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Toms A, Govender TR, Brisighelli G, Harrison D. Neonatal Sacrococcygeal Fetiform Teratoma Containing Bowel: A Case Report. European J Pediatr Surg Rep 2024; 12:e11-e15. [PMID: 38259260 PMCID: PMC10803182 DOI: 10.1055/a-2206-4825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 10/21/2023] [Indexed: 01/24/2024] Open
Abstract
A fetiform sacrococcygeal teratoma (homunculus) is a highly differentiated subgroup of mature cystic teratoma that resembles a malformed fetus. These tumors originate at the base of the coccyx and may vary in their intrapelvic and extrapelvic extent and location. It is important to differentiate this anomaly from fetus-in-fetu which has a higher degree of structural organization. A 5-day-old neonate presented with a type II sacrococcygeal fetiform teratoma. The mass contained both cystic and solid components. Upon surgical excision and coccygectomy, fully formed bowel was found inside the mass, as well as bones and other well-defined structures. The tumor was confirmed to be fully excised and no malignant or immature features were found on histopathological examination. The patient was last seen growing well with an alpha-fetoprotein of 3.5 μg/L, 14 months after resection.
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Affiliation(s)
- Ashley Toms
- Department of Paediatric surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Tarlia Rasa Govender
- Department of Paediatric surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Giulia Brisighelli
- Department of Paediatric surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Derek Harrison
- Department of Paediatric surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Hartford L, Schönfeldt N, Mohanlal R, Bebington C, Loveland J, Westgarth-Taylor C, Brisighelli G. Rectal suction biopsies to diagnose Hirschsprung's disease in a low-resource environment - optimising cost-effectiveness. S AFR J SURG 2023; 61:96-99. [PMID: 37381807 DOI: 10.36303/sajs.3913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND The diagnosis of Hirschsprung's disease (HD) by rectal suction biopsy (RSB) has cost implications that could be reduced by ascertaining the optimal number of specimens required. The aim was to audit our experience to optimise cost-effectiveness. METHODS Medical records of all patients who underwent an RSB between January 2018 and December 2021 were reviewed. In 2020, we transitioned from using the Solo-RBT to the rbi2 system (requiring single-use cartridges). Descriptive statistics were reported and a comparative analysis of the diagnostic efficacy of the Solo-RBT versus the rbi2 system was performed. The cost of consumables was calculated according to the number of specimens submitted. RESULTS Of 218 RSBs, 181 were first and 37 were repeat. The mean age at biopsy was 62 days (IQR 22-65). An average of two tissue specimens were obtained per biopsy. Of the 181 first biopsies, 151 were optimal and 30 suboptimal. HD was confirmed in 19 (10.5%) of the patients. Amongst biopsies where a single specimen was obtained, 16% were inconclusive, compared to 14% with two specimens and 5% with three specimens. The cartridges for the rbi2 system cost R530. If two cartridges are used at initial biopsy the total cost is double of a single tissue specimen sent for initial biopsy, and two specimens sent for repeat biopsies. CONCLUSION In a low-resource setting, selecting the appropriate RSB system and obtaining a single specimen is sufficient to diagnose HD. Patients with inconclusive results should undergo a repeat biopsy where two specimens are obtained.
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Affiliation(s)
- L Hartford
- Paediatric Colorectal and Pelvic Reconstruction Centre, Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, South Africa
| | - N Schönfeldt
- Paediatric Colorectal and Pelvic Reconstruction Centre, Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, South Africa
| | - R Mohanlal
- Department of Anatomical Pathology, University of the Witwatersrand, South Africa and Chris Hani Baragwanath Laboratory, National Health Laboratory Services, South Africa
| | - C Bebington
- Paediatric Colorectal and Pelvic Reconstruction Centre, Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, South Africa
| | - J Loveland
- Paediatric Colorectal and Pelvic Reconstruction Centre, Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, South Africa
| | - C Westgarth-Taylor
- Paediatric Colorectal and Pelvic Reconstruction Centre, Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, South Africa
| | - G Brisighelli
- Paediatric Colorectal and Pelvic Reconstruction Centre, Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, South Africa
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Zanini A, von Sochaczewski CO, Basson S, Brisighelli G, Di Cesare A, Gabler T, Gentilino V, Gopal M, Grieve A, Harrison D, Patel N, Westgarth-Taylor C, Withers A, Loveland JA. Globalization in Pediatric Surgical Training: The Benefit of an International Fellowship in a Low-to-Middle-Income Country Academic Hospital. Eur J Pediatr Surg 2022; 32:363-369. [PMID: 34407553 DOI: 10.1055/s-0041-1734029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE A relative oversupply of pediatric surgeons led to increasing difficulties in surgical training in high-income countries (HIC), popularizing international fellowships in low-to-middle-income countries (LMIC). The aim of this study was to evaluate the benefit of an international fellowship in an LMIC for the training of pediatric surgery trainees from HICs. METHODS We retrospectively reviewed and compared the prospectively maintained surgical logbooks of international pediatric surgical trainees who completed a fellowship at Chris Hani Baragwanath Academic Hospital in the last 10 years. We analyzed the number of surgeries, type of involvement, and level of supervision in the operations. Data are provided in mean differences between South Africa and the respective home country. RESULTS Seven fellows were included. Operative experience was higher in South Africa in general (Δx̅ = 381; 95% confidence interval [CI]: 236-656; p < 0.0001) and index cases (Δx̅ = 178; 95% CI: 109-279; p < 0.0001). In South Africa, fellows performed more index cases unsupervised (Δx̅ = 71; 95% CI: 42-111; p < 0.0001), but a similar number under supervision (Δx̅ = -1; 95% CI: -25-24; p = 0.901). Fellows were exposed to more surgical procedures in each pediatric surgical subspecialty. CONCLUSION An international fellowship in a high-volume subspecialized unit in an LMIC can be highly beneficial for HIC trainees, allowing exposure to higher caseload, opportunity to operate independently, and to receive a wider exposure to the different fields of pediatric surgery. The associated benefit for the local trainees is some reduction in their clinical responsibilities due to the additional workforce, providing them with the opportunity for protected academic and research time.
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Affiliation(s)
- Andrea Zanini
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Christina Oetzmann von Sochaczewski
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.,Clinic and Policlinic for Paediatric Surgery, University of Mainz, Mainz, Germany
| | - Sonia Basson
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Giulia Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Antonio Di Cesare
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.,Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Policlinico Milano, Italy
| | - Tarryn Gabler
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Valerio Gentilino
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.,Unit of Pediatric Surgery, Woman and Child Department, Filippo del Ponte Hospital - ASST Sette Laghi, Varese, Italy
| | - Milan Gopal
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.,Department of Pediatric Surgery, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Andrew Grieve
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Derek Harrison
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Nirav Patel
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Chris Westgarth-Taylor
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Aletha Withers
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Jerome A Loveland
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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Langham AR, Gabler T, Bebington C, Brisighelli G, Westgarth-Taylor C. Paediatric Anogenital Condylomata Acuminata: An assessment of patient characteristics and the need for surgical intervention. J Pediatr Surg 2022; 57:715-718. [PMID: 34969525 DOI: 10.1016/j.jpedsurg.2021.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 11/15/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Anogenital Condylomata Acuminata (AGCA) are caused by Human Papilloma Virus (HPV), which is one of the most common sexually transmitted illnesses in adults. Although commonly seen in the paediatric population, especially in the setting of immunocompromise, literature regarding transmission, viral type and management in this population is scant. The aim of this study was to assess the profile of patients presenting with anogenital warts in light of associated immunocompromise with Human Immunodeficiency Virus (HIV). METHODS Three years of patient records from Chis Hani Baragwanath Academic Hospital were reviewed (January 2017 - December 2019). Information collected included: gender, age of presentation, age at intervention, type and duration of medical treatment, type and number of surgical interventions, HIV status, and histology results. Fisher's and Pearson's test were used to assess correlation between immune status and surgical interventions necessary. RESULTS In the time frame considered, we treated 66 patients with AGCA . The average age was 4 years old (1-14). HIV status was recorded in 30 patients (15 positive and 15 negative). Only one patient out of 66 had a history of sexual abuse. Whilst the proportion of patients who required surgical intervention in the HIV negative and HIV positive groups was equal (2:1), the total number of surgical interventions needed to achieve clearance was significantly more in those with HIV (p = 0.03). CONCLUSIONS HIV positive patients with AGCA require more surgical interventions compared to HIV negative individuals. Further research will be conducted to ascertain the sub-type of HPV infection in this subset of patients and to assess if this impacts follow-up for future malignancy. Further research also needs to be conducted to ascertain whether surgical intervention should be instituted earlier in the treatment protocol for HIV positive children.
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Affiliation(s)
- Alice Rose Langham
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.
| | - Tarryn Gabler
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa; Paediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, Johannesburg, South Africa
| | - Catterina Bebington
- Paediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, Johannesburg, South Africa
| | - Giulia Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa; Paediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, Johannesburg, South Africa
| | - Chris Westgarth-Taylor
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa; Paediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, Johannesburg, South Africa
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Connor SJ, Brisighelli G, Patel N, Levitt MA. Clinical Quiz-A Rare Case of Anal Canal Duplication in the Context of Currarino Syndrome. European J Pediatr Surg Rep 2021; 9:e68-e71. [PMID: 34777941 PMCID: PMC8580735 DOI: 10.1055/s-0041-1735595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/05/2021] [Indexed: 11/05/2022] Open
Abstract
Currarino syndrome (CS) is a rare condition that presents with any combination of a sacral defect, a presacral mass, and an anorectal malformation. This collection, referred to as Currarino's triad, may not necessarily present as all three abnormalities in the diagnosis of the syndrome. Anal canal duplication (ACD) is an even rarer occurrence. We present a case that lies on the CS spectrum with an associated ACD and discuss a complex surgical challenge that necessitated a customized management plan, devised through a multidisciplinary approach.
