Failed back surgery syndrome: a new strategy by the epidural injection of MESNA.

PURPOSE: Evaluate the efficacy and safety of MESNA (sodium 2-mercaptoethanesulfonate) injection into the epidural space in the FBSS. METHODS: We designed a prospective phase II longitudinal study. Six consecutive patients were enrolled. Patients underwent one peridural injection per week for 3 weeks. NRS and ODI were investigated before and 48 h after injections, and at 1 week, 1 month and 2 months after the last procedures. Opioids intake is investigated before procedures and 1 week, 1 month and 3 months after the last procedures. Lumbosacral MRI is performed before the first procedure, at the end and 3 months after the last procedures. RESULTS: From baseline, at 3 months, NRS in standing, sitting and lying position improved, respectively, of 34.29, 30.56 and 26.47%; ODI improved of 20.3%; the average decrease in morphine intake was 20.54%. No difference in MR images was found. Conclusions Our preliminary results suggest that MESNA might be an efficacy alternative to common practice.

A case of Beauveria bassiana keratitis confirmed by internal transcribed spacer and LSU rDNA D1-D2 sequencing.

We describe a case of fungal keratitis due to Beauveria bassiana in a farmer with Fuchs' dystrophy, treated with amphotericin B. Surgery with penetrating keratoplasty was necessary to resolve the lesions. Susceptibility testing and molecular sequencing permitted the identification and treatment of this rare aetiological agent of invasive fungal disease.

Performance characteristics of current-generation Immulite 2000 TORCH Assays.

The performances of seven Immulite 2000 (Siemens Healthcare Diagnostics) TORCH (Toxoplasma gondii, other microorganisms, rubella virus, cytomegalovirus, and herpes simplex virus) assays were evaluated in comparison with the performances of the ETI-MAX 3000 (DiaSorin) TORCH assays. The two systems demonstrated good agreement, and given their sensitivity, specificity, and positive predictive value, they can be used with confidence for TORCH prenatal screening.

Performance of different commercial methods for determining minimum inhibitory concentrations of glycopeptides and linezolid against blood isolates of Staphylococcus aureus.

The aim of this study was to determine the accuracy of commercial systems (VITEK® 2, Etest and Sensititre®) in determining the minimum inhibitory concentrations of vancomycin, teicoplanin and linezolid of Staphylococcus aureus strains and to evaluate the reproducibility of each system in a clinical microbiology laboratory. In total, 115 strains of S. aureus isolated from blood cultures were tested with all three commercial methods as well as the broth microdilution method, which is designated as the standard for glycopeptides and linezolid. Fourteen different S. aureus strains were included in a reproducibility test for all methods and antibiotics. For these strains, antimicrobial susceptibility testing was repeated 10 times on different days with all four methods, each time using the same inoculum. All three commercial methods exhibited similar performance in categorisation of nearly all of the meticillin-susceptible S. aureus (MSSA) isolates. Discrepancies were registered for meticillin-resistant S. aureus (MRSA); 2.5% of the strains in the intermediate or resistant category with the VITEK 2 system were not recognised as resistant by Etest and Sensititre. Moreover, none of the three commercial methods provided accurate results compared with homemade broth microdilution. Reproducibility of vancomycin and teicoplanin was 100% with VITEK 2 and Sensititre and 98.75% with Etest. Microdilution showed a reproducibility of 95.6% with vancomycin and 83.1% with teicoplanin. In contrast to previous reports, the best agreement with microdilution was exhibited by VITEK 2 both for MSSA and MRSA. For the antibiotics tested, the best reproducibility was obtained with the VITEK 2 and Sensititre systems.

[Intussusception after congenital diaphragmatic hernia repair]. / Invagination intestinale après réparation d'une hernie diaphragmatique congénitale.

INTRODUCTION: Bowel intussusception is a common complication of abdominal surgery. However, the literature on intussusception after congenital diaphragmatic hernia (CDH) repair is scarce. CASE REPORT: A 24-month-old female was admitted with vomiting, crying and leukocytosis, with no objective abdominal signs. The chest x-ray showed the presence of bowel in the left hemithorax. Surgical exposure reduced a hernia across a Bochdalek defect, involving part of the left colon and the transverse colon. On the 7th postoperative day, the patient had symptoms of intestinal obstruction with worsening of her general condition. The explorative laparotomy evidenced an ileoileal intussusception, 15 cm from the ileocecal valve, in absence of a leading point. CONCLUSION: A postoperative intussusception in a similar case could be explained by atony of the herniated bowel, possibly a functional leading point in the postoperative phase, when the peristalsis is reactivated.

