Laparoscopic Trachelectomy for Cervix Yolk Sac Tumor in 11-Month-Old Girl: The Youngest Case.

BACKGROUND: Yolk sac tumor (YST) is a malignant entity that often occurs in girls less than 3 years of age and is the most frequent type of primary extragonadal germ cell tumor. CASE: We describe the case of an 11-month-old girl who was referred to our center for vaginal bleeding with evidence of a uterine mass on ultrasonography. Preoperative investigations confirmed YST of the uterine cervix without metastasis. After 4 cycles of systemic chemotherapy, the patient was treated with laparoscopic trachelectomy (fertility-sparing surgery) without perioperative complications. SUMMARY AND CONCLUSION: After 12 months of follow-up, no residual mass was seen. The laparoscopic technique for trachelectomy for uterine cervix YST seems to be feasible and safe in children under 1 year of age.

High-pressure balloon dilatation for the treatment of primary obstructive megaureter: is it the first line of treatment in children and infants?

AIMS OF THE STUDY: To evaluate the efficacy of high-pressure balloon dilatation (HPBD) as treatment of primary obstructive megaureter (POM) in paediatric patients, we analysed the data of our institute from June 2018 to September 2019. METHODS: 14 patients, aged 5 months to 5 years, with POM were treated with HPBD. All patients had a distal ureter dilatation greater than 7 mm associated with obstructive features on a mercaptoacetyl triglycine-3 diuretic renogram scan, and a voiding cystourethrogram without vesicoureteral reflux. HPBD was performed in 12 patients, whereas 2 patients (14%), aged 5 and 6 months, required open surgical treatment because of failure to pass the balloon catheter through the vesicoureteral junction. The procedure was performed with a 5 Fr balloon catheter for two cycles of 5 minutes each at 17 atm. A double-J stent and a urinary catheter were inserted at the end of procedure in all patients. RESULTS: No operative complications or symptoms or recurrence were recorded in our series. The patients were generally discharged 24 hours after surgery. All the patients showed an improvement on ultrasonography at the postoperative follow-up, with no evidence of obstruction. During the procedure a clear stenotic ring was identified in 10 of the 12 patients, which disappeared in all 10 cases after the HPBD technique. CONCLUSIONS: Based on our experience, HPBD may be considered the first-line surgical approach in the treatment of POM in children, avoiding bladder surgery in most cases.

Posterior Urethral Polyp Treated With Endoscopic Transurethral Resection: The Second Pediatric Case Managed With Holmium Laser.

Fibroepithelial urethral polyp is a rare benign tumor more common in children than adult that can cause bladder outlet obstruction. We describe a 3-year-old boy who presented with intermittent acute urinary retention affected by a fibroepithelial urethral polyp managed with endoscopic transurethral resection by HOLMIUM laser; no complications neither recurrence were observed. To our knowledge this is the second pediatric case of fibroepithelial urethral polyp treated by HOLMIUM laser.

Technical standardization of MIS management of children with pilonidal sinus disease using pediatric endoscopic pilonidal sinus treatment (PEPSiT) and laser epilation.

PURPOSE: This study aimed to standardize the technique of pediatric endoscopic pilonidal sinus treatment (PEPSiT) associated with laser epilation. METHODS: All pediatric patients presenting with acute or chronic pilonidal sinus disease (PSD) who underwent PEPSiT in our institution over a 36-month period (July 2015-July 2018), were included in the study. Pre- and postoperative management, recurrence rate, postoperative pain, hospital stay, analgesic requirements, and patient satisfaction levels were evaluated. RESULTS: A total of 59 patients (23 girls and 36 boys) underwent PEPSiT during the study period. Ten/59 patients (16.9%) had recurrent PSD after open repair, and 4/59 (6.7%) presented a concomitant pilonidal cyst. All children underwent laser epilation pre- and postoperatively over the last 15 months. The average length of surgery was 27.5 min (range 20-45). The average pain score during the first 48 postoperative hours was 2.7 (range 2-5), and the average analgesic requirement was 20 h (range 16-24). The average hospitalization was 22.4 h (range 18-36). At 1 month postoperatively, external openings were healed in all patients. During follow-up, 1 recurrence (1.6%) was recorded and successfully re-treated with PEPSiT. CONCLUSIONS: We believe that PEPSiT represents the technique of choice for treatment of PSD in the pediatric population. It is crucial to standardize the technique consisting of pre- and postoperative laser epilation, PEPSiT, and accurate postoperative wound management with eosin and sulfadiazine spray. LEVEL OF EVIDENCE: Treatment study - Level IV.

