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.

Ask Doctor Smartphone! An App to Help Physicians Manage Foreign Body Ingestions in Children.

BACKGROUND: Foreign body ingestion (FBI) represents the most common cause of emergent gastrointestinal endoscopy in children. FBI's management can be quite challenging for physicians because of the variability of the clinical presentation, and the decision tree becomes even more intricate because of patient-specific variables that must be considered in the pediatric age range (e.g., age of patients and neuropsychiatric disorders) in addition to the mere characteristics of the foreign body. We present an application for smartphones designed for pediatricians and pediatric surgeons based on the latest guidelines from the official pediatric societies. The app aims to help physicians manage FBI quickly and properly in children. MATERIALS AND METHODS: The latest pediatric FBI management guidelines were reviewed and summarized. The flow chart we obtained guided the development of a smartphone application. A questionnaire was administered to all pediatric surgeon trainees at our institute to test the feasibility and helpfulness of the application. RESULTS: An app for smartphones was obtained and shared for free on the Google Play Store and Apple Store. The app guides the physician step by step in the diagnostic process, analyzing all patient- and foreign body-specific characteristics. The app consultation ends with a suggestion of the most proper decision to make in terms of further radiological investigations and the indication and timing of endoscopy. A questionnaire administered to trainees proved the app to be useful and easy to use. CONCLUSION: We developed an app able to help pediatricians and pediatric surgeons manage FBI in children, providing standardized and updated recommendations in a smart and easily available way.

Corrigendum: Ovarian tissue cryopreservation and transplantation: 20 years experience in Bologna University.

[This corrects the article DOI: 10.3389/fendo.2022.1035109.].

Dirofilaria repens Testicular Infection in Child, Italy.

Testicular Dirofilaria repens infection was identified and confirmed by sequence analysis in a child in northeastern Italy. Because human dirofilariasis is emerging in southern and eastern Europe, this parasitic infection should be considered in the differential diagnosis of scrotal swelling in disease-endemic countries to avoid unnecessary interventions, such as orchiectomy.

Ovarian tissue cryopreservation and transplantation: 20 years experience in Bologna University.

Objective: To report the 20-year experience in ovarian tissue cryopreservation (OTC) and ovarian tissue transplantation (OTT) of the Bologna clinical center (Bologna, Italy). Design: Retrospective cohort study. Patients: 1026 pediatrics and women aged between 2 and 38 years who underwent OTC and OTT between January 2002 to January 2022. Results: Of the 1026 patients, 238 (22.8%) were pediatrics (≤ 17 years, Group 1) and 788 (77.2%) were adult women (range 18-38 years, Group 2). In Group 1, 184 (77.3%) patients had malignant diseases and 54 (22.7%) had non-malignant diseases. In Group 2, 746 (94.7%) patients had malignant diseases and 42 (5.3%) had non-malignant diseases. No real complications were observed during surgery. In all the samples analyzed most of the follicles were in the resting stage, while only a few follicles were growing. In both fresh and thawed samples, follicular density was higher in Group 1 than in Group 2 (p < 0.01). Regardless of age, good preservation of follicles and stroma was observed in fresh and thawed ovarian tissue by histological and immunohistochemical analyses (estrogen and progesterone receptors; Ki67 and Bcl2 markers; TUNEL). To date, out of 1026 total women, 812 (79.1%) had their tissue stored. Sixty-eight (6.6%) patients died from their primary disease. Twenty-four (2.3%) women performed 33 OTTs between December 2011 and January 2022. Restoration of menstruation was observed in 15 out of 17 menopausal women. Six pregnancies were achieved, two hesitated in abortion and four in the birth of healthy babies. Conclusion: OTC is the only fertility preservation technique applicable in pre-pubertal/pediatrics and in adult patients when stimulation for oocytes/embryos cryopreservation is not possible. The reported data can help future patients and physicians in their discussions and decisions about the need and possibilities of preserving ovarian function.

Consequences of COVID-19 Lockdown on Children and Their Pets: Dangerous Increase of Dog Bites among the Paediatric Population.

