Congenital lung malformations: a nationwide survey on management aspects by the Italian Society of Pediatric Surgery.

INTRODUCTION: Over the years, congenital lung malformations (CLM) management remains a controversial topic in pediatric thoracic surgery. The Italian Society of Pediatric Surgery performed a national survey to study the current management variability among centers, trying to define national guidelines and a standardized approach of children with congenital lung malformations. METHODS: Following a National Society approval, an electronic survey including 35 items on post-natal management was designed, focusing on surgical, anesthesiology, radiology and pneumology aspects. The survey was conducted contacting all pediatric surgical units performing thoracic surgery. RESULTS: 39 pediatric surgery units (97.5%) participated in the study. 13 centers (33.3%) were classified as high-volume (Group A), while 26 centers (66.7%) were low volume (Group B). Variances in diagnostic imaging protocols were observed, with Group A performing fewer CT scans compared to Group B (p = 0.012). Surgical indications favored operative approaches for asymptomatic CLM and pulmonary sequestrations in both groups, while a wait-and-see approach was common for congenital lobar emphysema. Surgical timing for asymptomatic CLM differed significantly, with most high-volume centers operating on patients younger than 12 months (p = 0.02). Thoracoscopy was the preferred approach for asymptomatic CLM in most of centers, while postoperative long-term follow-up was not performed in most of the centers. CONCLUSION: Thoracoscopic approach seems uniform in asymptomatic CLM patients and variable in symptomatic children. Lack of uniformity in surgical timing and preoperative imaging assessment has been identified as key areas to establish a common national pattern of care for CLM.

Granular Cell Tumor (Abrikossoff's Tumor) of the Vulva in Childhood.

Granular cell tumors (GCTs) (Abrikossoff's tumors) are rare neoplasms derived from Schwann cells. Immunohistochemistry remains the most useful instrument for diagnosing GCTs. Complete surgical excision has been demonstrated to be curative for benign lesions. However, long-term follow-up in these patients is strongly recommended.

Laparoscopic orchiopexy: short-term outcomes. Experience of a single centre.

BACKGROUND: Increased infertility and smaller volume accompany undescended testis. Timing of orchiopexy is still a matter of debate. We evaluated the growth of non-palpable testes after laparoscopic orchiopexy according to age at surgery, intraoperative findings and type of procedure. METHODS: Forty-one boys undergoing laparoscopy for nonpalpable testes were retrospectively reviewed and divided into two groups, ≤18 months and >18 months, according to their age at surgery. RESULTS: At follow-up, 14 testes in the younger group had normal size, while 3 atrophied either after single (2) or two stage procedure (1). Similarly, in older boys 11 testes grew normally, while 5 atrophied after both procedures. CONCLUSIONS: Most of the non-palpable testes grew normally after laparoscopic orchiopexy and the postoperative volume seemed independent from the surgical strategy. Both techniques led to a few cases of testicular hypotrophy. In our experience, the age at surgery did not affect the outcome in terms of testicular growth.

Informative nursery rhymes: a pilot study of children's satisfaction.

BACKGROUND: The aim of this study was to assess, by means of a questionnaire, the level of children's satisfaction relating to three informative charts, including a nursery rhyme, administered to the patient before a medical procedure. METHODS: We created three types of specific informative charts on three medical topics with the double function of informing the child before the medical procedure, and of distracting him/her by means of a nursery rhyme read aloud by the authors. To assess the level of children's satisfaction, we administered the patients a questionnaire. RESULTS: According to children's feedback, the charts were funny and useful. CONCLUSIONS: The charts conceived in this study seem to be an easily applicable and entertaining approach to provide information and distraction to children undergoing surgery.

Informed consent in minor and intermediate pediatric elective surgery: results of an in-house questionnaire.

