Accuracy of point-of-care ultrasound in the diagnosis of acute appendicitis in a pediatric emergency department.

PURPOSE: To investigate the accuracy of point-of-care ultrasound (PoCUS) in diagnosing acute appendicitis in children; to evaluate the concordance between PoCUS performed by a pediatric emergency physician (PedEm) and ultrasonography (US) performed by a radiologist; to draw a "learning curve." METHODS: We prospectively enrolled children aged 0-14 years old led to the Emergency Department of Regina Margherita Children's Hospital, from January 2021 to June 2021, with suspected acute appendicitis. PoCUS was performed by a single trained PedEm, blindly to the radiologist's scan. A "self-assessment score" and the "time of duration of PoCUS" were recorded for each patient. Final diagnosis of appendicitis was made by a pediatric surgeon. RESULTS: We enrolled 62 children (2-14 years). Overall sensitivity of PoCUS was 88%, specificity 90%; PPV 90.6%, and NPV 86.6%. Global concordance between the PedEm and the radiologist was good/excellent (k 0.74). The mean duration of PoCUS significantly decreased during the study period, while the self-assessment score increased. CONCLUSION: This is a preliminary study that shows the effectiveness of PoCUS in diagnosing acute appendicitis; furthermore, it shows how the PedEm's performance may improve over time. The learning curve showed how the experience of the PedEm affects the accuracy of PoCUS.

Laparoscopic ovarian tissue collection for fertility preservation in children with malignancies: a multicentric experience.

Introduction: Long survivors after childhood cancer are increasing thanks to oncological improvements. Their quality of life and fertility-sparing should be considered in the early phases of each oncological pathway. Cryopreservation of ovarian tissue removed before starting gonadotoxic therapies is the only fertility sparing procedure available for prepubertal children affected by cancer and it does not affect the timing of the start of the treatment. Materials and methods: The present study shows the surgical and clinical outcomes following laparoscopic ovarian tissue collection (LOTC) for a total of 311 patients aged between 0 and 17 years old from four different European Centers. Results: Only two major complications were reported according to the Clavien Dindo classification (0.6%). Discussion: LOTC can be considered a safe procedure.

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.

Role of coagulation tests in the management of acute appendicitis in children.

BACKGROUND: Acute appendicitis (AA) is one of the most common acute surgical conditions in children. Coagulation tests (CoTs) are usually utilized in preoperative assessment to rule out hemorrhagic risks. Our study aimed to evaluate the role of CoTs as predictors for the severity of AA. METHODS: In a retrospective study, we compared the blood tests of two cohorts of pediatric patients with AA (group A and B) evaluated in the Emergency Department of a Pediatric Tertiary care hospital between January 2017 and January 2020. Children in Group A underwent appendectomies while those in Group B were treated with conservative management per hospital protocol. Group A was then subdivided into non-complicated (NCA) and complicated appendicitis (CA), and the CoTs were compared between the two subgroups. RESULTS: Group A consisted of 198 patients and Group B of 150 patients. Blood tests, including CoTs and inflammatory markers, were compared between the 2 groups. We found a statistically significant difference in PT ratio mean value between Group A and B, suggesting that those who underwent appendicectomies had higher PT ratio values. From a pathophysiological point of view, we speculated that the variation of PT ratio in AA might be secondary to a vitamin K absorption deficit due to enteric inflammation. CONCLUSIONS: Our study underlined that a longer PT ratio could be helpful to distinguish CA from NCA. Further investigations may lead to the role of the PT ratio in the choice between conservative and surgical management.

Comparison of outcomes following radiological reduction of intussusception with or without sedation.

BACKGROUND: Non-operative radiological reduction (NORR) is usually the first line treatment in pediatric ileo-colic intussusception. The aim of our study was to compare outcomes of NORR with or without sedation. METHODS: All patients undergoing to contrast enema NORR for intussusception between 01.01.2015 to 31.12.2020 in two hospitals were included: in one centre patients were sedated (A) while in the other patients were awake (B). Primary outcome was the rate of radiological reduction. Secondary outcomes were length-of-stay, complications and recurrence rate. RESULTS: Seventy-seven and 49 patients were included in group A and B respectively. Successful reduction rate was 72.7% in group A and 61.2% in group B (P>0.05). There were no complications related to the procedure among the 2 groups. Adverse events to sedation were observed in 3 patients. CONCLUSIONS: NORR has similar success rate when performed under sedation or awake, despite the former being graved by additional anesthesiologic risks and thus warrant careful indications.

