Preliminary report on endoscopic pilonidal sinus treatment in children: results of a multicentric series.

BACKGROUND: Pilonidal disease is a troublesome acquired condition for whom various surgical treatments have been proposed with relatively high recurrence and complication rates. Since EPSiT technique has been described in 2013, it became an alternative treatment in adult practice. Our study reports the results of a multicentre series of pediatric patients who underwent EPSiT procedure over a 21-month period. METHODS: Between July 2015 and March 2017, all consecutive patients undergoing EPSiT in four different pediatric surgical units have been enrolled. Details regarding demographic data, detailed surgical procedure, outcome and complications have been recorded. RESULTS: A total of 43 patients underwent EPSiT procedure. Mean age was 15 years. There was a slight female preponderance. Mean weight and height at surgery were 67 kg and 168 cm, respectively. In 14% of cases a previous ineffective procedure was performed. Mean length of procedure was 34 min and median hospital stay was 24 h (12-72 h). Median length of follow-up was 4 months (range 3-18 months). Complications leading to reoperation were reported in 9% of cases with an overall resolution rate of 88%. DISCUSSION: EPSiT proved to be feasible and safe even in the pediatric population. The effectiveness and safety of the procedure suggest that this technique can represent a valid alternative for the treatment of pilonidal disease in children.

Morbidity and Risk Factors of Laparoscopic-Assisted Ileostomies in Children With Ulcerative Colitis.

INTRODUCTION: Laparoscopic-assisted ileostomy (LAI) represents a cornerstone for the staged approach to ulcerative colitis (UC). The aim is to determine stoma morbidity in a series of pediatric patients and possibly identify specific risk factors. METHODS: All of the patients who underwent LAI for UC between January 2008 and December 2014 were included. The following data were collected: patient demographics, preoperative medical treatment, body mass index (BMI) at surgery, Pediatric UC Index (PUCAI), and stoma-related complications. In this series of patients, a staged approach has been adopted (subtotal colectomy + ileostomy; restorative proctocolectomy with J-pouch ileo-rectal anastomosis + ileostomy; ileostomy closure). RESULTS: Seventy-two LAIs were fashioned in 37 pediatric patients with UC. Median age at surgery was 12 years (range 5-14.8 years). Boy to girl ratio was 0.85:1. Mortality was zero. Complications occurred after 8 procedures after a median of 31 days postoperatively (range 8-60 days). Those were significantly more frequent in the case of BMI-z score >-0.51 (deleted in revised manuscript, ie, relatively overweight patients) and in the case of preoperative azathioprine administration. Pediatric UC Index score, sex, number of preoperative medications, and other preoperative parameters did not correlate with the incidence of complications. CONCLUSIONS: Our study suggests to keep a prudent behavior in the case of patients with a BMI-z score >-0.51 and received preoperative azathioprine administration. Parents should be adequately acknowledged on this regard.

Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children.

BACKGROUND: Fundoplication is considered a mainstay in the treatment of gastro-esophageal reflux. However, the literature reports significant recurrences and limited data on long-term outcome. AIMS: To evaluate our long-term outcomes of antireflux surgery in children and to assess the results of redo surgery. METHODS: We retrospectively analyzed all patients who underwent Nissen fundoplication in 8 consecutive years. Reiterative surgery was indicated only in case of symptoms and anatomical alterations. A follow-up study was carried out to analyzed outcome and patients' Visick score assessed parents' perspective. RESULTS: Overall 162 children were included for 179 procedures in total. Median age at first intervention was 43 months. Comorbidities were 119 (73 %), particularly neurological impairments (73 %). Redo surgery is equal to 14 % (25/179). Comorbidities were risk factors to Nissen failure (p = 0.04), especially children suffering neurological impairment with seizures (p = 0.034). Follow-up datasets were obtained for 111/162 = 69 % (median time: 51 months). Parents' perspectives were excellent or good in 85 %. CONCLUSIONS: A significant positive impact of redo Nissen intervention on the patient's outcome was highlighted; antireflux surgery is useful and advantageous in children and their caregivers. Children with neurological impairment affected by seizures represent significant risk factors.

