Granulated sugar for adjuvant treatment of surgical wound infection due to multi-drug-resistant pathogens in a child with sarcoma: a case report and literature review

The use of sugar for treating wounds which are difficult to heal and positive to resistant pathogens has already been documented. The authors describe the successful treatment by direct instillation of granular sugar in the antibiotic-resistant infected surgical site wound of a child with sarcoma. Sugar instillation in the extended spectrum beta-lactamase (ESBL)-producing Enterobacter cloacae positive wound, in addition to systemic treatment with meropenem and levofloxacin, allowed culture negativization in six days and complete wound healing in 30 days. These results make the use of sugar an attractive option for wounds which are difficult to treat, even in an immunocompromised child.

Image-defined risk factors in unresectable neuroblastoma: SIOPEN study on incidence, chemotherapy-induced variation, and impact on surgical outcomes

PURPOSE

To evaluate the impact of image-defined risk factor (IDRF) modification after chemotherapy on surgical outcomes, event-free survival (EFS), and overall survival (OS) among patients enrolled in the European Unresectable Neuroblastoma (EUNB) study.

METHODS

IDRFs were assigned according to the corresponding surgical risk factors list reported in the database. Surgical outcomes, EFS, and OS were related to IDRF modification with chemotherapy. The predictive value of preoperative IDRF for surgical outcomes was analyzed. Cox proportional hazards models for EFS and OS, including preoperative IDRF, surgical outcomes, and other known clinical risk factors, were created.

RESULTS

Of the 160 patients enrolled in the EUNB study, 143 patients met the inclusion criteria. A total of 228 IDRF were thus collected. Following chemotherapy, 76 (33%) IDRF disappeared in 32.2% of patients, 33 (14%) new IDRF appeared in 18.8% of patients, and 49% of patients did not show any IDRF change. Complete resection/minimal residual disease (71.2%) was more frequent among children who had disappearance/numerical reduction of IDRF (P = 0.005). Infiltration of the branches of the mesenteric artery was predictive of an unfavorable surgical outcome. Prolonged preoperative chemotherapy over five courses and encasement of the celiac axis and/or mesenteric artery origin impacted EFS and OS.

CONCLUSIONS

The unchanged IDRF pattern in 50% of patients and the appearance of new IDRF during chemotherapy in approximately 20% of patients strengthens the idea that prolonged chemotherapy is useless for improving surgical resection in this population of patients. In addition, midline perivascular abdominal preoperative IDRF appeared to be predictive not only of surgical outcomes but also of EFS and OS.

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.

Primary intestinal mold infection in children with solid tumors: a case report in an adolescent with Ewing sarcoma, and literature review

We report a case of primary intestinal infection due to filamentous fungi in an adolescent with Ewing sarcoma. The clinical picture was that of peritonitis secondary to intestinal perforation and the diagnosis was established only on histopathological bases. This condition is very rare, and only one case of primary intestinal mold infection in children with solid tumors has been reported in the literature, although more records can be found describing similar conditions in other cancer patient populations (i.e. adults with solid tumors or children with hematological malignancies or patients receiving hemopoietic stem cell transplant). Clinicians must be aware of this possibility since only an aggressive medical and surgical approach can improve patients' prognosis.

Inguinal hernia in neonates and ex-preterm: complications, timing and need for routine contralateral exploration

BACKGROUND/PURPOSE

Aim of this study was to present a series of neonates and ex-preterm babies who underwent inguinal hernia repair focusing on complications and possible indication to perform routine contralateral groin exploration.

METHODS

This is a retrospective study of a series of consecutive patients weighing less than 5 kg who underwent inguinal hernia repair between January 2007 and December 2012. Only the affected side was treated. Patients have been routinely followed up postoperatively. We resorted to available outpatients' charts and admission notes to record demographic data, surgical details, complications and the occurrence of metachronous hernias. A questionnaire was administered to all patients' relatives to confirm the long-term outcome.

RESULTS

One hundred fifty-four patients were operated for a total of 184 herniotomies (88 right sided, 36 left sided and 30 bilateral). Median length of follow-up was 42 months (range 6 months-7.5 years). Thirteen patients (13/124 = 10.5 %) developed metachronous hernia that proved to be significantly more frequent in patients weighing less than 1,500 g at birth (p < 0.05). We observed 10 % of complications, including 2.7 % testicular atrophy and 4.5 % recurrence. Atrophy proved to occur more frequently in patients who experienced preoperative incarceration (p < 0.05). No other risk factors were identified.

CONCLUSIONS

The results of our series demonstrated that, though technically demanding, herniotomy in the neonate and ex-preterm is associated with a relatively low incidence of complications. Based on our results and in accordance with literature data, we do not advocate routine contralateral exploration in case of unilateral hernia but surgery to be performed only on the symptomatic side, as soon as possible after initial diagnosis. Very low birth weight patients should be followed with care in the early postoperative period due to the higher likelihood of developing a metachronous hernia.

Diffuse lipomatosis of the chest wall: report of a neonatal case

Diffuse lipomatosis is a very rare condition, the nature of which, neoplastic or hamartomatous, has not yet been defined. We report the case of a small child with a right thoracic lesion of neonatal onset and extremely rapid growth, who successfully underwent complete surgical resection. The differential diagnoses and proper surgical treatment are discussed.

Urological outcome in patients with Currarino syndrome

INTRODUCTION

Currarino syndrome is a type of caudal regression syndrome characterized by the association of hemisacrum, anorectal malformation and presacral mass. Only few studies on small series report the incidence of urinary dysfunction in Currarino syndrome. Our aim was to evaluate the urological outcome in patients with Currarino syndrome.

PATIENTS AND METHODS

We retrospectively reviewed all Currarino syndrome patients treated in our institution. Of 20 patients, we could evaluate the urological outcome in 16. This group of patients underwent clinical, radiological and urodynamic evaluation.

