Pediatric nutritional surgery and its implications: results from a unicentric retrospective analysis.

PURPOSE: Existing guidelines provide weak recommendations on the surgical management of nutritional problems in children. The objective was to design a management pathway to address the best nutritional surgery (NS) procedure in a given patient. METHODS: Retrospective analysis of children treated at our department from January 2015 to December 2019. The sample was divided into two groups according to presence or absence of neurological impairment (NI). Patients with NI (Group 1) were classified in three subgroups based on presenting symptoms: A-Dysphagia without gastroesophageal reflux (GER); B-GER with or without dysphagia; C-Symptoms associated with a delayed gastric emptying. RESULTS: A total of 154 patients were included, 111 with NI. One-hundred-twenty-eight patients underwent only one procedure. Complications and mortality were superior in Group 1. In subgroup A, isolated gastrostomy was the first NS in all patients. In subgroup B most of patients were subjected to a Nissen fundoplication, while in 5 cases total esophagogastric dissociation (TEGD) was the first intervention. Considering the entire sample, 92.3% patients who underwent a TEGD did not require further procedures. CONCLUSION: NS encompasses various procedures depending on presenting symptoms and neurological status. A management flowchart for these patients is proposed.

Functional Magnetic Resonance Urography in Ureteropelvic Junction Obstruction: Proposal for a Pediatric Quantitative Score.

Background: Ureteropelvic junction obstruction (UPJO) is one of the most frequent causes of congenital hydronephrosis. It is essential to distinguish UPJO which needs surgical treatment. fMRU combines high quality morphological details of the kidney and excretory pathways with functional data. Objective: This study aims to introduce a new radiological score based on fMRU findings to be able to differentiate surgical from non-surgical kidneys. Materials and Methods: We retrospectively selected patients with hydronephrosis due to UPJO who underwent fMRU (January 2009-June 2018). A multidisciplinary team identified a list of fMRU morpho-functional predictive variables to be included in the analysis. To evaluate the role of different independent variables in predicting the outcome, a multivariable logistic regression model has been performed; the outcome variable was the surgical intervention. For each predictive variable, Odds Ratio and 95% Confidence Intervals were calculated. The likelihood ratio test was used to assess the significance of the variables. Using the regression model, we assigned a numerical value to each predictive variable, rounding up the beta-coefficients. The cut-off value of the total score was obtained from the ROC curve analysis. Results: A total of 192 patients were enrolled, corresponding to 200 pathological kidneys. All of them underwent fMRU; 135 were surgically treated, while 65 underwent ultrasound or MRU follow-up. Predictive variables significantly associated with surgery resulted to be the urographic phase, the presence of abnormal vessels, and a baseline anterior-posterior pelvic diameter >23 mm. Beta coefficients of the logistic regression model were then converted in scores. The ROC curve of the score showed high sensitivity (84.3%) and specificity (81.3%) with a cut-off > 2.5. Conclusions: We propose a new fMRU score able to identify surgical vs. non-surgical kidneys with UPJO.

Ultrasound detected prenatal hyperechoic lung lesions and concordance with postnatal findings: A common aspect for multiple diagnoses.

OBJECTIVE: Hyperechoic lung lesions are largely detected prenatally but their underlying etiology is still poorly defined. The aim of the study was to determine the concordance between pre and postnatal diagnosis of hyperechoic lung lesions. METHODS: Prenatal ultrasound (US) evaluation was performed by a fetal medicine specialist. Postnatal diagnosis was based on CT-scan. Pre- and postnatal features were retrieved from medical charts. RESULTS: Seventy five patients were included from January 2009 to December 2018. Main prenatal diagnoses were bronchopulmonary sequestrations (BPS) (n = 24%-32%), pulmonary cystic malformations (PCM) (n = 19%-25%), congenital lobar emphysemas (CLE) (n = 15%-20%). Mediastinal shift was observed in 18 cases (24%). The prenatal detection of a systemic arterial supply had a diagnostic accuracy of 90%, while the prenatal detection of a cystic component had a diagnostic accuracy of 76.5%. All 16 neonates with prenatal isolated mediastinal shift were asymptomatic at birth. Seven neonates showed respiratory distress that was not predicted prenatally. CONCLUSIONS: Hyperechoic lung malformations reflect a heterogeneous group of lesions with a good concordance for bronchopulmonary sequestration, but not a satisfying prediction for cystic lesions.

Complications and trends in minimally invasive repair of pectus excavatum: A large volume, single institution experience.

BACKGROUND/PURPOSE: Complication risk in minimally invasive repair of pectus excavatum (MIRPE) is not negligible, particularly during learning curve. We reviewed the complications of a large series, evaluated the correlation with technical details and learning curve, and presented the strategies implemented to reduce them. METHODS: Data on MIRPE patients from 2005 to 2020 (divided in two groups: before and after 2013) were collected prospectively and reviewed. Complications were correlated to the number and type of bar/stabilizers, and to the surgeon learning curve. RESULTS: We placed 783 bars (484 Biomet, 273 Intrauma and 26 others) in 600 patients and removed 524 bars in 436 patients. Complications occurred in 108 MIRPE (18%): 3.7% intraoperative, 14.3% postoperative. No cardiac perforations were reported; in the second period we had fewer complications (15.3% versus 28.2%) particularly in intraoperative ones (0.3% versus 9%), the intervention was faster (64 versus 83 min and 92 versus 127 for 1 and 2 bars) and hospitalization shorter (5 versus 7.5 days). Complication rate of bar removal was 2.7% (all Biomet bars): one intra-thoracic bleeding and 2 lung injuries. CONCLUSIONS: MIRPE has a significant rate of complication, especially during learning curve. Postoperative complications are more frequent and less dependent on learning curve. Severe complications can be observed during bar removal. We have adopted new bars to reduce complications, but dislocation remains an unresolved problem.

Non-contrast-enhanced magnetic resonance angiography for detecting crossing renal vessels in infants and young children: comparison with contrast-enhanced angiography and surgical findings.

BACKGROUND: Knowing that ureteropelvic junction obstruction is due to a crossing renal vessel is essential in choosing the appropriate surgical treatment. OBJECTIVE: To evaluate the diagnostic accuracy of non-contrast magnetic resonance (MR) angiography in identifying crossing renal vessels in children younger than 4 years old with unilateral hydronephrosis. MATERIALS AND METHODS: A retrospective review of preoperative MR urography of children with unilateral hydronephrosis was conducted by two independent readers. The presence or absence of crossing renal vessels was identified and compared with surgical findings. RESULTS: Twenty-nine patients were included. The disagreement between MR angiography with and without contrast enhancement in detecting a crossing renal vessel was 8%. The disagreement between non-contrast-enhanced MR and surgical findings was 17%. The disagreement between contrast-enhanced MR angiography and surgical findings was 25%. The balanced triggered angiography without contrast enhancement had a sensitivity of 70% (95% confidence interval [CI]: 35-93%) and a specificity of 93% (95% CI: 66-100%). Contrast-enhanced MR angiography had a sensitivity of 56% (95% CI: 21-86%) and a specificity of 91%. (95% CI: 59-100%). CONCLUSION: MR without contrast enhancement may be a reliable, valid and safe alternative to contrast-enhanced MR angiography for identifying crossing renal vessels.