Learning curve for robotic surgery in children: a systematic review of outcomes and fellowship programs.

The learning curve (LC) of a new technique is fundamental for its application and assessment, and for the training. Literature was analysed to define the LCs of different surgical procedures and the impact of fellowship programs. MEDLINE, EMBASE and paediatric surgical journals' databases from January 1995 to December 2018 were systematically analysed. Two independent residents sought for articles providing description of robotic-assisted procedures' LCs in paediatric age/population. Seventeen articles were selected, describing LC of robotic-assisted pyeloplasty (n = 9), fundoplication (n = 4), cholecystectomy (n = 2), choledochal cyst resection (n = 1) and lingual tonsillectomy (n = 1), with 721 procedures. Ten studies refer to one single surgeon; six to more than one; one does not specify the number of operators. Eleven studies are unicentric retrospective, two multicentric retrospective, three prospective and one is a comparative analysis between a retrospective case series and a prospective cohort. The most recruited parameter is operative time alone in 3 articles, associated with complications in 12, length of hospital stay in 6, blood loss in 3, resolution in 4 and narcotic use in 2. The LC is described as impacting procedural planning (n = 17), training (n = 9) and economic costs (n = 2). To date, operative time is the most reported outcome to measure LC and proficiency. Efforts are needed to consider measures of surgical expertise and patient status. Robotic training should be standardized on targeted programs planned upon well-defined LCs.

Minimally Invasive Techniques for Hirschsprung Disease.

Background: Surgical treatment of Hirschsprung disease (HD) evolved in the last decades with the introduction of new innovative minimally invasive techniques. The aim of present study is to compare the results from two centers, applying similar minimal access approaches, total transanal endorectal pull-through (TEPT) and laparoscopic-assisted transanal pull-through (LA-TAPT). Materials and Methods: Data of all patients admitted between January 2011 and December 2016 in two Italian referral Hospitals for HD were retrospectively collected and analyzed. Exclusion criteria were as follows: redo procedure, patients with total colonic aganglionosis (ileostomy), patients lost at follow-up, or missing data. Patients who underwent TEPT and LA-TAPT were compared for gestational age, birth weight, age and weight at surgery, associated malformation, genetic syndrome, length of hospital stay, and early postoperative complications (within 30 days). Statistical analysis: Fisher's test and Mann-Whitney test; statistical significance set at P < .05. Results: None of the patients who underwent TEPT required laparotomy or laparoscopic assistance. Patients who underwent TEPT had lower age (P = .001), lower body weight (P < .0001), a significant higher rate of associated congenital heart disease (P = .006), and longer postoperative stay. In addition, the prevalence of perianal dermatitis was higher in TEPT patients (17/61 [28%] versus 2/46 [4%], P = .001). The two groups were similar in terms of postoperative enterocolitis, redo surgery, anastomotic stenosis, and other infective complications. Conclusion: Both minimally invasive techniques allow surgical advantages and outcomes; TEPT avoids pneumoperitoneum and the transperitoneal approach, with no need for laparoscopic instrumentation. TEPT group had longer postoperative stay, probably due to the higher prevalence of associated cardiac anomalies, and higher prevalence of perianal dermatitis, probably due to the lower age at operation.

Robotic-Assisted Minimally Invasive Total Esophagogastric Dissociation for Children with Severe Neurodisability.

BACKGROUND: Around 70% of children with neurodisability (ND) present pharyngeal neuromuscular incoordination and severe gastroesophageal reflux disease (GORD). METHODS: This is a pilot study with the Robotic-assisted minimally invasive total esophagogastric dissociation (TOGD). RESULTS: We included 4 patients, 2 males and 2 females, with ND and severe GORD refractory to medical treatment. CONCLUSIONS: Pharmacological management of GORD is often unsuccessful and antireflux surgery is common, but it has a high failure rate with symptom recurrence, requiring re-do surgery. TOGD is a good option for these patients.

A Provisional Experience with Robot-Assisted Soave Procedure for Older Children with Hirschsprung Disease: Back to the Future?