Indocyanine Green Fluorescence Lymphography: A New Technique to Perform Lymphatic Sparing Laparoscopic Palomo Varicocelectomy in Children.

BACKGROUND: Laparoscopic Palomo varicocelectomy is one the most common approaches adopted to treat pediatric varicocele, but postoperative hydrocele still remains a potential problem with this procedure. This study aimed to evaluate the outcome of a new technique of lymphography using indocyanine green (ICG)-enhanced fluorescence to perform lymphatic sparing laparoscopic Palomo varicocelectomy. PATIENTS AND METHODS: The records of 25 patients who underwent laparoscopic left varicocelectomy in our unit from March 2017 to March 2018 were retrospectively evaluated. The average patients' age was 13.7 years (range 12-16). All patients had a high degree varicocele associated with left testicular hypotrophy and symptoms. All procedures were performed in laparoscopy using three trocars. After trocars' positioning, 2 mL of ICG solution was directly injected into the left testicle. Using ICG fluorescence, the lymphatic vessels were clearly identified and spared, and then the entire spermatic bundle was clipped and divided according to Palomo's principle. RESULTS: The average operative time was 18 minutes (range 10-25). No conversions to open surgery and no allergy or other adverse reactions induced by ICG were reported. At a maximum follow-up of 18 months, no recurrence of varicocele or postoperative hydrocele was recorded. CONCLUSIONS: Our preliminary experience showed that ICG fluorescence lymphography is a safe and effective option to perform lymphatic sparing laparoscopic Palomo varicocelectomy in children and adolescents with high degree varicocele. The intratesticular injection of ICG and use of fluorescence vision allowed identification of lymphatic vessels in 100% of cases. No allergy to ICG or postoperative hydrocele was reported in our experience.

Two decades of experience with laparoscopic varicocele repair in children: Standardizing the technique.

BACKGROUND: Controversy still exists about the indications and the gold standard approach for varicocele treatment in pediatric population. OBJECTIVE: The authors report their 23 years of experience in laparoscopic varicocele repair in the pediatric population. STUDY DESIGN: We retrospectively evaluated the data of 345 consecutive patients who underwent laparoscopic left varicocelectomy from January 1993 to December 2015. Average patient age was 12.5 years (range 8-17). Seven out of 345 patients (2%) had a recurrent varicocele, and five out of 345 patients (1.4%) had a varicocele on a single testis. In 335/345 patients (97.1%) we performed a Palomo procedure, and in 10/345 patients (2.9%) an artery-sparing Palomo procedure. After 2010, in 105/345 patients (30.4%) we performed a lymphatic sparing procedure using isosulfan blue injection preoperatively. RESULTS: All procedures were completed in laparoscopy (Figure), without conversions or intraoperative complications. The average operative time was 17 min (range 14-45) for the Palomo procedure and 26 min (range 18-50) for artery-sparing Palomo. In 45/345 patients (13%) we performed additional procedures. We recorded 4/345 (1.3%) recurrences/persistences in patients undergoing Palomo, while we recorded 1/10 (10%) recurrence/persistence after artery-sparing Palomo. On 230 Palomo procedures performed in the pre-isosulfan blue era, we recorded 25 cases of hydrocele (10.8%), 13 of these were treated with transcrotal puncture and 12 required surgical operation. The last 105 patients undergoing isosulfan blue injection had no postoperative hydrocele. We also reported 10 other complications (I grade Clavien-Dindo) such as umbilical granuloma or instrumental problems. DISCUSSION: Analyzing the international literature of the last 25 years, most papers focused on the minimally invasive treatment of pediatric varicocele. There are several reasons to perform laparoscopic repair of pediatric varicocele. First of all, it is technically easy to perform, the average operative time is very short, and it has excellent outcome in regard to varicocele persistence/recurrence. In addition it has a very low complication rate, and in particular adopting the intradartoic/intratesticular isosulfan blue injection before surgery we recorded no postoperative hydrocele. CONCLUSION: On the basis of our 23 years of experience with varicocele repair, we clearly believe that laparoscopic Palomo lymphatic sparing varicocelectomy should be considered the standard of care for the treatment of pediatric patients with varicocele. Laparoscopic varicocelectomy is technically easy and quick to perform, painless, and scarless, with a recurrence rate of about 1%. The use of a preoperative injection of isosulfan blue completely eliminates postoperative hydrocele formation.

