Pediatric nutritional surgery and its implications: results from a unicentric retrospective analysis

PURPOSE

Existing guidelines provide weak recommendations on the surgical management of nutritional problems in children. The objective was to design a management pathway to address the best nutritional surgery (NS) procedure in a given patient.

METHODS

Retrospective analysis of children treated at our department from January 2015 to December 2019. The sample was divided into two groups according to presence or absence of neurological impairment (NI). Patients with NI (Group 1) were classified in three subgroups based on presenting symptoms: A-Dysphagia without gastroesophageal reflux (GER); B-GER with or without dysphagia; C-Symptoms associated with a delayed gastric emptying.

RESULTS

A total of 154 patients were included, 111 with NI. One-hundred-twenty-eight patients underwent only one procedure. Complications and mortality were superior in Group 1. In subgroup A, isolated gastrostomy was the first NS in all patients. In subgroup B most of patients were subjected to a Nissen fundoplication, while in 5 cases total esophagogastric dissociation (TEGD) was the first intervention. Considering the entire sample, 92.3% patients who underwent a TEGD did not require further procedures.

CONCLUSION

NS encompasses various procedures depending on presenting symptoms and neurological status. A management flowchart for these patients is proposed.

Laparoscopic ovarian tissue collection for fertility preservation in children with malignancies: a multicentric experience

Introduction

Long survivors after childhood cancer are increasing thanks to oncological improvements. Their quality of life and fertility-sparing should be considered in the early phases of each oncological pathway. Cryopreservation of ovarian tissue removed before starting gonadotoxic therapies is the only fertility sparing procedure available for prepubertal children affected by cancer and it does not affect the timing of the start of the treatment.

Materials and methods

The present study shows the surgical and clinical outcomes following laparoscopic ovarian tissue collection (LOTC) for a total of 311 patients aged between 0 and 17 years old from four different European Centers.

Results

Only two major complications were reported according to the Clavien Dindo classification (0.6%).

Discussion

LOTC can be considered a safe procedure.

Enterostomy-related complications in Hirschsprung's disease in a single cohort

BACKGROUND

Hirschsprung's disease (HSCR) is a frequent cause of intestinal obstruction in children and may require an enterostomy. The study aimed to describe the most common enterostomy-related complications in a series of patients treated in a single center.

METHODS

A series of consecutive HSCR patients treated or followed-up at our institution between January 1993 and December 2016 were included. Data about HSCR type, enterostomy site, duration and complications of the stoma were recorded.

RESULTS

Three hundred one patients with HSCR were followed-up. Sixty-one had ultralong forms (TCSA/TIA), 21 had long forms (L-HSCR) and 219 had classic short forms (S-HSCR). One hundred thirty-seven patients required a stoma (100% of patients with TCSA/TIA, 66.7% with L-HSCR and 28.3% with S-HSCR). We observed 64 stoma-related complications: 36 major complications and 28 minor complications. Major complications occurred more often in long forms (P=0.037). The presence of an ileostomy was statistically associated with an increased rate of complications compared to colostomy. The longer the stoma was in site, the higher the complication rate was.

CONCLUSIONS

Long and ultra-long forms are associated with a longer duration of the stoma and to a major risk of stoma-related complications.

Beyond image defined risk factors (IDRFs): a delphi survey highlighting definition of the surgical complexity index (SCI) in neuroblastoma

PURPOSE

Preoperative evaluation of Image Defined Risk Factors (IDRFs) in neuroblastoma (NB) is crucial for determining suitability for upfront resection or tumor biopsy. IDRFs do not all carry the same weighting in predicting tumor complexity and surgical risk. In this study we aimed to assess and categorize a surgical complexity (Surgical Complexity Index, SCI) in NB resection.

METHODS

A panel of 15 surgeons was involved in an electronic Delphi consensus survey to identify and score a set of shared items predictive and/or indicative of surgical complexity, including the number of preoperative IDRFs. A shared agreement included the achievement of at least 75% consensus focused on a single or two close risk categories.

RESULTS

After 3 Delphi rounds, agreement was established on 25/27 items (92.6%). A severity score was established for each item ranging from 0 to 3 with an overall SCI range varying from a minimum score of zero to a maximum score of 29 points for any given patient.

CONCLUSIONS

A consensus on a SCI to stratify the risks related to neuroblastoma tumor resection was established by the panel experts. This index will now be deployed to critically assign a better severity score to IDRFs involved in NB surgery.

A Novel Standard for Systematic Reporting of Neuroblastoma Surgery: The International Neuroblastoma Surgical Report Form (INSRF): A Joint Initiative by the Pediatric Oncological Cooperative Groups SIOPEN∗, COG∗∗, and GPOH∗∗∗

OBJECTIVE

To create the first structured surgical report form for NBL with international consensus, to permit standardized documentation of all NBL-related surgical procedures and their outcomes.

SUMMARY OF BACKGROUND DATA

NBL, the most common extracranial solid malignant tumor in children, covers a wide spectrum of tumors with significant differences in anatomical localization, organ or vessel involvement, and tumor biology. Complete surgical resection of the primary tumor is an important part of NBL treatment, but maybe hazardous, prone to complications and its role in high-risk disease remains debated. Various surgical guidelines exist within the protocols of the different cooperative groups, although there is no standardized operative report form to document the surgical treatment of NBL.

