Advanced Management Protocol of Transanal Irrigation in Order to Improve the Outcome of Pediatric Patients with Fecal Incontinence.

BACKGROUND: Transanal irrigation (TAI) is employed for children with fecal incontinence, but it can present several problems which require a study of their outcomes among different pathologies and without a tailored work up. The aim of our study was to evaluate the effectiveness of an advanced protocol in order to tailor TAI, prevent complications, and evaluate outcomes. METHODS: We included 70 patients (14 anorectal malformation, 12 Hirschsprung's disease, 24 neurological impairment, 20 functional incontinence) submitted to a comprehensive protocol with Peristeen®: fecal score, volumetric enema, rectal ultrasound, anorectal 3D manometry, and diary for testing and parameter adjustment. RESULTS: Among the patients, 62.9% needed adaptations to the parameters, mainly volume of irrigated water and number of puffs of balloon. These adaptations were positively correlated with pre-treatment manometric and enema data. In each group, the improvement of score was statistically significant in all cases (p 0.000); the main factor influencing the efficacy was the rate of sphincter anomalies. The ARM group had slower improvement than other groups, whereas functional patients had the best response. CONCLUSIONS: Our results showed that TAI should not be standardized for all patients, because each one has different peculiarities; evaluation of patients before TAI with rectal ultrasound, enema, and manometry allowed us to tailor the treatment, highlighting different outcomes among various pathologies, thus improving the efficacy.

The inconspicuous penis in children.

The term 'inconspicuous penis' refers to a group of anatomical abnormalities in which the penis looks smaller than is expected. Micropenis can be defined as 'true micropenis'--which results from a defect in the hypothalamic-pituitary-gonadal axis--and 'micropenis secondary to congenital anatomical anomalies of the surrounding and overlying structures'--also known as 'concealed penis'. The different forms of concealed penis include webbed penis, congenital megaprepuce and partially hidden penis caused by prepubic adiposity. This disorder can also have iatrogenic causes resulting from adhesions that are secondary to circumcision--this type of concealed penis is known as 'trapped penis'. However, in both groups, micropenis is defined as a stretched penile length that is at least 2.5 SD below the mean for the patient's age, but without any other penile defects. Patients with true micropenis can be managed with testosterone, which has demonstrated good penile elongation results in the long term. Surgery also has a pivotal role in reconstruction for elongating the penis and for correction of anatomical abnormalities in concealed penis.

Ileocecal duplication cysts: is the loss of the valve always necessary?

BACKGROUND: Ileocecal (IC) duplication cysts are enteric duplications located at the IC junction, not clearly identified in all the published series. The reported treatment is IC resection and ileocolic anastomosis. It is well known that the loss of the IC valve has several adverse effects. This study is aimed at demonstrating that cyst removal together with the common ileal wall and following enterorrhaphy is possible, safe, and effective in preserving the IC region. METHODS: Medical records of 3 patients who underwent surgery for IC duplication between 2003 and 2013 were retrospectively reviewed evaluating follow-up results. RESULTS: All patients had an antenatal diagnosis of intraabdominal cystic mass. In two cases associated malformations were reported. The lesions presented at newborn age with intermittent small bowel obstruction and required removal. No patients underwent IC resection. The diagnosis of duplication cyst was confirmed by histo-pathologic examination. The postoperative course was uneventful, even in the long-term follow-up. CONCLUSIONS: Our conservative approach is a simple and safe technique, effective in avoiding the loss of the IC valve in children with duplication at the IC junction.

Gastroesophageal reflux in patients treated for congenital diaphragmatic hernia: short- and long-term evaluation with multichannel intraluminal impedance.

PURPOSE: The incidence of GER, related symptoms and complications in patients treated for congenital diaphragmatic hernia (CDH) are poorly defined. The aim was to evaluate incidence and development of GER in children treated for CDH in a short- and long-term follow-up period, identifying potential risk factors of morbidity. METHODS: Thirty-six patients were evaluated with pH-MII at a median age of 6 months (T1) and re-evaluated with pH-MII and endoscopy at a median age of 5 years (T2). RESULTS: The incidence of reflux was 83 % in T1 and 61 % in T2; the incidence of symptoms was 62 % in T1 and 38 % in T2. In both groups the reflux was mainly non-acidic. Patch, intrathoracic stomach and esophageal dysmotility were risk factors for GER. CONCLUSIONS: The incidence of GER and symptoms decrease over the time but it was higher than in the literature, probably because it is mainly non-acidic and evaluable only with MII. The esophageal dysmotility was found to be the main risk factor. An high incidence of reflux and esophagitis was found also in asymptomatic patients, and so a close follow-up is recommended in all patients even if it is asymptomatic.

