Two-stage orchiopexy for intra-abdominal testis with short spermatic vessels wrapped in anti-adhesion conduit. 25 years of experience.

BACKGROUND: Treatment of high cryptorchidism can be challenging, often with frustrating results. We report 25 years of experience in the treatment of the cryptorchidism with very short spermatic vessels using an original two-stage orchiopexy that preserves the spermatic vessels. METHODS: We reviewed the clinical charts of children affected by cryptorchidism with very short spermatic vessels treated through our original surgical approach in tree Institutes of Pediatric Surgery. The first stage of the procedure started with an inguinal incision and a standard orchiopexy with a deep mobilization in the retroperitoneum to straighten the spermatic vessels that are entirely preserved. After realizing intraoperatively that such maximal retroperitoneal mobilization cannot ensure a satisfactory scrotal position of the testis, the spermatic cord is wrapped in a thin sheet of polytetrafluoroethylene (PTFE) shaped as a conduit. The testis is fixed to the bottom of the scrotum which remains invaginated due to the tension. [Fig. A - scheme of the operation]. This first stage can also be performed in laparoscopy, with a video-assisted positioning of the PTFE conduit [Fig. B - laparoscopic view with vessels and vas respectively marked by black and white arrows]. The second surgical stage is scheduled after 6-12 months to remove the PTFE conduit. RESULTS: A group of 100 children affected by cryptorchidism and very short spermatic vessels (9 bilateral, 86 intra-abdominal, 23 "peeping" at the internal ring) for a total of 109 testes underwent surgery with a two-stage procedure. From the first to the second stage, a progressive lowering of each testis towards the scrotum was observed. During the second stage, after removal of the PTFE sheet, the preserved cord was loose in the inguinal canal and all the testes were located in the scrotum: 68 testes were found correctly located with no further care needed, while 41 were still in a high scrotal position. However, the latter were easily detached from the scrotal bottom and re-fixed in a more satisfactory location. At 1-9 years follow-up all the testes but one (99%) were in the correct scrotal position with stable or increased testicular volume [Fig. C], while 1 testis vanished. No complications were observed all along the follow-up. CONCLUSIONS: This long term 25-year review indicates that our original surgical technique guarantees a high rate of success with neither evident contraindications nor drawbacks for patients affected by undescended testes with spermatic vessels so short to be untreatable through a standard orchiopexy.

Increasing Trend in Violence-Related Trauma and Suicide Attempts among Pediatric Trauma Patients: A 6-Year Analysis of Trauma Mechanisms and the Effects of the COVID-19 Pandemic.

Background: Trauma is the leading cause of morbidity and mortality in the pediatric population. During the COVID-19 pandemic (COVID-19), different trends for pediatric trauma (PT) were described. This study aims to explore the trend over time of PT in our center, also considering the effects of COVID-19, focusing on trauma mechanisms, violence-related trauma (VRT) and intentionality, especially suicide attempts (SAs). Methods: All PT patients accepted at Niguarda Trauma Center (NTC) in Milan from January 2015 to December 2020 were retrospectively analyzed. We considered demographics and clinical variables and performed descriptive and year comparison analyses. Results: There were 684 cases of PT accepted at NTC: 84 in 2015, 98 in 2016, 125 in 2017, 119 in 2018, 114 in 2019 and 144 in 2020 (p < 0.001), 66.2% male, mean age 9.88 (±5.17). We observed a higher number of traffic-related, fall-related injuries and an increasing trend for VRT and SAs, peaking in 2020. We report an increasing trend over time for head trauma (p = 0.002). The Injury Severity Score did not significantly change. During COVID-19 we recorded a higher number of self-presenting patients with low priority codes. Conclusions: NTC is the adult level I referral trauma center for the Milan urban area with pediatric commitment. During COVID-19, every traumatic emergency was centralized to NCT. In 2020, we observed an increasing trend in SAs and VRT among PT patients. The psychological impact of the COVID-19 restriction could explain this evidence. The long-term effects of COVID-19 on the mental health of the pediatric population should not be underestimated. Focused interventions on psychological support and prevention of SAs and VRT should be implemented, especially during socio-demographic storms such as the last pandemic.

Esophageal atresia: pre and post-operative management.

Esophageal atresia is a relatively common congenital malformation occurring in 1:3000-4500 live births. Improvement in surgical, anesthetic and neonatal care has achieved a survival rate near 100% in infants weighing over 1500 g and having no major cardiac problem. To achieve these outcomes, as well as a good surgical technique, careful preoperative management (early diagnosis, investigation of associated anomalies, suction of the upper pouch, prevention and treatment of gastric and bowel distension) and accurate postoperative care (postoperative analgesia and ventilation, management of trans-anastomotic and chest tube, prevention, early recognition and treatment of complications) are mandatory.