Paraplegia after thoracotomy: a single center experience with pediatric patients and a review of the literature.

AIM: Paraplegia is an infrequent although fearsome complication of anesthesia and surgical procedures, such as epidural anesthesia and thoracotomy. It may occur in both adults and children and a medullary lesion may be confirmed by magnetic resonance imaging, rather than computed tomography. The aim of this study is to describe the experience of two pediatric tertiary centers, contextualizing it with the other cases reported in literature. MATERIAL AND METHODS: We reported three pediatric cases of post-operative paraplegia in oncological patients, focusing on the potential causes and underling the possible strategies to prevent this complication. RESULTS: From our study, two principal features emerged: 1) Epidural anesthesia may expose children to a greater risk of spinal cord permanent damage due to the execution of the procedure under general anesthesia, which deprives the anesthesiologist of an important feedback about the position of the device; 2) In thoracotomy, the risk of paraplegia tends to increase along with the proximity to the costo-vertebral angle, especially if electrocautery or hemostatic materials are used. CONCLUSIONS: A prompt post-surgical neurological status routine assessment in pediatric patients undergoing epidural anesthesia or thoracotomy should be mandatory and, associated with the correct imaging study, may lead to the most appropriate therapeutic pathway and to a better prognosis. KEY WORDS: Anesthesia, Children, Epidural, Thoracotomy, Paraplegia.

Hemorrhage During Induction Chemotherapy in Neuroblastoma: Additional Risk Factors in High-Risk Patients.

Background: Neuroblastoma is the most common solid extracranial tumor in children. Patients affected by neuroblastoma are stratified into low, intermediate, and high risk in terms of event-free and overall survival. Some high-risk patients have an additional risk of acute hemorrhagic complications during induction chemotherapy. Aim: To find easily and rapidly assessed parameters that help clinicians identify those patients affected by high-risk neuroblastoma who have an additional risk of hemorrhagic complications. Methods: The clinical notes of patients diagnosed with high-risk neuroblastoma from January 2013 until February 2021 were retrospectively reviewed. Clinical, demographic and laboratory data, biological characteristics of the tumor, and information about treatment and hospital stay were identified. Results: In the examined period, 44 patients were diagnosed with high-risk neuroblastoma. Four of these patients had hemorrhagic complications within 2-7 days after the initiation of induction chemotherapy; two patients had hemothorax, one patient had hemoperitoneum and one patient had hemothorax and hemoperitoneum. The patient with isolated hemoperitoneum was treated with blood components transfusions, clotting factors and colloids infusions; the three patients with hemothorax underwent thoracostomy tube placement and respiratory support. At initial presentation, patients who suffered from hemorrhagic complications had a higher degree of hypertension (stage 2, p = 0.0003), higher levels of LDH (median 3,745 U/L, p = 0.009) and lower levels of hemoglobin (mean 7.6 gr/dl, p = 0.0007) compared to other high-risk patients. Conclusions: A subgroup of "additional" high-risk patients can be identified within the high-risk neuroblastoma patients based on mean arterial pressure, LDH levels and hemoglobin levels at presentation. Further studies to define cut-off values and optimal management strategies for these patients are needed.

Conservative management of congenital bronchial atresia: The Bambino Gesù children's hospital experience.

INTRODUCTION: Congenital bronchial atresia (CBA) is a rare airway malformation. No management guidelines exist because of limited evidence: treatment, surgical or conservative, is based on consensus and opinion. OBJECTIVE: To review the experience of a pediatric tertiary center and provide additional data about nonsurgical management of CBA and its outcomes after a structured follow-up, and to help formulate appropriate evidence-based guidelines. METHODS: A retrospective analysis of clinical, radiological, surgical, and pathological data of all pediatric patients with suspicion of CBA referred to the surgical department of the Bambino Gesù children's hospital of Rome between December 2013 and 2019, along with a review of the literature. RESULTS: Among the 18 children initially included in the study, 2 were lost to follow-up after radiological diagnosis, 4 underwent surgery for radiological suspicion of other pulmonary malformations. The final population is composed of 12 conservatively managed patients. At the end of the follow-up (median: 29 months, range 3-61), 1 patient (8%) was symptomatic. CONCLUSION: Conservative management for CBA appears to be safe. Surgery should be reserved for patients with symptomatic or complicated cases.