RESULTS

All 16 patients had a sacral defect, fourteen of them presenting a presacral mass (87.5%), eight a tethered cord (50%), and 7 anorectal malformations (43.7%). Eight patients underwent neurosurgical treatment for neural tube defects. In 14 patients, the presacral mass was resected. One case presented detrusor overactivity, 2 recurrent urinary tract infections and 2 vesicoureteral refluxes. Both patients with lipomyeloschisis had a neuropathic bladder. All the other patients could void the bladder spontaneously. Renal function was normal in all.

CONCLUSION

Currarino syndrome is a rare congenital disorder presenting a variable phenotype. Urological outcome is good in the majority of patients.

Adrenocortical tumors in Italian children: analysis of clinical characteristics and P53 status. Data from the national registries

AIM

Adrenocortical tumors are very rare in children. The distinction between adenoma and carcinoma is complex because of their clinical/histological characteristics. The analysis of the cases registered in two consecutive Italian Studies is described, in order to provide additional insight into their nature and possibly identify benign and malignant lesions.

MATERIALS AND METHODS

The analysis includes patients registered from?? 1.1982 to 6.2011 into two consecutive Italian protocols.

RESULTS

Fifty-eight children (age 2-210months) were evaluated. Endocrine manifestations were the most frequent symptoms. Stage distribution at diagnosis was: ST I 35, ST II 17, ST III 1, ST IV 5. Treatment consisted in mitotane for ST II, mitotane+chemotherapy for ST III/IV. Forty-four patients are alive without evidence of disease, 1 is alive with disease, 12 died of disease and 1 because of cardiomyopathy. The Wienecke score system was applied in 24 patients with good significance. A p53 mutation was found in 7 cases, and it was diagnostic for Li-Fraumeni syndrome in 2 benign tumors.

CONCLUSIONS

The results highlight the importance of a complete excision to obtain the cure of patients. The efficacy of chemotherapy is controversial, however it was able to control the disease in 4 patients in ST II. The value of the Wienecke score system in predicting patients' outcome was confirmed. p53 mutation was more frequent in malignant tumors and represented the sentinel of the Li-Fraumeni syndrome.

Congenital multifocal rhabdoid tumor: a case with peculiar biological behavior and different response to treatment according to location (central nervous system and kidney)

Atypical teratoid/rhabdoid tumor (AT/RT) of the central nervous system and malignant rhabdoid tumor of the kidney (MRTK) may present with different responses to chemotherapy and outcomes. We describe the case of an infant with multifocal rhabdoid tumor with different behavior and response to treatment, depending on the anatomic site.

[Role in mini-invasive surgery in children]

AIM

This paper describes our experience with minimally invasive surgery and underlines its increasingly important role in the treatment of pediatric patients.

METHODS

The study included all those patients undergoing a minimally invasive surgical procedure between January 2006 and March 2012. Patient demographics, type of operation (classified according to disease and anatomic site), complications, and length of hospital stay (LOS) were recorded.

RESULTS

Out of 12,596 surgeries, 1803 (14.3%) minimally invasive procedures were performed: Soave-Georgeson endorectal colon pull-through for Hirschsprung's disease (N.=82); colectomy for chronic inflammatory bowel disease (N.=37); ileal J-pouch ano-rectal Knight-Griffen anastomosis in colectomized patients with chronic ulcerative colitis (N.=35); Nissen fundoplication for gastroesophageal reflux disease (N.=148); cholecystectomy (N.=68); appendectomy (N.=341); laparoscopic or thoracoscopic tumor resection or biopsy (N.=90); reconstruction of the renal pelvi and ureters (N.=11); and Nuss thoracoplasty for pectus excavatum (N.=237). The median age was 3 years; the median LOS was 3 days; the complications rate was 0.9% (N.=18).

CONCLUSION

According to our experience, minimally invasive surgery is a safe and efficacious alternative to conventional surgery (in terms of complications) also in children. It was associated with shorter LOS and improved quality of life, with less pain and better aesthetic results. It has become the preferred surgical treatment option by parents.

Laparoscopic resection of adrenal neuroblastoma without image-defined risk factors: a prospective study on 21 consecutive pediatric patients

BACKGROUND

Over the last 20 years MIS has progressively gained popularity in children with cancer. We therefore aimed at evaluating the safety of Minimally Invasive Surgery (MIS) resection in a series of children affected by adrenal neuroblastoma (NB) presenting without Image-Defined Risk Factors (IDRFs).

METHODS

An Institutional protocol for MIS resection of adrenal NB in pediatric patients without IDRFs has been applied since 2008. Absence of IDRFs represented the main indication for MIS in NB, regardless of tumor size. All pediatric patients who underwent MIS for NB between January 2008 and May 2013 were included. Specific technical considerations, demographic data, and outcome have been recorded.

RESULTS

Twenty-one patients underwent MIS resection for IDRFs-negative adrenal NB. Nine of these patients experienced preoperative downgrading of IDRFs after chemotherapy. Radiological median diameter of the mass was 30 mm (range 10-83 mm). Median operative time was 90 min. Median hospital stay was 4 days. All patients were treated successfully, without serious intraoperative complications. One mild intraoperative hemorrhage occurred and was treated without the need for conversion to open surgery nor blood transfusion was required. No postoperative complications, including port-site or peritoneal metastases were experienced.

CONCLUSIONS

This study demonstrated the safety and effectiveness of MIS for the resection of adrenal NB without IDRFs in children. Pediatric surgeons dedicated to oncology should be aware of this alternative approach to open resection.