METHODS

After analyzing the treatment protocols of the SIOP Europe International Neuroblastoma Study Group, Children's Oncology Group, and Gesellschaft fuer Paediatrische Onkologie und Haematologie - German Association of Pediatric Oncology and Haematology pediatric cooperative groups, important variables were defined to completely describe surgical biopsy and resection of NBL and their outcomes. All variables were discussed within the Surgical Committees of SIOP Europe International Neuroblastoma Study Group, Children's Oncology Group, and Gesellschaft fuer Paediatrische Onkologie und Haematologie - German Association of Pediatric Oncology and Haematology. Thereafter, joint meetings were organized to obtain intercontinental consensus.

RESULTS

The "International Neuroblastoma Surgical Report Form" provides a structured reporting tool for all NBL surgery, in every anatomical region, documenting all Image Defined Risk Factors and structures involved, with obligatory reporting of intraoperative and 30 day-postoperative complications.

CONCLUSION

The International Neuroblastoma Surgical Report Form is the first universal form for the structured and uniform reporting of NBL-related surgical procedures and their outcomes, aiming to facilitate the postoperative communication, treatment planning and analysis of surgical treatment of NBL.

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.

A mathematical model of ctDNA shedding predicts tumor detection size

Early cancer detection aims to find tumors before they progress to an incurable stage. To determine the potential of circulating tumor DNA (ctDNA) for cancer detection, we developed a mathematical model of tumor evolution and ctDNA shedding to predict the size at which tumors become detectable. From 176 patients with stage I to III lung cancer, we inferred that, on average, 0.014% of a tumor cell's DNA is shed into the bloodstream per cell death. For annual screening, the model predicts median detection sizes of 2.0 to 2.3 cm representing a ~40% decrease from the current median detection size of 3.5 cm. For informed monthly cancer relapse testing, the model predicts a median detection size of 0.83 cm and suggests that treatment failure can be detected 140 days earlier than with imaging-based approaches. This mechanistic framework can help accelerate clinical trials by precomputing the most promising cancer early detection strategies.

Pheochromocytomas and paragangliomas in children: Data from the Italian Cooperative Study (TREP)

BACKGROUND

Pheochromocytomas (PCs) are neuroendocrine tumors arising from the chromaffin cells of the adrenal gland, and paragangliomas (PGLs) are their extra-adrenal counterparts arising from ganglia along the sympathetic/parasympathetic chain. Surgery is the cornerstone of treatment. A sporatic or inherited germline mutation is commonly associated.

MATERIALS AND METHODS

Among over 1000 patients registered into the Tumori Rari in Età Pediatrica-rare tumors in pediatric age project-from 2000 to 2019, 50 were affected by PC/PGL. All clinical and therapeutic data were evaluated.

RESULTS

Twenty-eight patients had PC and 22 had PGL. Age at diagnosis ranged between 5 and 17 years. Thirty-five patients had symptoms related to catecholamine hypersecretion; in 7 of 50 patients, diagnosis was incidental or done during assessment of a familial syndrome. In all cases, conventional imaging was effective to assess the presence of a tumor. In addition, 18 of 38 functional imaging studies were positive (61%). Forty-eight patients were eligible for surgery: a complete resection was more frequently achieved in PC than in PGL (26/28 vs 11/22). All relapses were treated with surgery alone, surgery plus medical treatment, or chemotherapy alone; one PC with metastasis at diagnosis received radiotherapy only. Forty-four patients were in the first, second, or third complete remission (10/50 recurred; 8/10 carried a germline mutation). Five of 50 patients were alive with disease. One patient died of disease.

CONCLUSIONS

Surgery can be curative in most tumors but it may not be always effective in removing PGLs. Severe postsurgical sequelae may affect these patients. Genetic tests should always be considered in individuals affected, and genetic counseling should be offered to their families.

Influence of Surgical Excision on the Survival of Patients With Stage 4 High-Risk Neuroblastoma: A Report From the HR-NBL1/SIOPEN Study

PURPOSE

To evaluate the impact of surgeon-assessed extent of primary tumor resection on local progression and survival in patients in the International Society of Pediatric Oncology Europe Neuroblastoma Group High-Risk Neuroblastoma 1 trial.

PATIENTS AND METHODS

Patients recruited between 2002 and 2015 with stage 4 disease > 1 year or stage 4/4S with MYCN amplification < 1 year who had completed induction without progression, achieved response criteria for high-dose therapy (HDT), and had no resection before induction were included. Data were collected on the extent of primary tumor excision, severe operative complications, and outcome.

RESULTS

A total of 1,531 patients were included (median observation time, 6.1 years). Surgeon-assessed extent of resection included complete macroscopic excision (CME) in 1,172 patients (77%) and incomplete macroscopic resection (IME) in 359 (23%). Surgical mortality was 7 (0.46%) of 1,531. Severe operative complications occurred in 142 patients (9.7%), and nephrectomy was performed in 124 (8.8%). Five-year event-free survival (EFS) ± SE (0.40 ± 0.01) and overall survival (OS; 0.45 ± 0.02) were significantly higher with CME compared with IME (5-year EFS, 0.33 ± 0.03; 5-year OS, 0.37 ± 0.03; P < .001 and P = .004). The cumulative incidence of local progression (CILP) was significantly lower after CME (0.17 ± 0.01) compared with IME (0.30 ± 0.02; P < .001). With immunotherapy, outcomes were still superior with CME versus IME (5-year EFS, 0.47 ± 0.02 v 0.39 ± 0.04; P = .038); CILP was 0.14 ± 0.01 after CME and 0.27 ± 0.03 after IME (P < .002). A hazard ratio of 1.3 for EFS associated with IME compared with CME was observed before and after the introduction of immunotherapy (P = .030 and P = .038).