Frequency of Antibiotic-Associated Diarrhea and Related Complications in Pediatric Patients Who Underwent Hypospadias Repair: a Comparative Study Using Probiotics vs Placebo.

This study aimed to evaluate the effectiveness of probiotics (Lactobacillus rhamnosus GG), as a preventive measure of antibiotic-associated diarrhea (AAD) in children who underwent hypospadias repair and its clinical consequences on postoperative outcome, comparing the group treated with probiotics + antibiotics with two control groups (only antibiotics and antibiotics + placebo). We performed a prospective, randomized, placebo-controlled study with three groups of patients (30 boys for each group) who underwent hypospadias repair in our unit from March 2016 to December 2016. G1 received antibiotics + probiotics (L. rhamnosus GG), while G2 and G3 respectively received only antibiotics or antibiotics + placebo (glucose solution at 5%) for the same period. The patients were evaluated in regard to the number of evacuations/day, stool consistency, and the number of dressings/day. The overall incidence of postoperative AAD was 33.3% (30/90), and it was statistically lower in G1 patients compared to G2 and G3 ones (p = 0.002). The duration of AAD was significantly longer in G2 and G3 compared to G1 (p = 0.001). In G1, the frequency of dressing change was significantly lower compared to G2 and G3 (p = 0.001).The incidence of postoperative complications (fistula and dehiscence) was significantly higher in G2 and G3 compared to G1 (p = 0.001). Our study confirmed that the use of probiotic L. rhamnosus GG associated with antibiotics significantly reduced the incidence and the duration of postoperative AAD. In addition, the use of probiotics LGG reduced the frequency of dressing changes and the incidence of postoperative complications, such as urethral fistula and foreskin dehiscence.

Pediatric Endoscopic Pilonidal Sinus Treatment, a Revolutionary Technique to Adopt in Children with Pilonidal Sinus Fistulas: Our Preliminary Experience.

AIM: This study aimed to report our preliminary experience with pediatric endoscopic pilonidal sinus treatment (PEPSiT). PATIENTS AND METHODS: We retrospectively reviewed the reports of 15 patients, 6 girls and 9 boys, with an average age of 16 years (range 13-18) with noninfected pilonidal sinus disease who underwent PEPSiT in our institution over an 18-month period. Four cases were redo-procedures, for recurrence of disease after open excision repair. Surgical outcomes of sinus healing, recurrence of disease, postoperative pain, hospital stay, analgesic requirements, and patient satisfaction levels were evaluated and a comparison analysis with classic open repair was performed. RESULTS: All procedures were performed under subarachnoid spinal anesthesia. We always adopted a fistuloscope, an endoscopic forceps, and a monopolar electrode to remove the hairs and to heal the fistula. The average length of surgery was 28.5 minutes (range 26-41). No intraoperative or postoperative complications were reported. The average pain score evaluated using Visual Analogue Scale (VAS) pain scale during the first 48 postoperative hours was 3.2 (range 2-5). The average analgesic requirement was 22 hours (range 16-28). The average hospital stay length was 28 hours (range 22-48). They changed dressing daily, by applying a topical solution of eosin 2% and a silver sulfadiazine spray. At 1 month postoperatively, the external openings were closed in all patients and no recurrence was recorded at a mean follow-up of 6 month. PEPSiT was associated with a significantly shorter, painless, and better outcome compared to open technique. CONCLUSION: On the basis of our preliminary experience, we believe that PEPSiT is a promising technique for surgical treatment of pilonidal sinus in children. It is technically easy and quick to perform, with a short and painless hospital stay, without recurrences in our series. It allows operated patients an early return to full daily activities without restrictions that happen for the classic treatment.

Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs.

BACKGROUND: The role of laparoscopy in pediatric inguinal hernia (IH) is still controversial. The authors reported their twenty-year experience in laparoscopic IH repair in children. METHODS: In a twenty-year period (1995-2015), we operated 1300 infants and children (935 boys-365 girls) with IH using laparoscopy. The average age at surgery was 18 months (range 7 days-14 years). Body weight ranged between 1.9 and 50 kg (average 9.3). Preoperatively all patients presented a monolateral IH, right-sided in 781 cases (60.1 %) and left-sided in 519 (39.9 %). We excluded patients with bilateral IH and unstable patients in which laparoscopy was contraindicated. If the inguinal orifice diameter was ≥10 mm, we performed a modified purse string suture on peri-orificial peritoneum, in orifices ≤5 mm, we performed a N-shaped suture. RESULTS: No conversion to open surgery was reported. In 533 cases (41 %), we found a contralateral patency of internal inguinal ring that was always closed in laparoscopy. In 1273 cases (97.9 %), we found an oblique external hernia; in 21 cases (1.6 %), a direct hernia; and in 6 cases (0.5 %), a double hernia on the same side (hernia en pantaloon). We found an incarcerated hernia in 27 patients (2 %). Average operative time was 18 min (range 7-65). We recorded 5/1300 recurrences (0.3 %), but in the last 950 patients, we had no recurrence (0 %). We recorded 20 complications (1.5 %): 18 umbilical granulomas and two trocars scar infections, treated in outpatient setting. CONCLUSIONS: On the basis of our twenty-year experience, we prefer to perform IH repair in children using laparoscopy rather than inguinal approach. Laparoscopy is as fast as inguinal approach, and it has the advantage to treat during the same anesthesia a contralateral patency occured in about 40 % of our cases and to treat also rare hernias in about 3 % of cases.

Retroperitoneal and laparoscopic heminephrectomy in duplex kidney in infants and children.

BACKGROUND: Two main techniques are adopted to perform partial nephrectomy in children: laparoscopy and retroperitoneoscopy. The aim of this paper is to review the larger multicentric experience recently published by our group to review indications, techniques and results of both approaches. METHODS: Data of 102 patients underwent partial nephrectomy in a 5-year period using minimally invasive surgery (MIS) procedures were analyzed. Fifty-two children underwent laparoscopic partial nephrectomy (LPN), and 50 children underwent retroperitoneoscopic partial nephrectomy (RPN). Median age at surgery was 4.2 years. Statistical analysis was performed using χ2 test and Student's t-test. RESULTS: The overall complications rate was significantly higher after RPN (15/50, 30%) than after LPN (10/52, 19%) (χ2 =0.05). In LPN group, complications [4 urinomas, 2 symptomatic refluxing distal ureteral stump (RDUS) and 4 urinary leakages] were conservatively managed. In RPN group, complications (6 urinomas, 8 RDUS, 1 opening of remaining calyxes) required a re-operation in 2 patients. In both groups no conversion to open surgery was reported. Operative time (LPN: 166.2 min vs. RPN: 255 min; P<0.001) and hospitalization (LPN: 3.5 days vs. RPN: 4.1 days; P<0.001) were significantly shorter in LPN group. No postoperative loss of renal function was reported in both groups. CONCLUSIONS: MIS now represents the gold standard technique to perform partial nephrectomy in children with duplex kidney. Our results demonstrate that RPN remains a technically demanding procedure with a significantly higher complications and re-operation rate compared to LPN. In addition, length of surgery and hospitalization were significantly shorter after LPN compared to RPN. LPN seems to be a faster, safer and technically easier procedure to perform in children compared to RPN due to a larger operative space and the possibility to perform a complete ureterectomy in refluxing systems.