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Affiliation(s)
- Sean Jared Connor
- Department of Paediatric Surgery, Chris Hani Baragwanath Hospital, Johannesburg, Gauteng, South Africa.,University of the Witwatersrand School of Clinical Medicine, Johannesburg, Gauteng, South Africa
| | - Giulia Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Hospital, Johannesburg, Gauteng, South Africa
| | - Nirav Patel
- Department of Paediatric Surgery, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Marc A Levitt
- Department of Surgery, Colorectal and Pelvic Reconstructive Surgery, Children's National Hospital, Washington, District of Columbia, United States
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Withers A, Cronin K, Mabaso M, Brisighelli G, Gabler T, Harrison D, Patel N, Westgarth-Taylor C, Loveland J. Neonatal surgical outcomes: a prospective observational study at a Tertiary Academic Hospital in Johannesburg, South Africa. Pediatr Surg Int 2021; 37:1061-1068. [PMID: 33740107 DOI: 10.1007/s00383-021-04881-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The neonatal period is the most vulnerable period for a child. There is a paucity of data on the burden of neonatal surgical disease in our setting. The aim of this study was to describe the frequency with which index neonatal surgical conditions are seen within our setting and to document the 30-day outcome of these patients. METHODS This was a single-centre prospective observational study in which all neonates with paediatric surgical pathology referred to the paediatric surgical unit with a corrected gestational age of 28 days were included. RESULTS Necrotising enterocolitis was the most frequent reason for referral to the paediatric surgical unit (n = 68, 34.34%). Gastroschisis was the most frequent congenital anomaly referred (n = 20, 10.10%). The overall morbidity was 57.58%. Surgical complications contributed to 18.51% of morbidities. The development of gram negative nosocomial sepsis was the most frequent cause of morbidity (n = 98, 50.78%). Mortality at 30 days was 21.74% (n = 40). Sepsis contributed to mortality in 35 patients (87.5%), 16 of which had gram negative sepsis. CONCLUSION Gram-negative sepsis was a major contributing factor in the development of morbidity and mortality in our cohort. Prevention and improvement in infection control are imperative if we are to improve outcomes in our surgical neonates.
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Affiliation(s)
- A Withers
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.
| | - K Cronin
- Surgeons for Little Lives, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - M Mabaso
- Surgeons for Little Lives, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - G Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - T Gabler
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - D Harrison
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - N Patel
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - C Westgarth-Taylor
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - J Loveland
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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Maistry N, Brisighelli G, Westgarth-Taylor C. Posterior Cloacal Variant with Clitorolabial Transposition and a Rectoperineal Fistula. European J Pediatr Surg Rep 2021; 9:e46-e49. [PMID: 34026420 PMCID: PMC8131129 DOI: 10.1055/s-0041-1728724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/06/2021] [Indexed: 11/08/2022] Open
Abstract
We present a case and discuss the management of a posterior cloacal variant not as yet described in the literature. A 5-week-old infant presented to our institution with a posterior cloacal variant and transposition of the clitoris and labia. After initial radiological investigations, staged operative intervention was performed over a 1-year period. This included an initial laparotomy (with drainage of hydrocolpos and formation of a colostomy), a left ureteric reimplantation and a posterior sagittal anorectoplasty due to a rectoperineal fistula. The child is under continued long-term follow-up by our specialist pediatric surgical team.
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Affiliation(s)
- Niveshni Maistry
- Department of Paediatric Surgery, Chris Hani Baragwanath Hospital, Diepkloof, Soweto, Gauteng, South Africa
| | - Giulia Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Hospital, Diepkloof, Soweto, Gauteng, South Africa
| | - Chris Westgarth-Taylor
- Department of Paediatric Surgery, Chris Hani Baragwanath Hospital, Diepkloof, Soweto, Gauteng, South Africa
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Caponcelli E, Meroni M, Brisighelli G, Rendeli C, Ausili E, Gamba P, Marte A, Iacobelli BD, Lombardi L, Leva E, Midrio P. Transanal irrigation (TAI) in the paediatric population: Literature review and consensus of an Italian multicentre working group. Pediatr Med Chir 2021; 43. [PMID: 33960759 DOI: 10.4081/pmc.2021.250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/20/2021] [Indexed: 11/23/2022] Open
Abstract
Constipation and fecal incontinence in pediatric patients are conditions due to either functional or organic bowel dysfunction and may represent a challenging situation both for parents, pediatricians, and pediatric surgeons. Different treatments have been proposed throughout the past decades with partial and alternant results and, among all proposed techniques, in the adult population the Transanal Irrigation (TAI) has become popular. However, little is known about its efficacy in children. Therefore, a group of Italian pediatric surgeons from different centers, all experts in bowel management, performed a literature review and discussed the best-practice for the use of TAI in the pediatric population. This article suggests some tips, such as the careful patients' selection, a structured training with expert in pediatric colorectal diseases, and a continuous follow-up, that are considered crucial for the full success of treatment.
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Affiliation(s)
| | - Milena Meroni
- Pediatric Surgery, Bambini Vittore Buzzi Hospital, Milan.
| | - Giulia Brisighelli
- Department Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg.
| | - Claudia Rendeli
- Department of Women's, children's and public health Studies, Foundation Policlinico Universitario Agostino Gemelli, IRCCS.
| | - Emanuele Ausili
- Department of Women's, children's and public health Studies, Foundation Policlinico Universitario Agostino Gemelli, IRCCS.
| | | | - Antonio Marte
- Pediatric Surgery, Luigi Vanvitelli, University o Campania Luigi Vanvitelli, Naples.
| | - Barbara Daniela Iacobelli
- Neuro-urology unit, spina bifida center and Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome.
| | - Laura Lombardi
- Pediatric Surgery, Nuovo Ospedale del bambino "P. Barilla", Maggiore Hospital, Parma.
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan.
| | - Paola Midrio
- Pediatric Surgery, Ca' Foncello Hospital, Treviso.
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Brisighelli G, Loveland J, Bebington C, Dyamara L, Ferrari G, Westgarth-Taylor C. Do social circumstances dictate a change in the setup of an anorectal malformation clinic? J Pediatr Surg 2020; 55:2820-2823. [PMID: 32273115 DOI: 10.1016/j.jpedsurg.2020.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND/PURPOSE To assess the number of patients seen at the colorectal clinic of a low-to-middle income-country with emphasis on their social circumstances. METHODS Between January 2013 and December 2018 we recorded the number of visits to colorectal clinic. From February 2019 prospective data on patients with anorectal malformations (ARMs) focusing on their social conditions (type of housing and sanitation) and HIV-exposure were collected. RESULTS At the clinic 452 visits were recorded in 2013, 608 in 2014, 904 in 2016, 1392 in 2017, and 1968 in 2018. The ARM cohort included 100 patients: at the time of delivery the HIV status of 74 mothers was negative, positive in 21, and unknown in 5. None of the HIV-exposed patients seroconverted to HIV positive (average follow-up:39 months). Seventy-four patients live in formal settlements, 23 in informal, and 3 in unknown type. Forty-six patients have inside toilets, 39 outside flushing toilets, 10 outside pit latrines, 2 community toilets, and 3 an unknown sanitation. CONCLUSIONS The clinic work-load has increased during the past years. A significant proportion of our patients are HIV-exposed, do not live in formal houses and do not have inside toilets. Tailored strategies for a successful surgical plan and bowel management need to be implemented. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Giulia Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa; Paediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, Johannesburg, South Africa.
| | - Jerome Loveland
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Catterina Bebington
- Paediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, Johannesburg, South Africa
| | - Lindiwe Dyamara
- Paediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, Johannesburg, South Africa
| | - Giasmin Ferrari
- Paediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, Johannesburg, South Africa
| | - Christopher Westgarth-Taylor
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa; Paediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, Johannesburg, South Africa
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10
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Brisighelli G, Etwire V, Lawal T, Arnold M, Westgarth-Taylor C. Treating pediatric colorectal patients in low and middle income settings: Creative adaptation to the resources available. Semin Pediatr Surg 2020; 29:150989. [PMID: 33288130 DOI: 10.1016/j.sempedsurg.2020.150989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Colorectal disease profiles for children in low- and middle-income settings (LMIC) are characterized by late presentation, increased complications and limited follow-up in many cases. There is a high prevalence of infectious conditions causing secondary colorectal disease such as Mycobacterium Tuberculosis(TB), Human Immunodeficiency Virus(HIV) and Human Papilloma Virus(HPV), which also impact the management of other primary colorectal conditions, such as wound-healing and intestinal anastomosis. Perineal trauma from sexual assault, motor vehicle or pedestrian accidents, burns, and traditional enemas are commonly encountered and may require adaptation of principles used in treatment of congenital anomalies such as Hirschsprung's disease and Anorectal Malformations for reconstruction. Endemic conditions in certain LMIC require further research to delineate underlying causes and optimize management, such as "African" degenerative visceral leiomyopathy, congenital pouch colon in the Indian subcontinent, and congenital H-type rectal fistulae prevalent in Asia. These unique disease profiles require creative adaptations of resources within poor healthcare infrastructure settings. These special challenges and pitfalls in colorectal care and complications of adverse socioeconomic conditions, are discussed.
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Affiliation(s)
- Giulia Brisighelli
- Department of Pediatric Surgery, Pediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, 7 York Road, Parktown, 2193 Johannesburg, South Africa.
| | - Victor Etwire
- Department of Surgery, Pediatric Surgery Unit, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Taiwo Lawal
- Division of Pediatric Surgery, University College Hospital and Department of Surgery, University of Ibadan, Ibadan, Nigeria
| | - Marion Arnold
- Division of Pediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Chris Westgarth-Taylor
- Department of Pediatric Surgery, Pediatric Colorectal and Pelvic Reconstruction Centre, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, 7 York Road, Parktown, 2193 Johannesburg, South Africa
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11
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Apte A, Brisighelli G, McKenna E, Levitt MA. Image of the Month: High Pressure Distal Colostogram in a Patient with an Anorectal Malformation. European J Pediatr Surg Rep 2020; 8:e108-e111. [PMID: 33244451 PMCID: PMC7684984 DOI: 10.1055/s-0040-1721051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/18/2020] [Indexed: 11/24/2022] Open
Abstract
An adequately performed high pressure distal colostogram is crucial to plan surgery in male patients born with anorectal malformations. We present two male patients that underwent a divided sigmoid colostomy with distal mucus fistula in the neonatal period and at 6 months of age underwent a high pressure distal colostogram. In the discussion, we will give some tricks beyond the known rules: how to correctly interpret a high pressure distal colostogram, how to identify the level of a recto-urinary fistula, and how to accurately plan the surgical approach.