A prospective observational study of associated anomalies in Hirschsprung's disease

BACKGROUND

Associated anomalies have been reported in around 20% of Hirschsprung patients but many Authors suggested a measure of underestimation. We therefore implemented a prospective observational study on 106 consecutive HSCR patients aimed at defining the percentage of associated anomalies and implementing a personalized and up-to-date diagnostic algorithm.

METHODS

After Institutional Ethical Committee approval, 106 consecutive Hirschsprung patients admitted to our Institution between January 2010 and December 2012 were included. All families were asked to sign a specific Informed Consent form and in case of acceptance each patient underwent an advanced diagnostic algorithm, including renal ultrasound scan (US), cardiologic assessment with cardiac US, cerebral US, audiometry, ENT and ophthalmologic assessments plus further specialist evaluations based on specific clinical features.

RESULTS

Male to female ratio of our series of patients was 3,4:1. Aganglionosis was confined to the rectosigmoid colon (classic forms) in 74,5% of cases. We detected 112 associated anomalies in 61 (57,5%) patients. The percentage did not significantly differ according to gender or length of aganglionosis. Overall, 43,4% of patients complained ophthalmologic issues (mostly refraction anomalies), 9,4% visual impairment, 20,7% congenital anomalies of the kidney and urinary tract, 4,7% congenital heart disease, 4,7% hearing impairment or deafness, 2,3% central nervous system anomalies, 8,5% chromosomal abnormalities or syndromes and 12,3% other associated anomalies.

CONCLUSIONS

Our study confirmed the underestimation of certain associated anomalies in Hirschsprung patients, such as hearing impairment and congenital anomalies of the kidney and urinary tract. Subsequently, based on our results we strongly suggest performing renal US and audiometry in all patients. Conversely, ophthalmologic assessment and cerebral and heart US can be performed according to guidelines applied to the general population or in case of patients with suspected clinical features or chromosomal abnormalities. This updated diagnostic algorithm aims at improving overall outcome thanks to better prognostic expectations, prevention strategies and early rehabilitation modalities. The investigation of genetic background of patients with associated anomalies might be the next step to explore this intriguing multifactorial congenital disease.

Magnetic resonance urography and laparoscopy in paediatric urology: a case series

Paediatric urology often presents challenging scenarios. Magnetic resonance urography (MRU) and laparoscopy are increasingly used. We retrospectively studied children affected by a disease of the upper urinary tract who after MRU were elected for laparoscopic treatment. This pictorial essay draws on our experience; it illustrates some specific MRU findings and highlights the usefulness of MRU for the diagnosis of upper urinary tract pathology in children. It also offers some examples of the potential additional diagnostic information provided by laparoscopy as well as its therapeutic role.

Susceptibility to antibiotics of aerobic bacteria isolated from community acquired secondary peritonitis in children: therapeutic guidelines might not always fit with and everyday experience

Appendicitis is a frequent clinical condition in normal children that may be complicated by community-acquired secondary peritonitis (CASP). We evaluated the potential efficacy of different drugs for initial treatment of this condition, as recommended by recent Consensus Conference and Guidelines for paediatric patients. Susceptibility to ampicillin-sulbactam, ertapenem, gentamycin, piperacillin, piperacillin-tazobactam, vancomycin, and teicoplanin was evaluated according to EUCST 2012 recommendations in aerobic bacteria isolated from peritoneal fluid in CASP diagnosed from 2005 to 2011 at 'Istituto Giannina Gaslini', Genoa, Italy. A total of 114 strains were analysed: 83 E. coli, 15 P. aeruginosa, 6 Enterococci, and 10 other Gram-negatives. Resistance to ampicillin-sulbactam was detected in 37% of strains, while ertapenem showed a potential resistance of 13% (all P. aeruginosa strains). However, the combination of these drugs with gentamicin would have been increased the efficacy of the treatment to 99 and 100%, respectively. Resistance to piperacillin-tazobactam was 3%, while no strain was resistant to meropenem. Our data suggest that monotherapy with ampicillin-sulbactam or ertapenem for community-acquired secondary peritonitis would present a non-negligible rate of failure, but the addition of gentamycin to these drugs could reset to zero this risk. On the contrary, monotherapy with piperacillin-tazobactam or meropenem is highly effective.

Abdominal wall defects: a 33-year unicentric experience

AIM

The aim of this paper was to provide the main clinical features, surgical details, and long term outcome of patients with gastroschisis and omphalocele operated on at Giannina Gaslini Institute between 1976 and 2009.

METHODS

All patients who were operated on between 1976 and 2009 for omphalocele or gastroschisis were included. Detailed informations regarding demographics, maternal history, type of delivery, associated anomalies, surgical details, complications, morbidity and mortality were collected.

RESULTS

Sixty-one patients were included. Type of delivery did not interfere with outcome. Although patients with omphalocele had higher incidence of associated anomalies with their obvious impact on survival and quality of life, they showed a quicker recovery from surgery. Mortality rate was around 5%. Long-term outcome was available in 18 of them and proved to be satisfactory in all although almost 70% of them complained some gastrointestinal issues.

CONCLUSION

Gastroschisis and Omphalocele showed improving survival and outcome during the last decades. Caesarean section proved not to confer advantages over vaginal delivery. Associated anomalies have the highest impact on survival being cardiac malformation the most significant risk factors. Although overall outcome is good in the majority of the patients, gastrointestinal and cosmetic issues seem to have a significant impact on quality of life and overall patients' perspectives.

Early diverting colostomy for perianal sepsis in children with acute leukemia

Perineal sepsis is a life-threatening complication of acute leukemia. Although conservative management (antibiotics, incision, and drainage, alone or in combination) is considered the criterion standard, it provides an outcome that is not fully satisfactory, with an overall mortality of roughly 30%. This report presents a case series of 4 children who underwent early defunctioning colostomy for the treatment of perineal sepsis during leukemia. This management proved to be successful and allowed prompt reestablishment of chemotherapy, thus improving overall results. Routine application of this "aggressive" management in these cases will presumably increase overall survival of children with leukemia.