Pyeloplasty techniques using minimally invasive surgery (MIS) in pediatric patients.

Hydronephrosis is the most common presentation of ureteropelvic junction (UPJ) obstruction. We reviewed literature, collecting data from Medline, to evaluate the current status of minimally invasive surgery (MIS) approach to pyeloplasty. Since the first pyeloplasty was described in 1939, several techniques has been applied to correct UPJ obstruction, but Anderson-Hynes dismembered pyeloplasty is established as the gold standard, to date also in MIS technique. According to literature several studies underline the safety and effectiveness of this approach for both trans- and retro-peritoneal routes, with a success rate between 81-100% and an operative time between 90-228 min. These studies have demonstrated the safety and efficacy of this procedure in the management of UPJ obstruction in children. Whether better the transperitoneal, than the retroperitoneal approach is still debated. A long learning curve is needed especially in suturing and knotting.

Treatment of vesico-ureteral reflux in infants and children using endoscopic approaches.

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Endoscopic treatment of VUR dates back to 1981 when Matouschek first described injection of the ureteral orifice in an attempt to correct VUR. In addition, also Politano and colleagues and McDonald described successful correction of reflux using endoscopic techniques. After these reports subureteral Teflon injection (STING) came to be appreciated as a viable new way to less invasively correct one of the most common pediatric urologic problems. The technique is technically easy to perform and is usually performed as an outpatient procedure. It is performed in general anesthesia in children and may require repeat injections, particularly in patients with high-grade reflux. As for endoscopic technique, a main problem existed. The success in children with high grade reflux was less than reported for open or laparoscopic reimplant techniques. However, in the past 10 years, newer products have become available that are changing the indications for endoscopic correction. In these review, we analyzed the papers published in the literature on this topic to give to the readers an updated overview about the results of endoscopic treatment of VUR after 30-years of his first description.

Training for MIS in pediatric urology: proposition of a structured training curriculum.

In Europe there are a lot of training centers for minimally invasive surgery (MIS) but a standardized MIS training program in pediatric urology doesn't exist at the moment. We performed a literature review with the last goals to propose a structured training curriculum in MIS urology for pediatric surgeons. Pediatric urologists have to obtain a valid MIS training curriculum completing the following 4 steps: (I) Theoretical part (theoretical courses, masterclass) to acquire theoretical knowledge; (II) experimental training (simulation on pelvic trainer, virtual reality simulators, animal models, 3-D ex-vivo models) to acquire basic laparoscopic skills; (III) stages in European centers of reference for pediatric MIS urology to learn all surgery aspects; (IV) personal operative experience. At the end of the training period, the trainee would be expected to perform several MIS urological procedures independently, under supervision of an expert tutor. At the end of the training program, each center will analyze the candidate training booklet and release for each applicant a certification after an exam. We think that this MIS training program in pediatric urology may assure an integrated acquisition of basic and advanced laparoscopic skills during residency training in pediatric urology. Each European country should adopt this program so as to secure a standardized technical qualification in MIS urology for all future pediatric urologists.

Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era.