BACKGROUND: The SARS-CoV-2 pandemic has not only put our national health systems to the test, but it also notably hit the economy, the society and the psychology of the people. Our pets have been subjected to the pandemic related stress too. The aim of the study was to evaluate whether the stress induced on domestic dogs resulted in an increase of dog bites in the paediatric population. METHODS: A retrospective study was conducted on all patients admitted to our paediatric emergency department for dog bite from January 2014 and December 2020. We compared the total mean dog bites of the years 2014-2019 and the mean number per single month with the respective 2020 data. The bites were divided between bites from family dogs and bites from stranger dogs. Continuous data were analysed using single sample t test while categorical values with chi-squared test, considering statistically significant a p value < 0.05. RESULTS: From January 2014 to December 2019, we recorded a mean of 41 ± 5.9 dog bites (range: 30-46) of which a mean 13 ± 2.6 (range: 10-17) were due to family dogs (32%) and a mean of 28 ± 2.4 (range: 25-31) were due to stranger dogs (68%); the male-to-female ratio was 3:2 and 43% of the injuries concerned the head and face, 26% the lower limbs, 25% the upper limbs, 3% the genitalia and 3% the torso. From January 2020 to December 2020, 30 children were admitted for dog bites: 22 were from family dogs (73%) and 8 from stranger dogs (27%); the male-to-female ratio was 14:11 and 72% of the injuries concerned the head and face, 16% the upper limbs, 8% the lower limbs and 4% the torso. The 2020 data's higher number of family dog bites compared with the mean of those in the 2014-2019 period was statistically significant (p < 0.01) such as the 2020 data's lower number of stranger dog bites when compared with the mean number of stranger dog bites in the 2014-2019 period (p < 0.01). Between 2014 and 2019, a mean of 9 ± 2 (range: 6-12) of the wounds needed to be sutured (22%), while 32 ± 3 (range: 28-35) wounds were discharged after application of Steri Strips (78%). On the other hand, in 2020, 21 wounds needed to be sutured (70%), and 9 received just Steri Strips application (41%). The frequency distribution of the treatments required (stitches vs. Steri Strips) between the 2014 to 2019 period and the 2020 period was statistically significant (p < 0.0001). CONCLUSIONS: The number of family dog bites in children increased in 2020, especially during the lockdown period. Paediatricians should pay a lot of attention now more than ever to educate parents on the importance of always supervising children who are playing with dogs.

Uretero-Pelvic Junction Stenosis: Considerations on the Appropriate Timing of Correction Based on an Infant Population Treated with a Minimally-Invasive Technique.

There is no univocal consensus about timing of intervention and best surgical approach for infants with asymptomatic uretero-pelvic junction obstruction (UPJO). We conducted a retrospective analysis of patients undergoing one-trocar-assisted pyeloplasty (OTAP) in a 13 year range period by creating two homogenous groups (indications for surgery were the same for all patients): patients operated on in the first 90 days of life (34 patients; Group 1) and patients operated on between 3 and 12 months of life (34 patients; Group 2). We observed no statistically significant differences between groups in regard to mean operative time, conversion rate to open surgery, mean hospital stay, early complications (urinary leakage) rate and mean antero-posterior diameter (APD) reduction rate. Moreover, no statistical improvement was seen between groups in regard to separate renal function (SRF) at 1-year-follow-up renogram. Thanks to the HSS calculated before and 1 year after surgery, we registered an important improvement in Group I patients (p = 0.023). In our study, there was no significant evidence, in terms of intraoperative data and early postoperative outcomes, between patients who underwent an early pyeloplasty and those who underwent a delayed correction. Nevertheless, we registered a significant improvement in those patients with an impaired SRF that underwent an early surgical correction, especially in terms of urinary flow. Even though this study cannot definitely establish the superiority of early timing of correction, it is evident that further research is needed to clarify this aspect.

Laparoscopy-Assisted Versus Open Surgery in Treating Intestinal Atresia: Single Center Experience.