The surgical approach for cervicothoracic masses in children

BACKGROUND

The surgical approach to masses located in the cervicothoracic juncton represents a challenge for surgeons. Many techniques have been described with good results.

METHODS

We analyzed and compared the results obtained in 2 Italian pediatric surgery centers using 2 different techniques in patients with tumors of the thoracic inlet: center 1, using anterior cervical transsternal approach on 7 patients, and center 2, applying "trap-door" technique on 5 patients.

RESULTS

Excision was incomplete in 5 patients and complete in 7 patients. Histologic examination revealed 5 patients with neuroblastoma; 3, ganglioneuroblastoma; 1, mixoid liposarcoma; 1, desmoid fibromatosis; 1, Castleman disease; and 1, Schwann cell tumor. The median duration of the procedure was 345 minutes in center 1 and 245 minutes in center 2. The median blood loss was 200 mL in both centers. The median hospital stay was 11 days in center 1 and 9 days in center 2. Globally, 5 patients developed postoperative complications. No significant differences were encountered comparing the main surgical outcome parameters between the 2 approaches.

CONCLUSIONS

Both techniques resulted in valid options to achieve a safe excision of thoracic inlet masses with a manageable complication rate and acceptable hospital stay. Surgical risk factors should be carefully investigated preoperatively. Postoperative pain control is important to guarantee early recovery.

Intraoperative bronchoscopy for bronchial carcinoid parenchymal-sparing resection: a pediatric case report

Bronchial carcinoid tumors are the most common primary pulmonary neoplasm in the pediatric population. The widely accepted treatment for carcinoid tumors is surgical, specifically aiming at being as much as conservative on lung parenchyma, while the entire tumor is resected. A brief case is described, highlighting the importance and advantages of a surgical and endoscopic combined approach.

Does surgery have a role in the treatment of local relapses of non-metastatic rhabdomyosarcoma?

PURPOSE

Patients with non-metastatic rhabdomyosarcoma (RMS) have a cure rate of 50-90%, but up to one-third of them experience mostly a local recurrence. Second-line treatment is not standardized as for newly diagnosed tumors. We evaluated the role of surgery on local relapses in a series of patients with RMS.

METHODS

This retrospective analysis involves 70 patients enrolled in two consecutives Italian Studies, RMS88 and RMS96, who presented local recurrence. After relapse, 40/70 underwent a surgical excision (Surgery Group, SG), that was demolitive in 10/40; 24/40 had radiotherapy, 16/40 did not receive radiotherapy or data are not known. Thirty patients out of 70 did not receive any surgical treatment (No-Surgery Group, NSG), and 20/30 received radiotherapy.

RESULTS

Overall survival (OS) after local relapse was 41.6% (mean follow-up 59 months, range 1-226). OS of SG patients was 54% versus 24.7% of the NSG patients (P = 0.0117). Furthermore, OS among the SG was 61.4% with and 41.8% without radiotherapy, and 37.1% with and 0% without radiotherapy among the NSG (P < 0.0001). One patient developed a second local relapse after excision without radiotherapy for the first one, and was cured with further treatment. Demolitive surgery did not improve survival compared to conservative surgery (40% vs. 58.4%, P = 0.1462).

CONCLUSION

The treatment of recurrent RMS represents a challenge. In our experience, patients with local relapse had a poor prognosis. SG patients had a better outcome than NSG patients and those treated with resection plus radiotherapy had the best outcome; patients who did not receive any local treatment had an unfavorable outcome.

Risk factors for renal function impairment in a series of 502 patients born with spinal dysraphisms

OBJECTIVE

To evaluate the risk of renal damage in a large series of patients affected by spinal dysraphism.

METHODS

Renal function was studied in 502 spinal dysraphisms treated over the last 25 years in a single center: 283 meningomyelocele (MMC), 90 caudal regression syndrome (CRS) and 129 spinal lipoma (SL) cases. In patients with normal and impaired renal function, we compared congenital renal anomalies, vesicoureteric reflux, bladder voiding pattern and upper tract dilatation, analyzing the results with the Fisher test.

RESULTS

Neuropathic bladder was observed in 97% of MMC, 60% of CRS, and 39% of SL cases. There was some degree of renal function impairment in 19 MMC (6.7%), 11 CRS (12%, increased to 20% if considering only neuropathic bladder patients), and two SL (1.5%) cases. Renal agenesis was more frequent in CRS (13%), but was not associated with decreased renal function. Overall, vesicoureteric reflux and upper tract dilatation were more frequent in patients with renal damage. Insufficient bladder voiding was statistically associated with renal damage only in the CRS population. Intermittent catheterization did not represent a protective factor against renal damage in patients able to void without significant residual urine.

CONCLUSION

This study has increased our understanding of the prognostic risk factors for renal deterioration. More prospective studies are necessary to confirm these results and correlate treatment with renal outcome.

Shifting from open surgical cut down to ultrasound-guided percutaneous central venous catheterization in children: learning curve and related complications

PURPOSE

Tunneled indwelling central venous catheters (CVC) are essential in the management of children with cancer, hematological, nephrological disorders and for parenteral nutrition. The aim of this study is to present the experience of a single center of the transition from traditional open surgical cut down procedure (OSC) to ultrasound (US)-guided percutaneous CVC insertion, focusing on learning curve and related complications.

METHODS

All CVCs inserted between April 2008 and November 2009 in children at the Gaslini Children Hospital were revised, and data on methods of cannulation, intraoperative and device-related complications and re-intervention were recorded.

