[Laparoscopy-assisted jejunostomy in neurological patients with chronic malnutrition and GERD. Technical considerations and analysis of the results]. / La digiunostomia laparo-assistita nei pazienti neurologici con malnutrizione cronica e RGE. Considerazioni tecniche ed analisi dei risultati.

BACKGROUND: Feeding difficulties and gastroesophageal reflux (GER) are major problems in severely neurologically impaired children. Many patients are managed with a simple gastrostomy, with or without fundoplication. Unfortunately, fundoplication and gastrostomy are not devoid of complications, indicating the need for other options in the management of these patients. METHODS: Between January 2002 and June 2010, ten patients (age range, 18 months-14 years) have been treated by creating a jejunostomy with the laparoscopic-assisted procedure. The procedure was performed using 2-3 trocars. The technique consists of identifying the first jeujnal loop, grasping it 20-30 cm away from the Treitz ligament, and exteriorizing it to the trocar orifice under visual guide. The jejunostomy was created outside the abdominal cavity during open surgery. At the end of the jejunostomy, the correct position of the intestinal loops was evaluated via laparoscopy. RESULTS: Surgery lasted 40 min on average, the laparoscopic portion about 10 min. Hospital stay was 3 or 7 days for all patients. At the longest follow-up (8 years), all patients had experienced a significant weight gain. One patient died 1 year after the procedure of unknown causes. As for the other complications: 4/10 patients experienced peristomal heritema, 2/10 device's dislocation and 1 patient a peristomal granuloma. CONCLUSIONS: Laparoscopic-assisted jejunostomy is a safe and effective procedure to adopt in neurologically impaired children with feeding problems and GER. We advocate the use of this procedure in neurologically impaired patients with feeding problems and reflux due to its overall practicability and because there is minimal surgical trauma. The improvement in the quality of life of these children after the jejunostomy seems to be the major advantage of this procedure. However the management of jejunostomy can be difficult for parents above all in the first postoperative months.

Meckel's diverticulum causing severe hemorrhage.

Meckel's diverticulum has varied presentations in children and often becomes a diagnostic challenge. The authors present a 10-year-old boy with abdominal pain and one episode of melena. His symptoms were undervalued during two previous hospitalizations in pediatric units until his hemoglobin level dropped from 8.2 to 3.5 g/dL. The laparoscopic intervention performed in emergency identified a bleeding Meckel's diverticulum that was resected after being exteriorized from the umbilicus. Our observation shows that severe hemorrhage due to a Meckel's diverticulum is possible albeit exceptional.

Blue rubber bleb nevus: an uncommon cause of intestinal intussusception.

UNLABELLED: The blue rubber bleb nevus syndrome or Bean syndrome is a rare disorder characterized by cutaneous and gastrointestinal vascular malformations. A 5-year-old girl with Bean syndrome hospitalized in a pediatric unit came under our observation with abdominal pain and vomiting. An X-ray of the abdomen showed an intestinal occlusion and an ultrasonography showed a suspected intestinal invagination. She underwent emergency laparoscopic surgery using three trocars. Laparoscopy revealed a huge ascitis and multiple vascular lesions located on the loops and on the parietal peritoneum, and we identified also an ileo-ileal invagination. We performed a laparoscopic disinvagination that showed one huge vascular lesion producing the invagination and causing a stenosis of intestinal lumen. We performed an intestinal resection after exteriorizing the loops through the umbilicus as well as a termino-terminal ileal anastomosis. CONCLUSIONS: Our case shows that an intestinal invagination due to Bean syndrome is extremely rare in pediatric patients but possible. In the emergency, laparoscopy seems to be a safe and effective procedure to confirm the diagnosis and to perform the disinvagination mini-invasivally. In addition, laparoscopy permits to have a clear picture of other intra-abdominal lesions linked to Bean syndrome.

Clinical analysis of multiple primary malignancies in the elderly.

