastomotic stricture. No major intraoperative complication occurred. No conversion to laparotomy was required. One patient experienced cuff stricture requiring laparoscopic release. Two patients reported bouts of enterocolitis postoperatively. Compared to classic laparotomic redo pull-throughs (49 patients with complete data), overall complications were significantly less frequent, accounting for 1 and 21 events, respectively (6% versus 43%) (P = .0067). Continence after a median of 21 months postoperatively scored excellent to good in 9 out of 12 patients, who were assessed on this regard (75%), without statistically significant differences. Conclusions: MIRPT proved to be effective and safe in HSCR patients complaining postoperative obstructive symptoms. Robotic surgery could play a crucial. Our study confirms that complicated HSCR cases can be safely managed by means of MIS, applying concepts of fast track care to serve the best for our patients.

Reluctance to seek pediatric care during the COVID-19 pandemic and the risks of delayed diagnosis

Since the outbreak of COVID-19 pandemic, the number of cases registered worldwide has risen to over 3 million. While COVID-19 per se does not seem to represent a significant threat to the pediatric population, which generally presents a benign course and a low lethality, the current emergency might negatively affect the care of pediatric patients and overall children welfare. In particular, the fear of contracting COVID-19 may determine a delayed access to pediatric emergency facilities. Present report focuses on the experience of The Children Hospital in Alessandria (northern Italy). The authors document a drop in the number of admissions to the emergency department (A&E) during the lock-down. They will also focus on four emblematic cases of pediatric patients who were seen to our A&E in severe conditions. All these cases share a significant diagnostic delay caused by the parents’ reluctance to seek medical attention, seen as a potential risk factor for COVID-19 contagion. None was found positive to all COVID-19 swab or immunologic testing. All in all, our data strongly support the importance of promoting a direct and timely interaction between patients and medical staff, to prevent the fear of COVID-19 from causing more harm than the virus itself.

Intrasphincteric BoTox injections in Hirschsprung's disease: indications and outcome in 64 procedures over a ten-year period

BACKGROUND

Intrasphincteric Botulinum toxin (BoTox) injection for symptomatic postoperative anal achalasia in Hirschsprung's disease (HSCR) has found wide application in the last twenty years. The aim of this study is to describe effectiveness and functional outcome of a series of patients treated over a 10-year period.

METHODS

All consecutive HSCR patients who received intrasphincteric BoTox injections between January 2007 and December 2016 were included. Demographic data and clinical features were collected. A detailed questionnaire focusing on outcome in the medium and long term was administered to all families.

RESULTS

In the study period 64 intrasphincteric BoTox injections were performed in 31 patients. Completed questionnaires were returned by 27 out of 28 eligible patients (96%) reporting improvement or symptoms resolution in 16 (59%). The highest success rates were experienced by patients younger than 4, with long HSCR forms and with recurrent enterocolitis (75%, 100% and 100% of success rates, respectively). No major complications occurred. Minor complications were described by 7 patients (26%).

CONCLUSIONS

Intrasphincteric BoTox injection proved to be feasible, safe and reasonably effective in children with HSCR and postoperative anal achalasia. Infants and toddlers with long HSCR forms and recurrent bouts of enterocolitis are those who would benefit most from this treatment.

Comparative retrospective study on the modalities of biopsying peripheral neuroblastic tumors: a report from the Italian Pediatric Surgical Oncology Group (GICOP)

BACKGROUND

Peripheral neuroblastic tumors are the most common extracranial solid neoplasms in children. Early and adequate tissue sampling may speed up the diagnostic process and ensure a prompt start of optimal treatment whenever needed. Different biopsy techniques have been described. The purpose of this multi-center study is to evaluate the accuracy and safety of the various examined techniques and to determine whether a preferential procedure exists.

METHODS

All children who underwent a biopsy, from January 2010 to December 2014, as a result of being diagnosed with a peripheral neuroblastic tumor, were retrospectively reviewed. Data collected included patients' demographics, clinical presentation, intraoperative technical details, postoperative parameters, complications, and histology reports. The Mann-Whitney U and Fisher's exact tests were used for statistical analysis.

RESULTS

The cohort included 100 patients, 32 of whom underwent an incisional biopsy (performed through open or minimally invasive access) (Group A), and the remaining 68 underwent multiple needle-core biopsies (either imaging-guided or laparoscopy/thoracoscopy-assisted) (Group B). Comparing the two groups revealed that Group A patients had a higher rate of complications, a greater need for postoperative analgesia, and required red blood cell transfusion more often. Overall adequacy rate was 94%, without significant differences between the two groups (100% vs. 91.2% for Group A and Group B, respectively, P = 0.0933).