A case of vanishing gastroschisis with short bowel syndrome treated by total parenteral nutrition and intestinal lengthening procedures.

The diagnosis of vanishing gastroschisis is made when in the presence of a full-thickness intrauterine abdominal wall defect the eviscerated loops are incarcerated in the fascial interruption. Four types of vanishing gastroschisis are described (A-D). We report on the case of a newborn with a vanishing gastroschisis-D. Gastroschisis was diagnosed at the 19th week of gestation, confirmed at the 30th, when the herniated loops previously visible to the right of the funiculus were no longer visualized. At the 32nd week, delivery was induced. The neonate weighed 1600 g, and the abdomen was distended, free from skin defects. On surgical exploration, the jejunum was 13 cm in length, with a blind ending. The post-atretic intestine measured 22 cm. A jejunostomy and a colostomy were built. The child received total parenteral nutrition for 13 months due to short bowel syndrome and was then subjected to intestinal lengthening procedure when she was 18 months old. Vanishing gastroschisis is a rare entity with a worse prognosis of the "classic" gastroschisis.

Endobronchial Inflammatory Myofibroblastic Tumor in a 3-Year-Old Child.

Inflammatory myofibroblastic tumor (IMT) is a mesenchymal tumor that can occur at any age. However, it is primarily seen in children, with the most common site being in the lung parenchyma, usually present with rare endobronchial lesions. This case reports the incidence in a 3-year-old girl diagnosed with pericardiac pneumonia treated with antibiotics with no clinical improvement. A chest computed tomography (CT) scan identified a 1.5-cm lesion in the left main bronchus. Bronchoscopy revealed complete obstruction of the left main stem bronchus. A left posterolateral thoracotomy was performed. Additionally, a left sleeve upper bronchial resection was conducted under fibroendoscopic control. Definitive histology confirmed IMT. After 2 years of endoscopic follow-up, there is no evidence of recurrence.

Handheld metal detector versus conventional chest and abdominal plain radiography in children with suspected metallic foreign body ingestion: can we safely abandon X-rays?

BACKGROUND: Ingestion of metallic foreign bodies (MFBs) is a frequent occurrence in children and is commonly diagnosed via X-rays. In recent years, the handheld metal detector (HMD) has been increasingly adopted by several pediatric hospitals as it is considered an effective and accurate diagnostic tool that avoids exposure to ionizing radiations. Sensitivity of HMD has been reported high (99.4%) in case of coin ingestion, but significantly lower (46%) when considering the ingestion of other types of MFBs. METHODS: We tested the effectiveness of the HMD in diagnosing ingested MFBs in children less than 14 years of age, in our Pediatric Emergency Department (PED). We prospectively evaluated all cases of MFBs ingestion that presented at the PED of our hospital from March 2015 to July 2017. RESULTS: Ninety-eight patients were included. The overall sensitivity was 63.2% (79.5% for coins, 25.5% for batteries and 56% for other objects) while the specificity was 95%. The HMD could have replaced the X-ray examination only if a MFB was detected below the xyphoid process. CONCLUSIONS: Based on our findings, a negative result of HMD is not sufficient to exclude an ingestion of MFBs. Therefore, in case of an evocative history and depending on type and size of the foreign body, a radiological investigation is still necessary.

Endoscopic Treatment of a Severe Vaginal Stenosis Following Battery Insertion in an 11-Year-Old Girl.