INTRODUCTION: Surgical management of jejuno-ileal atresia/stenosis (JIA) is shifting to a minimally invasive approach. Our purpose is to evaluate the safety and feasibility of laparoscopy-assisted surgery (LAS) in JIA by comparing outcomes with a control group of open surgery (OS). METHODS: A retrospective review of JIA cases was performed. Demographic, surgical, and outcomes data were extracted. LAS cases were compared with OS. Fisher's exact-test for qualitative and Mann-Whitney-test for quantitative values were used. p values <0.05 were considered significant. RESULTS: Forty-seven patients (24/23, F/M) were included. In 19 (40%), the LAS technique was successfully performed, while 3 (17%) required conversion to OS. No differences were observed between the LAS and OS (n = 28) groups concerning demographic data (sex, mean gestational age, mean weight, associated anomalies) and type of JIA. Operative time was shorter in LAS (112 ± 46 min) compared to OS (138 ± 40 min), p = 0.04. Time to start enteral feeding and time to full enteral was shorter in LAS compared to OS, p = 0.04. No difference was observed between the two groups concerning duration of parenteral nutrition, length of hospitalization and weight at discharge. Overall rate of postoperative complications was 14% (n = 7), with a slightly prevalence in OS (18%) compared to LAS (10%), p = 0.68. CONCLUSIONS: The LAS technique in the treatment of neonatal JIA is safe and feasible. LAS is associated with shorter operative and restoration of enteral feeding times. The post-operative outcomes in LAS are similar with OS, with a lower rate of postoperative complications.

Anastomotic Stricture Definition After Esophageal Atresia Repair: Role of Endoscopic Stricture Index.

BACKGROUND: To evaluate the feasibility and efficacy of endoscopic stricture index (SIEN) to define anastomotic strictures (ASs) and to predict the need of dilatations. MATERIALS AND METHODS: A retrospective longitudinal study was conducted on patients who underwent esophageal atresia repair from 1998-2020 (ethical committee approval CHPED-05-20-AS). SIEN was calculated on the first endoscopy performed as follows: (D - d)/D, where D is the maximum diameter of lumen of the upper esophagus close to the AS and d is the diameter of lumen of the stricture. Nonparametric variables were examined using Wilcoxon-Mann-Whitney test, and continuous variables were analyzed using Spearman's test and regression analysis. A P value <0.05 was considered statistically significant. The sensitivity, specificity, and positive and negative predictive values of SIEN were also calculated, and a receiver operating characteristic curve was designed. RESULTS: A total of 46 patients were included in the study. A statistically significant correlation was found between SIEN and number of dilations (Spearman's correlation rate, 0.7; P < 0.0005). A SIEN threshold value ≥0.6 showed sensitivity of 100%, specificity of 80%, positive predictive value of 54%, negative predictive value of 100%, and the area under the curve of 84%. CONCLUSIONS: SIEN seems to be a good AS definer and prognostic tool; our study suggests that an AS could be defined by a SIEN ≥0.6.

The APpendicitis PEdiatric (APPE) score: a new diagnostic tool in suspected pediatric acute appendicitis.

Our aim was to develop an APpendictis-PEdiatric score (APPE score) in quantifying risk of acute appendicitis based on combination of clinical and laboratory markers. 1025 patients were classified in: acute appendicitis (AA) and non-appendicitis. Demographic/clinical features, and laboratory were collected. They were compared for quantitative-variables and categorical-variables. Significant predictors (P=<0,05) were included in logistic regression model. Based on regression-coefficients, a diagnostic score was tested by calculating the area under the ROC curve. Two cut-offs were established to define classes of risk of AA. 9 variables were identified as potentially predictors for AA. Those underwent logistic regression and a score was assigned, for maximum 21-points. The score showed an area under the curve: 0.831 and a linear proportion with the state of appendicular inflammation (R20.85). Patients with a score ≤8 were at low risk of AA (sensitivity 94%); those with a score ≥15 were at high risk for AA (specificity 93%). Those between 8 and 15 were defined at intermediate risk class. APPE-score guides clinicians in classifying patients with suspected-AA according to clinical and laboratory findings in order to improve their management.

Robotic removal of Müllerian duct remnants in pediatric patients: our experience and a review of the literature.

Persistent Müllerian duct syndrome is a disorder of sexual development, which features a failure of involution of Müllerian structures. An enlarged prostatic utricle is a kind of Müllerian duct remnant (MDR) with a tubular shaped structure communicating with the prostatic urethra. Treatment is aimed at relieving symptoms when present, preserve fertility and prevent neoplastic degeneration. We describe 3 cases of successful robot assisted-removal of symptomatic MDRs. The first case came to our attention for pseudo-incontinence; the other two for recurrent urinary tract infections. The patients have not presented such symptoms anymore on follow-up. We then reviewed existent literature on authors who have recently investigated the main issues concerning MDRs and have attempted a roboticassisted approach on them. Robot-assisted laparoscopy can be considered a valid, safe and effective minimally-invasive technique for the primary treatment of prostatic utricle.