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Affiliation(s)
- Anisha Apte
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
| | - Giulia Brisighelli
- Department of Surgery, Paediatric Surgery, Chris Hani Baragwanath Hospital, Johannesburg, Gauteng, South Africa
| | - Elise McKenna
- Department of General and Thoracic Surgery, Children's National Medical Center, Washington, District of Columbia, United States
| | - Marc A Levitt
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States.,Department of General and Thoracic Surgery, Children's National Medical Center, Washington, District of Columbia, United States.,Division of Colorectal and Pelvic Reconstruction Surgery, Children's National Medical Center, Washington, District of Columbia, United States
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12
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Brisighelli G, Lorentz L, Pillay T, Westgarth-Taylor CJ. Rectal Perforation following High-Pressure Distal Colostogram. European J Pediatr Surg Rep 2020; 8:e39-e44. [PMID: 32550125 PMCID: PMC7224970 DOI: 10.1055/s-0040-1709140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/06/2019] [Indexed: 10/27/2022] Open
Abstract
In patients with anorectal malformations and a colostomy, the high-pressure distal colostogram is the technique of choice to determine the type of malformation and thus to plan the surgical repair. Perforations associated with high-pressure distal colostograms are very rare. The aim of our study was to identify pitfalls to prevent perforation secondary to high-pressure distal colostogram. The study included two male patients and was complicated with rectal perforations secondary to high-pressure distal colostogram. Both patients had an imperforate anus without a fistula. One patient had extraperitoneal rectal perforation with progressive contrast spillage into the peritoneum and demised. The other patient developed an extraperitoneal perforation and an associated necrotizing fasciitis of his perineum and scrotum, but he recovered well after debridement. Two further cases of rectal perforation have been described in the literature. Rectal perforation, although rare, is a described life-threatening complication secondary to high-pressure distal colostogram. The cause is excessive contrast pressure. Injection of contrast should be stopped once the distal end of the colon has a convex shape. Intraperitoneal perforation may cause hypovolemic/septic shock, and patients need to be appropriately resuscitated and should undergo laparotomy. Extraperitoneal perforation requires close monitoring for possible local complications, which may necessitate early debridement.
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Affiliation(s)
- Giulia Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Liam Lorentz
- Department of Radiology, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Tanyia Pillay
- Department of Radiology, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher J Westgarth-Taylor
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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13
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Brisighelli G, Levitt MA, Wood RJ, Westgarth-Taylor CJ. A Surgical Technique to Repair Perineal Body Disruption Secondary to Sexual Assault. European J Pediatr Surg Rep 2020; 8:e27-e31. [PMID: 32550122 PMCID: PMC7188516 DOI: 10.1055/s-0039-1695048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 07/08/2019] [Indexed: 10/25/2022] Open
Abstract
Perineal trauma is uncommon in the pediatric population and it is estimated that 5 to 21% is secondary to sexual abuse. We aim to present a proposed surgical technique to repair perineal injuries secondary to sexual assault in female children. The technique is based on the posterior sagittal anorectoplasty (PSARP) for repairing anorectal malformations and, between 2017 and 2019, it was used to treat three girls (2 months, 2 years, and 8 years of age) with fourth-degree perineal injuries secondary to sexual assault. One of them underwent laparotomy and Hartmann's colostomy for an acute abdomen. Two underwent wound debridement and suturing and only had a stoma fashioned at 5 days and 6 weeks posttrauma, respectively. The perineal repair was performed 2, 6, and 7 weeks postinjury and done as follows: with the child prone in jack-knife position, stay-sutures are placed on the common wall between the rectum and the vagina. Using a needle tip diathermy, a transverse incision is performed below the sutures lifting the anterior rectal wall up. Stay sutures are then positioned on the posterior wall of the vaginal mucosa. The incision between the walls is deepened until the rectum and the vagina are completely separated. The deep and superficial perineal body is then reconstructed using absorbable sutures and an anterior anoplasty and an introitoplasty are performed. The stoma in each was closed 6 weeks postreconstruction. At follow-up, now 1 year or more postrepair, all patients have an excellent cosmetic outcome and are fully continent for stools.
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Affiliation(s)
- Giulia Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Marc A Levitt
- Department of Colorectal and Pelvic Reconstructive Surgery, Children's National Hospital, Washington DC, United States
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Christopher J Westgarth-Taylor
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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14
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Mshumpela C, Brisighelli G, Westgarth-Taylor C. Devastating Outcomes of Traditional Enemas: Unusual Indications for Well-Known Operations. European J Pediatr Surg Rep 2020; 8:e3-e6. [PMID: 32042545 PMCID: PMC7007812 DOI: 10.1055/s-0039-1700957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/19/2019] [Indexed: 10/31/2022] Open
Abstract
Background Despite serious health risks having been described, traditional enemas are still often used in African traditional medicine. We aim to report two cases of complications secondary to traditional enemas, to illustrate how severe the injuries can be, and to describe the use of a Swenson type endoanal pull-through and a posterior sagittal anorectoplasty (PSARP) as surgical options. Case Description A 2-year-old girl presented with a necrotic rectum after a traditional enema administration. At admission, she required a laparotomy, colostomy fashioning, and extensive debridement of her rectum and perineum. She subsequently had a pull-through of the descending colon using a PSARP approach, a covering loop ileostomy, and a Malone Antegrade Continence Enema. The ileostomy was reversed at the age of 3 years of age and she is now clean with rectal washouts. The second case was a one- and a half-year-old boy with full-thickness burns to the perineum and rectum secondary to a hot-water enema. A colostomy was initially brought out and pulled through 7 months post the initial surgery. He is now growing well and is fully continent to stools. Conclusions The potential complications associated with the practice of administering at-home enemas can be quite devastating. A transanal pull-through and a PSARP have been proven to be successful techniques in patients who have suffered rectal burns due to traditional enemas.
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Affiliation(s)
- Cleopatra Mshumpela
- Department of Paediatric Surgery, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, Parktown, South Africa
| | - Giulia Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Hospital, Johannesburg, Gauteng, South Africa
| | - Chris Westgarth-Taylor
- Department of Paediatric Surgery, Chris Hani Baragwanath Hospital, Johannesburg, Gauteng, South Africa
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15
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Midrio P, van Rooij IALM, Brisighelli G, Garcia A, Fanjul M, Broens P, Iacobelli BD, Giné C, Lisi G, Sloots CEJ, Fascetti Leon F, Morandi A, van der Steeg H, Giuliani S, Grasshoff-Derr S, Lacher M, de Blaauw I, Jenetzky E. Inter- and Intraobserver Variation in the Assessment of Preoperative Colostograms in Male Anorectal Malformations: An ARM-Net Consortium Survey. Front Pediatr 2020; 8:571. [PMID: 33072661 PMCID: PMC7531276 DOI: 10.3389/fped.2020.00571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/05/2020] [Indexed: 11/13/2022] Open
Abstract
Aim: Male patients with anorectal malformations (ARM) are classified according to presence and level of the recto-urinary fistula. This is traditionally established by a preoperative high-pressure distal colostogram that may be variably interpreted by different surgeons. The aim of this study was to evaluate the inter- and intraobserver variation in the assessment by pediatric surgeons of preoperative colostograms with respect to the level of the recto-urinary fistula. Materials and Methods: Sixteen pediatric surgeons from 14 European centers belonging to the ARM-Net Consortium twice scored 130 images of distal colostograms taken in sagittal projection at a median age of 66 days of life (range: 4-1,106 days). Surgeons were asked to classify the fistula in bulbar, prostatic, bladder-neck, no fistula, and "unclear anatomy" example. Their assessments were compared with the intraoperative findings (kappa) for two scoring rounds with an interval of 6 months (intraobserver variation). Agreement among the surgeons' scores (interobserver variation) was also calculated using Krippendorff's alpha. A kappa over 0.75 is considered excellent, between 0.40 and 0.75 fair to good, and below 0.40 poor. Surgeons were asked to score the images in "poor" and "good" quality and to provide their years of experience in ARM treatment. Results: Agreement between the image-based rating of surgeons and the intraoperative findings ranges from 0.06 to 0.45 (mean 0.31). Interobserver variation is higher (Krippendorff's alpha between 0.40 and 0.45). Years of experience in ARM treatment does not seem to influence the scoring. The mean intraobserver variation between the two rounds is 0.64. Overall, the quality of the images is considered poor. Images categorized as having a good quality result in a statistically significant higher kappa (mean: 0.36 and 0.37 in the first and second round, respectively) than in the group of bad-quality images (mean: 0.25 and 0.23, respectively). Conclusions: There is poor agreement among experienced pediatric colorectal surgeons on preoperative colostograms. Techniques and analyses of images need to be improved in order to generate a homogeneous series of patients and make comparison of outcomes reliable.