CONCLUSION

In patients with stage 4 high-risk neuroblastoma who have responded to induction therapy, CME of the primary tumor is associated with improved survival and local control after HDT, local radiotherapy (21 Gy), and immunotherapy.

Abstract PR01: ctDNA shedding dynamics dictate early lung cancer detection potential

Early cancer detection aims to find tumors before they progress to an incurable stage. Prospective studies with tens of thousands of healthy participants are ongoing to determine whether asymptomatic cancers can be accurately detected by analyzing circulating tumor DNA (ctDNA) from blood samples. We developed a stochastic mathematical model of tumor evolution and ctDNA shedding to investigate the potential and the limitations of ctDNA-based cancer early detection tests. We inferred ctDNA shedding rates of early-stage lung cancers and calculated that a 15-mL blood sample contains on average only 1.5 genome equivalents (GE) of ctDNA for lung tumors with 1 billion cells (concentration of 0.19 GE per plasma mL; tumor fraction of 0.02%). This low level of ctDNA can be explained by the relatively low turnover rate of lung cancer cells. Similarly, fast-growing tumors led to lower levels of ctDNA because a lower number of cell death events decreases the amount of released ctDNA. We designed a detection test of virtual tumors that accounts for the varying plasma DNA concentrations in cancer and cancer-free patients and that incorporates various sources for technical and biologic errors. Two important considerations for disease detection are the expected number of mutations per tumor covered by the sequencing panel and the underlying error rate of the sequencing assay. To determine the potential performance of mutation-based ctDNA detection tests, we computed receiver operating characteristic (ROC) curves and calculated area under the curve (AUC) values. In the case of early relapse detection, we assumed that the sequencing panel covers 20 known clonal mutations per primary tumor with a background error-rate of 1.5 × 10−5 per base pair. For monthly relapse testing with a specificity of 99.5%, we found a median detection size of 0.19 cm3. Moreover, we observed a lead time of 180 days compared to monthly imaging-based relapse detection. While tracking fewer than 20 mutations drastically decreased the expected lead time, tracking more than 20 mutations only minimally increased the expected lead time. Similarly, the increases in lead time gained slowed down for more frequent testing than one month for relapsing tumors with a growth rate of 1%. In the case of cancer screening, we assumed that the sequencing panel has the same error rate as above and covers 2,000 base pairs, resulting in approximately one detectable mutation per lung cancer, which is similar to the CancerSEEK panel. For an annual screening test with a specificity of 99.5%, we found a median lung cancer detection size of 4.4 cm3. This detection size constitutes a more than 80% reduction from the current median detection size of 22.5 cm3 for lung cancers and suggests a potential lead time of 410 days. This mathematical framework provides a mechanistic interpretation of ctDNA-based test results and informs the design of future screening and relapse detection initiatives across cancer types and subpopulations with varying risks.

This abstract is also being presented as Poster A01.

Citation Format: Stefano Avanzini, David M. Kurtz, Jacob J. Chabon, Sharon S. Hori, Ash A. Alizadeh, Maximilian Diehn, Johannes G. Reiter. ctDNA shedding dynamics dictate early lung cancer detection potential [abstract]. In: Proceedings of the AACR Special Conference on Advances in Liquid Biopsies; Jan 13-16, 2020; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(11_Suppl):Abstract nr PR01.

Thoraco-abdominal neuroblastoma resection: the thoracophrenolaparotomic (TPL) approach

OBJECTIVE

The aim of the present study is to describe, for the first time in paediatric age, the technique and the outcomes of the thoracophrenolaparotomic (TPL) approach for surgical resection of thoraco-abdominal neuroblastomas (NBs) in children.

METHODS

A retrospective study was performed analysing clinical features and surgical outcomes of all children undergoing surgical resection of thoraco-abdominal NBs via the TPL approach in our third referral children's hospital, from January 2010 to November 2018. The details of the surgical technique were also reported.

RESULTS

5 children suffering from thoraco-abdominal NBs (n = 4 stage L2, n = 1 stage M-according to the International Neuroblastoma Risk Group Staging System, INRGSS-and n = 4 stage 3, n = 1 stage 4-according to International Neuroblastoma Staging System, INSS) underwent the TPL approach at a mean age of 72 months (range 27-180 months). The surgical procedure was performed in a mean operative time of 5 h 57 min (range 2 h 56 min-9 h) without any major intraoperative or postoperative complications. Following 24 h in intensive care unit, all patients were safely discharged in a mean time of 12 days (range 4-21 days). All patients were alive, without any tumour relapse, at the last follow-up visit (mean 3.2 years, range 1-7 years).

CONCLUSION

This is the first study reporting the excellent surgical results we gained applying the TPL approach for surgical excision of multi-compartment tumours in children, allowing a gross total resection without intra- or post-operative complications.