BACKGROUND: Cancer incidence raises progressively during life span; it is estimated that by the year 2030 almost 70% of all neoplasms will occur in people over 65 years old. As carcinogenesis is a multistep, time-requiring process, it is expected that as people live longer they are more likely to develop cancer, and therefore, the prevalence of multiple primary malignancies (MPM) is destined to increase with age. PATIENTS AND METHODS: Records of all consecutive cancer patients referred to our center from January 2004 to January 2007 were reviewed. We chose the definition of MPM proposed by Warren and Gates. Multiple malignancies were assessed for elderly (>or=70 years old) and younger patients. t-Test and Mc Nemar test were used; subgroup analysis was also performed according to age stratification. RESULTS: A total of 1,503 consecutive patients were considered; 566 were 70 years old or more (mean age 76.5 years, range 70-96 years) and 878 were younger (mean age 57 years, range 18-69 years). The prevalence of multiple malignancies in the elderly people versus younger ones was 15% and 6%, respectively (P = 0.001). As far as the elderly population is concerned, 21% (56/271) of males compared with 14% (42/295) of females had developed MPM; no significant difference was found between the subgroups with MPM or not as far as age (P = 0.16), comorbidities (P = 0.79), medications (P = 0.76), CIRS-G score and index (P = 0.47, P = 0.54), and PS (P = 0.93) are concerned. Most frequent associations among cancer types were prostate with lung (10/87, 11%), prostate with colorectal cancer (10/87, 11%), and smoking-related cancer, namely lung and head and neck cancer (X/Y, 6%). CONCLUSIONS: Elderly patients are more likely to develop MPM compared to younger ones. Significant cancer association according to field cancerogenesis concept was the one of smoking-related cancer; other MPM patterns were apparently a random phenomenon.

A stochastic model for interacting neurons in the olfactory bulb.

We focus on interacting neurons organized in a block-layered network devoted to the information processing from the sensory system to the brain. Specifically, we consider the firing activity of olfactory sensory neurons, periglomerular, granule and mitral cells in the context of the neuronal activity of the olfactory bulb. We propose and investigate a stochastic model of a layered and modular network to describe the dynamic behavior of each prototypical neuron, taking into account both its role (excitatory/inhibitory) and its location within the network. We adopt specific Gauss-Markov processes suitable to provide reliable estimates of the firing activity of the different neurons, given their linkages. Furthermore, we study the impact of selective excitation/inhibition on the information transmission by means of simulations and numerical estimates obtained through a Volterra integral approach.

Do elderly cancer patients achieve an adequate dose intensity in common clinical practice?

BACKGROUND: Elderly patients rarely receive adequate dose intensity (DI) using conventional regimens. Possible causes are improper patient assessment, the chemotherapy (CT) regimen chosen, the number and severity of comorbidities, patient compliance and physician experience. To explore this issue, DI was retrospectively analyzed in elderly patients treated with conventional CT regimens for advanced solid cancer. PATIENTS AND METHODS: Patients > or =69 years were evaluated. All patients had metastatic solid tumors. Comorbidities, performance status (PS), toxicities, number of CT cycles, dose reduction and discontinuation of treatment were recorded. Relative DI (RDI) was calculated and regressed against these parameters. RESULTS: 108 patients were eligible. The most frequent diagnoses were: lung, head-and-neck and colorectal cancer. In 48 patients (44%), their initially scheduled treatment was modified. Mean RDI was 79% (range 19-100%, SD 20.6). Grade 3/4 non-hematological and hematological toxicity occurred in 27 (35/130) and 8% of patients (11/130), respectively. In regression analysis, RDI was significantly associated with hematological toxicity. RDI affected response rate but not overall survival. CONCLUSIONS: RDI is significantly affected by toxicity. These data suggest the importance of the treatment schedule and patient selection as predictorsof adequate treatment. Some non-ratable variables, however, might also play a role regarding the dose intensity delivered.