A 4-years-old girl with a mesenteric cyst.

This Letter to the Editor deals with the case of a 4-years-old female affected by a mesenteric cyst, initially confused with an ovarian cyst. The emergency situation justified our open approach. However, as expressed by the Authors, a laparoscopy should be always considered, also in pediatric age.

Amyand's hernia in premature twins.

Amyand's hernia (AH) is the presence of a normal or inflamed vermiform appendix in an inguinal hernia sac. This condition is unusual in neonates and in infants, and it has not been described in premature twins. We present two 32-day-old biovular twins with a right AH, treated with sparing of the appendix and herniotomy. The correct management of AH is discussed via a brief review of the literature.

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.

Transanal coloanal anastomosis for Hirschsprung's disease: comparison between endorectal and perirectal pull-through procedures.

BACKGROUND/PURPOSE: The aim of this study was to compare the results of 2 procedures of transanal pull-through for the management of rectosigmoid Hirschsprung's disease. METHODS: Twenty-one consecutive children with rectal or rectosigmoid Hirschsprung's disease were operated on between November 1999 and April 2003, in two pediatric surgical departments (Dijon and Strasbourg). Twelve children underwent a transanal perirectal pull-through procedure (TPR) and 9 had a transanal endorectal (Soave) pull-through procedure (TER). The collected data in each group included demographic data, length of aganglionosis, age and weight at operation, operating time, duration of hospital stay, incidence of postoperative complications (sepsis, enterocolitis, stricture) and quality of fecal continence on long-term follow-up. RESULTS: No significant differences were observed between the TPR and TER groups with respect to mean age at presentation, length of aganglionosis (rectosigmoid in 10/12 and 8/9 patients respectively), age at operation, with seventeen children operated on before one year of age (mean 3.8 and 3.3 months, respectively) and duration of hospital stay (5.2 vs. 5.3 days), frequency of bowel movements at 3 months postoperatively (1 - 3 per day). Mild differences were observed between TPR and TER groups for gender (ratio M : F 5 : 1 vs. 2 : 1), gestational age at term (39 vs. 37.5 weeks), birth weight (3240 g vs. 2520 g) and operating time (116 min vs. 138 min). No iatrogenic injury of the surrounding pelvic structures occurred during surgery and no blood transfusion was required in either of the groups. A retrorectal pelvic abscess was found in one child of the TPR group. It resolved after an enterostomy had been performed with parenteral antibiotics. Anal dilatation for postoperative anorectal stricture was required in 3 and 2 patients, respectively, for the TPR and TER groups. A mild postoperative enterocolitis developed in one case in the TER group. The average follow-up period was 35.3 months, but ten children still wear diapers, making a functional evaluation difficult. Constipation was noted in 4 and 3 patients, respectively, for the TPR and TER groups. No permanent soiling has been noted at long-term follow-up. CONCLUSION: As an objective assessment of fecal continence could not yet be done for this short series, further follow-up is required. Up to now, no significant difference was observed between these two transanal pull-through procedures.

Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease.

BACKGROUND: Nissen fundoplication is the most popular laparoscopic operation for the management of gastroesophageal reflux disease (GERD). Partial fundoplications seem to be associated with a lower incidence of postoperative dysphagia, and thus a better quality of life for patients. The aim of this study was to compare the long-term outcome in neurologically normal children who underwent laparoscopic Nissen, Toupet, or Thal procedures in three European centers with a large experience in laparoscopic antireflux procedures. METHODS: This study retrospectively analyzed the data of 300 consecutive patients with GERD who underwent laparoscopic surgery. The first 100 cases were recorded for each team, with the first team using the Toupet, the second team using the Thal, and the third team using the Nissen procedure. The only exclusion criteria for this study was neurologic impairment. For this reason, 66 neurologically impaired children (52 Thal, 10 Nissen, 4 Toupet) were excluded from the study. This evaluation focuses on the data for the remaining 238 neurologically normal children. The patients varied in age from 5 months to 16 years (median, 58 months). The median weight was 20 kg. All the children underwent a complete preoperative workup, and all had well-documented GERD. The position of the trocars and the dissection phase were similar in all the procedures, as was the posterior approximation of the crura. The short gastric vessels were divided in only six patients (2.5%). The only difference in the surgical procedures was the type of antireflux valve created. RESULTS: The median duration of surgery was 70 min. There was no mortality and no conversion in this series. A total of 12 (5%) intraoperative complications (5 Nissen, 5 Toupet, 2 Thal) and 13 (5.4%) postoperative complications (3 Toupet, 4 Nissen, 6 Thal) were recorded. Only six (2.5%) redo procedures (2 Thal, 2 Toupet, 2 Nissen) were performed. After a minimum follow-up period of 5 years, all the children were free of symptoms except nine (3.7%), who sometimes still require medication. The incidence of complications and redo surgery for the three procedures analyzed with the Mann-Whitney U test are not statistically significant. CONCLUSIONS: For pediatric patients with GERD, laparoscopic Nissen, Toupet, and Thal antireflux procedures yielded satisfactory results, and none of the approaches led to increased dysphagia. The 5% rate for intraoperative complications seems linked to the learning curve period. The authors consider the three procedures as extremely effective for the treatment of children with GERD, and they believe that the choice of one procedure over the other depends only on the surgeon's experience. Parental satisfaction with laparoscopic treatment was very high in all the three series.