CONSERVATIVE MANAGEMENT OF CHYLOUS ASCITES AFTER ONCOLOGICAL SURGERY FOR PERIPHERAL NEUROBLASTIC TUMORS IN PEDIATRIC PATIENTS

Chylous ascites may complicate the postoperative course of abdominal surgery mainly due to the iatrogenic disruption of the lymphatic channels during extensive retroperitoneal dissection. Sparse data are available regarding treatment; however, in many cases a recommended first-line treatment approach is by way of enteral feeding, consisting of a formula high in medium-chain triglycerides (MCTs) together with a complete total parenteral nutrition teamed with somatostatin (or an equivalent). Nonetheless, the ligation of chylous fistulae, together with the application of Fibrin glue, as well as the creation of peritoneal-venous shunts have also been documented. The aims of this study are to document incidence of postoperative chylous ascites following resection of abdominal peripheral neuroblastic tumors, evaluate efficacy of the management of chylous ascites, and investigate the main risk factors. A survey was carried out over a span of six years, from March 2010 to March 2016 at Giannina Gaslini Children's Hospital involving seventy-seven children with resections of peripheral neuroblastic tumors. Incidence rate of postoperative chylous ascites following a normal diet was 9% (n=7). Treatment using total parenteral nutrition with octreotide resulted in a complete recovery from chylous ascites within a 20 day period without recurrence. Length of operative time, nephrectomy, and the extension of lymphadenectomy were all significantly associated with a higher incidence of postoperative chylous ascites (p&lt;0.05) which also lengthened hospital stay (p&lt;0.05) and possibly delayed beginning adjuvant chemotherapy.

Conservative management of chylous ascites after oncological surgery for peripheral neuroblastic tumors in pediatric patients

Chylous ascites may complicate the postoperative course of abdominal surgery mainly due to the iatrogenic disruption of the lymphatic channels during extensive retroperitoneal dissection. Sparse data are available regarding treatment; however, in many cases a recommended first-line treatment approach is by way of enteral feeding, consisting of a formula high in medium-chain triglycerides (MCTs) together with a complete total parenteral nutrition teamed with somatostatin (or an equivalent). Nonetheless, the ligation of chylous fistulae, together with the application of Fibrin glue, as well as the creation of peritoneal-venous shunts have also been documented. The aims of this study are to document incidence of postoperative chylous ascites following resection of abdominal peripheral neuroblastic tumors, evaluate efficacy of the management of chylous ascites, and investigate the main risk factors. A survey was carried out over a span of six years, from March 2010 to March 2016 at Giannina Gaslini Children's Hospital involving seventy-seven children with resections of peripheral neuroblastic tumors. Incidence rate of postoperative chylous ascites following a normal diet was 9% (n=7). Treatment using total parenteral nutrition with octreotide resulted in a complete recovery from chylous ascites within a 20 day period without recurrence. Length of operative time, nephrectomy, and the extension of lymphadenectomy were all significantly associated with a higher incidence of postoperative chylous ascites (p<0.05) which also lengthened hospital stay (p<0.05) and possibly delayed beginning adjuvant chemotherapy.

A Metagenomics Study on Hirschsprung's Disease Associated Enterocolitis: Biodiversity and Gut Microbial Homeostasis Depend on Resection Length and Patient's Clinical History

Objectives: Since 2010, several researches demonstrated that microbiota dynamics correlate and can even predispose to Hirschsprung (HSCR) associated enterocolitis (HAEC). This study aims at assessing the structure of the microbiota of HSCR patients in relation to extent of aganglionosis and HAEC status. Methods: All consecutive HSCR patients admitted to Gaslini Institute (Genova, Italy) between May 2012 and November 2014 were enrolled. Institutional review board (IRB) approval was obtained. Stools were sampled and 16S rDNA V3-V4 regions were sequenced using the Illumina-MiSeq. Taxonomy assignments were performed using QIIME RDP. Alpha diversity indexes were analyzed by Shannon and Simpson Indexes, and Phylogenetic Diversity. Results: We enrolled 20 patients. Male to female ratio was 4:1. Six patients suffered from Total Colonic Aganglionosis (TCSA). Considering sample site (i.e., extent of aganglionosis), we confirmed the known relationship between sample site and both biodiversity and composition of intestinal microbiota. Patients with TCSA showed lower biodiversity and increased Proteobacteria/Bacteroidetes relative abundance ratio. When addressing biodiversity, composition and dynamics of TCSA patients we could not find any significant relationship with regard to HAEC occurrences. Conclusions: The composition of HAEC predisposing microbiota is specific to each patient. We could confirm that total colon resections can change the composition of intestinal microbiota and to dramatically reduce microbial diversity. The subsequent reduction of system robustness could expose TCSA patients to environmental microbes that might not be part of the normal microbiota. Future long-term studies should investigate both patients and their family environment, as well as their disease history.