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Affiliation(s)
- Paola Midrio
- Pediatric Surgery Unit, Cà Foncello Hospital, Treviso, Italy
| | - Iris A L M van Rooij
- Department of Health Evidence, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda- Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pediatric Surgery, Chris Hani Baragwanath Hospital and University of Witwatersrand, Johannesburg, South Africa
| | - Aracelli Garcia
- Pediatric Surgery Unit, Doce de Octubre Universitary Hospital, Madrid, Spain
| | - Maria Fanjul
- Pediatric Surgery Unit, Gregorio Marañón Universitary Hospital, Madrid, Spain
| | - Paul Broens
- Division of Pediatric Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Barbara D Iacobelli
- Department of Medical and Surgical Neonatology, Bambino Gesù Childrens Hospital, Rome, Italy
| | - Carlos Giné
- Department of Pediatric Surgery, Hospital Universitary Vall d'Hebron, Barcelona, Spain
| | - Gabriele Lisi
- Pediatric Surgery Unit, Department of Aging Science, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus Medical Center (MC)-Sophia Children's Hospital, Rotterdam, Netherlands
| | | | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda- Ospedale Maggiore Policlinico, Milan, Italy
| | - Herjan van der Steeg
- Division of Pediatric Surgery, Department of Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, Netherlands
| | - Stefan Giuliani
- Department of Pediatric Surgery, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sabine Grasshoff-Derr
- Pediatric Surgery Unit, Buergerhospital and Clementine Kinderhospital, Frankfurt, Germany
| | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
| | - Ivo de Blaauw
- Division of Pediatric Surgery, Department of Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, Netherlands
| | - Ekkehart Jenetzky
- Department of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany.,Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of Johannes Gutenberg-University, Mainz, Germany
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16
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van de Putte R, Dworschak GC, Brosens E, Reutter HM, Marcelis CLM, Acuna-Hidalgo R, Kurtas NE, Steehouwer M, Dunwoodie SL, Schmiedeke E, Märzheuser S, Schwarzer N, Brooks AS, de Klein A, Sloots CEJ, Tibboel D, Brisighelli G, Morandi A, Bedeschi MF, Bates MD, Levitt MA, Peña A, de Blaauw I, Roeleveld N, Brunner HG, van Rooij IALM, Hoischen A. A Genetics-First Approach Revealed Monogenic Disorders in Patients With ARM and VACTERL Anomalies. Front Pediatr 2020; 8:310. [PMID: 32656166 PMCID: PMC7324789 DOI: 10.3389/fped.2020.00310] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/13/2020] [Indexed: 12/19/2022] Open
Abstract
Background: The VATER/VACTERL association (VACTERL) is defined as the non-random occurrence of the following congenital anomalies: Vertebral, Anal, Cardiac, Tracheal-Esophageal, Renal, and Limb anomalies. As no unequivocal candidate gene has been identified yet, patients are diagnosed phenotypically. The aims of this study were to identify patients with monogenic disorders using a genetics-first approach, and to study whether variants in candidate genes are involved in the etiology of VACTERL or the individual features of VACTERL: Anorectal malformation (ARM) or esophageal atresia with or without trachea-esophageal fistula (EA/TEF). Methods: Using molecular inversion probes, a candidate gene panel of 56 genes was sequenced in three patient groups: VACTERL (n = 211), ARM (n = 204), and EA/TEF (n = 95). Loss-of-function (LoF) and additional likely pathogenic missense variants, were prioritized and validated using Sanger sequencing. Validated variants were tested for segregation and patients were clinically re-evaluated. Results: In 7 out of the 510 patients (1.4%), pathogenic or likely pathogenic variants were identified in SALL1, SALL4, and MID1, genes that are associated with Townes-Brocks, Duane-radial-ray, and Opitz-G/BBB syndrome. These syndromes always include ARM or EA/TEF, in combination with at least two other VACTERL features. We did not identify LoF variants in the remaining candidate genes. Conclusions: None of the other candidate genes were identified as novel unequivocal disease genes for VACTERL. However, a genetics-first approach allowed refinement of the clinical diagnosis in seven patients, in whom an alternative molecular-based diagnosis was found with important implications for the counseling of the families.
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Affiliation(s)
- Romy van de Putte
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gabriel C Dworschak
- Department of Pediatrics, Children's Hospital, University Hospital Bonn, Bonn, Germany.,Institute of Human Genetics, University of Bonn, Bonn, Germany
| | - Erwin Brosens
- Department of Clinical Genetics, Erasmus Medical Centre, Rotterdam, Netherlands.,Department of Pediatric Surgery, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Heiko M Reutter
- Institute of Human Genetics, University of Bonn, Bonn, Germany.,Department of Neonatology, Children's Hospital, University Hospital Bonn, Bonn, Germany
| | - Carlo L M Marcelis
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rocio Acuna-Hidalgo
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nehir E Kurtas
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marloes Steehouwer
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sally L Dunwoodie
- Victor Chang Cardiac Research Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Eberhard Schmiedeke
- Department of Pediatric Surgery and Urology, Centre for Child and Youth Health, Klinikum Bremen-Mitte, Bremen, Germany
| | - Stefanie Märzheuser
- Department of Pediatric Surgery, Campus Virchow Clinic, Charité University Hospital Berlin, Berlin, Germany
| | - Nicole Schwarzer
- SoMA e.V., Self-Help Organization for People With Anorectal Malformation, Munich, Germany
| | - Alice S Brooks
- Department of Clinical Genetics, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Annelies de Klein
- Department of Clinical Genetics, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Giulia Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria F Bedeschi
- Medical Genetic Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Michael D Bates
- Division of Gastroenterology and Nutrition, Dayton Children's Hospital, Dayton, OH, United States.,Department of Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH, United States
| | - Marc A Levitt
- Division of Gastroenterology and Nutrition, Dayton Children's Hospital, Dayton, OH, United States.,Department of Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH, United States.,Department of Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States
| | - Alberto Peña
- Division of Gastroenterology and Nutrition, Dayton Children's Hospital, Dayton, OH, United States.,Department of Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH, United States.,Department of Surgery, International Center for Colorectal Care, Children's Hospital Colorado, University of Colorado, Aurora, CO, United States
| | - Ivo de Blaauw
- Department of Surgery-Pediatric Surgery, Radboudumc Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nel Roeleveld
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Han G Brunner
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Clinical Genetics and School for Oncology & Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, Netherlands
| | - Iris A L M van Rooij
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alexander Hoischen
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
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17
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Charlton R, Brisighelli G, Gabler T, Westgarth-Taylor C. Management of fetal extraperitoneal rectal perforation: a case series and review of the literature. Pediatr Surg Int 2019; 35:989-997. [PMID: 31278480 DOI: 10.1007/s00383-019-04514-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Fetal extraperitoneal rectal perforation (FERP) is an extremely rare entity. The objective of this report is to review the available literature on this condition and to add our experience with four additional cases managed at our institution. METHODS A literature search was performed for journal articles addressing this condition. Management strategies and outcomes were then analysed, together with additional information provided from retrospective record review of four cases managed at our institution. RESULTS A total of 18 patients were identified and included, 14 from the literature and 4 from our records. Initial investigations varied between authors with contrast enema being the most frequently performed study (7/18). All patients were treated with faecal diversion via colostomy formation. Exploratory laparotomy was performed in 6 cases, perineal debridement and washout in 9 cases while drains were left in situ in 14 cases. At 3-6 months of age, a distal contrast study was performed before closure of colostomy. CONCLUSION Although FERP is a rarely encountered clinical condition, timely recognition and appropriate management can result in good outcomes. Diagnosis can be achieved based on clinical and abdominal X-ray features alone. General management principles involve a diverting colostomy and extended drainage with closure of the colostomy 3-6 months later.
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Affiliation(s)
- R Charlton
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.
| | - G Brisighelli
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - T Gabler
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - C Westgarth-Taylor
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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18
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Zanini A, Macchini F, Farris G, Morandi A, Festa I, Brisighelli G, Gentilino V, Leva E. Follow-up of Congenital Diaphragmatic Hernia: Need for Routinary Assessment of Acid Gastroesophageal Reflux with pH-metry. Eur J Pediatr Surg 2018; 28:502-507. [PMID: 29020688 DOI: 10.1055/s-0037-1607290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION We aim to assess gastroesophageal reflux (GER) in patients treated for congenital diaphragmatic hernia (CDH) and to determine whether a pH-metry investigation should be routinely performed in follow-up. MATERIALS AND METHODS Twenty-four-hour pH-metry at 1 year was performed in all patients treated for CDH between January 2014 and April 2015 (Group 1). We compared pH-metry results to those of two other groups: children treated for esophageal atresia (EA) (Group 2) and normal babies presenting with typical symptoms (Group 3). All the pH-metric findings were analyzed and compared. Intra-group analysis was performed in Group 1. RESULTS Group 1 consisted of 21, Group 2 of 24, and Group 3 of 21 patients. Mean pH-metry values for Groups 1, 2, and 3 were, respectively: reflux index (RI) 4.3, 5.1, and 3.9; total number of refluxes (NR) 79.5, 88.8, and 88.7; refluxes longer than 5' (R > 5) 1.7, 2.3, and 1.47; and longest reflux episode (LR) 11.4, 13.3, and 8.6. No significant differences were found between Group 1 and the others. Only two CDH patients presented with GER-related symptoms. Patch was associated with significantly higher RI (8.5 vs. 2.98, p = 0.03). The worse was the defect, the worse were the pH-metric results (RI: A3.09, B3.15, and C9.1). CONCLUSION We believe that a routine GER assessment should be performed in all CDH patients regardless the presence of symptoms. LEVEL OF EVIDENCE This is a Level II study.
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Affiliation(s)
- Andrea Zanini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Farris
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Festa
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valerio Gentilino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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19
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Ausili E, Marte A, Brisighelli G, Midrio P, Mosiello G, La Pergola E, Lombardi L, Iacobelli BD, Caponcelli E, Meroni M, Leva E, Rendeli C. Short versus mid-long-term outcome of transanal irrigation in children with spina bifida and anorectal malformations. Childs Nerv Syst 2018; 34:2471-2479. [PMID: 29948136 DOI: 10.1007/s00381-018-3860-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/30/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE We assessed short- and mid-long-term clinical efficacy of transanal irrigation (TAI) and its effect on the quality of life of children with spina bifida (SB) and anorectal malformations (ARM). METHODS Seventy-four pediatric patients (age 6-17 years) with SB and ARM with neurogenic bowel dysfunction were enrolled for a prospective and multicentric study. Patients were evaluated before the beginning of TAI (T0), after 3 months (T1) and after at least 2 years (range 24-32 months) (T2) using a questionnaire assessing bowel function, the Bristol scale, and two validated questionnaires on quality of life: the CHQ-PF50 questionnaire for the parents of patients aged 6-11 years and the SF36 questionnaires for patients aged between 12 and 18 years. RESULTS Seventy-two patients completed TAI program in T1, and 67 continued into T2. Bowel outcomes (constipation and fecal incontinence) improved in both the SB and the ARM groups in the short and mid-long term. In both groups at T1 and T2, parents and children reported an improvement in quality of life and there was a significant increase of stool form types 4 and 5 as described by the Bristol scale. Common adverse effects during the study were similar at T1 and T2 without serious complications. CONCLUSIONS We observed a sustained improvement in bowel management and quality of life in SB and ARM children during the study, more significant in the short term than in mid-long term. To maintain success rates in the mid-long term and to reduce the dropout rate, we propose patient training and careful follow-ups.