RESULTS

194 CVCs were positioned in 188 patients. 128 out of 194 CVCs were positioned through an OSC technique, whereas the remaining 66 CVCs were inserted percutaneously with US guidance. Of the 27 recorded complications, 15 were mechanical events, 7 cases developed infection, whereas the remaining 5 (2.6%) were classified as intraoperative complications. A second surgical procedure was described in 23 (11.8%) cases.

CONCLUSION

Shifting from OSC to US-guided percutaneous CVC insertion inevitably involves a challenging learning curve which is generally associated with high complication rates. Complications progressively decrease once a good experience in US guidance and percutaneous technique has been obtained.

Preperitoneoscopic approach for bladder neck sling suspension in a boy: preliminary experience

OBJECTIVES

This report is aimed at describing our preliminary experience with the preperitoneoscopic approach to the bladder neck for rectus fascial sling suspension in neurogenic bladder.

MATERIALS AND METHODS

A 13-year-old boy with spina bifida was admitted to our institution to treat bladder incontinence. A bladder neck suspension and bladder augmentation was planned. The preperitoneal space was progressively gained by blunt dissection under direct vision (laparoscopy with a single left subcostal trocar), and a total of three preperitoneal ports were inserted. Dissection of the bladder proved to be relatively easy, and the retropubic space as well as the deep pelvis were safely exposed. Owing to the excellent endoscopic visualization, the bladder was dissected downward from the rectum. Once complete mobilization of the bladder neck was achieved, an umbilical tape was passed around the proximal urethra to create an adequate passage for the fascial sling.

RESULTS

The preperitoneoscopic procedure lasted 2 hours. No complications occurred. A good daytime dry period was achieved at the 4-month follow-up.

DISCUSSION

Direct visualization of the bladder neck and minimal dissection to the deep pelvis are the key points of this approach. Provided certain technical details are considered, the minimally invasive preperitoneal access is a valuable alternative to the open approach for the rectus fascial sling procedure, particularly when dealing with male patients. Technical advances will, presumably, lead to a complete minimally invasive treatment of urinary incontinence in male patients with spina bifida.

Neuroblastoma in the newborn. A study of the Italian Neuroblastoma Registry

AIM

Presenting features, treatment and outcome of 134 newborns with neuroblastoma diagnosed over a 27-year period are described.

METHODS

Analyses were performed on the entire cohort and on patients distributed over three periods of diagnosis.

RESULTS

Twenty-seven tumours (20.1%) were detected prenatally. Localised disease prevailed (65.7%) with an increase of stage 1 patients over time from 18.8% to 46.5%. Disseminated disease accounted for 34.3% of tumours with only one stage 4 and 45 stage 4S. Five-year overall survival (OS) of the entire cohort was 88.3%. Five/88 patients with localised disease died, including three who died of complications (OS, 95.3%). The only stage 4 patient survived. Eleven/45 stage 4S patients died, including 7/18 symptomatic and 4/27 asymptomatic (OS, 74.1%).

CONCLUSION

The outcome of neuroblastoma in newborns is excellent. In localised tumours, surgery-related deaths outnumbered deaths due to disease. Symptomatic stage 4S patients were at greater risk of dying.

Risk management in pediatric surgery

PURPOSE

To present the experience documented over 1 year of analysis and quality control on surgical complications and organizational accidents.

METHODS

All children admitted during the study period at our Institution were included in the analysis, which consisted of four phases: (1) definition and standardization of perioperative diagnostic and therapeutic tracks; (2) staff education; (3) documentation and data implementation, and (4) "Morbidity and Mortality" audit.

RESULTS

Over a 1-year study period, 3,116 children were admitted to our Institution: 2,222 out of 3,116 (71.3%) children underwent a surgical procedure. A total number of 184 complications were recorded in 149 patients. One hundred and seventy-one (92.9%) complications occurred following a surgical procedure. Fifty-six out of 149 complicated patients (37.6%) required a re-operation. Thirty-five out of 184 (19%) complications were classified as organizational. Infection represented the most common complication. All cases of anastomotic dehiscence and perforation, bowel obstruction, and stoma malfunction required reintervention. None of the postoperative bleedings required a second surgical procedure.

CONCLUSION

Although a proper statistical comparison with literature complication rates is not feasible, our experience confirms the importance of quality-control audit in health care systems. Prolonged observation, long-term follow up, and comparison with previous results will represent our future goal.

Incidence of indwelling central venous catheter-related complications using the Sri Paran technique for device fixation in children with cancer

PURPOSE

Mechanical complications in tunneled indwelling central venous catheters (CVCs) often involve a risk of displacement. Fixation procedures are, therefore, of primary importance. We prospectively evaluated the incidence of CVC-related mechanical and infectious complications observed in devices fixated with the Sri Paran technique.

METHODS

All CVCs inserted in children with cancer at our Institution from October 2005 to January 2007 were prospectively monitored for device-related mechanical and infectious complications. The Sri Paran fixation technique was used in all cases. The complication rate per 1,000 days was calculated as 1,000 times the number of complications divided by the total number of catheter days.

RESULTS

Ninety-five CVCs were positioned in 84 children. The overall length of observation ranged between 41 and 482 days for a total of 18,618 catheter days. Mechanical complications occurred in 5% of the devices (specific rate 0.27); infections were observed in 6% of the devices (specific rate 0.32). No complications were observed during the first 30 days after CVC insertion.

CONCLUSIONS

The results, we obtained with the Sri Paran technique are extremely encouraging. Yet, randomized studies are required to prove these preliminary data.

Treatment of neurogenic bowel dysfunction using transanal irrigation: a multicenter Italian study

STUDY DESIGN

Thirty-six patients with unsatisfactory treatment of neurogenic bowel dysfunctions (NBD) were enrolled from Spinal Units and Rehabilitation Centers in Italy. Treatment was for 3 weeks using a newly developed integrated system with an enema continence catheter for transanal irrigation (Peristeen, Coloplast A/S Kokkedal Denmark).