Antibiotic prophylaxis in children undergoing abdominal surgery for neoplastic diseases

Little is known about the effectiveness of antibiotic prophylaxis for prevention of surgical site infections (SSIs) in paediatric abdominopelvic surgical oncology. A retrospective analysis was performed upon the incidence of SSIs in children receiving a 24-hour antibiotic prophylaxis with cefazolin for abdominopelvic oncological surgery. In all, 145 patients (57% females) with a median age of 4 years underwent surgical procedures for abdominopelvic tumours. No SSIs were detected, despite the various risk factors known to be associated with their occurrence (such as pre- and post- surgical chemotherapy, long hospitalization, intensive care unit admission and drain placement). Cefazolin prophylaxis seems to be safe and effective in preventing SSIs in children undergoing abdominopelvic surgery for oncological diseases.

Complete Posterior Sagittal Anorectal Mobilization (PSAM): A new surgical approach for pediatric pelvic-perineal tumor resections

INTRODUCTION

Diffuse or massive tumors involving the perineal and pelvic compartments may require aggressive surgical treatment in children. The authors, propose and present their results using a Posterior Sagittal Anorectal Mobilization (PSAM) METHODS: The oncologic patient is placed in a prone position with the pelvis elevated, without a previous colostomy. A 10 Ch bladder catheter is positioned. A midline sagittal incision is performed from the coccyx to the posterior margin of the anus. Fine electrocautery is used to obtain an accurate dissection all around the anal margin itself. The incisional so involves the midline dissection into the perineal body. Reconstruction is achieved by the classical pelvic-perineal anatomical structure approximation.

RESULTS

The authors describe for the first time a novel posterior anorectal mobilization technique for four children with pelvic-perineal tumors. No intraoperative or post-operative complications occurred. The oldest boy presented at follow-up a complete normal faecal and urinary continence (Krickenbeck criteria).

CONCLUSION

The presented technical approach, defined as PSAM, is completely suitable for surgical resection of perineal-pelvic tumors, without the need of more invasive operations including transpubic dissection and/or anorectal split. Moreover, nervous and muscular sphincter structures are easily identified and preserved.

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.

Perioperative management of hypertensive neuroblastoma: A study from the Italian Group of Pediatric Surgical Oncologists (GICOP)

BACKGROUND

Hypertension (HT) is rarely reported in patients affected by Neuroblastoma (NB), and management guidelines are lacking. Clinical features and perioperative medical treatment in such patients were reviewed to 1) ascertain whether a shared treatment strategy exists among centers and 2) if possible, propose some recommendations for the perioperative management of HT in NB patients.

METHODS

A retrospective multicenter survey was conducted on patients affected by NB who presented HT symptoms.

RESULTS

From 2006 to 2014, 1126 children were registered in the Italian Registry of Neuroblastoma (RINB). Of these, 21 with HT (1.8%) were included in our analysis. Pre- and intraoperative HT management was somewhat dissimilar among the participating centers, apart from a certain consistency in the intraoperative use of the alpha-1 blocker urapidil. Six of the 21 patients (28%) needed persistent antihypertensive treatment at a median follow-up of 36months (range 4-96months) despite tumor removal. Involvement of the renal pedicle was the only risk factor constantly associated to HT persistency following surgery. A correlation between the presence of HT and the secretion of specific catecholamines and/or compression of the renal vascular pedicle could not be demonstrated.

CONCLUSION

Based on this retrospective review of NB patients with HT, no definite therapeutic protocol can be recommended owing to heterogeneity of adopted treatments in different centers. A proposal of perioperative HT management in NB patients is however presented.

LEVEL OF EVIDENCE

IV.

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.

Management of nontuberculous mycobacterial lymphadenitis in a tertiary care children's hospital: A 20year experience

PURPOSE

Nontuberculous mycobacteria are uncommon cause of chronic cervicofacial lymphadenitis in healthy children. We describe clinical features and management strategies of cervicofacial nontuberculous mycobacterium lymphadenitis in a tertiary pediatric hospital.

METHODS

Retrospective analysis of medical records of children discharged from 1992 to 2014 with a diagnosis of cervicofacial nontuberculous mycobacterium was made. Diagnosis certainty was based on microhistological investigations. Clinical stage was evaluated according to lymph node size and presence of fistulas. Successful therapy was defined by the regression of the lymph node enlargement (>75%) or complete surgical excision without relapse.

RESULTS

Cervicofacial nontuberculous mycobacterium was diagnosed in 33 patients. Complete excision was performed in 73% of cases primarily observed in our hospital, while 83% of those referred from other hospitals required further surgical treatment. No case of relapse was observed after one year of follow-up.

CONCLUSIONS

We recommend surgical approach as the first therapeutic option in the management of cervicofacial nontuberculous mycobacterium lymphadenitis.

LEVELS OF EVIDENCE

Prognosis and Retrospective Study - Level II.

Brachiocephalic vein for percutaneous ultrasound-guided central line positioning in children: A 20-month preliminary experience with 109 procedures

BACKGROUND

Ultrasound-guided (USG) cannulation of the brachiocephalic vein (BCV) is gaining worldwide consensus for central venous access in children. This study reports a 20-month experience with this approach in children.

METHODS

All patients who underwent percutaneous USG central venous catheter (CVC) positioning in the BCV between August 2013 and March 2015 have been included. Devices inserted during this period were open-ended, either single or double-lumen tunneled CVC. Our series was divided into three consecutive study periods in order to determine the relative incidence of repositioning and complications.