Vinorelbine-based chemotherapy in hormone-refractory prostate cancer.

BACKGROUND: No consensus exists regarding further therapy for the management of hormone-refractory prostate cancer. In this phase II study, the combination of Vinorelbine with 5-Fluorouracil and folinic acid (FLN regimen) was evaluated in patients with progressive or resistant disease after hormone therapy. PATIENTS AND METHODS: Thirty-four patients were treated with Vinorelbine at a dose of 20 mg/m2 intravenously (i.v.) on days 1 and 3, folinic acid (FA), 100 mg/m2 i.v. and 5-Fluorouracil (5-FU), 350 mg/m2 i.v. as a short infusion on days 1 to 3. The therapy was given in an out-patient setting, every 3 weeks. RESULTS: All of the 34 eligible patients were evaluable for toxicity and 30 for activity. A total of 127 cycles was administered (91% at full dose). Among thelS5 patients with measurable disease, four had a partial response (26.6%; C.I. 95%, 28.3% to 65.7%) and four achieved stable disease. In 14 patients (47%) a clinical benefit was documented. Six out of 15 patients with bone-only involvement had stable disease (40%). The median duration of stabilization and partial response was 16 weeks (range 4-24 weeks). The most common toxicity was hematological: Grade 4 (NCI-CTC scale) in five patients at re-cycle. Other toxicities were of low incidence and easy to manage. CONCLUSION: The encouraging results obtained with the FLN regimen in terms of clinical benefit and its predictable and manageable toxicity support the palliative role of this chemotherapeutic strategy in hormone-refractory prostate patients.

Laparoscopic-assisted jejunostomy: an effective procedure for the treatment of neurologically impaired children with feeding problems and gastroesophageal reflux.

BACKGROUND: Feeding difficulties and gastroesophageal reflux (GER) are major problems in severely neurologically impaired children. Many patients are managed with a simple gastrostomy, with or without fundoplication. Unfortunately, fundoplication and gastrostomy are not devoid of complications, indicating the need for other options in the management of these patients. METHODS: Since January 2002, seven patients (age range, 5-14 years) have been treated by creating a jejunostomy with the laparoscopic-assisted procedure. The procedure was performed using two 10-mm trocars. The technique consists of identifying the first jejunal loop, grasping it 20-30 cm away from the Treitz ligament with fenestrated atraumatic forceps, and exteriorizing it to the trocar orifice under visual guide. The jejunostomy was created outside the abdominal cavity during open surgery. At the end of the jejunostomy, the correct positions of the intestinal loop and feeding tube were evaluated via laparoscopy. RESULTS: Surgery lasted 40 min on average, the laparoscopic portion only 5 min. There were no perioperative complications; hospital stay was 3 or 4 days for all patients. At the longest follow-up (18 months), all patients had experienced a significant weight gain, with a high level of parental satisfaction. One patient died 1 year after the procedure of unknown causes. All the others are well, without complications or problems, and their parents are extremely satisfied with the improved quality of life of their children. CONCLUSIONS: Laparoscopic-assisted jejunostomy is a safe and effective procedure to adopt in neurologically impaired children with feeding problems and GER. This procedure solves these patients' feeding problems even if the reflux is not completely eliminated. We advocate the use of this procedure in neurologically impaired patients with feeding problems and reflux due to its overall practicability and because there is minimal surgical trauma. This technique is extremely safe because the surgeon is able to verify, at the end of procedure, the status of the jejunostomy from outside and inside the abdominal cavity. The improvement in the quality of life of these children after the jejunostomy seems to be the major advantage of this procedure.

One-trocar laparoscopy: a valid procedure to treat abdominal complications in children with peritoneal shunt for hydrocephalus.