CONCLUSIONS

Both incision and needle-core biopsying methods provided sub-optimal to optimal sampling adequacy rates in children affected by peripheral neuroblastic tumors. However, the former method was associated with a higher risk of both intraoperative and postoperative complications compared with the latter.

Video-Assisted Needle Core Biopsy in Children Affected by Neuroblastoma: A Novel Combined Technique

Aim This study aims to evaluate the experience gained with video-assisted needle-core biopsy in patients affected by neuroblastoma (NB). Patient and Methods We retrospectively reviewed all the patients presenting at our center with a thoracic, abdominal, and/or pelvic NB who underwent biopsy between 2007 and 2014. Data on demographics, localization, and size of the tumor, image-defined risk factors involved in each case, technical details about biopsies performed, qualitative and quantitative adequacy of tumor sampling and histological diagnosis, postoperative details, and complications were recorded and analyzed. Results During the 7 years of our study 51 patients affected by NB underwent 55 biopsies. Our results focus on the 29 patients undergoing 32 video-assisted needle-core biopsies. The median age was 4 years with a median weight of 13.5 kg. Out of 29, 28 tumors were localized in the abdomen/pelvis compartment, whereas 1 patient presented with a thoracic mass. The median size of the tumors was 57 mm. A total of 28 patients had an adequate tissue sampling for complete tumor characterization. Biopsies were repeated twice in a patient. Three complications occurred in three patients. Conclusions The video-assisted needle-core biopsy combines minimally invasive surgery several advantages with the possibility to obtain multiple samples in different regions with minimal tumor exposition and low complication rate.

Minimally invasive surgery for paediatric inflammatory bowel disease: Personal experience and literature review

The incidence of paediatric inflammatory bowel disease (PIBD) has dramatically increased in the last 20 years. Although first reported in mid 1970s’, diagnostic laparoscopy has started to be routinely adopted in paediatric surgical practice since late 1990s’. Minimally invasive surgery was first limited to diagnostic purposes. After 2002 it was also applied to the radical treatment of PIBD, either Crohn’s disease (CD) or Ulcerative colitis. During the last decade minimally invasive approaches to PIBD have gained popularity and have recently became the “gold standard” for the treatment of such invalidating and troublesome chronic diseases. The authors describe and track the historical evolution of minimally invasive surgery for PIBD and address all available opportunities, including most recent advancements such as robotic surgery, single port approaches and minimally invasive treatment of perianal fistulising CD. A systematic review of all series of PIBD treated with minimally invasive approaches published so far is provided in order to determine the incidence and type of patients’ complications reported up to present days. The authors also describe their experience with minimally invasive surgery for PIBD and will report the results of 104 laparoscopic procedures performed in a series of 61 patients between January 2006 and December 2014.

Laparascopic-assisted nephroureterectomy for shaped urolithiasis and xanthogranulomatous pyelonephritis: case report and review of literature

We report a case of xanthogranulomatous pyelonephritis (XGP) complicated by shaped urolithiasis, severe hydroureteronephrosis and kidney exclusion treated by laparoscopic-assisted nephroureterectomy. A 9 year-old boy was referred to us for recurrent episodes of urinary tract infection, abdominal pain and severe hydronephrosis. Abdominal CT and a Tc-99m MAG3 scan showed a non-functioning obstructed kidney with shaped urolithiasis of the distal ureter. XGP was suspected, and nephroureterectomy was performed by laparoscopic distal ureterectomy and open extraperitoneal nephrectomy. This technique avoided the need for a more extended nephrectomy incision or even a second iliac incision. It also ensured complete excision of the distal ureter with minimal risk of developing the ureteral stump syndrome, which sometimes follows nephroureterectomy. We believe that laparoscopic-assisted nephroureterectomy may be a suitable technique in those cases of difficult nephrectomy where a ureteral stump syndrome is likely to develop.

Update on complications in pediatric anesthesia

Complications in pediatric anesthesia can happen, even in our modern hospitals with the most advanced equipment and skilled anesthesiologists. It is important, albeit in a tranquil and reassuring way, to inform parents of the possibility of complications and, in general, of the anesthetic risks. This is especially imperative when speaking to the parents of children who will be operated on for minor procedures: in our experience, they tend to think that the anesthesia will be a light anesthesia without risks. Often the surgeons tell them that the operation is very simple without stressing the fact that it will be done under general anesthesia which is identical to the one we give for major operations. Different is the scenario for the parents of children who are affected by malignant neoplasms: in these cases they already know that the illness is serious. They have this tremendous burden and we choose not to add another one by discussing anesthetic risks, so we usually go along with the examination of the child without bringing up the possibility of complications, unless there is some specific problem such as a mediastinal mass.