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Affiliation(s)
- Emanuele Ausili
- Spina Bifida Center, Department of Science of the Health of Women and Children, Catholic University Medical School, Rome, Italy. .,Spina Bifida Center-Pediatric Department, Catholic University of Sacred Heart, Largo Gemelli 8, 00168, Rome, Italy.
| | - A Marte
- Pediatric Surgery Unit, Università della Campania Luigi Vanvitelli, Naples, Italy
| | - G Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - P Midrio
- Mother and Child Department, Cà Foncello Regional Hospital, Treviso, Italy
| | - G Mosiello
- Neuro-Urology Unit/Spina Bifida Center and Department of Medical and Surgical Neonatology, Bambino Gesù Children Hospital and Research Institute, Rome, Italy
| | - E La Pergola
- Mother and Child Department, Cà Foncello Regional Hospital, Treviso, Italy
| | - L Lombardi
- Pediatric Surgery Unit, Pediatric Hospital, Parma, Italy
| | - B D Iacobelli
- Neuro-Urology Unit/Spina Bifida Center and Department of Medical and Surgical Neonatology, Bambino Gesù Children Hospital and Research Institute, Rome, Italy
| | - E Caponcelli
- Pediatric Surgery Unit, Vittore Buzzi Pediatric Hospital, Milan, Italy
| | - M Meroni
- Pediatric Surgery Unit, Vittore Buzzi Pediatric Hospital, Milan, Italy
| | - E Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - C Rendeli
- Spina Bifida Center, Department of Science of the Health of Women and Children, Catholic University Medical School, Rome, Italy
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Brisighelli G, Macchini F, Consonni D, Di Cesare A, Morandi A, Leva E. Continence after posterior sagittal anorectoplasty for anorectal malformations: comparison of different scores. J Pediatr Surg 2018; 53:1727-1733. [PMID: 29370894 DOI: 10.1016/j.jpedsurg.2017.12.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 11/09/2017] [Accepted: 12/11/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate bowel function in patients with anorectal malformations (ARM) comparing existing scoring systems. METHODS Parents of ARM patients treated at our institution were asked to fill in Holschneider, Kricknebeck, and Rintala questionnaires. Scores obtained from the questionnaires were expressed per cent and analyzed depending on the age and type of ARM according to Krickenbeck classification. Patients younger than 3 years of age or with developmental delay were excluded. RESULTS Eighty patients (42 males: 52%) were included. Median age was 7.6 years (range 3-22). Twenty eight patients (35%) had perineal fistula, 13 (16%) bulbar, 7 (9%) prostatic, 5 (6%) rectobladder neck, 15 (19%) vestibular, 7 (9%) had a cloaca and 5 (6%) imperforate anus without fistula. Using Holschneider, Krickenbeck, and Rintala, average scores were respectively 72, 71 and 73 (p = 0.4 with ANOVA). Using the three questionnaires patients with perineal fistula scored 82, 76 and 84 respectively (p = 0.003), with bulbar 70, 71, 73 (p = 0.8), with prostatic 52,69,59 (p = 0.06), with bladder neck 56, 80, 57 (p = 0.004), with vestibular 75,67,75 (p = 0.02), with cloaca 64, 67, 65 (p = 0.9), and with imperforate anus without fistula 61,49, 53 (p = 0.12). Patients from 3 to 6 years of age scored 74,72 and 76 (p = 0.37), from 7 to 12: 70,71 and 71 (p = 0.87), and older than twelve: 74,66 e 73 (p = 0.08). CONCLUSION The scores obtained using Holschneider, Rintala, and Krickenbeck questionnaires are significantly lower with increasing severity of the ARM. For each type of ARM there are some differences in the results obtained using the three questionnaires. In general, Krickenbeck and Peña questionnaires tend to give lower scores in patients with ARMs that have good prognosis, and higher scores for ARMs with poor prognosis. Age is not significantly related to the score obtained. LEVEL OF EVIDENCE III TYPE OF STUDY: Diagnostic study.
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Affiliation(s)
- Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy.
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy.
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via San Barnaba 8, 20122 Milan, Italy.
| | - Antonio Di Cesare
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy.
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy.
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122 Milano, Italy.
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Macchini F, Zanini A, Farris G, Morandi A, Brisighelli G, Gentilino V, Fava G, Leva E. Infant Percutaneous Endoscopic Gastrostomy: Risks or Benefits? Clin Endosc 2018; 51:260-265. [PMID: 29310429 PMCID: PMC5997076 DOI: 10.5946/ce.2017.137] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/16/2017] [Accepted: 10/27/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND/AIMS To present a single center's experience with percutaneous endoscopic gastrostomy (PEG) tube placement in infants. METHODS Clinical records of infants who underwent PEG tube placement between January 2010 and December 2015 were reviewed. All patients underwent an upper gastrointestinal contrast study and an abdominal ultrasonography before the procedure. PEGs were performed with a 6-mm endoscope using the standard pull-through technique. Data regarding gestational age, birth weight, age and weight, days to feeding start, days to full diet, and complications were reviewed. RESULTS Twenty-three patients were included. The most common indication was dysphagia related to hypoxic-ischemic encephalopathy. Median gestational age was 37 weeks (range, 24-41) and median birth weight was 2,605 grams (560-4,460). Patients underwent PEG procedures at a median age of 114 days (48-350); mean weight was 5.1 kg (3.2-8.8). In all patients but one, a 12-Fr tube was positioned. Median feeding start was 3 days (1-5) and on average full diet was achieved 5 days after the procedure (2-11). Six minor complications were recorded and effectively treated in the outpatient clinic; no major complications were recorded. CONCLUSIONS PEG is safe and feasible in infants when performed by highly experienced physicians.
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Affiliation(s)
- Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Andrea Zanini
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Giorgio Farris
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Valerio Gentilino
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Giorgio Fava
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
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Giuliani S, Grano C, Aminoff D, Schwarzer N, Van De Vorle M, Cretolle C, Haanen M, Brisighelli G, Marzheuser S, Connor M. Transition of care in patients with anorectal malformations: Consensus by the ARM-net consortium. J Pediatr Surg 2017; 52:1866-1872. [PMID: 28688794 DOI: 10.1016/j.jpedsurg.2017.06.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 06/02/2017] [Accepted: 06/04/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To develop the first consensus to standardize the management of patients with Anorectal Malformations (ARMs) transitioning from childhood to adulthood. METHODS A dedicated task force of experts performed an extensive literature review and multiple meetings to define the most important aspects of transition of care. The findings were discussed with all ARM-net consortium members and a set of practical recommendations agreed upon at the annual meeting in 2016. RESULT We defined seven domains that are essential to provide an effective and practical transition process. Within each domain we have developed a set of key recommendations that are important to be considered for ARM patients entering the age of transition. CONCLUSIONS It is crucial that transition begins at an early age with regular and well-structured follow-up. Cooperation with a selected multidisciplinary team of pediatric and adult practitioners is required to prepare patients and families for effective transition to adult care and to reduce long term morbidity. TYPE OF STUDY Review/Consensus paper. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Stefano Giuliani
- Department of Specialist Neonatal and Pediatric Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, WC1N 3JH London, United Kingdom.
| | - Caterina Grano
- Department of Psychology, Sapienza University of Rome, Via dei Marsi, 78, 00185 Rome, Italy
| | - Dalia Aminoff
- AIMAR-Italian Patients' and Parents' Organization for Anorectal Malformation, Via Tripolitania, 211, Rome, Italy
| | - Nicole Schwarzer
- SoMA e.V.-German organization for people with ARM/HD, Korbinianplatz 17, D-80807 Munich, Germany
| | - Mariette Van De Vorle
- Department of Pediatric Surgery, Radboudumc Amalia Children's Hospital, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Celia Cretolle
- National Reference Centre for Rare Diseases on Anorectal Malformations and Rare Pelvic Anomalies (MAREP), Rare Diseases National Network NeuroSphinx, Necker-Enfants Malades Hospital, APHP, René Descartes University, Paris, France
| | - Michel Haanen
- "Vereniging Anusatresie" Postbus 78, 1270 AB Huizen, The Netherlands
| | - Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 10, 20122, Milano, Italy
| | - Stefanie Marzheuser
- Department of Pediatric Surgery, Charité Uniklinik Abt., Kinderchirurgie, Augustenburger Platz, 1, Berlin, Germany
| | - Martin Connor
- Department of Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, United Kingdom
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Costanzo S, Spaccini L, Pio L, Mattioli G, Virgone C, Dall'Igna P, Iacobelli B, Inserra A, Brisighelli G, Fagnani AM, Leva E, Giannotti G, Cheli M, Frumento P, Riccipetitoni G. Currarino syndrome: does the presence of a genetic anomaly correlate with a more severe phenotype? A multicentre study. J Pediatr Surg 2017; 52:1591-1596. [PMID: 28689883 DOI: 10.1016/j.jpedsurg.2017.06.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 06/11/2017] [Accepted: 06/13/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE Currarino syndrome (CS) phenotype, initially described as the triad of hemisacrum, anorectal malformation (ARM) and presacral mass, can be extremely variable. The triad is often incomplete and 3 main CS phenotypical subtypes have been described: Complete, Mild and Minimal. Various associated malformations are often present. Mutations in the MNX1 gene are the main genetic background of CS, although they are not present in almost half of the cases. Aim of our study is to analyze the distribution of the 3 CS subtypes and the incidence of associated malformations in a large sample of patients and to add information about the role of the genetic testing in guiding the diagnostic and prognostic evaluation of CS patients. METHODS A multicentre retrospective data collection was performed. CS patients' phenotype was accurately analyzed according to a diagnostic-therapeutic standardized data collection sheet. The distribution of the three CS types and the frequency of each associated malformation were calculated. The phenotype of the patients with a known genetic anomaly was compared to the phenotype of the population with no genetic diagnosis, in order to determine whether the presence of a known genetic defect could correlate with a more severe CS phenotype. RESULTS Data from 45 patients were analyzed. Twenty patients (44.5%) presented a Complete CS type, 19 (42.2%) a Mild CS and 6 (13.3%) a Minimal CS. In addition to the classical triad elements, 38 (84.5%) patients showed associated anomalies. The group of patients who resulted positive for a MNX1 mutation comprised a higher number (56.5%) of Complete CS cases than the group of patients that did not carry any MNX1 mutation (13%) (p = 0.0085). We could not find any relationship between CS subtype and the number of associated anomalies (p = 0.5102). CONCLUSIONS The presence of a MNX1 mutation seems to correlate with a more severe CS phenotype. MNX1 seems the main responsible for the expression and the severity of the CS triad, while the associated anomalies appear to be prevalently determined by genes sited on different loci. A thorough multidisciplinary diagnostic overview of CS patients should always include genetic counseling and analysis, both in postnatal and prenatal settings. TYPE OF STUDY Retrospective Study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Sara Costanzo
- Pediatric Surgery Unit, V. Buzzi Children's Hospital, Milan, Italy.