BACKGROUND: The aim of this paper is to show the efficacy of laparoscopy using only one umbilical trocar to treat abdominal complications of hydrocephalic children with ventriculoperitoneal shunts (VPS). MATERIALS AND METHODS: In a 15-year period, 14 laparoscopies were performed on as many children with VPS complications: in the last 4 patients only one trocar was used to solve the complications, and this subgroup will be the object of the present study. Concerning the indication for surgery, the patients presented one catheter lost in the abdominal cavity; one cerebrospinal fluid pseudocysts; one bowel obstruction; and one malfunctioning peritoneal limbs of the catheter. We used the one-trocar laparoscopic approach in all the 4 patients, and the 10-mm trocar was always introduced through the umbilical orifice in open laparoscopy. RESULTS: The laparoscopic technique was curative in all four cases and permitted the solution of the complication. CONCLUSIONS: One-trocar laparoscopic surgery can be considered as the ideal procedure in case of abdominal complications of VPS in children with hydrocephalus.

Characterization of enterotoxigenic E. coli (ETEC), Shiga-toxin producing E. coli (STEC) and necrotoxigenic E. coli (NTEC) isolated from diarrhoeic Mediterranean water buffalo calves (Bubalus bubalis).

Two hundred and twenty Escherichia coli isolates from 314 Mediterranean water buffalo calves less than 4 weeks old affected by severe diarrhoea with a lethal outcome were characterized for the presence of the virulence factors LT, ST, Stx1, Stx2, haemolysins, intimin, CNF1, CNF2, CDT-I, CDT-II, CDT-III, CDT-IV, and F17-related fimbriae (F17a, F17b, F17c, F17d). The prevalence of ETEC, STEC and NTEC were 1.8%, 6.8% and 20.9%, respectively. The ETEC isolates were all LT-positive and ST-negative. The STEC isolates were all Stx and intimin-positive, with Stx1 (80%) more frequent than Stx2 (27%). The NTEC isolates were all CNF and Hly-positive, with CNF2 (83%) more frequent than CNF1 (22%). Susceptibility assays to 11 antimicrobials displayed high rates of resistance (>30%) to antimicrobials tested. These data show that the most prevalent strains in diarrhoeic water buffalo calves were NTEC, mostly CNF2 and HlyA-positive, with strong associations CNF2/CDT-III and CNF2/F17c.

Dose intensity correlate with survival in elderly patients treated with chemotherapy for advanced non-small cell lung cancer.

INTRODUCTION: In elderly patients treated with chemotherapy for advanced non-small cell lung cancer (NSCLC), frequently an adequate dose intensity (DI) is difficult to be delivered. We therefore performed in this population a study to assess the delivered DI and its impact on clinical outcome. PATIENTS AND METHODS: Inclusion criteria were: age equal or greater than 70 years; cytological or histological diagnosis of NSCLC; stage IIIB or IV; no previous chemotherapy for advanced disease. Total relative dose intensity (RDI) was taken into account for the analysis. An RDI less than 80% was considered as suboptimal for tumor shrinkage. A survival comparison between subgroups (more or less than 80% RDI) was done. RESULTS: 107 patients were eligible for the analysis. Mean age was 74.3 years. PS was 0-1 in 92.5% of subjects. Mean number of comorbidities was 1.86. The most frequently chemotherapy regimens used were single agent vinorelbine and single agent gemcitabine. Overall mean RDI was 68%; 36% of patients received a RDI>80% of the originally planned one. The objective response rate (RR) was 55.2% and 33.3% respectively for patients receiving more or less than 80% of the RDI (p<0.01); a significant difference in overall survival between these two groups (p<0.0001) was also recorded. Baseline hemoglobin and body mass index (BMI) were the variables that significantly influenced the delivered RDI. CONCLUSIONS: These data suggest that in elderly patients treated with chemotherapy for advanced NSCLC an adequate dose intensity has a significant positive impact on both response rate and overall survival.

Bochdaleck diaphragmatic hernia, complicated by an antenatal gastric perforation, presenting as a pneumothorax and a perforative peritonitis.