OBJECTIVES

To evaluate the effects of Peristeen Anal Irrigation on NBD and patient quality of life (QoL).

SETTING

Italy.

METHODS

Lesion level, ambulatory status and hand functionality were determined in all patients. NBD symptoms and QoL were evaluated before and after treatment, using a specific questionnaire. Statistical analysis was performed using McNemar Test and Sign Test.

RESULTS

Thirty-six patients were enrolled, and 32 patients completed the study. At the end of the treatment, 28.6% of patients reduced or eliminated their use of pharmaceuticals. Twenty-four patients became less dependent on their caregiver. There was a significant increase in patients' opinion of their intestinal functionality (P=0.001), QoL score (P=0.001) and their answers regarding their degree of satisfaction (P=0.001). A successful outcome was recorded for 68% of patients with fecal incontinence, and for 63% of patients with constipation.

CONCLUSION

Peristeen Anal Irrigation is a simple therapeutic method for managing NBD and improving QoL. It should be considered as the treatment of choice for NBD, playing a role in the neurogenic bowel analogous to that of intermittent clean catheterization in bladder treatment.

Long-term urologic outcome in patients with caudal regression syndrome, compared with meningomyelocele and spinal cord lipoma

BACKGROUND/PURPOSE

The long-term urologic outcome in a large series of patients with neural tube defects was evaluated.

METHODS

The following clinical parameters in 398 patients ranging from 1 to 37 years of age--69 with caudal regression syndrome (CRS), 244 with meningomyelocele (MMC), and 85 with spinal lipoma (SL)--were studied: congenital renal anomalies, renal function, vesico-ureteric reflux, upper tract dilatation, urodynamic pattern, and urinary continence.

RESULTS

Single kidney was much more frequent in CRS (20.3%), compared with MMC (1.2%) and SL (0%). Vesico-ureteric reflux was found in 37.7% of patients with CRS, 43.0% of MMC, and 21.2% of SL. Patients with CRS had a higher risk of impaired renal function (8.7%), compared with MMC (5.3%) and SL (1.2%). Neuropathic bladder was found in 61% of patients with CRS, 98% of MMC, and 42% of SL. Among them, clean intermittent catheterization and drugs allowed 30% of patients with CRS, 45% of MMC, and 71% of SL to be dry for more than 4 hours.

CONCLUSIONS

Diagnosis influences the urologic outcome in neural tube defect. In CRS, the incidence of renal agenesis and vesico-ureteric reflux was unexpectedly high. The risk of renal damage and, in those with neuropathic bladder, of urinary incontinence, was similar to patients with MMC.

Urinary diversion in infants with primary high-grade vesicoureteric reflux, urinary sepsis and renal function impairment

INTRODUCTION

General consensus on the optimal treatment of septic infants with primary high-grade vesicoureteric reflux (VUR) and renal function impairment has not been reached. Our study aims at evaluating the role of temporary urinary diversion.

MATERIALS AND METHODS

Twenty male infants, affected by sepsis and primary high-grade VUR, underwent urinary diversion in 1996-2001 because of estimated risk of renal function deterioration, due to non-compliance with the antibiotic treatment. Plasmatic creatinine clearance, ultrasonography, micturition cystography and scintigraphy were evaluated.

RESULTS

Creatinine clearance was abnormal in 13 infants on admission, in 10 after urinary diversion and in 6 after second surgery. Renal damage (focal or diffuse) was evident in 16 patients, without modifications after surgery. No patient developed urinary tract infections (UTI). Vesicostomy was done in 12 cases, ureterostomy in 8. Nephrectomy was performed in 3 cases with poor renal function, and ureteroneocystostomy in 17.

CONCLUSIONS

Urinary diversion in septic infants with high-grade VUR can represent an alternative approach to the conservative or surgical treatment in selected patients presenting risk of renal function impairment. This procedure allowed an easy management of UTI without worsening of renal function while waiting for a better anatomical status to perform reconstructive surgery.

Histological changes following two-step flap gastrocystoplasty in rats

INTRODUCTION

A gastric segment used to increase bladder capacity can undergo considerable changes over time, as can all intestinal segments implanted in the urinary tract and in contact with urine. This experimental study reports the differences between the histological alterations observed in the gastric patch transposed in the bladder both with its own pedicle and after deafferentation from the stomach.

MATERIALS AND METHODS

A group of 30 young male Sprague-Dawley rats underwent gastrocystoplasty. Survivors were divided into 3 groups: gastrocystoplasty alone (8 rats); gastrocystoplasty with vascular deafferentation at 15 days (7 rats), and at 2 months (8 rats). 5 rats were used as controls. Urinary pH was evaluated during a 6-month follow-up.

RESULTS

Histology showed that early devascularization hindered the fusion of the two mucosae in the junctional area but reduced papillary hyperplasia (p = 0.013) of the gastric mucosa. No changes were observed in urinary pH after patch devascularization.

CONCLUSIONS

Vascular deafferentation creates a gastric flap on the bladder which, even if it does not prevent urinary acidification, reduces the frequency of histologically detected changes susceptible for transformation into neoplasms.

Mechanical complications related to indwelling central venous catheter in pediatric hematology/oncology patients

Indwelling central venous catheters (CVC) are essential devices in the management of children with oncologic/hematologic diseases or following bone marrow transplantation. The authors report data on the mechanical complications observed in pediatric hematology/oncology patients, collected by a retrospective analysis of clinical records of 482 patients in whom 567 indwelling central venous catheters had been inserted from January 1992 to December 1998 at the G. Gaslini Institute. During the study period, 52 episodes of mechanical complications (9%) were observed: mechanical obstruction (24 episodes), catheter dislocation (13), problems related to catheter material (12), and accidental removal (3). In 25 cases removal and replacement of CVC was necessary for the treatment of complications, while medical treatment (thrombolytic-antithrombotic) was successful and well tolerated in 8. The study shows the importance of mechanical complications in children with indwelling CVC for hematologic or oncologic diseases. Moreover, the experience of administering a systemic low-dosage thrombolytic therapy demonstrates new prospects of reducing CVC replacement by restoring CVC viability.