| | | | - Luca Pio
- Pediatric Surgery Department, DINOGMI - University of Genoa, Genoa, Italy
| | - Girolamo Mattioli
- Pediatric Surgery Department, DINOGMI - University of Genoa, Genoa, Italy; Pediatric Surgery Unit, G. Gaslini Children's Hospital, Genoa, Italy
| | - Calogero Virgone
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Patrizia Dall'Igna
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | | | | | - Giulia Brisighelli
- Pediatric Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Maria Fagnani
- Pediatric Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ernesto Leva
- Pediatric Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Giannotti
- Pediatric Surgery Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maurizio Cheli
- Pediatric Surgery Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Paolo Frumento
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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Gasior A, Brisighelli G, Diefenbach K, Lane VA, Reck C, Wood RJ, Levitt M. Surgical Management of Functional Constipation: Preliminary Report of a New Approach Using a Laparoscopic Sigmoid Resection Combined with a Malone Appendicostomy. Eur J Pediatr Surg 2017; 27:336-340. [PMID: 27780281 DOI: 10.1055/s-0036-1593606] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction Functional constipation is a common problem in children. It usually can be managed with laxatives but a small subset of patients develop intolerable cramps and need to be temporarily treated with enemas. The senior author has previously reported: 1) open sigmoid resection as a surgical option, but this did not sufficiently reduce the laxative need, then 2) a transanal approach (with resection of rectosigmoid), but this led to a high rate of soiling due to extensive stretching of the anal canal and loss of the rectal reservoir. The understanding of these procedures' results has led us to use a laparoscopic sigmoid ± left colonic resection with a Malone appendicostomy for these patients, to decrease the laxative requirements, temporarily treat with antegrade flushes, and to reduce postoperative soiling. Methods A single-institution retrospective review (3/2014-9/2015) included patients who failed our laxative protocol, and therefore were considered surgical candidates. Patients with anorectal malformation (ARM), Hirschsprung disease, spina bifida, tethered cord, trisomy 21, cerebral palsy, mitochondrial disease, prior colon resection at other facilities, or those that did not participate in our laxative program were excluded. Demographics, duration of symptoms, prior treatments, postoperative complications, and postoperative bowel regimens were evaluated. Results A total of 6 patients (3 males; median age of 12.5 years) presented with soiling related to constipation and intolerance to laxatives. Four patients failed preoperative cecostomy (done prior to referral to us). An average of 4.7 medication treatments were previously tried. In all, 4 patients had required in-patient disimpactions. Duration of symptoms was 7.5 years (median). The median senna dose was 30 mg (range, 15-150 mg), and all patients had intolerable symptoms or failed to empty their colon, which we considered a failed laxative trial. All had contrast enemas that demonstrated a dilated and/or redundant sigmoid colon, and colonic manometry was abnormal in 4. All patients underwent laparoscopic sigmoid and left colon resection, or only sigmoid resection (a low anterior resection). Two patients had postoperative colitis treated with oral antibiotics. The median follow-up was 52 days (range, 8-304 days). Five patients are on antegrade enemas with plans to convert to laxatives at 6 months, 1 is taking laxatives alone at a 33% lower dosage. Five of six are completely clean, 1 soils occasionally and their daily flush is being adjusted. Conclusion Only a minority of patients with functional constipation are medically unmanageable. This preliminary report shows that laparoscopic colon resection combined with antegrade flushes is an effective surgical technique to treat that group. A laparoscopic approach, guided by contrast enema and colonic manometry, allows for a defined resection of the abnormal segment of colon with the advantages of minimally invasive surgery including allowing for an extensive rectal resection (an improvement over open sigmoid resection) and avoidance of overstretching of the anal canal and removal of the rectal reservoir (an improvement over the transanal approach). Having antegrade access is useful to manage soiling and avoiding cramping from laxatives in the early postoperative period. Although our series is small, we believe that long-term most patients can avoid antegrade flushes and be on no, or a dramatically reduced, laxative dose.
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Affiliation(s)
- Alessandra Gasior
- Center for Colorectal and Pelvic Reconstriction, Nationwide Children\'s Hospital, Columbus, Ohio, United States
| | - Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca Garnda Ospedale Maggiore Policlinico, Milan, Italy
| | - Karen Diefenbach
- Center for Colorectal and Pelvic Reconstriction, Nationwide Children\'s Hospital, Columbus, Ohio, United States
| | - Victoria Alison Lane
- Center for Colorectal and Pelvic Reconstriction, Nationwide Children\'s Hospital, Columbus, Ohio, United States
| | - Carlos Reck
- Center for Colorectal and Pelvic Reconstriction, Nationwide Children\'s Hospital, Columbus, Ohio, United States
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstriction, Nationwide Children\'s Hospital, Columbus, Ohio, United States
| | - Marc Levitt
- Center for Colorectal and Pelvic Reconstriction, Nationwide Children\'s Hospital, Columbus, Ohio, United States
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Federici S, DE Biagi L, Straziuso S, Leva E, Brisighelli G, Mattioli G, Pio L, Bagolan P, Totonelli G, Noccioli B, Severi E, Lelli Chiesa P, Lisi G, Tramontano A, DE Chiara C, Del Rossi C, Casadio G, Messina M, Angotti R, Appignani A, Bertozzi M, Rossi F, Gabriele V, Franchella A, Zocca V. Multicenter retrospective study on management and outcome of newborns affected by surgical necrotizing enterocolitis. MINERVA CHIR 2017; 72:183-187. [PMID: 28150915 DOI: 10.23736/s0026-4733.17.07159-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Ernesto Leva
- Pediatric Surgery Department, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Brisighelli
- Pediatric Surgery Department, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Luca Pio
- Pediatric Surgery Unit, Giannina Gaslini Institute, Genoa, Italy
| | - Pietro Bagolan
- Medical and Surgical Neonatology Department, Bambin Gesù Children's Hospital, Rome, Italy
| | - Giorgia Totonelli
- Medical and Surgical Neonatology Department, Bambin Gesù Children's Hospital, Rome, Italy
| | - Bruno Noccioli
- Neonatal Surgery Unit, Meyer University Children's Hospital, Florence, Italy
| | - Elisa Severi
- Neonatal Surgery Unit, Meyer University Children's Hospital, Florence, Italy
| | - Pierluigi Lelli Chiesa
- Pediatric Surgery Department, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy.,Pediatric Surgery Unit, Spirito Santo Hospital, Pescara, Italy
| | - Gabriele Lisi
- Pediatric Surgery Department, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy.,Pediatric Surgery Unit, Spirito Santo Hospital, Pescara, Italy
| | | | | | - Carmine Del Rossi
- Pediatric Surgery Unit, Maggiore University Hospital of Parma, Parma, Italy
| | - Giovanni Casadio
- Pediatric Surgery Unit, Maggiore University Hospital of Parma, Parma, Italy
| | - Mario Messina
- Pediatric Surgery Unit, Department of Medical Sciences, Surgery, and Neuroscience, University of Siena, Siena, Italy
| | - Rossella Angotti
- Pediatric Surgery Unit, Department of Medical Sciences, Surgery, and Neuroscience, University of Siena, Siena, Italy
| | | | - Mirko Bertozzi
- Pediatric Surgery Unit, University of Perugia, Perugia, Italy
| | - Fabio Rossi
- Pediatric Surgery Department, Ospedale Maggiore della Carità, Novara, Italy
| | - Valeria Gabriele
- Pediatric Surgery Department, Ospedale Maggiore della Carità, Novara, Italy
| | - Andrea Franchella
- Pediatric Surgery Department, Sant'Anna Hospital, Cona, Ferrara, Italy
| | - Veronica Zocca
- Pediatric Surgery Department, Sant'Anna Hospital, Cona, Ferrara, Italy
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Ronzoni L, Novelli A, Brisighelli G, Peron A, Triulzi F, Bianchi V, Leva E, Bedeschi MF. 2q33.1q34 Deletion in a Girl with Brain Anomalies and Anorectal Malformation. Cytogenet Genome Res 2016; 150:23-28. [DOI: 10.1159/000452090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2016] [Indexed: 11/19/2022] Open
Abstract
2q33 deletions are considered to constitute a distinct clinical entity (Glass syndrome or 2q33 microdeletion syndrome) with a characteristic phenotype. Most patients have moderate to severe developmental delay, speech delay, a particular behavioural phenotype, feeding problems, growth restriction, a typical facial appearance, thin and sparse hair, tooth abnormalities, and skeletal anomalies. Here, we report on a patient with a 2q33.1q34 deletion spanning 8.3 Mb of genomic DNA. Although her clinical features are very reminiscent of the 2q33 microdeletion syndrome, she also presented with brain and anorectal malformations. Based on the present and published patients with 2q33 deletions, we suggest that the critical region for the Glass syndrome may be larger than initially proposed. Moreover, we suggest that brain abnormalities might be an additional feature of the 2q33 microdeletion syndrome, but that anorectal malformation is likely not a key marker.