The presentation of congenital diaphragmatic hernia (CDH) at birth may fall outside the typical features (cyanosis, tachypnea and respiratory failure), manifesting, instead, also with others pictures that make the diagnosis difficult or even impossible. We report a case of CDH presenting as a pneumothorax and a perforative peritonitis due to an antenatal gastric perforation.

Pediatric laparoscopic splenectomy: are there real advantages in comparison with the traditional open approach?

The hospital records of patients who underwent splenectomy during the last 2 years were reviewed to compare the advantages of the laparoscopic approach with traditional open splenectomy (OS). Between March 1994 and March 1996, 16 children underwent splenectomy, in 8 using an open approach and 8 by a laparoscopic procedure. Of the patients who underwent laparoscopic splenectomy (LS), 2 had a concomitant cholecystectomy. Ages ranged between 4 and 11 years (mean 6.4 years); there were 9 girls and 7 boys. The indications for splenectomy were: hereditary spherocytosis (7 cases); idiopathic thrombocytopenic purpura (4); sickle-cell disease (3); and beta-thalassemia (2). The average operating time for OS was 100 min (range, 50-155), for LS 170 min (range 125-240). The hospital stay for patients who had OS ranged from 3 to 9 days (mean 4.7), for those who had LS from 2 to 5 days (mean 3). One OS patient developed a wound infection. In 3 of the LS patients, the spleen was removed via a 7-cm Pfannenstiel minilaparotomy in the suprapubic region; in 5 cases the spleen was captured into an extraction bag, crushed, and removed through the umbilical orifice. The authors believe that LS must be performed only when it is possible to use the extraction bag to remove the spleen from the umbilical orifice (spleens weighing less than 700 g) and when a concomitant procedure such as cholecystectomy is indicated; in other cases OS is preferable.

[Anteposition of the anus. A cause of constipation in children]. / Antéposition de l'anus. Cause de constipation chez l'enfant.

Certain forms of severe constipation, unresponsive to medical treatment and classified as "idiopathic", have been thought to be anatomical anomalies due to anterior-displacement of the anus. The difficulty in defecation varies with the anal anomaly: this may range from passing of feces every 3-4 days to sub-occlusion episodes due to obstruction of the rectum from phecaloma and with sign of malnutrition, anemia and hypotrophy. Anatomically the anomaly is characterized by an anterior positioning of the anus which deviates the terminal part of the rectum in a horizontal plane creating a "cul-de-sac" which arrests normal fecal advancement. Fecal stasis in the rectal ampulla leads to an increase in the distensibility of the rectum with loss of the normal stimulus to defecate and contractile activity. Diagnosis is made by physical examination, barium enema (which reveals the rectal "cul-de-sac" and the distension of the colon) and ano-rectal manometry to rule out Hirschsprung diseases. The authors report their experience with 11 cases of anterior displacement of the anus, presenting a simple surgical treatment and the favorable results.

Human apurinic endonuclease gene (APE): structure and genomic mapping (chromosome 14q11.2-12).

Abasic (AP) sites in DNA are produced spontaneously and by many genotoxic agents. The repair of such damages is initiated by AP endonucleases, which are evidently ubiquitous. We employed the recently cloned cDNA, APE, that encodes the major human AP endonuclease, to isolate large genomic fragments that contain the intact APE gene. The sequence of 3 kb encompassing APE was determined (GenBank Accession No. M99703). The APE gene contains four small introns (ranging 130 to 566 bp) and five exons, the first of which is untranslated. The 0.5 kb of DNA sequence upstream of APE did revealed only a possible CCAAT box, but no other regulatory sites or a TATA box, consistent with the constitutive expression of AP endonuclease activity observed in other studies. The location of APE in the human genome was mapped to chromosome 14, bands q11.2-12, by fluorescence in situ hybridization of metaphase cells with DNA from the genomic clones and subclones. Although this locus has not been associated causally with genetic diseases of DNA repair, some translocations that affect 14q11.2-12 could compromise APE and lead to genetic instability.