Hirschsprung disease is a congenital disease characterized by intestinal aganglionosis of various extents. Most patients are younger than 1 year of age. Though, a minority of cases can be older or even adult. Older the patient the more difficult and prolonged is the endorectal dissection required for the pull-through procedure. Longer surgery leads to longer anal dilatation and trauma with subsequent higher likelihood of continence impairment. The article aims at describing the first case series of robot-assisted Soave procedure, which was adopted as an alternative minimally invasive approach to older patients with Hirschsprung disease. The technical principles are represented by intraoperative seromuscolar leveling biopsies, intracorporeal endorectal cranial dissection, and endorectal pull-through with colo-anal anastomosis. The authors report three procedures that were carried on without complication with a limited requirement for anal dilatation and trauma, given the reduced need for endorectal caudal dissection. The results demonstrate the feasibility of the proposed approach. The robotic approach should be considered as an alternative minimally invasive approach for older children or adults with Hirschsprung disease.

Da Vinci Robotic Surgery in a Pediatric Hospital.

INTRODUCTION: Since the use of robotic surgery (RS) revolutionized some adult surgery procedures such as radical prostatectomy, it has been progressively and increasingly introduced in pediatric surgery. The aim of this study is to evaluate how the Da Vinci® Si HD technology impacts a pediatric public hospital and to define the use of a robotic system in pediatric surgery. MATERIALS AND METHODS: We prospectively included patients older than 6 months of age undergoing RS or conventional minimal access surgery (MAS): Study period ranges between February 2015 and April 2016. Surgical indications were defined after a detailed disease-specific diagnostic work-up. We analyzed surgical outcomes and the most relevant economic aspects. The 30-day postoperative complications were evaluated and retrospectively collected in an electronic database. RESULTS: From February 2015 to April 2016, we performed 77 procedures with RS and 84 with conventional MAS in patients with a median age of 77 and 98 months at surgery and a median weight of 20 and 23 kg, respectively. Median operative times were 130 and 109 minutes, respectively. We observed 9.1% of complications in the RS group and 6% in the MAS group and the difference was not statistically significant. Of note, 8 out of 77 RS procedures would have been performed with open classic surgery in case of conversion or failure of RS. CONCLUSIONS: This initial experience confirms that RS is as safe and effective as conventional MAS. A number of selected procedures performed with RS would only benefit from this approach, as it is not suitable for conventional MAS. Although economically demanding, in particular for a pediatric hospital, we firmly believe that centralization of care would allow pediatric surgeons adopting RS to perform complex reconstructive surgical procedures with great advantages for the patients and a minimal increase in overall costs for the health system.

Minimally Invasive Repair of Pectus Excavatum Without Bar Stabilizers Using Endo Close.

OBJECTIVES: Since the introduction of the Nuss technique for pectus excavatum (PE) repair, stabilization of the bar has been a matter of debate and a crucial point for the outcome, as bar dislocation remains one of the most frequent complications. Several techniques have been described, most of them including the use of a metal stabilizer, which, however, can increase morbidity and be difficult to remove. Our study compares bar stabilization techniques in two groups of patients, respectively, with and without the metal stabilizer. SUBJECTS AND METHODS: A retrospective study on patients affected by PE and treated by the Nuss technique from January 2012 to June 2013 at our institution was performed in order to evaluate the efficacy of metal stabilizers. Group 1 included patients who did not have the metal stabilizer inserted; stabilization was achieved with multiple (at least four) bilateral pericostal Endo Close™ (Auto Suture, US Surgical; Tyco Healthcare Group, Norwalk, CT) sutures. Group 2 included patients who had a metal stabilizer placed because pericostal sutures could not be used bilaterally. We compared the two groups in terms of bar dislocation rate, surgical operative time, and other complications. Statistical analysis was performed with the Mann-Whitney U test and Fisher's exact test. RESULTS: Fifty-seven patients were included in the study: 37 in Group 1 and 20 in Group 2. Two patients from Group 2 had a bar dislocation. Statistical analysis showed no difference between the two groups in dislocation rate or other complications. CONCLUSIONS: In our experience, the placement of a metal stabilizer did not reduce the rate of bar dislocation. Bar stabilization by the pericostal Endo Close suture technique appears to have no increase in morbidity or migration compared with the metal lateral stabilizer technique.