Robot-assisted Pyeloureterostomy in Bifid Renal Pelvis With Ureteropelvic Junction Obstruction of the Lower Moiety.

Duplications of the urinary collecting system and pyelo-ureteral junction obstruction (PUJO) are common, but the simultaneous presence of both anomalies is rarely encountered. In incomplete duplicated systems, PUJO usually affects the lower moiety. We present the case of a 5-year old boy with left bifid renal pelvis and hydronephosis of the lower moiety treated by robot-assisted pyeloureterostomy.

Thoracoscopic Approach for Congenital Diaphragmatic Hernia: A Useful Tool in Diagnosis and Treatment of Unexpected Associated Lung Lesion.

We report the case of a neonate affected by prenatally diagnosed congenital diaphragmatic hernia (CDH), treated by thoracoscopy. During the procedure, we detected an associated extralobar pulmonary sequestration (EPS), which was preoperatively undiagnosed, and we removed it. EPS has been shown to be associated with CDH in up to 15 to 40% of cases. A possible explanation hypothesized is that pulmonary sequestration, which develops at 4 to 5 weeks of gestation, can disturb the fusion of the diaphragm and closure of the pleuroperitoneal canal. The thoracoscopic approach permitted us to identify the thoracic EPS that probably would have been otherwise missed.

Octreotide in a Critically Ill Extremely Preterm Infant With Perforated Necrotizing Enterocolitis.

Necrotizing enterocolitis (NEC) is the most severe gastrointestinal complication of prematurity. Surgery, either peritoneal drainage placement or laparotomy with resection of the intestinal necrotic tracts, is the definitive treatment of perforated NEC; however, when clinical conditions contraindicate surgical approaches, little is known about medical treatments adjuvant or alternative to surgery. Octreotide is a synthetic somatostatin analog that inhibits pancreatic secretion and leads to splanchnic vasoconstriction. In preterm neonates, it is mainly used off-label for chylothorax and congenital hyperinsulinism, whereas gastrointestinal indications are limited. We describe the case of a critically ill extremely low birth weight infant with perforated NEC, who had unsuccessfully undergone peritoneal drainage placement and laparotomy. Her unstable condition contraindicated a further laparotomy, thus off-label treatment with octreotide was attempted. No adverse events occurred. The infant's condition gradually improved and progressive reduction of peritoneal outputs and successful resolution of pneumoperitoneum were achieved, with no relapse after octreotide discontinuation.

Laparoscopic treatment of congenital choledochal cyst and hepaticojejunostomy with extracorporeal Roux-en-Y anastomosis: technical aspects and early experience with three cases.

Choledochal cyst (CDC) is a congenital dilatation of the extra and/or intrahepatic bile ducts and it is a rare condition in western countries. Classical treatment consists of cyst excision and hepaticojejunostomy. The first case of a laparoscopic CDC excision was described in 1995 and since that time an increasing number of institutions have adopted this technique, with good success. We describe our early experience of 3 cases of CDC treated with laparoscopic approach. We used a 10 mm umbilical port for the camera, and four 3-5 mm operative ports. We performed the laparoscopic removal of the cyst and gallbladder, videoassisted preparation of the Roux-en-Y loop and laparoscopic hepaticjejunostomy. No post-operative complications occurred. Laparoscopic excision of CDCs has been supposed to give better observation, a better cosmetic result, potentially less postoperative pain, and a shorter recovery. The main argument for performing an extracorporeal anastomosis is that it decreases the operative time. We recommend caution to prevent injury to the pancreatic duct and biliary structures during dissection and anastomosis. Lifelong surveillance is mandatory, even after resection of the choledochal cyst.