Background: The aim of this study was to evaluate the quality of our surgical informed consent and parents'/guardians' late recall of surgical procedures and risks of elective day surgery after pre-operative interview with surgeons. Methods: All parents/guardians of patients <18 years of age undergoing minor and intermediate elective procedures from January 15th to September 1st, 2022, were prospectively enrolled in the study. Before discharge, parents/guardians were asked to complete an in-house questionnaire regarding the duration of the consent procedure, duration of the interview, quality of the informative handouts, and their ability to recall the type of disease, type of surgical procedure, and surgical risks. Results: One hundred and two questionnaires were returned. In all cases, informed consent was obtained between 24 and 72 h prior to surgery. The following responses were collected: 98/102 (96%) parents/guardians reported that the duration of the consent process was adequate; 95/102 (93%) reported that the handouts were fully informative, and 7/102 (7%) reported that they were partially informative regarding explanation of the disease and surgical procedure; regarding complications, 93/102 (91%) perceived the handouts to be fully/partially informative, while 4/102 (4%) perceived the handouts to be poorly/non-informative, and 5/102 (5%) did not provide a response; 94/102 (92%) stated that they remembered the pathology, but only 87/94 (93%) recalled it correctly; 90/102 (88%) stated that they remembered the type of procedure, but only 76/90 (84%) recalled it correctly; and 53/102 (52%) stated that they remembered the surgical risks, but only 20/53 (38%) could recall more than one complication. Conclusions: Late recall of surgical complications by parents was poor despite the high perceived quality of the surgical risk handouts and medical interview. Implementation of expedient methods may improve overall comprehension and satisfaction of parents/guardians regarding the IC process. Further, more efforts should be made to develop standardized guidelines for an optimal IC process.

Robotic-assisted surgery in pediatrics: what is evidence-based?-a literature review.

Background and Objective: The use of robotic-assisted surgery (RAS) has increased more slowly in pediatrics than in the adult population. Despite the many advantages of robotic instruments, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) still presents some limitations for use in pediatric surgery. This study aims to examine evidence-based indications for RAS in the different fields of pediatric surgery according to the published literature. Methods: A database search (MEDLINE, Scopus, Web of Science) was performed to identify articles covering any aspect of RAS in the pediatric population. Using Boolean operators AND/OR, all possible combinations of the following search terms were used: robotic surgery, pediatrics, neonatal surgery, thoracic surgery, abdominal surgery, urologic surgery, hepatobiliary surgery, and surgical oncology. The selection criteria were limited to the English language, pediatric patients (under 18 years of age), and articles published after 2010. Key Content and Findings: A total of 239 abstracts were reviewed. Of these, 10 published articles met the purposes of our study with the highest level of evidence and therefore were analyzed. Notably, most of the articles included in this review reported evidence-based indications in urological surgery. Conclusions: According to this study, the exclusive indications for RAS in the pediatric population are pyeloplasty for ureteropelvic junction obstruction in older children and ureteral reimplantation according to the Lich-Gregoire technique in selected cases for the need to access the pelvis with a narrow anatomical and working space. All other indications for RAS in pediatric surgery are still under discussion to date, and cannot be supported by papers with a high level of evidence. However, RAS is certainly a promising technology. Further evidence is strongly encouraged in the future.

Management of pleural effusion and empyema in a third-level pediatric surgical center.

BACKGROUND: Pleural effusion and empyema are frequent complications of acute bacterial pneumonia in children. To date, evidence regarding the optimal treatment of this condition is limited in the literature. METHODS: Patients with pleural effusion and empyema admitted at our Department of Pediatric Surgery over the last ten years were enrolled in this retrospective study, and successively compared with the clinical charts of patients treated before the introduction of a new diagnostic and therapeutic algorithm. In particular, primary outcomes investigated between pre- and postalgorithm period were the use of diagnostic tools and antibiotics, the need for additional therapeutic approaches, complications, and the length of stay. RESULTS: After the introduction of the new algorithm there were a decrease in the use of chest radiography for re-evaluation (100% vs. 79%, P=0.003), a more focused use of computed tomography (68% vs. 15%, P=0.001), and a decrease in the use of a second computed tomography (18% vs. 3%, P=0.07); in favor of an increase in the use of the ultrasound scan (40% vs. 100%, P=0.001). There was also a shift from the use of chest tube drainage alone to the use of drainage for urokinase administration (50% vs. 92.3%, P=0.001), and a statistically significant decrease in the need for video-assisted thoracoscopic surgery (25% vs. 7.7%, P=0.001). CONCLUSIONS: The introduction of a diagnostic and therapeutic algorithm for the management of pediatric pleural effusion and empyema has notably resulted in a decrease in the utilization of radiography and computed tomography and an increase in the use of ultrasonography, reducing unnecessary radiation exposure in children and overall costs.

Provisional unicentric experience with an electronic incident reporting form in pediatric anesthesia.