The surgical repair of inguinal hernia and hydrocele is one of the most common operations performed in pediatric surgery practice. This article reviews current concepts in the management of inguinal hernia and hydrocele based on the recent literature and the authors׳ experience. We describe the principles of clinical assessment and anesthetic management of children undergoing repair of inguinal hernia, underlining the differences between an inguinal approach and minimally invasive surgery (MIS). Other points discussed include the current management of particular aspects of these pathologies such as bilateral hernias; contralateral patency of the peritoneal processus vaginalis; hernias in premature infants; direct, femoral, and other rare hernias; and the management of incarcerated or recurrent hernias. In addition, the authors discuss the role of laparoscopy in the surgical treatment of an inguinal hernia and hydrocele, emphasizing that the current use of MIS in pediatric patients has completely changed the management of pediatric inguinal hernias.

Evaluation and outcome of the distal ureteral stump after nephro-ureterectomy in children. A comparison between laparoscopy and retroperitoneoscopy.

BACKGROUND: In children with a poorly functioning kidney due to vesicoureteral reflux (VUR) or ureteropelvic junction obstruction, management is by nephrectomy with total or proximal ureterectomy. The complete removal of all the ureter minimizes the risk of future morbidity associated with the distal ureteral stump (DUS), including febrile urinary tract infections (UTIs), lower quadrant pain and hematuria, the so-called ureteral stump syndrome. OBJECTIVE: To assess the outcome of the DUS after nephroureterectomy, we analyzed our recent experience of nephrectomy performed via retroperitoneoscopy and via laparoscopy. METHODS: The records of 21 consecutive patients (median age 3.5 years, range 1-10 years) who underwent nephroureterectomy via laparoscopy or via retroperitoneoscopy were retrospectively reviewed for symptoms caused by DUS and their management. Nephrectomy was undertaken for a poorly functioning dysplastic (4), scarred from VUR (10) or hydronephrotic (7) kidney. In the laparoscopic group (11 pts), 6 cases required nephrectomy for reflux while 5 patients were operated for hydronephrotic or dysplastic non-functioning kidney. In the retroperitoneoscopic group (10 pts), nephrectomy was performed for reflux in 4 cases versus 6 patients affected by hydronephrotic or dysplastic non-functioning kidney. The patients were evaluated using ultrasound (US) to check DUS length and clinically to evaluate symptoms due to a symptomatic DUS. RESULTS: The average length of surgery was 50 min for laparoscopy and 80 min for retroperitoneoscopy. The average of follow-up was 5 years. The length of DUS after laparoscopic nephrectomy was shorter (range 3-7 mm, statistically significant) than the DUS after retroperitoneoscopy (range 2-5 cm) (p < 0.001). Laparoscopic patients were all asymptomatic. Two patients, after retroperitoneoscopic nephrectomy, presented with recurrent UTIs; a voiding cystography revealed a VUR on the residual DUS and a redo surgery was performed in both the patients to remove the DUS (Figure). DISCUSSION: Several authors have stated that, in case of subtotal ureterectomy, the incidence of symptomatic DUS after nephrectomy for high-grade vesicoureteric reflux is low. However, in our series, the incidence of symptomatic DUS after nephroureterectomy was not insignificant (2/21, 9.5%). Symptoms related to a refluxing DUS occurred only in patients undergoing retroperitoneoscopic nephroureterectomy, where the DUS was longer than the DUS detected in laparoscopic patients. CONCLUSIONS: Considering that laparoscopy permits removal of all the ureter near the bladder dome, in children with non-functioning kidney due to VUR, it is advisable to always perform a laparoscopic rather than a retroperitoneoscopic nephrectomy to prevent problems related to a symptomatic DUS.

Twenty-year experience with laparoscopic and retroperitoneoscopic nephrectomy in children: considerations and details of technique.