RESULTS

During the study period, a total of 95 patients underwent 109 CVC insertions in the BCV. The median length of CVC duration was 230 days for a total of 23,212 catheter days. No major intraoperative complications occurred. Overall rate of CVC-related postoperative complications requiring repositioning or precocious removal was 0.90 per 1,000 catheter days and involved 21 CVC (19%, 95% confidence interval 13-28). These included 18 dislodgments, two infections, and one malfunction. Double-lumen CVCs represented the only significant risk factor for complications (52% complications-three per 1,000 catheter days).

CONCLUSION

USG supraclavicular cannulation of the BCV represents a safe approach for central line placement in children. It proved to be versatile, as it can be used in premature infants as well as in adolescents. Provided it is adopted by operators experienced in USG cannulation, we strongly suggest to resort to this approach as a first-line choice in children undergoing tunnelled central line placement for long-lasting therapy.

Sixteen years of experience with persistent chylothorax in children

BACKGROUND

Persistent chylothorax in children is rare. Conservative management represents the gold standard but, in case of failure (persistent effusion or relapse), surgery must be considered. This paper aimed at presenting our series of patients who underwent surgical treatment of persistent idiopathic chylothorax and at discussing the role of thoracic duct ligation in its management.

METHODS

We included all patients who underwent surgery for persistent chylothorax in the period between January 1994 and January 2010.

RESULTS

Nine patients were included (median age 25 months). Five patients had primitive or idiopathic chylothorax. Five patients had right-sided chylothorax, 3 left-sided, and 1 bilateral. Pleurodesis was applied to 8 patients (bilateral in one) and thoracic duct ligation to 4 patients for a total of 12 procedures in 9 patients. Complete cessation occurred within a median of 5 days (range 2 to 10) after thoracic duct ligation and 10 days (range 4 to 25) after pleurodesis. In 3 patients (all with right sided effusion and a median daily output higher than 20 ml/kg) pleurodesis failed and thoracic duct ligation was subsequently required to definitively treat chylothorax. Conversely, 5 patients were effectively treated with pleurodesis and 1 with thoracic duct ligation alone. Regardless of previous procedures, none of the patients who underwent thoracic duct ligation experienced relapses.

CONCLUSIONS

Although based on a small number of patients, our experience confirmed that thoracic duct ligation represents an effective therapeutic option for persistent unresponsive chylothorax. In cases of right sided effusion with high output rate (>20 mL/kg) thoracic duct ligation might be considered as first choice treatment.

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.

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.

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.

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.

Provisional unicentric experience with an electronic incident reporting form in pediatric anesthesia

OBJECTIVE

To present and compare with literature our experience with an electronic anesthesia-related incident reporting form as a quality control measure at Gaslini Children's Hospital over a 19-month period.

METHODS

All events that occurred between March 2009 and September 2010 were recorded. We adopted an electronic reporting form included in the online recording process of every anesthetic procedure. Events were divided into near misses and adverse events. Adverse events were further divided into incidents, minor events, and major events. Patients were divided into three age-groups: <1, between 1 and 3, and >3 years.

RESULTS

A total of 12,850 anesthetics were performed. Eight (0.06%) near misses and 108 (0.8%) adverse events were reported. Adverse events occurred more frequently in infants. Of 108 events, 35 (32.4%), 61 (56.5%), and 12 (11.1%) were classified as incidents, minor, and major events, respectively. Of all the adverse events, 66 (61%) were respiratory, 27 (25%) organizational, six (5%) drug-related, four (4%) cardiocirculatory, and five (5%) miscellaneous.

CONCLUSIONS

Infants were at the highest risk to experience adverse events. Although experimental electronic incident reporting proved to be feasible, there is reason to suspect that there was underreporting of near misses. Overreporting of near miss events may be enhanced by easier and more straightforward reporting forms as well as by better education for anesthetic providers about the importance of recognizing and reporting near misses.

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 the length of the history influence the outcome of pneumatic reduction of intussusception in children?

PURPOSE

Intussusception is the most common cause of acute abdomen in infants and preschool children. Nonoperative reduction using air enema is an established treatment in children with intussusception. The aim of this study was to determine whether length of the history influences the outcome of pneumatic reduction of intussusception in children?

METHODS

The medical records of 256 consecutive children with intussusception between July 1998 and June 2010, who underwent air enema reduction regardless of the length of the history were reviewed. In all 256 patients, intussusception was confirmed by ultrasound before proceeding to air enema.

RESULTS

The length of history ranged from 2 to 240 h with median time of 18.5 h. The median age in 256 patients was 7 months (range 1 day to 12 years). The presenting clinical features included irritability/abdominal pain (77%), vomiting (80%), bleeding per rectum (36%) and palpable abdominal mass (50%). Air enema reduction was successful in 234 (91.5%) of the 256 patients. In 22 (8.5%) patients, air enema failed to reduce the intussusception and 3 (1.1%) of these patients had colonic perforation during the procedure. All 22 patients required surgery. The duration of symptoms did not influence the outcome of pneumatic reduction. 37 (14%) patients developed recurrence after successful pneumatic reduction of intussusception, with 58% presenting within 48 h of the initial procedure.

CONCLUSION

Our data suggest that pneumatic reduction should be first-line treatment in all children with intussusception regardless of the length of the history.

Hirschsprung's disease: what about mortality?