Coverage of urethroplasty in pediatric hypospadias: randomized comparison between different flaps.

OBJECTIVES: The use of covering urethroplasty with flaps in hypospadias surgery has been well recommended. Various techniques have been described for flap harvesting. The aim of the present study was to compare the outcome and complication rate of dorsal preputial flaps and ventral dartos flaps. METHODS: A total of 130 patients were prospectively evaluated from January 2008 to December 2011. Using the tubularized incised plate urethroplasty procedure, urethroplasty was carried out by a single surgeon. Patients were randomly divided in two groups: group A (57 patients), in which a preputial flap was carried out using three different techniques; and group B (73 patients), in which a single or a double ventral dartos flap was used. RESULTS: A total of 41 complications occurred in 24 patients. Urethrocutaneous fistulas were observed in 14.9%, quite equally distributed between groups A and B. There was only one urethrocutaneous fistula in a patient treated with the double ventral dartos flaps. Five cases (3.8%) of glans dehiscence were observed: four after single ventral dartos flap and one after dorsal preputial flap. Six patients in group A and seven in group B experienced meatal stenosis. In three cases of iatrogenic torsion of the penis, a dorsal preputial flap was laterally transposed. Finally, a lower complication rate was observed for double ventral dartos flap versus the other techniques. CONCLUSIONS: The use of a double ventral dartos flap should represent the first-line technique for coverage of distal urethroplasty.

A simple technique of oblique anastomosis can prevent stricture formation in primary repair of esophageal atresia.

BACKGROUND: Anastomotic stricture is an important problem after esophageal atresia (EA) repair. This study evaluates a technique of oblique esophageal anastomosis without use of a flap in order to prevent stricture formation. METHODS: Medical records of 16 patients (14 with EA type III and 2 with EA type IV Ladd-Gross classification) who underwent primary repair of EA at birth without anastomotic tension were reviewed, evaluating long-term follow-up results. All patients were studied with esophageal contrast study, pH-multichannel intraluminal impedance, and endoscopy. The incidence of complications and their management were analysed. RESULTS: Contrast esophagogram and esophagoscopy always showed regular patency of the suture line. CONCLUSIONS: Our technique of oblique anastomosis is simple, safe, and effective in preventing stricture formation even in the long-term follow-up.

Case of obscure-overt gastrointestinal bleeding after pediatric liver transplantation explained by endoscopic ultrasound.

Portal hypertension, which is a common finding in children awaiting liver transplantation, is also found after transplantation. It's reported the case of a 6-year-old girl, transplanted for biliary atresia, who had a severe obscure-overt bleeding presenting with melena. An esophagogastroduodenoscopy showed several duodenal small, bulging lesions, with some red signs. Near the lesions, a depressed area of 2 cm, covered with mixed hyperemic and white mucosa, was observed. To better evaluate these lesions, we performed an endoscopic ultrasonography (EUS) that showed multiple, round hypoechoic areas 0.5-5 mm in diameter, compatible with duodenal varices, and several periduodenal anechoic lesions compatible with collaterals. A consecutive computed tomography scan showed a stenosis of the portal vein anastomosis confirmed with a transhepatic portography, which was successfully treated with balloon angioplasty. No further episodes of bleeding were observed during the follow-up. This case report suggests that EUS is safe and feasible in young children when using echoendoscopes designed for use in adults. However further studies are needed to validate the employment of this technique in the management and follow-up of pediatric portal hypertension.

Gastroesophageal reflux in young children treated for esophageal atresia: evaluation with pH-multichannel intraluminal impedance.