OBJECTIVE: To present and compare with literature our experience with an electronic anesthesia-related incident reporting form as a quality control measure at Gaslini Children's Hospital over a 19-month period. METHODS: All events that occurred between March 2009 and September 2010 were recorded. We adopted an electronic reporting form included in the online recording process of every anesthetic procedure. Events were divided into near misses and adverse events. Adverse events were further divided into incidents, minor events, and major events. Patients were divided into three age-groups: <1, between 1 and 3, and >3 years. RESULTS: A total of 12,850 anesthetics were performed. Eight (0.06%) near misses and 108 (0.8%) adverse events were reported. Adverse events occurred more frequently in infants. Of 108 events, 35 (32.4%), 61 (56.5%), and 12 (11.1%) were classified as incidents, minor, and major events, respectively. Of all the adverse events, 66 (61%) were respiratory, 27 (25%) organizational, six (5%) drug-related, four (4%) cardiocirculatory, and five (5%) miscellaneous. CONCLUSIONS: Infants were at the highest risk to experience adverse events. Although experimental electronic incident reporting proved to be feasible, there is reason to suspect that there was underreporting of near misses. Overreporting of near miss events may be enhanced by easier and more straightforward reporting forms as well as by better education for anesthetic providers about the importance of recognizing and reporting near misses.

Technical considerations in children undergoing laparoscopic ileal-J-pouch anorectal anastomosis for ulcerative colitis.

BACKGROUND: Sub-total colectomy and restorative proctocolectomy with j-pouch ileo-anorectal anastomosis is the treatment of choice in children with ulcerative colitis uncontrolled with medical therapy. OBJECTIVE: To present some technical considerations about children undergoing laparoscopic ileal-J-pouch anorectal anastomosis. SETTINGS AND PATIENTS: All patients with ulcerative colitis undergoing laparoscopic ileal-J-pouch anorectal anastomosis were evaluated from January 2006 to February 2011. INTERVENTION: The new technical innovations herein are (1) total laparoscopic approach, (2) a very short 3-cm J-pouch ileal reservoir created outside the stoma incision, (3) preservation of the entire anal canal and the Knight-Griffen double stapled anastomosis, less than 3 cm from the dentate line, (4) use of a Multiple Instrument Access Port system in the stoma skin incision to reduce the number of port site incisions and (5) proctectomy performed using only an electrosurgical vessels sealing device thus avoiding clips to close rectal pedicle. RESULTS: Seventeen laparoscopic ileo J-pouch low rectal anastomosis were performed by the same surgical staff. Three complications occurred postoperatively: one bowel obstruction, one ileostomy prolapse, and one anastomotic stricture. Satisfactory functional results were achieved in all, there was no significant perineal excoriation and quality of life was excellent. CONCLUSIONS: A Multiport Instrument Access Port placed in the stoma site allowed the use of more instruments through a single incision. The very short ileo J-pouch low rectal anastomosis has been shown to be a safe, feasible, and effective reconstructive procedure.

Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery.

PURPOSE: The aim of this study was to evaluate the frequency of surgical and organizational events that occurred in the whole Department of Paediatric Surgery at Gaslini Children's Hospital through an incident-reporting system in order to identify the vulnerabilities of this system and improve it. MATERIALS AND METHODS: This is a 6-month prospective observational study (1st January-1st July 2010) of all events (including surgical and organizational events, and near misses) that occurred in our department of surgery (pediatric surgery, orthopedics and neurosurgery units). RESULTS: Over a 6-month study period, 3,635 children were admitted: 1,904 out of 3,635 (52.4%) children underwent a surgical procedure. A total number of 111 adverse events and 4 near misses were recorded in 100 patients. A total of 108 (97.3%) adverse events occurred following a surgical procedure. Of 111 adverse events, 34 (30.6%) required re-intervention. Eighteen of 100 patients (18%) required a re-admission, and 18 of 111 adverse events (16.2%) were classified as organizational. Infection represented the most common event. CONCLUSIONS: An electronic physician-reported event tracking system should be incorporated into all surgery departments to report more accurately adverse events and near misses. In this system, all definitions must be standardized and near misses should be considered as important as the other events, being a rich source of learning.

Oxygen-enriched oleic matrix (NovoX) for wound healing in pediatric patients undergoing open surgical treatment for pilonidal disease: Preliminary experience.

Introduction: Pilonidal disease (PD) is a common infectious and inflammatory condition affecting the gluteal cleft and sacrococcygeal region. The optimal treatment for PD remains controversial. While the open technique reduces the number of relapses compared to minimally invasive approaches, it is associated with a longer healing time. Reactive oxygen species are a key part of the normal wound-healing process. Herein, we reported our preliminary experience using a new oxygen-enriched oil-based product called NovoX for wound healing after open surgery for PD. Materials and methods: We used a new oxygen-enriched product for wound healing in three pediatric patients undergoing open surgical repair for PD between December 2021 and April 2022. During postoperative follow-up, healing time and the aesthetic result were evaluated. Results: Our preliminary study included three patients with chronic PD. The average follow-up time was 5 weeks, corresponding to the end of the healing process and the resumption of normal daily activities. Only one mild complication occurred during the study period. No short-term side effects were reported. The cosmetic result was reported as satisfactory. Conclusion: NovoX is easy to apply, safe, and effective for treating pediatric patients undergoing open surgical treatment for PD, leading to slightly faster wound healing with good aesthetic outcomes.