PURPOSE

Although significantly decreased during last decades, mortality rate for Hirschsprung's disease still ranges between 1 and 10%. The authors reviewed the main features of patients with Hirschsprung's disease treated in our Institution who died in the period between 1993 and 2010 in order to detect possible risk factors or prevention strategies.

METHODS

The notes of all patients with Hirschsprung's disease admitted to our Institution between January 1993 and January 2010 were reviewed. All families were interviewed and possible unknown deaths were recorded. We reported demographic data, length of aganglionosis, type and number of associated anomalies, age and type of onset, age and cause of death, chronological relationship between death and pull-through, and all other significant details.

RESULTS

Eight out of a series of 313 patients with Hirschsprung's disease died during the study period (mortality rate = 2.56%). Six patients were male for a male to female ratio of 3:1. Eleven associated anomalies were detected in five patients, including four congenital anomalies of the kidney and urinary tract, four heart, two central nervous system, and one skeletal malformations. One patient had Down Syndrome and one Cat Eye Syndrome. Two patients were born preterm. All patients had neonatal onset with delayed meconium passage. Five patients had aganglionosis confined to rectosigmoid colon (classic forms), two had total colonic aganglionosis and one had total intestinal aganglionosis. Enterostomy was performed in five patients. Median age at death was 75 days (range 30 days-8 years). The cause of death was enterocolitis in four patients, heart failure in three, and intestinal failure in one. Six patients died before the pull-through. Two patients died postoperatively. All patients but two died at home.

CONCLUSIONS

Onset and clinical features do correlate with severity. Newborns and infants seem to be more likely to develop serious life-threatening complications, particularly in case of associated cardiovascular malformations. Although enterostomies do not have protective effects over cardiovascular issues, prophylactic stoma should be considered in high-risk patients. Radical treatment (pull-through) should be performed as soon as possible. Alternatively, protected and cautious discharge of newborns with associated heart anomalies is strongly recommended in order to prevent serious and uncontrolled complications, regardless of the presence of a protective enterostomy. Postoperatively, close follow-up appointments are recommended. Families should be acknowledged and educated for prompt recognition and treatment of severe life-threatening complications.

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.

Genomics approach to the analysis of bacterial communities dynamics in Hirschsprung's disease-associated enterocolitis: a pilot study

INTRODUCTION

The most invalidating and life-threatening complication in Hirschsprung's disease patients (HSCR) is Hirschsprung's disease-associated enterocolitis (HAEC). The mechanisms underlying enterocolitis have not been identified. The limited knowledge of the role of intestinal microflora is in part due to the complexity of the intestinal microbiome and to the limitation of cultivation-based technologies, given that less than 25% of the intestinal bacterial species can be cultured.

MATERIALS AND METHODS

We used amplified ribosomal DNA restriction analysis (ARDRA) with four different restriction enzymes to study variations of microflora composition of the stools of a selected HSCR patient in different clinical conditions (acute phase vs. remission).

RESULTS

We assessed a total of 15 stool specimens belonging to the same 3-year-old male patient suffering from HSCR, which were harvested during 4 HAEC episodes and remission phases. Restriction analysis showed that HAEC episodes seem to cluster together at ARDRA analysis, thus suggesting a sort of predisposing bacterial community for HAEC development and the need for a microflora equilibrium to maintain wellness.

CONCLUSIONS

This approach proved to be effective, useful and powerful in assessing microflora dynamics and indicated that the differences in microflora associated with acute HAEC or remission are likely to result from a combination of disease activity and different antibiotic therapies. ARDRA proved to be useful in discriminating disease versus remission. Our findings indicated that HAEC results from a change in the equilibrium between bacterial species or from altered discrimination of harmless from harmful microorganisms, challenging the definition of pathogenic and non-pathogenic species. Based on these results, we propose ARDRA as a rapid inexpensive tool to assess microflora dynamics during HAEC episodes.

Nephrectomy for multicystic dysplastic kidney and renal hypodysplasia in children: where do we stand?

OBJECTIVES

Little is reported in literature regarding correct management of benign lesions of the kidney. The aim of our study is to present a series of total and partial nephrectomies performed in the last 5 years and to discuss indications.

MATERIALS AND METHODS

Patients with benign lesions who underwent nephrectomy and partial nephrectomy at our institution in the period 2003-2008 were retrospectively included in the study. Notes were carefully reviewed and demographic data, symptoms onset, preoperative diagnosis, investigations, medical and/or surgical treatment, postoperative complications and definitive histological reports were collected.

RESULTS

Forty procedures were performed. Twelve patients were preoperatively diagnosed of having multicystic dysplastic kidney (MCDK), which was confirmed in 10, whereas the remaining 28 patients of having severe dysplasia or hypodysplasia. Thirty-four patients underwent total nephrectomy, six underwent partial nephrectomy. Histopathological analysis confirmed segmental or complete abnormalities of the involved kidney in all cases. No malignancies were detected.

DISCUSSION

Our study confirmed the extremely low malignancy rate of MCDK and hypodysplastic kidneys. The 20% mismatch of pre- and post-operative diagnosis suggests a common aetiology and shared therapeutic strategies for MCDK and hypodysplasia. At present, there is no consensus regarding correct indications for nephrectomy in paediatric age. As nephrectomy seems not to provide any advantage over preservation, but surgical and anesthesiological risks, we should be prudent in preserving every asymptomatic poorly or non-functioning kidneys maintaining a strict follow-up. Randomised controlled studies on larger multicentric series are strongly warranted to define this topic.