Laparoscopic resection of a rare gastrointestinal stromal tumor in children.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are uncommon mesenchymal tumors of the gastrointestinal (GI) tract, accounting for 0.1% to 3% of all GI malignancies. Paediatric GIST have an annual incidence of 0.02 per million children, have a female predisposition, are usually located in the stomach (50-60%) and in up to 85% of cases CD117-cKit or PDGFRA mutation is absent, resulting in a decreased efficacy of the target therapy. CASE DESCRIPTION: We report the case of an incidentally diagnosed gastric GIST in a 14-year-old boy with multiple malformations. Genetic tests and Kariotype resulted negative. Recently, an abdominal US visualized an hypoechoic heterogeneous abdominal mass. The common tumor markers resulted negative and the abdominal CT-scan confirmed the presence of a solid round lesion (42×36mm) in contact with the stomach and the pancreas. Laparoscopy allowed the recognition and the removal of the nodular mass at the posterior margin of the stomach. The histopathologic and the molecular biology findings were consistent with a kit-wilde type GIST. Surgical margins were microscopically free of tumor cells. These results justify the decision not to add other surgical or medical therapy. However, for high risk of recurrence and metastasis, a close follow-up was started. DISCUSSION AND EVALUATION: GIST are asymptomatic in 10% to 30% of patients or present nonspecific symptoms and signs. These tumors present usually irregular, lobulated and ulcerated. CT-scan of the abdomen and pelvis or magnetic resonance imaging (MRI) are mandatory in the diagnostic work-up. The final diagnosis is based on histology and immunohistochemistry. Surgery is the first-line treatment in patients with localized disease. CONCLUSION: Guidelines for the management of pediatric GIST are not presently available for the paucity of reports and data. However it is widely accepted that surgery is the first-line treatment and gross resection with negative microscopic margins can be considered therapeutic and lead to full remission of the pathology. Laparoscopy is a safe surgical approach for the exploration of the abdominal cavity, the evaluation of the disease and the complete removal of the tumor.

Ovarian tissue collection for cryopreservation in pediatric age: laparoscopic technical tips.

As the number of young girls subjected to chemo and radiotherapy is steadily increasing it is our duty to try to preserve their future fertility and ovarian function. A possibility is to collect ovarian samples, cryopreserve them and reimplant the tissue when the treatments are over. We report our 11 year experience with the use of laparoscopy to collect ovarian tissue samples. In particular we focus on the details of the surgical technique. The procedure was performed in 54 patients affected by malignancies or pathologies requiring chemo or radiotherapy, with good results. Cryopreservation seems to be a good option to preserve future fertility although it is still an experimental method.

An Interesting Case of Double Compound Intussusception without Intestinal Occlusion in a 5-Year-Old Boy.

Intussusception is a very common surgical finding in children. Idiopathic intussusception is relatively frequent in children within the first year and it usually causes an acute abdomen. Instead, complex intussusception involving multiple or remote intestinal segments is a very rare entity and it is frequently diagnosed intraoperatively. It is often because of an anatomical cause and it can occur at any age. We report a unique case of contemporary double site anterograde and retrograde ileoileal intussusception without intestinal occlusion because of a submucous intestinal lipoma. In our case, imaging studies were important for clinical suspicion and laparoscopy was essential for final diagnosis and its resolution.

A Rare Case of Chylothorax due to Pulmonary Lymphangiectasia in a 7-Year-Old Boy.

Pulmonary lymphangiectasia (PL) is a rare condition characterized by dilatation of the lymphatic vessels. Post-neonatal PL is usually associated with pleural effusion and should therefore be suspected in the presence of chylothorax. We describe a post-neonatal manifestation of PL in a 7-year-old boy presenting chylothorax. Radiological examinations included thorax X-ray, ultrasound, and computed tomography scans. After the failure of conservative management (maintenance of the chest tube, total parenteral nutrition, administration of somatostatin synthetic analogues) we performed a thoracoscopic massive ligation of the thoracic duct's collateral along with a lung biopsy. Histology was compatible with type 1 congenital pulmonary lymphangectasia. One month after surgery a thoracoscopic pleurodesis was required for persistent chylothorax. The boy is now doing well 1 year after surgery.

Secondary omental torsion as a rare cause of acute abdomen in a child and the advantages of laparoscopic approach.

Omental torsion is an underdiagnosed cause of acute abdomen in children. Most cases occur in adults, with only 15% presenting in children. It is estimated that omental infarct is found in approximately 0.1 to 0.5% of children undergoing operations for appendicitis. It may present with various signs and symptoms, although the clinical presentation usually mimics that of acute appendicitis. Definitive diagnosis is often established during surgery. We report a case of a 9-year-old boy who came to our attention for acute abdomen. We performed a laparoscopy-assisted procedure suspecting acute appendicitis. We therefore identified a secondary omental torsion associated with patency of the right inguinal duct and herniated omentum. Laparoscopy allowed a correct diagnosis and therapy.