Management of Primary Spontaneous Pneumothorax in a Third-Level Pediatric Surgical Center: A Retrospective Study.

Introduction: The management of primary spontaneous pneumothorax (PSP) in pediatrics remains controversial. The aim of this study was to investigate the risk of recurrence after non-surgical treatment vs. surgery, the difference in the length of stay (LOS) between various treatment options, and the role of computed tomography (CT) in the management of PSP. Materials and Methods: We retrospectively reviewed patients admitted to our Pediatric Surgery Unit for an episode of PSP between June 2009 and July 2020. Medical records including clinical presentation at admission, diagnostics, treatments, complications, and LOS were collected. Results: Twenty-three patients (22 males and 1 female) were included in this study. Median age was 15.65 (range 9-18). Chest X-rays were performed in all patients and showed 5 small (22%) and 18 large (78%) PSP. Chest drain was used for large PSP (≥2 cm) if the patient was clinically unstable. Eleven patients (48%) were managed non-operatively with observation alone and a recurrence rate of 18%, chest drain was used in 11 patients with a recurrence rate of 36%, and surgery was deemed necessary as a first treatment choice in one case. Six patients (27%) had an episode of relapse after non-operative management or chest drain placement. Following surgery, a relapse occurred in 2 of the 6 patients. Chest drain insertion was associated with a longer LOS than observation alone (6.36 vs. 2.4 days), and surgery resulted in a longer LOS than other types of treatment (P = 0.001). Conclusion: According to our experience, small PSP or clinically stable larger PSP can be treated conservatively with observation alone. Operative management should be taken into consideration in children with large symptomatic PSP, persistent air leak, and/or relapse after chest drain insertion.

Laparoscopic approach for children with inflammatory bowel diseases.

BACKGROUND: Minimally invasive surgery is being increasingly applied to inflammatory bowel diseases (IBDs). Few pediatric series from selected research have been described to date. This study describes a unicentric experience of laparoscopic treatment of children with IBDs. MATERIALS AND METHODS: All consecutive patients with IBDs between February 2006 and February 2010 who underwent laparoscopic treatment were included. We reviewed notes and recorded demographic data, indications, perioperative management, surgical details, length of surgery, complications, postoperative management, length of hospitalization and functional outcome. RESULTS: We performed 25 procedures on 16 patients (12 ulcerative colitis, 3 Crohn's disease, and 1 indeterminate colitis). Median age was 12 years. A total of 50% patients underwent elective surgery; 11 underwent staged laparoscopic subtotal colectomy (LSTC) followed by J-pouch ileorectal anastomosis (JPIRA). Three patients underwent straight LSTC + JPIRA. All procedures included protective ileostomy. Length of surgery ranged between 120 and 380 min depending on the procedure (LSTC ± JPIRA). No conversion was required. Length of hospitalization ranged between 3 and 18 days. We observed six complications (24%) mainly represented by adhesions that were effectively treated laparoscopically. Ten patients were restored (ileostomy closure) and were assessed for continence that turned out to be good in 80%. CONCLUSIONS: Laparoscopy proved to be feasible, safe and effective for the treatment of IBD in children. Although we observed a relatively low incidence of complications, stoma site adhesions still remain the major issue, which can be effectively dealt with laparoscopically. Functional outcome as well as cosmesis is satisfactory. As results are encouraging, at present we prefer laparoscopy for the surgical treatment of IBD in pediatric patients.

Lipoblastoma as a cause of secondary omental torsion in children: report of the first case.

Acute abdominal pain remains a major diagnostic challenge to date. Omental torsion is an infrequent cause of abdominal pain in children, which usually presents with non-specific symptoms. Herein, we report a case of persistent abdominal pain after a minor abdominal trauma. A solid mass was found in the lower abdomen at ultrasound imaging evaluation. Surgical exploration demonstrated an omental torsion secondary to a rare neoplasm of childhood.

The Histopathology of the Appendix in Children at Interval Appendectomy.