BACKGROUND: Nephrectomy is probably the most common urological indication for minimally invasive surgery (MIS) in children. The authors reported their experience in laparoscopic and retroperitoneoscopic nephrectomy analyzing their 20 years of experience in this procedure. METHODS: In a 20-year period (1995-2015), the authors performed 149 nephrectomies in children using MIS (87 left, 62 right). One hundred and one nephrectomies were performed using laparoscopy (LN) and 48 using retroperitoneoscopy (RN). Patients included 90 girls and 59 boys (average age 5.7 years). All the removed kidneys were nonfunctioning because of benign diseases: VUR (84), UPJO (38), MKDK (20), xanthogranulomatosis pyelonephritis (4), nephropathy causing uncontrollable hypertension (2) and nephrolithiasis (1). RESULTS: We had no conversion in laparoscopy. As for RN, we had 2 conversions to laparoscopy at the beginning of experience due to peritoneal opening. Operative time varied from 30 to 130 min in laparoscopy (average 47 min) and from 60 to 150 min (average 78 min) in retroperitoneoscopy. We recorded 8 complications (5.3 %): 3 small bleedings (2 RN, 1 LN) during dissection, 2 peritoneal perforations during RN requiring conversion in LN, 1 abdominal abscess in case of xanthogranulomatosis pyelonephritis after LN requiring a redo surgery to drain the abscess, 1 instrumentation failure (LN) and 1 refluxing ureteral stump after RN requiring a redo surgery to remove it. CONCLUSIONS: LN is easier and faster to perform compared to RN. Complication rate was higher after RN compared to LN. In case of xanthogranulomatous pyelonephritis or other kidney infections or in case of previous renal surgery, retroperitoneoscopy is contraindicated. In case of VUR, LN is preferable to RN because it is fundamental to remove all the ureter. On the basis of our 20-year experience, we clearly prefer to perform nephrectomy using laparoscopy rather than retroperitoneoscopy leaving the indication to adopt RN only for the rare cases of MKDK.

Management of gastroesophageal reflux disease in pediatric patients: a literature review.

Gastroesophageal reflux (GER), defined as the passage of gastric contents into the esophagus, is a physiologic process that occurs throughout the day in healthy infants and children. Gastroesophageal reflux disease (GERD) occurs when gastric contents flow back into the esophagus and produce symptoms. The most common esophageal symptoms are vomiting and regurgitation. Lifestyle changes are the first-line therapy in both GER and GERD; medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. The laparoscopic Nissen antireflux procedure is the gold standard for the treatment of this pathology. A literature search on PubMed and Cochrane Database was conducted with regard to the management of GERD in children to provide a view of state-of-the-art treatment of GERD in pediatrics.

Superficial ulnar artery perforator flap.

Superficial ulnar artery is a rare finding but shows significant surgical implications. Its thinness and pliability make this flap an excellent solution for soft tissue reconstruction, especially in the head and neck region. We hereby report a successful free superficial ulnar artery perforator forearm flap transfer for tongue reconstruction. A 64-year-old man presenting with a squamous cell carcinoma of the left tongue underwent a wide resection of the tumor, left radical neck dissection, and reconstruction of the tongue and the left tonsillar pillar with the mentioned flap. No complications were observed postoperatively. The flap survived completely; no recurrence at 6 months of follow-up was detected. Superficial ulnar artery perforator flap has shown to be a safe alternative to other free tissue flaps in specific forearm anatomic conditions.

Microvascular free-flap transfer for head and neck reconstruction in elderly patients.

BACKGROUND: With the increase in life expectancy, the incidence of head and neck cancer has grown in the elderly population. Free tissue transfer has become the first choice, among all the reconstructive techniques, in these cases. The safety and success of micro vascular transfer have been well documented in the general population, but its positive results achieved in elderly patients have received less attention. METHODS: We retrospectively studied 28 patients over the age of 60 years. The aim of this paper was to study the success rate of free tissue transfer and investigate the complication incidence in this patient population. RESULTS: Twenty-eight free flaps were performed to reconstruct medium to large cervico-facial surgical defects in six years. No difference was noted between success and complication rates observed between general and elderly population. CONCLUSION: This study indicates that free-flap technique for head and neck reconstruction could be considered a safe option in elderly patients when a good pre-operative general status is present.