OBJECTIVES: Gastroesophageal reflux (GER) and dismotility occur frequently after repair of esophageal atresia (EA). GER-associated complications can manifest either early or later; then precocious diagnosis and treatment are essential. The aim of the study was to evaluate characteristics of GER and esophageal clearance in children treated for EA with distal tracheoesophageal fistula, using pH-multichannel intraluminal impedance (pH-MII). PATIENTS AND METHODS: Twenty-two children (ages 3-40 months) treated for EA at birth, and 20 normal children of similar age with suspected GER disease were included in the study. Impedance parameters were analyzed according to age and symptoms. RESULTS: Reflux events were mainly nonacidic. About bolus exposure index, mean acid clearing time (MACT), and mean bolus clearing time (MBCT), a significant difference was found between 2 groups: the median MACT and MBCT were longer, with values of 281 and 39 seconds, respectively, in the EA group and 110 and 15 seconds in the control group (P < 0.0005). CONCLUSIONS: Our data show that in young patients the majority of refluxes are not acid. This implies that the incidence of GER may be underestimated if pH-metry is used. The pH-MII is an ideal test in children because it studies both GER with its characteristics and motility pattern. The quality of reflux does not seem to influence the onset of symptoms that are related to an impaired esophageal clearance. Hence, this technique could be useful to study patients treated for EA, avoiding the onset of complications.

Evaluation of esophageal motility and reflux in children treated for esophageal atresia with the use of combined multichannel intraluminal impedance and pH monitoring.

BACKGROUND: Gastroesophageal reflux (GER) and dysmotility are frequent in patients treated for esophageal atresia (EA). This aim of this study is to evaluate GER and dysmotility in young EA patients using pH-multichannel intraluminal impedance (pH-MII). METHODS: Fifteen patients with a mean age of 7.5 years (group 1) have been studied and compared with 15 children without congenital malformation, submitted to pH-MII for suspected GER (group 2). These latter patients serve as a control group of healthy subjects. The following impedance reflux and motility parameters have been studied on 10 standardized swallows: number of reflux episodes, mean acid clearing time, median bolus clearing time, bolus presence time, total bolus transit time, segmental transit time, and total propagation velocity. RESULTS: In the group of EA patients, mean acid clearing time and median bolus clearing time were pathological. In the control group, all reflux parameters were normal. Patients with EA had significantly longer median bolus presence time at each measuring site, median total bolus transit time, and median segmental transit time and slower total propagation velocity (P < .001). CONCLUSIONS: pH-multichannel intraluminal impedance evaluates both GER and motility patterns. Our report studies impedance parameters of esophageal motility in healthy children and in EA patients using only pH-MII.

Evaluation of esophageal motility using multichannel intraluminal impedance in healthy children and children with gastroesophageal reflux.

OBJECTIVE: Multichannel intraluminal impedance (MII) directly evaluates esophageal bolus transport. There is a good correlation between MII and manometry in healthy adults, but there are no reports concerning children.The aim of the present study was to determine normal values of esophageal motility using only impedance measurements in healthy children and in a pediatric population with gastroesophageal reflux (GER). PATIENTS AND METHODS: We described in the present study 60 children submitted to pH-MII for 24 hours for suspected GER. Patients were divided into 2 different groups on the basis of their pH-MII report. Group 1 patients showed acid GER, whereas group 2 patients had negative pH-MII analysis for GER despite symptoms. We described impedance reflux and motility parameters on 10 standardized swallows: number of reflux, mean acid clearing time, median bolus clearing time, bolus presence time, total bolus transit time, segmental transit time, and total propagation velocity. RESULTS: In group 1, the median mean acid clearing time was 151 seconds, whereas the median mean bolus clearing time was 25 seconds. In group 2 patients, all of the reflux parameters were normal. In group 1 the median bolus presence time at each measuring site, the median total bolus transit time, and the median segmental transit time were significantly greater and total propagation velocity lower than values reported in group 2 (P < 0.001), if compared with those described for adult patients. CONCLUSIONS: The pH-MII is an ideal test in children because it studies GER with its characteristics and motility pattern. Our report summarizes for the first time impedance motility parameters in healthy children.

Balloon dilatation of postoperative small bowel anastomotic stricture in an infant with apple peel intestinal atresia after serial transverse enteroplasty and jejunoileal anastomosis.