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Brisighelli G, Morandi A, Di Cesare A, Leva E. The Practice of Anal Dilations following Anorectal Reconstruction in Patients with Anorectal Malformations: An International Survey. Eur J Pediatr Surg 2016; 26:500-507. [PMID: 26766212 DOI: 10.1055/s-0035-1570755] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Purpose The objective of this study was to investigate the current practices of anal dilations after anorectal reconstruction for anorectal malformations (ARMs) in different centers. Materials and Methods An online survey, consisting of 27 questions about the practice of anal dilations, was launched in March 2015 among 54 pediatric surgeons with expertise in colorectal surgery. The survey was divided into three sections. The first section included questions regarding the country of origin, the role in the department, the average number of ARM cases treated per year, and the surgical approach used to repair ARMs. The second section was accessible only for surgeons who perform anal dilations and enquired about their modality of performing anal dilations-their attitude toward complications such as rectal prolapse, bleeding, or perineal dehiscence occurring during dilations-and about the incidence of rectal prolapse and/or anal stenosis, which required surgical repair, in their series of patients with ARMs. The third section was accessible only for surgeons who do not perform anal dilations and enquired the incidence of rectal prolapse and/or anal stenosis that required surgical repair in their series of patients with ARMs. Results A total of 36 pediatric surgeons from 20 countries completed the survey. All participants performed anal dilations. Twenty-five (70%) surgeons performed the first dilation 14 days after anorectal reconstruction; 30 (83%) surgeons performed it in the outpatient clinic; 34 (94%) surgeons used metal dilators and 30 (83%) surgeons lubricated the dilator with an anesthetic/steroid-free ointment; 21 (59%) surgeons tailored the first dilator size to the specific anatomical features of each patient; 27 (75%) surgeons used 1-mm-diameter increments in the dilator size and 22 (61%) surgeons increased the size weekly; 16 (45%) surgeons followed up with the patients weekly until the proper dilator size was reached. This was determined according to Peña's protocol by 25 (70%) surgeons: 23(64%) surgeons initially performed dilations twice daily; 24(66%) surgeons tapered the frequency of dilations once the desired caliber was reached. No general agreement exists in the management of complications such as rectal prolapse, bleeding, or perineal dehiscence occurring during dilations. Incidence of rectal prolapse and anal stenosis was reported less than 5%, respectively, by 25(70%) and 29(81%) respondents. Conclusion Anal dilations for ARM are performed worldwide according to different modalities. Prospective and randomized clinical trials could be useful to establish a standardized protocol.
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Affiliation(s)
- Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Antonio Di Cesare
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Morandi A, Borzani I, Macchini F, Brisighelli G, Consonni D, Leva E. Correlation between magnetic resonance imaging findings after posterior sagittal anorectoplasty for anorectal malformations and the clinical outcome: Preliminary report. J Pediatr Surg 2016; 51:1859-1863. [PMID: 27519558 DOI: 10.1016/j.jpedsurg.2016.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 07/01/2016] [Accepted: 07/18/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE To assess the anatomical results after posterior sagittal anorectoplasty (PSARP) by magnetic resonance imaging (MRI) and to evaluate the correlation of these findings with clinical outcomes. METHODS Patients followed-up at our center after PSARP, being at least 6year old, with neither evidence of sacral abnormalities nor spinal dysraphisms were prospectively included. Complex ARMs were excluded. MRI was performed on a 1.5T unit. T1- and T2-weighted sequences were acquired, in orthogonal planes, according to the anal canal orientation. The degree of anorectal centering in the muscle complex (DARC), the pelvic floor symmetry, the rectal maximum diameter, the fat tissue interposition, and the presence of fibrosis were evaluated. A clinical questionnaire (Rintala score) was filled in by the parents. MRI findings were compared to the clinical outcomes assessed by the Rintala score. For statistical analysis the Spearman rho correlation coefficient was calculated and the Wilcoxon rank-sum test was performed. RESULTS We recruited 11 patients (mean age 12years, range 6-19) with MRI. DARC (range 252-360°) was strongly correlated with the degree of fecal incontinence (rho=0.70), mildly with the ability to hold back defecation (rho=0.58), constipation (rho=0.46) and total Rintala score (rho=0.41). Pelvic floor symmetry correlated with the frequency of defecation (rho=0.58). Rectal maximum diameter negatively correlated with the ability to feel the urge to defecate (rho=-0.60). Patients with fibrosis were slightly more constipated (p=0.056) and presented more social impairment (p=0.04). Fat tissue interposition had no correlation with the clinical outcome. CONCLUSIONS Thanks to soft tissue definition, multiplanar imaging, and lack of ionizing radiation, MRI is a valuable tool in the postoperative anatomical evaluation of patients with ARM. Our preliminary results show that abnormal anatomical findings can correlate to a nonoptimal functional outcome, thus helping in understanding the clinical course. The degree of anorectal centering in the muscle complex (DARC) seems to have the better correlation with the outcome, especially in terms of fecal continence. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE level IV.
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Affiliation(s)
- Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Commenda 10, 20122 Milan, Italy.
| | - Irene Borzani
- Radiology Unit-Pediatric Division, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy.
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Commenda 10, 20122 Milan, Italy.
| | - Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Commenda 10, 20122 Milan, Italy.
| | - Dario Consonni
- Epidemiology Unit, Department of Preventive Medicine, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via San Barnaba 8, 20122 Milan, Italy.
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Commenda 10, 20122 Milan, Italy.
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Midrio P, Mosiello G, Ausili E, Gamba P, Marte A, Lombardi L, Iacobelli BD, Caponcelli E, Marrello S, Meroni M, Brisighelli G, Leva E, Rendeli C. Peristeen(®) transanal irrigation in paediatric patients with anorectal malformations and spinal cord lesions: a multicentre Italian study. Colorectal Dis 2016; 18:86-93. [PMID: 26304756 DOI: 10.1111/codi.13101] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/29/2015] [Indexed: 02/08/2023]
Abstract
AIM In paediatric and adult patients with neurogenic bowel, transanal irrigation (TAI) of the colon has gained popularity due to the introduction of a specifically designed device. The aim of this pilot study was to present the results of TAI using the Peristeen(®) TAI system in a group of paediatric patients with anorectal malformation (ARM) and congenital or acquired spinal cord lesions (SCLs). METHOD Eight Italian paediatric surgery and spina bifida centres participated in the study. The inclusion criteria were age between 6 and 17 years, weight above 20 kg and unsatisfactory bowel management. Patients with chronic inflammatory bowel disease, mental disability and surgery within the previous 3 months were excluded. At the beginning of treatment (T0) and after 3 months (T1) the Bristol scale, a questionnaire assessing bowel function, and two questionnaires on quality of life (QoL) for patients aged 6-11 years (CHQ-pf50) and 12-17 years (SF36) were administered. RESULTS Eighty-three patients were enrolled, and seventy-eight completed the study (41 ARMs, 37 SCLs). At T1, constipation was reduced in ARMs from 69% to 25.6% and in SCLs from 92.7% to 41.5%, faecal incontinence in ARMs from 50% to 18.6% and in SCLs from 39% to 9.8% and flatus incontinence in ARMs from 20.9% to 9.8% and in SCLs from 31.7% to 10%. At T0, the Bristol Stool Scale types were 1-2 in 45% of ARMs and 77.5% of SCL patients, whereas at T1 types 1-2 were recorded in only 2.5% of SCL patients. QoL improved in both groups. In the younger group, a significant improvement in QoL was recorded in ARM patients for eight of nine variables and in SCL patients for seven of nine variables. CONCLUSION This study showed that Peristeen TAI resulted in a significant time reduction in colonic cleansing, increased independence from the carer and improved QoL in paediatric patients with ARMs and SCLs.
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Affiliation(s)
- P Midrio
- Pediatric Surgery Unit, Department of Woman and Child Health, University Hospital, Padua, Italy
| | - G Mosiello
- Neuro-Urology Unit/Spina Bifida Center and Department of Medical and Surgical Neonatology, Bambino Gesù Children Hospital and Research Institute, Rome, Italy
| | - E Ausili
- Spina Bifida Center, Department of Paediatric Science, Catholic University Medical School, Rome, Italy
| | - P Gamba
- Pediatric Surgery Unit, Department of Woman and Child Health, University Hospital, Padua, Italy
| | - A Marte
- Pediatric Surgery Unit, Second University of Naples, Naples, Italy
| | - L Lombardi
- Pediatric Surgery Unit, Pediatric Hospital, Parma, Italy
| | - B D Iacobelli
- Neuro-Urology Unit/Spina Bifida Center and Department of Medical and Surgical Neonatology, Bambino Gesù Children Hospital and Research Institute, Rome, Italy
| | - E Caponcelli
- Pediatric Surgery Unit, Vittore Buzzi Pediatric Hospital, Milan, Italy
| | - S Marrello
- Pediatric Surgery Unit, Annunziata Hospital, Cosenza, Italy
| | - M Meroni
- Pediatric Surgery Unit, Vittore Buzzi Pediatric Hospital, Milan, Italy
| | - G Brisighelli
- Department of Pediatric Surgery, Fondazione Ca'Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - E Leva
- Department of Pediatric Surgery, Fondazione Ca'Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - C Rendeli
- Spina Bifida Center, Department of Paediatric Science, Catholic University Medical School, Rome, Italy
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Arnoldi R, Macchini F, Gentilino V, Farris G, Morandi A, Brisighelli G, Leva E. Anorectal malformations with good prognosis: variables affecting the functional outcome. J Pediatr Surg 2014; 49:1232-6. [PMID: 25092082 DOI: 10.1016/j.jpedsurg.2014.01.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 12/20/2013] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to investigate the outcome of patients operated for anorectal malformations (ARMs) with good prognosis. METHODS Thirty patients underwent clinical evaluation by Rintala score and anorectal manometry recording anal resting pressure (ARP), rectoanal inhibitory reflex (RAIR), and rectal volume (RV). The results were analysed with regard to sex, type of ARM, surgical timing of posterior sagittal anorectoplasty (PSARP), neurospinal cord dysraphism (ND), neonatal colostomy, and institution where they underwent surgery. RESULTS 6/30 (20%) presented ND despite normal sacrum. 17/30 (57%) patients had a normal Rintala score. ND and neonatal colostomy were significantly associated with a pathologic score (p=0.0029 and p=0.0016). Patients with ND had significantly lower ARP compared to patients with normal spine (23.5±7.2mmHg vs 32±7.9mmHg, p=0.023). ARP was significantly lower in patients with neonatal colostomy compared to patients with primary repair (25.22±10.24mmHg vs 32.57±6.68mmHg, p=0.026). RAIR was present in only 2/6 (33%) patients with ND, while in 21/24 (87.5%) without ND (p=0.015) and in 4/9 (44%) patients with neonatal colostomy, while in 19/21 (90.5%) patients submitted to primary repair (p=0.014). CONCLUSIONS Neurospinal cord dysraphism may be present despite normal sacral ratio. From a clinical point of view, patients with good prognosis ARMs are not completely comparable to healthy children. Neurospinal cord dysraphism and neonatal colostomy seem to worsen the clinical and manometric (ARP and RAIR) outcomes of these patients.