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.

Redo surgery in Hirschsprung disease: what did we learn? Unicentric experience on 70 patients

PURPOSE

This article is aimed at describing a series of 70 patients who underwent a redo pull-through in the period between January 1991 and January 2007 and to compare them with a series of consecutive patients with Hirschsprung disease who underwent a single pull-through.

METHODS

The notes were reviewed, and a comprehensive interview based on a disease-specific questionnaire for continence and quality of life was submitted to all eligible patients. We used a number of consecutive patients who underwent a single pull-through for Hirschsprung disease as control group.

RESULTS

Seventy patients were included. Residual aganglionosis in pulled-through bowel or retained aganglionic rectum represented the indications to reoperation in most cases. Intestinal obstruction represented the leading symptom in more than 60% of patients. We adopted either the endorectal pull-through, the Duhamel, or the Swenson procedure. Thirty-six patients were assessed for long-term outcome. One third experienced complications. Long-term continence was satisfactory in 70%. Enterocolitis, soiling, and perineal excoriations were complained by 30%. Excellent to good perspectives were described by 94%, and excellent to good cosmetic results by 22%. The only significant difference with control group (109 patients) involved cosmetic appearance, whereas soiling, although more frequent, could not be considered significantly increased.

CONCLUSIONS

Patients who experience failure of a pull-through must go through multiple procedures to achieve definitive results. Although overall outcome does not significantly differ from that of a single effective pull-through, great efforts should be made to minimize complications and avoid the need for a redo, which requires experienced surgeons and highly committed families for a longer course of the disease.

Fast-track surgery of the colon in children

INTRODUCTION

The aim of this study is to present the "fast-track" experience in children who underwent colon resection.

MATERIALS AND METHODS

Forty-six children who underwent laparoscopic colon resection were prospectively included in the study. Anomalies of colon innervation and inflammatory bowel disease represented the main surgical indications.

RESULTS

Left colon/sigmoid resection was performed in 37, total colon resection was done in 5, and right colon resection in 4 children. Total colon resection was always associated to ileostomy. Anastomosis was performed in 41 cases. Patients were postoperatively monitored for pain, return to normal activity, feeding, bowel movements, and complications. Stool passage and oral feeding were started on postoperative day 1, and all patients were discharged before postoperative day 4. One child was readmitted the day after discharge because of an anastomotic leak. No other major complications were recorded.

DISCUSSION

Minimally invasive surgery is safe and effective in pediatric colonic surgery and allows a fast recovery time (fast-track).

Spleen surgery in pediatric age: seven-year unicentric experience

BACKGROUND

Either "open" and laparoscopic spleen surgery in pediatric age are well known and performed with ease in children. Yet, few data regarding follow-up and outcome are discussed in the international literature.

MATERIALS AND METHODS

Clinical notes of all patient who underwent spleen surgery in a single center between 2000 and 2007 were reviewed and a specific follow-up questionnaire was administered, aiming to evaluate pre- and postoperative data, especially considering underlying disease, cosmetic results, and quality of life after surgery.

RESULTS

Fifty-one patients underwent spleen surgery in our series, 33 of whom returned a complete follow-up questionnaire and were included in the study. Splenectomy was performed in 26 patients, whereas 7 patients underwent a partial splenectomy; 19 cases (57.6%) were approached laparoscopically. A total of 4 complications (12%) occurred in our series, none of them being intraoperative. Hospital stay resulted as significantly shorter in laparoscopic cases (5.5 +/- 2.9 vs. 8.7 +/- 4.8 days; P < 0.01), with better results in terms of cosmetics. Quality of life is strictly related to underlying disease, as well as long-term survival.

CONCLUSIONS

Whatever surgical approach is adopted, spleen surgery is safe, effective, and reproducible. When feasible, the laparoscopic approach should be preferred to the traditional open approach, as far as efficacy and safety are similar, in order to reduce hospital stay, abdominal wall traumatism, and consequently, improve postoperative pain control and cosmetic results.

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.

Uncommon causes of postoperative chronic diarrhoea mimicking enterocolitis in Hirschsprung's disease: is there a role for digestive endoscopy?

Severe chronic diarrhoea secondary to enterocolitis is a severe complication of Hirschsprung's disease (HSCR). Persistent outlet obstruction, immunologic issues, and mucin/mucous imbalance can cooperate in the development of this complication. Furthermore, isolated reports described severe postoperative chronic diarrhoea mimicking enterocolitis in patients with sucrase-isomaltase deficiency, inflammatory bowel disease (IBD), or intestinal microvillus atrophy. This paper is aimed in describing three patients from our HSCR series who experienced severe chronic postoperative diarrhoea secondary to such uncommon associated anomalies: sucrase-isomaltase deficiency (one patient) and IBD (two patients). With an appropriate sucrose-free diet or immunosuppressive therapy these patients improved dramatically and their diarrhoea settled. These associated anomalies can be diagnosed with digestive endoscopies (both gastro-duodenoscopy and colonoscopy). Therefore, we developed a diagnostic and therapeutic algorithm for patients with chronic diarrhoea after a pull-through, which includes digestive endoscopy to be performed in selected cases.