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.

Intrasphincteric Botox injections in Hirschsprung's disease: indications and outcome in 64 procedures over a ten-year period.

BACKGROUND: Intrasphincteric botulinum toxin (Botox) injection for symptomatic postoperative anal achalasia in Hirschsprung's disease (HSCR) has found wide application in the last twenty years. The aim of this study was to describe effectiveness and functional outcome of a series of patients treated over a 10-year period. METHODS: All consecutive HSCR patients who received intrasphincteric Botox injections between January 2007 and December 2016 were included. Demographic data and clinical features were collected. A detailed questionnaire focusing on outcome in the medium and long-term was administered to all families. RESULTS: In the study period 64 intrasphincteric Botox injections were performed in 31 patients. Completed questionnaires were returned by 27 out of 28 eligible patients (96%) reporting improvement or symptoms resolution in 16 (59%). The highest success rates were experienced by patients younger than 4, with long HSCR forms and with recurrent enterocolitis (75%, 100% and 100% of success rates, respectively). No major complications occurred. Minor complications were described by 7 patients (26%). CONCLUSIONS: Intrasphincteric Botox injection proved to be feasible, safe and reasonably effective in children with HSCR and postoperative anal achalasia. Infants and toddlers with long HSCR forms and recurrent bouts of enterocolitis are those who would benefit most from this treatment.

Enterostomy-related complications in Hirschsprung's disease in a single cohort.

BACKGROUND: Hirschsprung's disease (HSCR) is a frequent cause of intestinal obstruction in children and may require an enterostomy. The study aimed to describe the most common enterostomy-related complications in a series of patients treated in a single center. METHODS: A series of consecutive HSCR patients treated or followed-up at our institution between January 1993 and December 2016 were included. Data about HSCR type, enterostomy site, duration and complications of the stoma were recorded. RESULTS: Three hundred one patients with HSCR were followed-up. Sixty-one had ultralong forms (TCSA/TIA), 21 had long forms (L-HSCR) and 219 had classic short forms (S-HSCR). One hundred thirty-seven patients required a stoma (100% of patients with TCSA/TIA, 66.7% with L-HSCR and 28.3% with S-HSCR). We observed 64 stoma-related complications: 36 major complications and 28 minor complications. Major complications occurred more often in long forms (P=0.037). The presence of an ileostomy was statistically associated with an increased rate of complications compared to colostomy. The longer the stoma was in site, the higher the complication rate was. CONCLUSIONS: Long and ultra-long forms are associated with a longer duration of the stoma and to a major risk of stoma-related complications.

Total oesophago-gastric dissociation in neurologically impaired children: Laparoscopic vs robotic approach.

PURPOSE: To evaluate and compare the feasibility and short-term results of laparoscopic and robotic total oesophago-gastric dissociation (TOGD) with a Roux-en-Y oesophago-jejunostomy. Minimal invasive surgery has multiple advantages in neurologically impaired patients. Robotic approach has overcome disadvantages linked to laparoscopy, in particular, referring to the surgeon fatigue. METHODS: A retrospective study comparing five laparoscopic and five robotic TOGD was conducted between February and October 2016 in Giannina Gaslini Children's Hospital and Section of Pediatric Surgery of Siena. Neurologically impaired children scheduled for TOGD were included. Age, sex, weight, symptomatology, presence of epilepsy, and preoperative X-ray contrast were considered. Operative time, hospital stay, postoperative complications, redo surgery, nutrition rehabilitation, and X-ray contrast study after 5 days and after 1 month from the intervention were recorded. RESULTS: In our series, there were no intraoperative complications, no conversions to open surgery, and no vagal lesions. In two of five robotic cases, a pyloroplasty was necessary. The median operative time was statistically longer in the robotic group. One dehiscence in the robotic group was recorded, and no dumping episodes occurred. No statistical differences in terms of complications were detected. CONCLUSION: TOGD is feasible both with laparoscopic and robotic-assisted surgery with similar results. Robotic approach is considered feasible. At the same time, high laparoscopic skills allow to reach the same results as robotic approach with shorter operative time.

Hirschsprung disease and Down syndrome: From the reappraisal of risk factors to the impact of surgery.

