PARENTERAL NUTRITION IN A GLUT1DS PATIENT FOLLOWING CLASSIC KETOGENIC DIET: IDEAL VERSUS REAL-WORLD MANAGEMENT IN AN ACUTE SURGICAL SETTING

BACKGROUND

GLUT1 deficiency syndrome is a rare neurometabolic disorder, whose current gold standard treatment is represented by ketogenic dietary treatments (KDTs). KDTs are generally administered per os; however, in an immediate gastro-enteric post-surgical setting, short-term parenteral (PN) administration might be required.

CASE REPORT

a 14-year-old boy diagnosed with GLUT1DS and in chronic treatment for many years with KDTs underwent urgent laparoscopic appendectomy. Subsequently, after one day of fasting, PN-KDT was started as the boy was unable to tolerate enteral nutrition postoperatively. On the sixth day, enteral nutrition was progressively reintroduced. Since ad hoc PN-KDTs products were unavailable, the patient received infusion of OLIMEL N4 (Baxter). Outcome was characterized by prompt recovery and no exacerbation of neurological symptoms was observed.

CONCLUSION

we described the first pediatric patient with GLUT1DS in chronic treatment with KDT efficiently treated with exclusive PN for five days. We presented our real word management and the ideal recommendations for PN-KDT in acute surgical setting. This article is protected by copyright. All rights reserved.

Extrarenal testicular Wilms' tumor in a 3-year-old child

We report an extremely rare case of extrarenal testicular Wilms' tumor in a 3-year-old boy with intrabdominal undescended left testis. The patient was admitted because of pain and vomiting, with evidence of a huge abdominal mass. At surgery a large tumor arising from the intrabdominal testis was found. Histology showed the classical triphasic Wilms' tumor elements: epithelial, mesenchymal and blastemal areas. Extrarenal Wilms' tumors account for only 3% of all Wilms' tumors and just -100 cases have been reported in literature. Testicular origin is anecdotic. We present histomorphological, histogenetic, clinical, diagnostic, prognostic and therapeutic features of this rare tumor.

European multicenter survey on the laparoscopic treatment of gastroesophageal reflux in patients aged less than 12 months with supraesophageal symptoms

BACKGROUND

This multicenter survey includes neonates and infants who underwent surgery for primary gastroesophageal reflux (GER) who presented with supraesophageal symptoms of unknown origin with a minimum of 12 months postoperative follow-up.

METHODS

A total of 726 patients underwent GER surgery in 10 European Centers in the period 1998-2002. Respiratory symptoms were present in 204 patients (28%); 135 patients (17%) had surgery under 1 year of age, and 46 of them (6.3%) because of respiratory symptoms. Surgery was performed without any previous medical treatment in 10 cases (21%). The type of procedure included 37 complete 360 degrees wraps (80%) (Nissen, 12, and Rossetti, 25) and nine partial wraps (20%) (Thal five, Lortat Jacob one, Toupet one, others two). Gastrostomy was associated in 17 cases (37%) (6 PEG and 11 modified Stamm). No gastric emptying procedures were recorded.

RESULTS

No major intraoperative complications were reported. Six patients developed complications (13%) and a redo operation was performed in three (6.5%). Respiratory outcome after antireflux surgery was good in 35 patients (76%) and fair with significantly improved respiratory symptoms in 11 (24%).

CONCLUSIONS

This multicenter survey underlines that GER has to be suspected and aggressively treated in infants with difficult-to-treat supraesophageal symptoms, and also in high-risk cases, in order to prevent major complications.

Effectiveness of esophageal manometry in predicting the outcome of children with primary GER after floppy Nissen-Rossetti wrap

BACKGROUND

Surgical treatment of gastroesophageal reflux (GER) can result in many postoperative problems because of an incorrect indication or an unsuitable fundoplication. Many preoperative tests have been suggested to perform a "tailored fundoplication," but there is no clear evidence as to which is the best. The aim of our study was to define the effectiveness of esophageal manometry in predicting the outcome of children who need fundoplication because of refractory primary gastroesophageal reflux.

METHODS

Thirty-two children were included in the study. Patients with gastroenterologic and respiratory symptoms numbered 10 (31%) and 22 (69%), respectively. The preoperative motility pattern was (1) inappropriate relaxations alone in nine patients (28%) and associated with esophageal body dysmotility in one patients (3%); (2) low-pressure lower esophageal sphincter (LES), alone in 13 patients (41%) and associated with body dysmotility in eight (25%). Motility pattern of the esophageal body was abnormal in nine children. Manometric anomalies were absent only in one case.

RESULTS

Low pressure of the LES associated with atypical esophageal motility disorders was significantly higher in the gastroenterological group and in the older patients. Low pressure of the LES associated with good esophageal activity was significantly higher in the respiratory group and in the patients younger than 24 months. There was no correlation between motility pattern and outcome, and no statistically significant differences were found between pressure values at the different levels and symptoms, outcome, and age groups.

CONCLUSIONS

Esophageal manometry is not mandatory to predict the outcome of patients undergoing laparoscopic Nissen-Rossetti fundoplication for refractory primary GER treatment.