Whilst most surgeons agree that conservative treatment of appendiceal abscess in children is an adequate treatment, the need for subsequent interval appendectomy is still controversial. We analyzed the histopathology in interval appendectomy in search of signs of inflammation. All patients admitted between 2010 and 2017 with appendiceal abscess and scheduled for interval appendectomy were reviewed. The specimens were evaluated for grade of inflammation, type and distribution of cellular infiltrate, presence of necrosis or hemorrhage and infiltrate in the serosa. Forty-two patients had appendiceal abscess and were treated conservatively. Seven underwent emergent appendectomy. Thirty-three out of 35 patients underwent elective interval appendectomy. Thirty-two specimens were revised. Carcinoid tumor or other malignant lesions were not found. All of them presented some amount of inflammation, grade 1 to 2 in 53%, grade 3 to 4 in 47%. Twenty-five percent of the specimens had signs of necrosis accompanied by hemorrhage and in more than the half (53%) the infiltrate extended to the serosa. Conclusions: Although the appendix was mostly found not macroscopically inflamed intraoperatively, histology confirmed a certain grade of inflammation even months after the conservative treatment. No correlation was found between histopathologic findings and lapse of time between abscess treatment and interval appendectomy.

Pyogenic granuloma arising within capillary malformations in children: A case report and literature review.

Pyogenic granuloma (PG) is an acquired benign vascular hyperplasia. Even though PG is not so rare, its etiology is still unclear. Assuredly, an association between vascular anomalies and PG is an extremely rare finding, and a proper management of these cases is not well standardized to date. Herein, we report our experience with a giant PG arising spontaneously within a port-wine stain of the thorax. Previous cases reported in the pediatric literature and strategies of treatment are also discussed.

Glans ischemia after circumcision in children: Two case reports.

BACKGROUND: Circumcision refers to the removal of the skin covering the tip of the penis and is one of the most common surgical procedures performed in childhood. Even though circumcision is a well-standardized operation, several minor and major complications may be experienced by paediatric surgeons. Glans ischemia (GI) has been widely reported in the paediatric literature as a complication following circumcision. Nonetheless, etiopathogenesis of GI is not well defined and management guidelines are lacking. CASE SUMMARY: We describe our experience with this rare and scary complication using subcutaneous enoxaparin alone or in association with a topical vasodilator. CONCLUSION: Hypothetical causes and different management strategies are discussed.

Fast-track surgery of the colon in children.

INTRODUCTION: The aim of this study is to present the "fast-track" experience in children who underwent colon resection. MATERIALS AND METHODS: Forty-six children who underwent laparoscopic colon resection were prospectively included in the study. Anomalies of colon innervation and inflammatory bowel disease represented the main surgical indications. RESULTS: Left colon/sigmoid resection was performed in 37, total colon resection was done in 5, and right colon resection in 4 children. Total colon resection was always associated to ileostomy. Anastomosis was performed in 41 cases. Patients were postoperatively monitored for pain, return to normal activity, feeding, bowel movements, and complications. Stool passage and oral feeding were started on postoperative day 1, and all patients were discharged before postoperative day 4. One child was readmitted the day after discharge because of an anastomotic leak. No other major complications were recorded. DISCUSSION: Minimally invasive surgery is safe and effective in pediatric colonic surgery and allows a fast recovery time (fast-track).

Risk management in pediatric surgery.

PURPOSE: To present the experience documented over 1 year of analysis and quality control on surgical complications and organizational accidents. METHODS: All children admitted during the study period at our Institution were included in the analysis, which consisted of four phases: (1) definition and standardization of perioperative diagnostic and therapeutic tracks; (2) staff education; (3) documentation and data implementation, and (4) "Morbidity and Mortality" audit. RESULTS: Over a 1-year study period, 3,116 children were admitted to our Institution: 2,222 out of 3,116 (71.3%) children underwent a surgical procedure. A total number of 184 complications were recorded in 149 patients. One hundred and seventy-one (92.9%) complications occurred following a surgical procedure. Fifty-six out of 149 complicated patients (37.6%) required a re-operation. Thirty-five out of 184 (19%) complications were classified as organizational. Infection represented the most common complication. All cases of anastomotic dehiscence and perforation, bowel obstruction, and stoma malfunction required reintervention. None of the postoperative bleedings required a second surgical procedure. CONCLUSION: Although a proper statistical comparison with literature complication rates is not feasible, our experience confirms the importance of quality-control audit in health care systems. Prolonged observation, long-term follow up, and comparison with previous results will represent our future goal.