Nissen fundoplication and combined procedures to reduce recurrence of gastroesophageal reflux disease in neurologically impaired children.

Neurologically impaired children account for almost half of the fundoplication procedures performed for gastroesophageal reflux disease. Aim of the present study was to report results of antireflux surgery in neurologically impaired children. A retrospective study of neurologically impaired children who underwent fundoplication over a 13-year period (1999-2012) was performed. Recurrence rate, major complications and parents/caregivers perceptions of their child's quality of life following antireflux surgery were analyzed. A total of 122 children (median age: 8 years 9 months; range: 3 months to 18 years) had open "tension-free" Nissen fundoplication, gastrostomy + /- pyloroplasty. Gastroesophageal reflux disease was in all cases documented by at least two diagnostic exams. Median duration of follow-up was 9.7 (1.9-13) years. Three (2.4%) recurrences were documented and required surgery re-do. Major complications were 6%. Seventy-nine of 87 (90%) caregivers reported that weight gain was improved after fundoplication with a median score of 1 (IQR: 1-2). Significant improvement was perceived in postoperative overall quality of life. In this series of fundoplication recurrence incidence was low, serious complications were uncommon and caregivers' satisfaction with surgery was high. Accurate patient's selection and creating a "low-pressure" surgical system are mandatory to obtain these results.

Obalon intragastric balloon in the treatment of paediatric obesity: a pilot study.

BACKGROUND: Lifestyle interventions are often ineffective in the treatment of pediatric obesity. Weight loss devices have been introduced for the temporary nonsurgical treatment of morbid obesity. OBJECTIVE: The aim of the study is to evaluate the efficacy of Obalon Intragastric Balloon on weight loss and on metabolic and cardiovascular parameters in a pediatric population with severe obesity. METHODS: We enrolled 10 children with severe obesity. In all patients anthropometric parameters, biochemical tests, ultrasound liver examination and blood pressure monitoring were evaluated at the time of insertion and after removal of device. RESULTS: The Obalon had a positive effect on decrease of weight, body mass index and percentage of excess body weight within 3 months from placement. Moreover, this safe minimally invasive device improves the cardio-metabolic profiles of obese children. CONCLUSIONS: The Obalon could be a useful tool in the difficult management of pediatric patients with morbid obesity, inducing in short-term a meaningful weight loss.

BioEnterics intragastric balloon for treatment of morbid obesity in Prader-Willi syndrome: specific risks and benefits.

BACKGROUND: Obesity in Prader-Willi Syndrome (PWS) is progressive, severe, and resistant to dietary, pharmacological, and behavioral treatment. A body weight reduction is mandatory to reduce the risk of cardio-respiratory and metabolic complications. The aim of the study was to assess risks and benefits of BioEnterics Intragastric Balloon (BIB) for treatment of morbid obesity in PWS patients. METHODS: Twenty-one BIB were positioned in 12 PWS patients (4 M, 8 F), aged from 8.1 to 30.1 years, and removed after 8 +/- 1.4 months (range: 5-10 months). Auxological, clinical, and nutritional evaluations were performed every 2 months. Variations in body composition were analysed by dual energy X-ray absorbiometry (DXA). RESULTS: One patient (28.5 years, BMI: 59.3 kg/m(2)) died 22 days after BIB positioning because of gastric perforation. In another case (26.2 years, BMI: 57.6 kg/m(2)), BIB was surgically removed after 25 days because of symptoms suggesting gastric perforation (not confirmed). The remaining ten patients showed a significant decrease of BMI (p = 0.005) and of fat tissue as measured by DXA (p = 0.012). No significant modifications in bone mineral density (BMD) occurred, but a slight loss in lean body mass (p = 0.036) was documented. In five patients, BIB treatment was repeated more than once. CONCLUSION: This study shows that when noninvasive pharmacological therapies fail, BIB may be effective to control body weight in PWS patients with morbid obesity, particularly when treatment is started in early childhood. However, careful clinical follow-up and close collaboration with parents are crucial to avoid severe complications, which can be caused by persisting unrestrained food intake.

Role of cyclosporin in preventing or delaying colectomy in children with severe ulcerative colitis.

BACKGROUND: Oral cyclosporin (CyA) has been widely and successfully used in adult patients with severe ulcerative colitis (UC) to delay or avoid colectomy. AIM: To determine if treatment with oral CyA is similarly effective in pediatric patients MATERIALS AND METHODS: Data on all patients with severe UC treated with oral CyA in our unit were collected retrospectively. Patients were treated with CyA if dependent on or resistant to steroids, and therefore, candidates for colectomy. RESULTS: Thirty-two patients with severe UC were treated with CyA administered orally at a dose needed to obtain therapeutic blood levels (150-250 ng/ml). Twenty-eight of 32 patients (87%) had an immediate response within 11 days. Four (13%) did not respond and underwent colectomy. One patient had two cycles of treatment and is in remission. Two patients underwent three cycles of treatment because of relapse, but both eventually underwent elective colectomy. Three other patients underwent elective colectomy. A total of nine colectomies were performed. CONCLUSIONS: Treatment with oral CyA altered the course of UC in 28/32 (87%) of patients; 4/32 (13%) did not respond to oral CyA and underwent colectomy. Of the 28 patients that responded to CyA, five underwent later elective colectomy. Overall, in 72% of patients, colectomy was avoided. We, therefore, suggest a trial of oral CyA in all children with severe UC who are dependent or resistant to corticosteroids.