Outcome of laparoscopic Nissen-Rossetti fundoplication in children with gastroesophageal reflux disease and supraesophageal symptoms

BACKGROUND

The role of surgery is debated for children with gastroesophageal reflux disease (GERD), particularly when they show atypical symptoms. This study was designed to evaluate the safety and outcome of laparoscopic Nissen-Rossetti fundoplication performed in a selected population of children with gastroesophageal reflux and atypical supraesophageal symptoms.

METHODS

This prospective study included 595 patients younger than 14 years with GERD who reported recurrent respiratory symptoms and had no benefit from standard medical treatment. Surgery was performed for 48 patients with anatomic anomalies, life-threatening events, or respiratory complications after ineffective medical treatment. The subjective and objective outcomes were evaluated.

RESULTS

No major intraoperative complications were experienced, and there was no recurrence of gastroesophageal reflux during a postoperative follow-up period of 12 months. The parents' final subjective evaluation of the outcomes 12 months after surgery was positive in 44 cases and negative in 4 cases.

CONCLUSIONS

Children with difficult-to-treat chronic respiratory symptoms must be evaluated for GERD, even if the need for surgery is low (8%), because complete eradication of reflux is mandatory. Radical treatment of GERD allows the pulmonologist to perform correct respiratory treatment and to prevent the development chronic and life-threatening complications.

Necessity for surgery in children with gastrooesophageal reflux and supraoesophageal symptoms

BACKGROUND/PURPOSE

The majority of gastrooesophageal reflux (GER) manifestations in children are supraoesophageal, and "spitting/posseting" is "the tip of the iceberg" because most reflux episodes are not regurgitated. Aim of the present study was to prospectively evaluate the incidence of gastrooesophageal reflux and the incidence of antireflux surgery in patients with difficult-to-treat respiratory symptoms.

PATIENTS AND METHODS

Five hundred and ninety-five children with difficult-to-treat respiratory symptoms were prospectively enrolled in a blind study looking for the correlation between clinical presentation (asthma or non-asthma), oesophageal pH monitoring, X-ray barium meal, broncho-alveolar lavage, necessity for surgery, and outcome.

RESULTS

pH monitoring was anomalous in 47% of patients with asthma (group A) and in 43% of those who did not have asthma as main symptom (group B). Overall, 48 patients finally underwent anti-reflux surgery (8%) as anti-reflux medical treatment did not ensure stable benefits. No major surgical complications were experienced. Postoperatively, respiratory symptoms improved strongly (Visick 1) in 69% of cases, moderately (Visick 2) in 27%, while clinical worsening (Visick 4) was observed in 4%.

CONCLUSIONS

The results of this study stress the importance of symptoms, clinical response to anti-reflux medical treatment and broncho-alveolar lavage compared to classical pH parameters in the decision-making process for patients with difficult-to-treat supraoesophageal symptoms. To date no single tool alone has proved to be diagnostic in these patients. Fundoplication is recommended only when a relationship between supraoesophageal symptoms and gastrooesophageal reflux is strongly suspected.

Anesthesiologic aspects of laparoscopic fundoplication for gastroesophageal reflux in children with chronic respiratory and gastroenterological symptoms

INTRODUCTION

During the past three decades laparoscopy has significantly improved. As fundoplication extensively benefits by the great advantages of the minimally invasive approach, many surgeons chose laparoscopic fundoplication for the treatment of gastroesophageal reflux in adults and children as well. Pneumothorax, cardiovascular collapse, hypoxia, and hypercarbia are some of the anesthesiologist's principal fears during carbon dioxide insufflation. Thus, monitoring cardiovascular and respiratory status is mandatory to early detect any complication and to maintain a proper balance during pneumoperitoneum.

MATERIALS AND METHODS

At Gaslini Children's Hospital we performed a prospective nonrandomized study aimed at describing the main cardiorespiratory changes produced by pneumoperitoneum in 33 pediatric patients operated on by laparoscopic fundoplication between January 2000 and June 2001. Patients were divided into two groups; namely, group A and group B. Group A included 14 patients with chronic respiratory symptoms, and group B included 19 children who preoperatively mainly emphasized gastrointestinal symptoms. We monitored intraoperative cardiorespiratory status, timed length of surgery, and described intraoperative complications.

RESULTS

No significant cardiovascular changes occurred during carbon dioxide insufflation. Partial oxygen saturation remained still in all the patients. End tidal CO2, meanly higher in group A children, increased in all the patients after pneumoperitoneum creation, but never exceeded 45 mmHg. Similarly, peak inspiratory pressure increased in all the patients, but was always maintained within acceptable values. Finally, group B patients required a harder and slower surgery, whose length seems to be negatively influenced by age. No intraoperative complication occurred.

CONCLUSIONS

Carbon dioxide insufflation does not impair cardiovascular function, if intraabdominal pressure is maintained lower than 10 mmHg nor does it interfere with gas exchanges. Pneumoperitoneum slightly reduces ventilatory function, mainly in respiratory patients with various degrees of underlying bronchopulmonary impairments, but this effect is easily correctable. Thus, laparoscopic fundoplication is feasible and safe in both respiratory and gastroenterological patients, although surgery is easier and faster if periesophagitis is less evident.