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.

Enlarged wandering spleen treated with hemisplenectomy and fixation of the residual spleen.

A case of enlarged wandering spleen presenting as an abdominal mass in a 7-year-old girl is reported. The diagnosis was performed by ultrasonography and confirmed by aortography. Treatment consisted of an elective partial splenectomy and fixation of the residual spleen to the left hemidiaphragm. The patient's symptoms regressed, and now, after more than 2 years, she is doing well. Two years postoperatively scintigraphy demonstrated a good captation of radionuclide by a normal-sized spleen at the left hypochondrium. The results obtained with the procedure that was adopted for treating this case of wandering spleen allow the authors to state that hemispleen fixation is a valid option for treating symptomatic enlarged wandering spleen.

Experience with the use of tissue adhesives in pediatric endoscopic surgery.

BACKGROUND: Due to technological improvements, the use of tissue adhesives and glues for tissue approximation and hemostasis in surgery has increased. We report our preliminary experience with this technology in pediatric endosurgery. METHODS: Between 1997 and 2000, we employed tissue adhesives in 48 pediatric patients during laparoscopic procedures. In 25 patients, the glue was adopted for the hemostasis of parenchimal organs (liver in 24 cases and spleen in one). In three cases, the glue was used to repair organ perforation, in 19 it was used to close the distal part of a patent processus vaginalis in case of congenital inguinal hernia. In the final case, the glue was adopted to achieve optimal airtightness in case of pulmonary biopsy. The glue was injected with the aid of a needle positioned transparietally. RESULTS: The procedure was easy and rapid in all cases, and there were no problems or complications related to glue positioning at a mean follow up of 51 months. CONCLUSION: Tissue adhesives are a very versatile product for use in pediatric laparoscopic surgery. It is likely that their usage will increase as the technology improves and more effective products are developed.

Impact of laparoscopy on the management of an unusual case of nonpalpable testis in an adult patient.

BACKGROUND: In the past decade, cryptorchidism has generally been treated in the first 36 months of life using an inguinal approach, in the case of palpable testis, or using laparoscopy, in the case of nonpalpable testis. Nevertheless, before this period some children were managed incorrectly. This case report shows how laparoscopy and the collaboration between pediatric surgeons and urologists may lead to optimal results. CASE REPORT: A 19-year-old male was referred to our unit following routine medical examination for enrollment in the military service with a diagnosis of right cryptorchidism. The clinical history showed the anamnesis of right cryptorchidism diagnosed at birth as a right nonpalpable testis, confirmed at 2 years of age with clinical examination and computer tomography. The patient came to our attention to again undergo a clinical examination, ultrasonography, computed tomography, and magnetic resonance imaging. We found a left, well-positioned testis of 20 ml in volume and an empty right scrotum; all the instrumental examinations were negative. The patient was thus scheduled for a diagnostic laparoscopy. A pediatric surgeon with extensive experience in this pathology performed the procedure. The 10-mm 30 degrees optics introduced through the umbilicus showed a closed right inguinal ring, with no evidence of either vas deferens or inner spermatic vessels at the level of the inguinal region or pelvis. Two more trocars were introduced and a testis of 15 ml in volume was found under the ascending colon 10 cm away from the cecum. An orchiectomy was performed via laparoscopy. CONCLUSION: This case clearly shows that some males with nonpalpable testis may have been treated incorrectly in the prelaparoscopic era and may now have an intraabdominal testis. In addition, our experience shows that intraabdominal testis may sometime be in an unusual location, and a laparoscopic surgeon with experience in this pathology is fundamental to finding the testis. In the case of adults with nonpalpable testis, when echography, computed tomography, and magnetic resonance imaging are not useful, the only effective diagnostic procedure is laparoscopy.