We report successful fluoroscopically guided balloon dilatation of an early postoperative stricture of a jejunoileal anastomosis in a 3-month-old infant who underwent serial transverse enteroplasty for type IIIb apple peel intestinal atresia.

Is rectal disimpact always necessary in children with chronic constipation? Evaluation with pelvic ultrasound.

PURPOSE: The aim of study was to evaluate if pelvic ultrasound can be useful in managing children with chronic idiopathic constipation. METHODS: A total of 270 children with idiopathic chronic constipation were enrolled in the study. At baseline and at monthly checkups children were evaluated by clinical score and pelvic ultrasound (US). Patients have been divided in 2 groups, based on pelvic US results: group A with a rectal diameter >3 cm, group B with a rectal diameter <3 cm or rectum not visualized. Both groups were subsequently randomly divided in two subgroups (A1, A2, B1, B2) on the basis of the prescribed treatment (disimpaction for the first week and daily laxative or only daily laxative). RESULTS: After 1 month of therapy all clinical features improved in group A1 and at pelvic US, rectal size reduced and became not visualized; group A2 showed poor clinical response and transverse diameter of rectum did not modify significantly; B1 and B2 groups showed significant improvement only after 2-3 months. CONCLUSIONS: Rectal disimpaction is necessary only in presence of MR. Pelvic US is a useful to diagnose MR and to set up the most appropriate treatment protocol for different chronic constipation cases.

Efficacy of periportal infiltration and intraperitoneal instillation of ropivacaine after laparoscopic surgery in children.

UNLABELLED: Postoperative pain is less intense after laparoscopic than after open surgery. However, minimally invasive surgery is not a a pain-free procedure. Many trials have been done in adults using intraperitoneal and/or incisional local anesthetic, but similar studies have not yet been reported in the literature in children. AIM: The aim of this study was to evaluate the analgesic effect of periportal infiltration and intraperitoneal instillation of ropivacaine in children undergoing laparoscopic surgery. MATERIALS AND METHODS: Thirty patients who underwent laparoscopic surgery were randomly allocated to one of three groups. Group A (n = 10) received local infiltration of port sites with 10 mL of ropivacaine. Group B (n = 10) received both an infiltration of port sites with 10 mL of ropivacaine and an intraperitoneal instillation of 10 mL of ropivacaine. Group C did not receive any analgesic treatment. The local anesthetic was always administered at the end of surgery. The degree of postoperative abdominal parietal pain, abdominal visceral pain, and shoulder pain was assessed by using a Wong-Baker pain scale and a Visual Analog Scale (VAS) at 3, 6 12, and 24 hours postoperatively. The following parameters were also evaluated: rescue analgesic treatment, length of hospital stay, and time of return to normal activities. RESULTS: Three hours after operation, patients had low pain scores. Six and 12 hours postoperatively, the abdominal parietal pain was significantly higher (P < 0.0005) in group C than in the other two groups, both treated with an infiltration at the trocar sites; mean intensity of abdominal visceral pain was significantly lower (P < 0.0005) in group B than in groups A and C; the overall incidence of shoulder pain was significantly lower (P < 0.0005) in group B patients than in patients of groups A and C. At 20 hours postoperatively, pain scores were significantly reduced of intensity in all groups. Rescue analgesic treatment was significantly higher in group C, if compared to groups A and B 12 hours after the operation. No statistically significant difference was found in length of hospital stay, but children who received analgesic treatment had a more rapid return to normal activities than untreated patients (P < 0.0005). CONCLUSIONS: Our study demonstrates that the combination of local infiltration and intraperitoneal instillation of ropivacaine is more effective for pain relief in children after laparoscopic surgery than the administration of ropivacaine only at the trocar sites.

Laparoscopic surgery of deferential reflux in pediatric and adolescent varicocele.