INTRODUCTION: The association of Hirschsprung disease (HSCR) and Down Syndrome (DS) is not uncommon (HSCR+DS). This paper aims at reporting the results of a 24-year series focusing on surgical approach, complications and long term outcome. MATERIALS AND METHODS: The notes of all patients admitted with a diagnosis of HSCR+DS have been retrospectively reviewed. Surgical details, intraoperative complications, long term issues and functional outcome have been recorded. The results have been compared to those of patients without DS and were assessed based on surgical approach. RESULTS: A total of 23 HSCR+DS out of a series of 385 HSCR (6%) have been included. Preoperative enterocolitis (HAEC) was reported by 32%. Associated anomalies were detected in more than half of the patients. In particular, Congenital Heart Defects (CHDs) were reported by 57%. Postoperative complications (mostly symptomatic anal sphincter achalasia) were experienced by 55%. Constipation was experienced by 30%; severe continence issues, by 53%. One patient suffering from severe CHDs died. With regard to complications, only symptomatic anal achalasia requiring intrasphincteric BoTox injection was significantly more frequent in HSCR+DS (30% vs 10%, p = 0.0071). Similarly, continence proved to be significantly worse in HSCR+DS. DISCUSSION: With the exception of symptomatic anal achalasia, HSCR+DS patients proved not to have a higher likelihood of complications compared to HSCR alone. On the other hand, functional results in the long term are worse. As a consequence, long term follow up and personalized rehabilitation programs are warranted for this delicate subset of HSCR patients. LEVEL OF EVIDENCE: Level III.

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.

Minimally invasive surgery for paediatric inflammatory bowel disease: Personal experience and literature review.

The incidence of paediatric inflammatory bowel disease (PIBD) has dramatically increased in the last 20 years. Although first reported in mid 1970s', diagnostic laparoscopy has started to be routinely adopted in paediatric surgical practice since late 1990s'. Minimally invasive surgery was first limited to diagnostic purposes. After 2002 it was also applied to the radical treatment of PIBD, either Crohn's disease (CD) or Ulcerative colitis. During the last decade minimally invasive approaches to PIBD have gained popularity and have recently became the "gold standard" for the treatment of such invalidating and troublesome chronic diseases. The authors describe and track the historical evolution of minimally invasive surgery for PIBD and address all available opportunities, including most recent advancements such as robotic surgery, single port approaches and minimally invasive treatment of perianal fistulising CD. A systematic review of all series of PIBD treated with minimally invasive approaches published so far is provided in order to determine the incidence and type of patients' complications reported up to present days. The authors also describe their experience with minimally invasive surgery for PIBD and will report the results of 104 laparoscopic procedures performed in a series of 61 patients between January 2006 and December 2014.

A single institution observational study of early mechanical complications in central venous catheters (valved and open-ended) in children with cancer.

The use of indwelling central venous catheters (CVCs) has become essential for managing children undergoing cancer treatment. Various types of CVCs are available, but reports on complications observed in pediatric series are scarce. We describe our experience concerning early mechanical complications at our institute by providing a prospective evaluation of three types of CVCs that were inserted over a 39-month period. Between January 1, 2000, and March 31, 2003, double-lumen (DL) or single-lumen (SL) Hickman-Broviac (HB) and single-lumen pressure-activated safety-valved (PASV) catheters were inserted and prospectively evaluated. Five groups of possible mechanical complications were defined a priori: dislodgement, migration, rupture, accidental removal, and blockage. We took into consideration complications occurring only within the first 30 days of insertion. A total of 272 CVCs (118 PASV, 57 DL-HB, and 97 SL-HB) were inserted in 232 children. A total of 29 early mechanical complications (10.7% of all CVCs) were diagnosed: 15.2% of the PASV, 10.5% of the DL-HB, and 4.1% of the SL-HB. Elective removal of the catheter due to complications was required in eight patients. SL-HB catheters had fewer complications, while the complication rate and the number of devices that were removed were significantly higher in patients with PASV catheters. We conclude that catheter type correlates with the risk of early mechanical complications and removal.

Prospective study of indwelling central venous catheter-related complications in children with broviac or clampless valved catheters.

PURPOSE: To compare two types of central venous catheters (Broviac and valved clampless) for the incidence and severity of catheter-related complications in children. PATIENTS AND METHODS: The authors report data on the mechanical and infectious complications collected in a prospective analysis of 92 catheters inserted in 82 children from January 2000 to March 2001. RESULTS: Two different devices were inserted: 51 Broviac and 41 clampless valved catheters. During the follow-up of 17,803 catheter-days 52 complications were observed: 40 mechanical episodes and 12 infectious events. In the Broviac group the median follow-up was 179 days and the total number of catheter-days was 10,911. A total of 29 complications were observed, occurring in 22 catheters (43%), with an overall incidence of 0.27/100 catheter-days. In the clampless group the median follow-up was 134 days and the total number of catheter days was 6893. A total of 23 complications were observed, occurring in 19 devices (46%), with an incidence of 0.32/100 catheter days. CONCLUSIONS: There were no major differences in the incidence of mechanical or infectious complications between the two devices. Malfunction was more frequent in Broviac catheters, whereas catheter displacement occurred more frequently in clampless valved catheters. These results show the importance of central venous catheter-related mechanical complications in the management of children with hematologic or oncologic malignancies.