Complications of pediatric laparoscopic surgery.

BACKGROUND: Surgical complications of laparoscopy most often occur during Veress needle or primary trocar placement. Veress needle punctures are insignificant and require no further treatment, whereas trocar-induced vascular injuries can be catastrophic. The frequency of vascular and viscus injuries is difficult to calculate because several complications are not reported in the literature. METHODS: During a 10-year-period (1984-1995), at the Division of Pediatric Surgery at "Federico II" University of Naples, 430 laparoscopic procedures were performed in 395 children with a mean age of 5 years. The incidence of complications related to laparoscopy was 1.8% with eight complications, one of which was rather severe. The complications included one abdominal wall hematoma, two perforations of abdominal viscus (stomach, ovary), one umbilical scar complication, one postoperative hydrocele, one subcutaneous emphysema, and one pneumothorax during a Nissen procedure. The only severe complication occurred in a young girl with neurologic problems and a kyphoscoliosis operated on via laparoscopy for a gastroesophageal reflux. She suffered injuries of both right common iliac vessels and several intestinal perforations due to blind introduction of the first umbilical trocar. RESULTS: In this case rapid conversion, complex vascular reconstruction, and multiple intestinal sutures were performed. The Nissen fundoplication with pyloroplasty was performed traditionally and the patient left the hospital free of symptoms after 20 days. The other seven complications were resolved without any problem intra- or postoperatively. CONCLUSIONS: The authors believe that the open approach with a blunt trocar is most important in helping to avoid complications in pediatric laparoscopy.

[Enlarged substitutive colocystoplasty for congenital neurological bladder in children. Apropos of 8 cases]. / Colocystoplastie d'agrandissement et de substitution pour vessie neurologique congénitale de l'enfant. A propos de 8 cas.

The encouraging success of replacement of the detrusor for contracted bladder due to a tuberculosis or other causes prompted an attempt to reconstruct bladder in a patient with neuropathic bladder. Colocystoplasty has been used by the authors in a total of 12 children with neurogenic bladder: 8 with a sufficient follow-up (6 months to 10 years). Technical data are given with some details. The sclerosed detrusor inducing elevated bladder pressure must be resected and the sigmoid is anastomosed to the trigone of the bladder. The sigmoid conduit is extraperitonized. The new colonic bladder give ample and supply cystern allowing protection of ureters and kidneys. The incontinence is not modified. Simultaneously with colocystoplasty the patient must be managed by self-catheterization or by urinary artificial sphincter or by a continent cystostomy. The initial results are very encouraging.

Splenectomy in childhood. The laparoscopic approach.

BACKGROUND: We set out to analyze the results of the first 19 laparoscopic splenectomies performed by our team in order to show the advantages and limitations of the laparoscopic approach to this kind of procedure in children. METHODS: Between March 1994 and June 1997, 19 children underwent laparoscopic splenectomy; two of them also had a concomitant cholecystectomy. Their ages ranged between 4 and 14 years (median, 7.2 years). There were 14 girls and 5 boys. All the patients underwent elective laparoscopic splenectomy: seven children had hereditary spherocytosis, six were affected by a beta thalassemia, five had an idiopathic thrombocytopenia purpura, and one presented with sickle cell disease. RESULTS: Mean operating time was 145 min (range, 110-240 min). Hospital stay ranged from 2 to 5 days (median, 3 days). In three patients, the spleen was removed with a 7-cm mini-laparotomy, according to the technique of Pfannenstiell, in the suprapubic region. In the other 16 cases, the spleen was captured into a extraction bag, finger-fragmented, and removed from the umbilical orifice. CONCLUSIONS: Laparoscopic splenectomy can be performed only when the spleen can be removed through the umbilical orifice with an extraction bag. For this reason, preoperative ultrasonography is necessary to measure the exact spleen volume. When the spleen is very large, an open splenectomy is preferable.