Percutaneous endoscopic cecostomy for antegrade colonic irrigation in fecally incontinent children.

The Malone surgical procedure for antegrade continence enema (ACE) greatly improves the quality of life of many patients with fecal incontinence but has several complications. This report describes a technique of percutaneous endoscopic cecostomy (PEC) which was applied in three children with fecal incontinence secondary to anorectal malformation or spina bifida. Using a pediatric fiberscope, a colonoscopy was done which reached the right colon. An intraoperative ultrasound examination confirmed the position of the cecum just below the layers of the abdominal wall. The cecostomy tube was then percutaneously inserted, imitating the steps of percutaneous endoscopic gastrostomy (PEG) using the pull technique. The preliminary results are very encouraging: there are no procedure-related complications in this small series; all the patients are able to carry out the antegrade enema by themselves; and complete control of defecation has been obtained.

Stenting for caustic strictures: esophageal replacement replaced.

METHODS: From 1983 to 1996, 31 children with caustic esophageal strictures were seen at Bambino Gesù Children's Hospital; they were all treated conservatively except for two cases complicated by tracheoesophageal fistula. The remaining 29 patients were divided into three groups depending on the treatment, which was modified over the years. Group A (1983 to 1987) consisted of seven patients treated by periodic dilatations; group B (1988 to 1992) consisted of 10 children treated by 40 days of esophageal stenting plus dexamethasone, 0.5 mg/kg/d plus ranitidine plus no oral feeding for 7 to 10 days; group C (1993 to 1996) consisted of 12 cases treated by 40 days of esophageal stenting plus dexamethasone, 1 mg/kg/d plus omeprazole plus early oral feeding resumption. RESULTS: No differences were observed between the three groups of patients with regard to the mean age and to the ingested substance, whereas a significant difference (P = .007) was observed in the mean length of the stricture between group A and C (3.4+/-1.3 and 5.6+/-1.6 cm, respectively). In all but one of the patients (96.5%) complete healing of the stenosis was achieved by conservative treatment, with definitive relief of dysphagia. One patient in group C did not improve after a repeated stenting procedure and was surgically treated. However, in group A, resolution of the stricture was obtained after an average of 19.9+/-14.8 dilatations in a mean period of 25.3+/-17.2 months. In group B, a mean of 12+/-11.3 dilatations were required in a mean period of treatment of 14.1+/-10.6 months. In patients in group C, a mean of 3.5+/-3.2 dilatations were necessary in a mean of 5.8+/-4.8 months. A statistically significant difference was observed both with regard to the number of dilatations and to the duration of treatment, between group A and group C (P = .002) and group B and C (P = .03). CONCLUSION: Esophageal replacement should be considered only in cases complicated by tracheoesophageal fistula or in the rare patients who do not respond to repeated esophageal stenting.

Hepatogonadal fusion.

Fusion of the testis with adrenal remnants is a relatively common incidental finding during orchidopexy. Splenogonadal fusion has been described in several cases. Herein the authors report a case of hepatogonadal fusion. To their knowledge, this is the first such case in the literature. Ectopic liver tissue has been encountered in a variety of locations, but had not been found in a testicle. The trapping of hepatocyte-destined mesenchyma in different areas may explain the presence of heterotopic liver tissue in different organs. If these cell aggregates are trapped in the area of peritoneum where the testis is forming, heterotopic liver tissue can end up in the testis.

Multivariate analysis of a tissue CEA, TPA, and CA 19.9 quantitative study in colorectal cancer patients. A preliminary finding.

Tissue CEA, TPA, and CA 19.9 concentrations from samples of surgical specimens were measured in 47 evaluable colorectal cancer patients (median follow-up, 20 months, 13 recurrences) and correlated with individual patient follow-up status. The quantitative method appeared to be sensitive, easily reproducible, and standardizable. The tissue marker concentration was analyzed by means of the multivariate discriminant analysis, to evaluate the risk of relapse in each patient; the tumor CEA (CEA T) showed the best discriminant capacity (P = .005). The relative Fisher function provided a reliable prognostic patient index, independently of other recognized prognostic factors (Dukes' stage and cellular differentiation grade). The Cox model showed a statistical significance analyzing the tumor (T) and healthy mucosa (M) CEA values (P = .001 and P = .006, respectively). The combination of these two variables allowed for identification of three classes of patients according to CEA T and M threshold values of 216 and 85 ng/mg of protein, respectively, and different disease-free curves were obtained for each group. The two-year disease-free rate was 81 percent for patients with low values of both CEA T and M, and 21.4 percent for the group with both values above these thresholds (P = .0008). In the third class (CEA T or M higher than the reported cut-off levels), the two-year disease-free rate was 65.9 percent.