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Affiliation(s)
- Rossella Arnoldi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy.
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Valerio Gentilino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Giorgio Farris
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Giulia Brisighelli
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
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Abstract
INTRODUCTION A common error in the initial operative management of patients with cloacal exstrophy is to create an ileostomy leaving the colon defunctionalized and connected to the urinary tract. These patients benefit from a "rescue operation" to give them the best opportunity to be future pull-through candidates. METHODS Nineteen patients were identified who underwent an inadequate diversion during the newborn period, leaving a distal defunctionalized colon, and required a "rescue operation". A retrospective review of the medical records of these patients was performed. RESULTS A piece of colon was disconnected from the urinary tract, rescued from the pelvis, and incorporated into the fecal stream. The original stoma was closed, and an end colostomy was created. Fifteen patients were females and four were males. The length of rescued colon ranged from 5.5 to 20 cm. Symptoms present before the operation included: hyperchloremic acidosis (6), urinary tract infections (6), failure to thrive (5), sepsis (1), dehydration (1), and TPN dependent (1). There was resolution of these symptoms post-operatively. On follow up, 10 patients still have their colostomies as we are waiting for continued colonic growth, 6 patients had a pull-through after responding to our bowel management program through the stoma, 2 patients have a permanent stoma, and one patient expired. CONCLUSION When patients with cloacal exstrophy, or its variants, receive an ileostomy or proximal colostomy at birth, a rescue operation should be attempted.
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Affiliation(s)
- Andrea Bischoff
- Division of Pediatric Surgery, Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH, 45229, USA,
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Brisighelli G, Bischoff A, Levitt M, Hall J, Monti E, Peña A. Coloboma and anorectal malformations: a rare association with important clinical implications. Pediatr Surg Int 2013; 29:905-12. [PMID: 23907175 DOI: 10.1007/s00383-013-3356-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE In a patient with an anorectal malformation (ARM), the presence of a coloboma is commonly associated with other serious anomalies. METHODS Our database and the world literature were reviewed searching for associated defects in patients with ARM and coloboma. RESULTS Of 2,482 ARMs in our database, 11 had coloboma (0.4%): 2 were females. No specific associated type of ARM was identified. Six patients were developmentally delayed. Eight had a cardiac anomaly (3 had TAPVR, 2 VSD, 3 ASD), five required a cardiac operation. Five had a gastrointestinal anomaly (3 malrotation, 1 biliary and 1 duodenal atresia). Six had eye and seven had ear anomalies. Five had a genetic abnormality. In the literature, 71 patients with ARM and coloboma were found: 65 % were females. 24% died prematurely. 74% were developmentally delayed. 70% had a cardiac malformation (35% had TAPVR, 38% required an operation). 57% had gastrointestinal anomalies (31% malrotation, 31 % biliary atresia, 17% Hirschsprung disease). Eye and ear anomalies were present in 80 and 97% of patients, respectively. 81% had a genetic abnormality. CONCLUSIONS An ocular inspection in patients born with ARM is crucial. The finding of a coloboma should increase awareness to evaluate for a developmental, cardiologic or gastrointestinal anomaly.
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Affiliation(s)
- Giulia Brisighelli
- Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH 45229, USA
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Rossi V, Sartori A, Bordin G, Parolini F, Morandi A, Arnoldi R, Brisighelli G, Leva E, Torricelli EM. Cryptorchidism: medium- and long-term follow-up. Minerva Pediatr 2013; 65:261-269. [PMID: 23685377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
AIM Cryptorchidism represents the most frequent male genital anomaly in paediatric population and may potentially interfere with fertility and determine neoplastic testicular diseases. We wanted to evaluate the correlation between age at orchiopexy and follicle-stimulating hormone (FSH), luteinizing hormone (LH) and testosterone levels in adulthood, determining the long-term complications of surgical treatment. METHODS Fifty-seven patients (mean age 19 years, range 18-27) surgically treated for cryptorchidism in pediatric age were included in a medium and long-term follow-up (10-19 years). We divided this population into four groups: A) monolateral cryptorchidism operated on before 36 months of age (15); B) monolateral cryptorchidism operated on over 36 months (32); C) bilateral cryptorchidism operated on before 36 months (5); and D) bilateral cryptorchidism operated on over 36 months (5). All patients underwent andrological examination, testosterone, FSH and LH dosage, measurement of testicular volume and spermiogram. RESULTS Significant different FSH levels were found between group A and C and between A and D (P<0.01), while groups A and D presented also different mean testicular volume (P<0.01). In addition group D showed an abnormal morphology of spermiogram. The main complications found in follow-up were hydrocele (17,5%), varicocele (8,7%) and epididymal cysts (3.6%). CONCLUSION Monolateral cryptorchidism is associated with normal fertility when treated early (group A). Subjects in Group D, on the contrary, have a rise of FSH, a reduction of testicular volume and semen abnormalities. The long-term follow-up of these patients can also detect associated.
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Affiliation(s)
- V Rossi
- Dipartimento Salute della Donna, Ospedale Maggiore Policlinico, Milano, Italia.
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Leva E, Arnoldi R, Ferrari C, Morandi A, Brisighelli G, Parolini F, Farris G. Surgical treatment of toraco-abdominal teratoma diagnosed in utero, approached with mini-invasive technique: a case report. Minerva Pediatr 2012; 64:357-359. [PMID: 22555330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Thoracic tumours of childhood arise either in the mediastinum, or from the chest wall and rarely from the lung parenchyma. Mediastinal teratoma occur in the anterior mediastinum and are usually very large at presentation; initial treatment is under discussion, but it appears that surgical excision and histological examination are the treatments of choice and it will determine whether the lesion is benign or malignant. The authors report a case of thoracic-abdominal teratoma, diagnosed in utero, and treated successfully with thoracoscopy and laparoscopy. No complication was described in short follow up, and the child was discharged in day 8th postoperative day. Histology showed mature teratoma. Follow-up at one year: no evidence of recurrence. Due to the rarity of multifocal teratoma in newborns, author believe that mini-invasive technique was useful to stage histological the mass, giving the opportunity to plans a second stage in treatment of the patient. Day of hospitalization resulted shorter in both surgical approaches, and discomfort less for the thoracic approach. This staging must be anyway planned, in the way of prenatal counselling and in the perinatal period, with the team involved in the procedure, that include anaesthetists, oncology staff, obstetricians, neonatologists and pediatric surgeons. It is mandatory in cases like the one reported that a multisciplinary team manage the patients and expert surgeons, especially in minimal invasive surgery, make the adequate plans.
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Affiliation(s)
- E Leva
- Department of Pediatric Surgery, IRCCS Ca' Granda Foundation, Maggiore Policlinico Hospital, Milan, Italy.
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Abstract
Although appendicitis is the condition that most commonly requires emergent abdominal surgery in the paediatric population, less than 2% of the disease occurs in infants and it is even more uncommon in neonates. In this report, we describe a rare case of a 14-month-old child presenting with abdominal pain first diagnosed with upper respiratory tract infection and then admitted to our Paediatric Surgery Department with a final diagnosis of acute appendicitis. A particular attention has to be kept on children presenting with an upper respiratory tract infection since symptoms can mask abdominal signs. Due to high morbidity and mortality rate related to a delayed diagnosis, appendicitis always has to be considered as a possible diagnosis, in order to ensure a prompt treatment.
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Affiliation(s)
- Giulia Brisighelli
- Department of Pediatric Surgery, FONDAZIONE IRCCS CA' GRANDA - Ospedale Maggiore Policlinico, Milano, Italy
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Arnoldi R, Macchini F, Brisighelli G, Farris G, Ferrari C, Esposito V, Leva E. Ectopic thymus presenting as neck mass in a neonate: a case report. Minerva Pediatr 2011; 63:237-238. [PMID: 21654604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Neck masses are rare in newborns and can represent a big challenge for the paediatric surgeons. Different histological types are reported in the recent literature; while 80% of neck masses are benign, the pediatric surgeon is often called upon to assist in the evaluation, diagnosis and treatment. A two-month old baby was evaluated for an asymptomatic left sided cervical mass, presented at birth, which slowly increased in size. A magnetic resonance imaging scan was performed, with evidence of capsulated solid neck mass, lateral to the sternocleidomastoid muscle, not including the major vassel structures of the neck. The patient underwent surgical excision in the criteria to define the histology of the mass. A well capsulated mass was detected at surgery. At histology, an ectopic cervical thymus tissue was reported. The ectopic cervical thymus is an uncommon entity with only 91 cases reported; only nine occurred in infants, two in the neonatal period. According to the authors, in case of enlarging solid neck mass with unclear imaging or clinical data, complete surgical resection is the only and safe procedure to perform.
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Affiliation(s)
- R Arnoldi
- Neonatal Surgical Unit, Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Maggiore Hospital, Milan, Italy.
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