BACKGROUND: This study aimed to assess whether deferential reflux in pediatric and adolescent varicocele can be successfully treated laparoscopically. MATERIALS AND METHODS: Since 2001 at our institution, 148 boys were evaluated for a left varicocele. Preoperatively,all the patients underwent ultrasound scan assessment of testicular volume and color-Doppler US (CDUS)to rule out reflux into the internal spermatic vein (ISV), deferential vein, or cremasteric vein. Boys with ISV reflux were treated by laparoscopic transperitoneal Palomo; boys with isolated deferential reflux or associated to ISV reflux were laparoscopically managed adding to the former procedure, coagulation or clipping of refluxing deferential veins. RESULTS: Reflux in both the ISV and the deferential vein was observed in 21 (14.1%) out 148 boys with varicocele.Only one case (0.6%) of varicocele was caused by an isolated deferential reflux. No reflux in the cremasteric vein was observed. After a median follow up period of 2 years (range, 6 months-5 years), none of our patients with deferential reflux experienced varicocele recurrence either clinically or according to CDUS scanning.No testicular atrophy was observed. CONCLUSION: Our diagnostic approach is a rigorous standard for identifying all the venous systems concurring with the varicocele. Our proposed technique with laparoscopic interruption or coagulation of deferential veins when proved by CDUS to be refluxing may allow successful treatment for most varicoceles. This method allows reduction in recurrence of varicocele due to a missed deferential reflux.

Different types of intestinal atresia in identical twins.

The authors present a previously unreported association of different types of intestinal atresia in identical low-birth-weight twins. Both babies were affected by duodenal atresia, associated in the first case with a complete mucosal duodenal membrane and in the second one with an "apple-peel" jejunal atresia. These occurrences may suggest that they were either the consequence of linkage of 2 genes or a pleiotropic expression of a single gene responsible for such rare conditions.

'Preemptive hydrocelectomy' in subinguinal varicocelectomy.

BACKGROUND/AIMS: The hydrocele rate is very low after microsurgical subinguinal varicocelectomy, but microsurgical expertise is not always available in pediatric centers. We describe a modified technique to reduce the hydrocele rate after subinguinal varicocelectomy performed without an operating microscope. METHODS: A retrospective review was performed of 142 non-microsurgical subinguinal varicocelectomies performed at a single pediatric center. In 96 patients, varicocelectomy was combined with the excision and eversion of the tunica vaginalis ('pre-emptive hydrocelectomy') while in the remaining 46 cases the vaginalis was left untouched. RESULTS: Pre-emptive hydrocelectomy allowed a significant reduction in the hydrocele rate in comparison to cases in whom the vaginalis was left untouched, hydrocele rate 4.3 vs. 13% (p = 0.04). In patients undergoing preemptive hydrocelectomy, hydrocele occurred in 3 of 54 (5.5%) cases in whom the vaginalis was only excised and only 1 of 42 (2.4%) in whom it was also everted. No testicular complications were observed. CONCLUSIONS: In centers performing subinguinal varicocelectomy without the aid of an operating microscope, pre-emptive hydrocelectomy with eversion of the vaginalis might be offered as an adjunctive treatment with limited associated morbidity that might be able to reduce the incidence of postoperative hydrocele.

Evolving management of adolescent varicocele.

OBJECTIVE: To review the evolution in indications for treatment and treatment modalities for adolescent varicocele at our centre, and evaluate the impact of varicocelectomy on final outcome. PATIENTS AND METHODS: Between 1995 and 2006, we treated 242 left varicoceles. Preoperative assessment included clinical evaluation, measurement of testicular volumes, and colour-Doppler ultrasound (CDUS). A subinguinal varicocelectomy was performed in 124 patients (group A), and a laparoscopic non-artery-sparing Palomo procedure in the remaining 118 (group B). In group B patients, CDUS was also used to investigate the functional anatomy of varicocele, and all the veins found to be refluxing were divided during surgery. The two groups were compared with regard to indications for surgery and outcome. RESULTS: Over time the proportion of patients operated on because of testicular growth retardation increased. Persistence/recurrence rate was comparable between the two groups. In 13% of group B patients, the deferential vein was found to be refluxing on preoperative CDUS and was divided at surgery. Hydrocele rate was higher in group A, unless the vaginalis was excised and everted during varicocelectomy. About 75% of patients with preoperative left testicular growth failure experienced postoperative catch-up growth, irrespective of treatment. CONCLUSION: Indications for treatment are still evolving. Varicocele can successfully be treated in the majority of cases by either a laparoscopic or subinguinal approach. Both techniques require care, and CDUS can aid in the decision making. Most patients with preoperative testicular growth failure experience postoperative catch-up growth.