Treatment of vesico-ureteric reflux in children with neuropathic bladder: a comparison of surgical and endoscopic correction

BACKGROUND/PURPOSE

Vesico-ureteric reflux (VUR) is a common problem in children with neuropathic bladder. Lesser-degree VUR may be manageable by intermittent catheterization or by anticholinergics, but higher grades usually require surgical treatment. If left untreated, two thirds of such patients may experience deterioration of the upper renal tracts. The aim of this study was to compare the results of the STING (Subureteric Teflon Injection) technique with surgical ureteric reimplantation as treatment for VUR in neuropathic bladder.

METHODS

From January 1981 to December 1996, 58 children with NB (81 ureters) were treated for VUR. STING and Cohen ureteroneocystotomy were performed in 40 and 41 ureters, respectively. Mean age was 4.5 years (STING) and 5.1 years (Cohen).

RESULTS

Twenty-nine of 40 refluxing ureters (72.5%) were cured by STING, whereas Cohen eradicated reflux in 39 of 41 ureters (95.5%). No complications were observed in either group. All the ureters in which STING failed were treated successfully by Cohen ureteroneocystostomy. The 2 ureters still refluxing after surgical reimplantation were cured successfully by a single STING. The mean follow-up was 6.8 years in the Cohen group and 4.8 years in the STING group. During follow-up, no recurrence was observed in patients cured by open reimplantation. In the STING group, 2 previously cured ureters showed recurrence of VUR: both were treated successfully by a further STING.

CONCLUSIONS

Open ureteral reimplantation is more effective than STING in correcting VUR in children with neuropathic bladder dysfunction. Nevertheless, the good success rate, the relative technical simplicity, outpatient nature, and rapid recovery point to STING as a safe and effective procedure for the initial treatment of VUR. Failure of STING does not preclude a successful open operation.

Pancreatitis caused by duodenal duplication

The authors present the investigations and surgical treatment of two cases of duodenal cystic duplication. Abdominal pain and gastroesophageal reflux were the most important symptoms and signs associated with an history of recurrent acute pancreatitis. Computed tomography scan, ultrasound examination, and cholangiography confirmed preoperatively the diagnosis, and a transduodenal surgical approach was carried out in both children. A simple marsupialization of the cyst was performed in the former, and a sphincterotomy with papillosphincteroplasty was associated in the latter. The diagnosis was confirmed by microscopy, and both the children are asymptomatic after a 14 and 18 months of follow-up. This report focuses on the importance of the cholangiopancreatography for every child presenting with recurrent, unexplained bouts of acute pancreatitis, and underlines the technical surgical aspects on the basis of the anatomic identification of the malformation.

Cervical lymphadenitis caused by nontuberculous mycobacteria in immunocompetent children: clinical and therapeutic experience

BACKGROUND

Cervical lymphadenitis is a frequent manifestation of nontuberculous mycobacteria (NTM) infection in immunocompetent children. Surgical excision, the treatment of choice, is often incomplete and may be difficult. A medical approach could reduce treatment morbidity.

METHODS

Systemic antibiotic therapy was administered to seven children for at least 6 months as treatment for cervical lymphadenitis due to NTM: rifabutin and clarithromycin in 4 cases; rifabutin, clarithromicyn, and ethambutol in 2 cases; rifabutin, amikacin, and cycloserine in 1 case.

RESULTS

All patients, six followed for a mean of 3 years and one for 6 months, were initially seen with regression of local signs of infection without relapse. Toxicity, likely due to rifabutin, was represented by neutropenia in three patients and yellow skin pigmentation in one patient.

CONCLUSIONS

Systemic antibiotic therapy was safe and effective in children with lymphadenitis due to NTM. This approach could represent a sound alternative or adjunct to surgery.

All mechanical low rectal anastomosis in children

PURPOSE

The aim of this study is to demonstrate the feasibility and usefulness of mechanical suturing in children for low rectal anastomosis.

METHODS

The study group includes 31 children operated on from January 1993 to July 1996 by the same senior surgeon, performing the modified Duhamel procedure for Hirschsprung's disease in 17 children, intestinal neuronal dysplasia in seven, and the Knight-Griffen procedure in seven pediatric patients with chronic ulcerative colitis.

RESULTS

In all the cases the technique of "viscero-synthesis" was performed using the mechanical stapler. A circular stapler has been used for the end-to-end and the end-to-side anastomosis between the anal canal or the back wall of the rectum with the pulled viscus, while a linear endoscopic stapler (GIA) has been used for the consolidation of the rectocolic wall in the modified Duhamel technique.

CONCLUSIONS

The results obtained demonstrate that the mechanical staplers in children are safe and effective in low rectal anastomosis, sparing operative time and reducing the risk of anastomotic dehiscence; however, the size of circular instruments limits its use in neonates and small infants.

Lung resection in pediatric patients

An evaluation of all pediatric patients with primary or secondary pulmonary disease operated upon from January 1993 to July 1996 by the same senior surgeon was carried out. The inclusion criterion was a lung resection in patients aged less than 14 years. Children were divided into two categories according to the neoplastic or non-neoplastic nature of their disease. In the first group a lobectomy was performed for primary lesions and wedge resection for secondary ones. In the second group lobar emphysema and cystic dysplasia were the major indications for lobectomy, while diagnostic wedge resections were performed for interstitial/infiltrative lesions. Several groups of techniques were identified according to the type of approach and the suture method. Video-assisted thoracoscopic surgery and a muscle-sparing approach were compared to classic posterolateral thoracotomy. The mechanical stapler-suturing method was compared to the manual suturing. Our results demonstrate the importance of mechanical suturing, particularly in decreasing anesthesia time and reducing the risk of dehiscence. The minimally invasive approach associated with mini-thoracotomy was particularly useful for patients with reduced oxygen saturation due to ventilatory and gas-exchange problems. The roles of staplers in lung parenchymal resection and minimally invasive procedures for improving the postoperative thoracic compliance of pediatric patients are stressed.

