Comparison between two minimally invasive techniques for Hirschsprung disease: transanal endorectal pull-through (TERPT) versus laparoscopic-TERPT

INTRODUCTION

Surgical treatment for Hirschsprung disease (HD) has recently evolved into different minimally invasive techniques. The aim of the present study is to compare results from two different minimal invasive approaches, transanal endorectal pull-through (TERPT) and laparoscopic-assisted endorectal pull-through (LA-TERPT).

METHODS

Patients have been divided into two groups according to surgical technique. Data of HD patients treated by TERPT and those treated by LA-TERPT, respectively, performed at two different centers from January 2007 to December 2017, were retrospectively collected. Patients with aganglionosis confined to the recto-sigmoid colon with a minimum follow-up period of 4 years have been included. Demographic, clinical, surgical and functional outcome data were reviewed for each group using Chi-square and Fisher tests (statistical differences were considered for p < 0.05).

RESULTS

Among patients treated for HD in the two centers during the study period, 65 met the inclusion criteria (37 TERPT group and 28 LA-TERPT group). No differences regarding demographic and clinical data were observed between the two groups. Operative time was longer in the LA-TERPT group (p < 0.001). Time to start oral feeding was faster in the TERPT group while hospital stay was similar between the two groups. Three patients of the TERPT group required an additional abdominal approach. The rate of early complications was higher in the TERPT group. Long-term bowel function was assessed in 31 patients for the TERPT group and 24 patients for the LA-TERPT group. Outcomes showed that the bowel functional outcome was good (BFS ≥ 17) in 55% (n = 17) of TERPT group and 54% of LA-TERPT group (p = 0.97), moderate (BFS 12 to 16) in 16% (n = 5) and 33% (n = 8), respectively (p = 0.24), and poor in 29% (n = 9) and 13% (n = 3), respectively (p = 0.23).

CONCLUSIONS

Both TERPT and LA-TERPT techniques should be considered safe and feasible for the treatment of HD patients. TERPT patients present faster time to return to normal bowel function while LA-TERPT patients have slightly lower incidence of postoperative complications. Long-term functional outcomes are similar between the two groups.

LEVEL OF EVIDENCE

III.

Extralobar pulmonary sequestrations hiding congenital diaphragmatic defects: A case series

Background: Association between pulmonary sequestration and diaphragmatic hernia is well known. Extralobar sequestrations are masses of the non-functioning lung, surrounded by separate pleura, without bronchial communication, and with a systemic arterial blood supply. They may be placed in the thorax, within the diaphragm, or rarely in a sub-diaphragmatic position. Case Series: We present three cases of extra-lobar extra-thoracic pulmonary sequestrations associated with different types of diaphragmatic defects.  In none of the three cases, the diaphragmatic defect was detected prenatally. Conclusion: Pulmonary sequestration may be involved in the embryological origin of the diaphragmatic defect. Simultaneously, it acts as an anatomical barrier and prevents the herniation of the abdominal content into the thorax. If extralobar pulmonary sequestration is diagnosed prenatally, a coexistent diaphragmatic hernia should always be considered.

Surgical approach to giant ovarian masses in adolescents: technical considerations

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

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.

Multicenter retrospective study on management and outcome of newborns affected by surgical necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common surgical emergency in newborns and it is still a leading cause of death despite the improvements reached in the management of the critically ill neonate. The purpose of this study was to evaluate risk factors, surgical treatments and outcome of surgical NEC.

METHODS

We retrospectively evaluated a multicentric group of 184 patients with surgical NEC over a period of 5 years (2008-2012). Indications to operation were modified NEC Bell stages IIIA or IIIB. The main outcome was measured in terms of survival and postsurgical complications.

RESULTS

Data on 184 patients who had a surgical NEC were collected. The majority of patients (153) had a primary laparotomy (83%); 10 patients had peritoneal drainage insertion alone (5%) and 21 patients had peritoneal drainage followed by laparotomy (12%). Overall mortality was 28%. Patients with lower gestational age (P=0.001), lower birth weight (P=0.001), more extensive intestinal involvement (P=0.002) and cardiac diseases (P=0.012) had a significantly higher incidence of mortality. There was no statistically significant association between free abdominal air on the X-ray and mortality (P=0.407). Mortality in the drainage group was 60%, in the laparotomy group and drainage followed by laparotomy group was of 23-24% (P=0.043). There was a high incidence of stenosis (28%) in the drainage group (P=0.002). On multivariable regression, lower birth weight, feeding, bradycardia-desaturation and extent of bowel involvement were independent predictors of mortality.