Acquired vaginal strictures are rare entities in children. As a result, they are generally difficult to manage and tend to recur despite appropriate initial therapy. This case study reports the staged management of vaginal stenosis following the insertion of a button battery. In this case, an 11-year-old girl experienced at 4 years old a battery insertion in the vaginal canal by her neighbor's son, who was 6-year-old at the time. Two weeks from insertion, the parents noted the foreign body discharge spontaneously. The girl had not complained of any symptoms at the time and had been asymptomatic for many years. In November 2020, she came to the emergency department reporting cramping abdominal pain accompanied by mucopurulent discharge. An abdominal ultrasound showed the presence of hematometrocolpos, and a vaginal stenosis dilation under general anesthesia was performed the following day. After 3 weeks, the stenosis was still present, preventing the passage of Hegar number 4. The girl was subjected to a vaginoscopic stenosis resection utilizing a monopolar hook passed through an operative channel. A Bakri catheter filled with 120 mL of water was left in place. After 10 days, the girl was discharged home with the Bakri inserted. Two weeks after discharge, she was reevaluated in the outpatient setting, where the Bakri was removed with no signs of residual stenosis. Acquired vaginal stenosis could be demanding to treat, particularly with the sole conservative approach. A first-line option can be the Hegar dilation. The endoscopic approach can be a second-line, minimally invasive treatment, but long-term outcomes are difficult to predict.

Testicular torsion during the COVID-19 pandemic: Results of a multicenter study in northern Italy.

INTRODUCTION: The literature reported an increased avoidance of the Emergency Department (ED) during COrona VIrus Disease 19 (COVID-19) pandemic, causing a subsequent increase of morbidity and mortality for acute conditions. Testicular torsion is a surgical emergency, which can lead to the loss of the affected testicle if a delayed treatment occurs. As testicular loss is time-related, outcome was hypothesized to be negatively affected by the pandemic. OBJECTIVE: The aim is to investigate whether presentation, treatment and outcomes of children with testicular torsion were delayed during COVID-19. STUDY DESIGN: Medical records of pediatric patients operated for testicular torsion of six Paediatric Surgical Units in Northern Italy between January 2019 and December 2020 were retrospectively reviewed. Patients were divided as for ones treated during (dC) or before the pandemic (pC). To reflect possible seasonality, related to lockdown restrictions, winter and summer calendar blocks were also analysed. For all cohorts, demographic data, pre-operative evaluation, operative notes and post-operative outcomes were reviewed. Primary outcomes were referral time, time from diagnosis to surgery and ischemic time, while secondary outcomes were orchiectomy and atrophy rates. Statistic was conducted as appropriate. RESULTS: A total of 188 patients with acute testicular torsion were included in the study period, 89 in the pre-COVID-19 (pC) period and 99 during COVID-19 (dC). Time from symptom onset to the access to the Emergency Department (T1) was not different among the two populations (pC: 5,5 h, dC: 6 h, p 0.374), and similarly time from diagnosis to surgery (pC: 2,5 h, dC: 2,5 h, p 0.970) and ischemic time (pC: 8,2 h, dC: 10 h, p 0.655). T1 was <6 h in 46/99 patients (46%) pC and 45/89 patients (51%) dC (p = 0.88, Fisher's exact test). Subgroup analysis accounting for different lockdown measures, confirm the absence of any difference. Orchiectomies rate was 23% (23/99) dC and 21% (19/89) pC (p = 0.861, Fisher's exact test) and rate of post-operative atrophy was 9% dC (7/76) and 14% pC (10/70), p = 0,44, Fisher's exact test. DISCUSSION: Despite worldwide pediatric ED accesses reduction, we reported that neither ischemic time nor the long-term outcomes in children with testicular torsion increased during the COVID-19 pandemic. In the available literature, few studies investigated the topic and are controversial on the results. Similarly to our findings, some studies found that timing and orchiectomy rates were not significantly different during the pandemic, while others reported a correlation to pandemic seasonality. Furthermore, in the recent pediatric literature it has been reported a delayed testicular torsion diagnosis due to shame in informing parents. Strengths of this study are the large numerosity, its multicentric design and a long study period. Its main limitation is being retrospective. CONCLUSIONS: We reported our large cohort from one of the most heavily COVID-19-affected regions, finding that referral, intra-hospital protocols and ischemic time in testicular torsion were not increased during to the pandemic, as well as orchiectomy rate and atrophy.

Quality of life and long-term results in patients operated on for Esophageal Atresia.