[Benign mediastinal teratoma with pericardial symptoms. The utility of echocardiography in diagnosis]

The authors describe the clinical case of a 21-year-old girl who was admitted to the hospital because of pericardial symptomatology. On admission, a transthoracic echocardiogram revealed moderate pericardial effusion and an anterior parenchimallike mediastinal mass, that extended as far as the main vessels and the anterior wall of the right ventricle. This report was subsequently confirmed by a computed tomography chest scan. Due to the rupture into the pericardial cavity, which was followed by considerable pericardial effusion, she was immediately taken to the operating room for pericardiocentesis and the decision was then made in order to excise the mass. The hystological diagnosis revealed "benign cystic mature teratoma of the mediastinum". The authors' literature data is included, and the article also emphasizes the importance of using echocardiograms in casualties in order to obtain a differential diagnosis of chest pain.

[Surgical implications of familial polyposis coli]

Surgical treatment of familial congenital polyposis (FCP) is deemed necessary as soon as diagnosis is obtained. The goals of any surgical procedure must be: removal of all adenomatous tissue, reliable prophylaxis of cancer, good quality of life. Among the different procedures (proctocolectomy with ileostomy, total colectomy with ileo-rectal anastomosis and postoperative endoscopic surveillance, ileo-rectal pull-through) we consider Soave ileo-endorectal pull-through as the treatment of choice. Between 1974 and 1993, 14 patients, 12 to 40 years old, underwent an ileo-endorectal pull-through (in 4 cases as secondary procedure after ileo-rectal anastomosis performed elsewhere). We had only two major complications, ileal perforation in one case and breakdown of ileo-rectal anastomosis in another case that needed permanent ileostomy. Continence is good in all patients (safe for the one with ileostomy) with an average of three bowel movements per day. Prophylaxis of cancer must be considered complete and permanent without need of surveillance.

[Intraoperative cholangiography in laparoscopic cholecystectomy. Our experience]

Cholangiography during conventional cholecystectomy has always been useful for anatomo-topographic study and for research of the stones of biliary tree. After a natural period of training the authors included the easy technique of cholangiography in laparoscopic cholecystectomy. The study was performed in 13 patients using Olsen's cannula with an internal a normal catheter for cholangiography. The catheterization of the cystic duct was performed in 85% of cases (11 patients), in the other 15% (2 patients) it was not possible to cannulate the cystic duct. Non complication. The mean duration of the study was 14 minutes. The authors describe the technique and conclude, after a brief discussion of the reports in the literature and personal experience, that peroperative cholangiography is an easy and safe procedure without risk and prevents the injuries to the biliary tract whose incidence is about 1.3%.

[Sepsis in children with malignant neoplasia, equipped with a Broviac-type venous catheter]

Indwelling central venous catheters obviate many problems in the care of children with malignancies, but they also are a well-known source of infection. We are reviewed the history of 584 Broviac catheters inserted from January 1984 to December 1991, in 475 children with cancer in order to assess the etiology of bacteremias, their association with neutropenia and their relationship with the presence of the catheters. The overall duration-time of the catheters, employed for blood tests, drug and blood infusions and parenteral nutrition, was 1-835 days (median 263, mean 186). Total catheter courses was 108.678 days. In this period 226 episodes of sepsis were observed in 180 patients: 157 in neutropenic patients and 69 in non neutropenic. Catheter related bacteremias were diagnosed in 65/226 episodes (29%): 23 (35%) were observed in neutropenic patients and 42 (65%) in non neutropenic (P < 0.005). Gram-positive pathogens were isolated in 28/65 (43%) episodes, Gram-negatives in 15/65 (23%), fungi in 9/65 (14%), and the remaining 13 (20%) were polymicrobial. In the last years we observed an increase of catheter related bacteremias due to Gram-negative rods no change was observed in pathogens causing catheters unrelated bacteremias. The high incidence of catheters related bacteremias in non neutropenic, non hospitalized patients, stress on the home-care of the catheters; a high level of suspicion of Gram-negative infections should be maintained in cancer patients with an indwelling central venous catheters.

[Diabetic foot. A clinical case]

Diabetic neuropathy may cause an alteration of the function of the muscles of the sole of the foot. This is at the origin of the chronic dislocation of the articular heads, mainly of the little metatarsal bones (neuro diabetes arthropathy), with formation of areas of pathological pressure. The tissues below being chronically under pressure are affected by trophic lesions called "plantar perforating disease". Recovery may be obtained by not exposing the injured area of the foot to pressure and through careful local therapy. This doesn't prevent disease from appearing again, even though some specially conceived soles are being used, aiming at a correct weight redistribution on the sole of the foot. The clinical case we are describing applies to a man affected by insulin dependent diabetes mellitus, with relapsing diabetic foot ulcers, in spite of him using a specifically designed sole. Such lesion is aggravated by a serious infection which, by gradually penetrating in depth, leads to osteomyelitis, affecting the 5th Metatarsal head. The bone area, dislocated by neuroarthropathy, was presumably responsible for the persisting plantar lesion. The amputation of this infected necrotic structure, has led to the overcoming of the serious septic problem. By eliminating the bone link responsible for the transmission of the pathological pressure, the plantar lesion the patient had been suffering from for a long time, has consequently disappeared.