CONCLUSIONS

Laparotomy was the most frequent method of treatment (83%). Primary laparotomy and drainage with laparotomy groups had similar mortalities (23-24%), while the drainage alone treatment cohort was associated with the highest mortality (60%) with statistical value (P=0.043). Consequently laparotomy is highly protective in terms of survival rate. Stenosis seemed to be statistically associated with drainage. These findings could discourage the use of peritoneal drainage versus a primary laparotomy whenever the clinical conditions of patients allow this procedure.

Large and prolonged food-borne multistate hepatitis A outbreak in Europe associated with consumption of frozen berries, 2013 to 2014

In May 2013, Italy declared a national outbreak of hepatitis A, which also affected several foreign tourists who had recently visited the country. Molecular investigations identified some cases as infected with an identical strain of hepatitis A virus subgenotype IA. After additional European Union/European Economic Area (EU/EEA) countries reported locally acquired and travel-related cases associated with the same outbreak, an international outbreak investigation team was convened, a European outbreak case definition was issued and harmonisation of the national epidemiological and microbiological investigations was encouraged. From January 2013 to August 2014, 1,589 hepatitis A cases were reported associated with the multistate outbreak; 1,102 (70%) of the cases were hospitalised for a median time of six days; two related deaths were reported. Epidemiological and microbiological investigations implicated mixed frozen berries as the vehicle of infection of the outbreak. In order to control the spread of the outbreak, suspected or contaminated food batches were recalled, the public was recommended to heat-treat berries, and post-exposure prophylaxis of contacts was performed. The outbreak highlighted how large food-borne hepatitis A outbreaks may affect the increasingly susceptible EU/EEA general population and how, with the growing international food trade, frozen berries are a potential high-risk food.

Changing hepatitis A epidemiology in the European Union: new challenges and opportunities

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Multistate foodborne hepatitis A outbreak among European tourists returning from Egypt--need for reinforced vaccination recommendations, November 2012 to April 2013

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Three simultaneous, food-borne, multi-country outbreaks of hepatitis A virus infection reported in EPIS-FWD in 2013: what does it mean for the European Union?

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Evaluation of the Health Protection Event-Based Surveillance for the London 2012 Olympic and Paralympic Games

The Health Protection Agency (HPA) (currently Public Health England) implemented the Health Protection Event-Based Surveillance (EBS) to provide additional national epidemic intelligence for the 2012 London Olympic and Paralympic Games (the Games). We describe EBS and evaluate the system attributes. EBS aimed at identifying, assessing and reporting to the HPA Olympic Coordination Centre (OCC) possible national infectious disease threats that may significantly impact the Games. EBS reported events in England from 2 July to 12 September 2012. EBS sourced events from reports from local health protection units and from screening an electronic application 'HPZone Dashboard' (DB). During this period, 147 new events were reported to EBS, mostly food-borne and vaccine-preventable diseases: 79 from regional units, 144 from DB (76 from both). EBS reported 61 events to the OCC: 21 of these were reported onwards. EBS sensitivity was 95.2%; positive predictive value was 32.8%; reports were timely (median one day; 10th percentile: 0 days - same day; 90th percentile: 3.6 days); completeness was 99.7%; stability was 100%; EBS simplicity was assessed as good; the daily time per regional or national unit dedicated to EBS was approximately 4 hours (weekdays) and 3 hours (weekends). OCC directors judged EBS as efficient, fast and responsive. EBS provided reliable, reassuring, timely, simple and stable national epidemic intelligence for the Games.

Measles outbreak on a cruise ship in the western Mediterranean, February 2014, preliminary report

A measles outbreak occurred in February 2014 on a ship cruising the western Mediterranean Sea. Overall 27 cases were reported: 21 crew members, four passengers.For two cases the status crew or passenger was unknown. Genotype B3 was identified. Because of different nationalities of cases and persons on board,the event qualified as a cross-border health threat. The Italian Ministry of Health coordinated rapid response.Alerts were posted through the Early Warning and Response System.