BACKGROUND: Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) represents the most severe entity among the foregut malformations, with patients at risk of chronic morbidity. This study aims to investigate on health-related quality of life (QoL) and long-term results in patients with EA. METHODS: 50 patients (30M, 20F, mean age: 14-year-old), among 82 patients operated from January 1995 to December 2005, answered the questionnaire. Two groups where compared: 8-12 years (A), 12-18 years (B). The survey investigated on 5 itmes: dysphagia; GERD; pulmonary affections (asthma, bronchitis, episodes of chronic cough during a year); growth and nutritional status (BMI); QoL scores. A control group of 50 healthy children was used. RESULTS: 42 type III AE (3 long-gap and 1 VACTER association). Median BMI was 18,72 (SD 3,38) (range: 30,52-12,80). In 22 pts BMI < 18,5. 19 pts were positive for dysphagia (EAT-10 score > = 3). A correlation was found between dysphagia and low BMI (Pearson 0,37). Dysphagia and low BMI were more diffuse in the younger population, while decreased in group B. 15 pts treated in their life for GERD (8 with medical therapy; 7 fundoplication). GerdQ test data showed only 4 pts with score > 6. GERD and dysphagia: 11 pts with GERD presented EAT-10 test > 3 (Pearson value confirmed this correlation: 0,59). Respiratory pathologies: 26 pts with positive anamnesis for chronic pulmonary affections (recurrent bronchitis in 21 pts; chronic cough in 15; the association of both in 12; 11 pts with asthma). PedsQL 4.0 median value was 15,4 (SD 10,1), control group value was 15,6 (SD 7,6); difference between the 2 groups was not statistically significant (p-value: 0,11). Correlation test for comparing high value of PedsQL and long-term complication in AE: the strongest association was with the dysphagia (Pearson: 0,55). CONCLUSIONS: Dysphagia resulted the most disabling symptom in group A but swallowing function slightly improved with the growth. Generally, AE seems not heavily influence patients' QoL.

Incidental Ultrasound Diagnosis of Neonatal Intussusception Secondary to Meckel's Diverticulum in a Neurologically Impaired Child.

BACKGROUND Intussusception is the most common cause of intestinal obstruction in children, with a peak incidence usually before the second year of age, while in neonates it is a rare entity. We describe a delayed and incidental diagnosis of neonatal intussusception secondary to Meckel's diverticulum in a neonate with shaken baby syndrome (SBS). This is, to the best of our knowledge, the first reported case of a neonatal intussusception with a Meckel's diverticulum as a lead point in a neurologically impaired child. CASE REPORT A term baby presented at 22 days of age at our Emergency Department in severe conditions due to a suspected SBS. Eight days following hospitalization in the Intensive Care Unit, an isolated episode of rectal bleeding occurred, without any worsening of general conditions or abdominal distension. The ultrasonography showed a "doughnut sign" with high suspicion of ileocecal intussusception. A rectal barium contrast enema was performed but was not resolutive. At exploratory laparotomy an ileocecal intussusception with Meckel's diverticulum acting as a lead point was identified and an intestinal resection was needed due to the ischemic condition of the ileum. The post-operative course was uneventful and the baby recovered well; the residual neurological impairment needed long-term follow-up. CONCLUSIONS Intussusception is a rare entity in neonates and, when severe neurological impairment is present, the diagnosis can be missed because of the compromised condition of the baby and the paucity of gastrointestinal manifestations. In addition, due to the high incidence of lead point in neonatal cases, we recommend reserving non-operative treatment only for selected cases.

Idiopathic bilateral jugular phlebectasia in a 9-year-old boy.

A nine-year-old boy came to our clinic for the appearance of a voluminous swelling at the base of the neck in the jugular area after coughing. He underwent fibroscopy and a contrast-enhanced chest computed tomography (CT) scan, which did not indicate pathological findings even during the Valsalva maneuvre. After a color-Doppler ultrasound of the epiaortic vessels was obtained, a diagnosis of idiopathic phlebectasia of the internal jugular veins was made. The cause of the jugular phlebectasia remains unclear, and no treatment is indicated for this rare, benign, and self-limiting condition.