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.

The uncertain primary diagnosis of inflammatory bowel diseases.

BACKGROUND: The purpose of this study is to re-evaluate our series of patients affected by a colonic non-neoplastic disease, in order to measure the percentage in whom we were unable to make a correct diagnosis after the first clinical and histological approach and to single-out the reasons for our inability to reach the correct diagnosis. METHODS: During the period 1985-1999 we observed 1228 patients affected by chronic inflammatory colonic diseases. RESULTS: In 859 patients (69.9%) an ulcerative colitis was diagnosed for the first time, and 248 patients (20.1%) were affected by Crohn's colitis. One hundred and twenty-one patients (9.8%) were defined as being affected by an undetermined colitis. Forty-three patients of these had a definite diagnosis, afterwards: 27 patients were affected by ulcerative colitis and 16 by Crohn's colitis. Differential diagnosis between inflammatory large bowel diseases (ILBD) and other forms of colitis was set out as follows: 62 cases out of 1228 were consequent on a bacterial infection or parasitosis; in 28 patients a colitis pseudomembranosus was diagnosed. Eighteen cases of ischemic colitis are reported and 14 patients were affected by NSAID-related colitis. In another 6 patients we diagnosed a postradiation colitis. In 22 cases mimicking a Crohn's colitis we ascertained 9 patients affected by intestinal lymphoma, 11 mycobacterium tuberculosis related intestinal infections and 2 cytomegalovirus related colitis. CONCLUSIONS: Despite progress in scientific acquisitions and in diagnostic methods, correct initial diagnosis of ILBD is still difficult, even though it will be defined with time.

Laparoscopic solution of a vascular complication occurring during an open procedure in a child.

Usually the word conversion implies conversion from a laparoscopic procedure to an open procedure to solve complications occurring during laparoscopy. In this article we report a conversion from an open procedure to a laparoscopic one, to treat a vascular complication that occurred during an orchiectomy performed in open surgery. A 2-year-old boy came to our center for a right orchiectomy. The clinical history of this baby showed the presence of a right atrophic testis positioned in the medial part of the inguinal canal, a finding also confirmed by ultrasonography. One of our residents performed a right orchiectomy via an open inguinal procedure. After removing the testis, and before ligating the inner spermatic vessels at the level of the internal inguinal ring, the forceps that held the vessels was inadvertently opened, causing a contraction of the spermatic vessels. Since we were unable to identify the vessels and achieve hemostasis via the inguinal opening, a conversion to laparoscopic surgery was decided. A 10-mm 0 degrees optics was introduced through an umbilical trocar and revealed a large retroperitoneal hematoma along both the inner spermatic vessels and the deferential vessels, for about 3-4 cm from the internal inguinal ring. Two 5-mm trocars were positioned in triangulation and hemostasis was achieved by positioning clips on the vessels at the level of internal inguinal ring and proximally to the hematoma. Surgery lasted 1 hour; the laparoscopic procedure, 25 minutes. The baby was discharged 2 days after surgery. At a 9-month follow-up the clinical and ultrasonographical evaluation was normal. This case clearly shows the usefulness of laparoscopy in pediatric surgery, as well as to solve complications due to open surgery. We think that nowadays the use of laparoscopy should be considered indispensable by every pediatric surgical team.

The efficacy of laparoscopy in detecting and treating associated congenital malformations in children.

One of the main advantages of laparoscopy in children is the fact that it enables a magnified view and the possibility to explore the whole abdominal cavity. This case report clearly shows these advantages. We report the case of a 3-yr-old girl, suffering from severe GERD and right inguinal inguinal hernia, who had already been operated at birth for esophageal atresia. We performed a laparoscopic fundoplication according to Nissen and, at the end of procedure, we decided to turn the optic down to control the right inguinal region to confirm the presence of an inguinal hernia. To our great surprise we found a right oblique external hernia as well as a direct inguinal hernia on the same side. Both hernias was treated successfully in laparoscopy. At a 1-year follow-up, the patient presented no reflux and no recurrence of the inguinal hernias. The laparoscopy in this case permitted operation on two different pathologies involving the upper and lower parts of the abdominal cavity using the same ports and without enlarging the incision, as would happen in laparotomy. The main relevance of this case is that laparoscopy allowed the detection of an associated pathology like a direct inguinal hernia that would have been certainly overlooked in open surgery and could have caused a recurrent hernia if operated via open surgery.