Timeliness of electronic reporting and acceptability of public health follow-up of routine nonparatyphoidal and nontyphoidal Salmonella infections, London and South East England, 2010 to 2011

Nonparatyphoidal and nontyphoidal Salmonella (NTS) infections are major causes of food poisoning in England. Diagnostic laboratories and clinicians have a statutory responsibility to report NTS infection cases to the Health Protection Agency via various means, with electronic reporting encouraged as the universal method. The Health Protection Agency (Public Health England since 1 April 2013) refers cases to environmental health departments for follow-up. Timeliness of reporting and adequacy of NTS infection case follow-up are key factors in the implementation of public health actions. Laboratories, health protection units, and environmental health departments in London and South East (SE) regions of England completed three surveys between December 2010 and April 2011, collecting data about the NTS infection case reporting methods and the time elapsed between symptom onset and public health actions. The median period between symptom onset and public health investigation was 25 days in London and 23 days in SE when electronic reporting was used and 12 days in London and 11 days in SE when other means of reporting were used. The most common follow-up method was a telephone questionnaire in London (53%) and a postal questionnaire in SE (52%). The telephone questionnaire had the highest response rate (98% in London; 96% in SE). Timeliness and efficiency of electronic NTS infection case reports can be improved by decreasing the electronic laboratory report period and using telephone-administered questionnaires to maximize the public health benefit when following up single cases of NTS infection.

Infectious disease surveillance for the London 2012 Olympic and Paralympic Games

The London 2012 Olympic and Paralympic Games will be one of the largest mass gathering events in British history. In order to minimise potential infectious disease threats related to the event, the Health Protection Agency (HPA) has set up a suite of robust and multisource surveillance systems. These include enhancements of already established systems (notification of infectious diseases, local and regional reporting,laboratory surveillance, mortality surveillance, international surveillance, and syndromic surveillance in primary care), as well as new systems created for the Games (syndromic surveillance in emergency departments and out-of-hours/unscheduled care,undiagnosed serious infectious illness surveillance).Enhanced existing and newly established surveillance systems will continue after the Games or will be ready for future reactivation should the need arise. In addition to the direct improvements to surveillance, the strengthening of relationships with national and international stakeholders will constitute a major post-Games legacy for the HPA.

A thoracic wall lipoblastoma in a 3-month-old infant: A case report and review of the literature

Lipoblastoma is a rare benign tumor of adipose tissue seen almost always in infancy and early childhood. Lipoblastoma is present in 2 forms which are pathologically identical: circumscribed and diffuse. It is typically located in the extremities, and less frequently in head-neck region, trunk, and various organs. Lipoblastoma is a tumor with good prognosis with no reported metastases, despite its potential for local invasion and rapid growth. Our patient was a 3-month-old boy who was brought to our clinic for rapidly growing mass in the right hemithorax. With the aim of both diagnosis and treatment, the lipomatous mass was removed by local resection. In addition to the patient's age, histologic and cytogenetic analyses assisted the diagnosis of diffuse lipoblastoma. In the postoperative period, the thorax wall was unaffected, and after 6 years of follow-up no recurrence was observed. In the English literature, 8 cases of thoracic wall lipoblastoma have been previously reported, and only 3 of diffuse form. Here, we report, at our knowledge, the fourth case of thoracic diffuse lipoblastoma, in which cytogenetic analysis showed a previously undescribed karyotype aberration involving chromosomes 8, 13, and 16.

The Escherichia coli AmtB protein as a model system for understanding ammonium transport by Amt and Rh proteins

The Escherichia coli ammonium transport protein (AmtB) has become the model system of choice for analysis of the process of ammonium uptake by the ubiquitous Amt family of inner membrane proteins. Over the past 6 years we have developed a range of genetic and biochemical tools in this system. These have allowed structure/function analysis to develop rapidly, offering insight initially into the membrane topology of the protein and most recently leading to the solution of high-resolution 3D structures. Genetic analysis has revealed a novel regulatory mechanism that is apparently conserved in prokaryotic Amt proteins and genetic approaches are also now being used to dissect structure/function relationships in Amt proteins. The now well-recognised homology between the Amt proteins, found in archaea, eubacteria, fungi and plants, and the Rhesus proteins, found characteristically in animals, also means that studies on E. coli AmtB can potentially shed light on structure/function relationships in the clinically important Rh proteins.