Bronchogenic Cyst in Infants-Clinical and Histopathological Features.

A male infant, one month old, weight 4000 g, breastfed only, no pathological history, was admitted to the 2nd Pediatric Clinic, Clinical Emergency County Hospital in Craiova with fever and cough. Clinical findings when he was admitted: fever 38.7°C, perioral cyanosis, spastic cough, expiratory dyspnea, intercostal retraction, polypnea, subcrepitant rales in the right lung area. The chest x-ray revealed pneumonia aspect in the right middle perihilar region. He was administered antibiotic treatment, HHC, antithermics, with a favorable evolution. The control x-ray, when the infant was in a fair general state, with no disease symptomatology, pointed out a cystic formation at the level of the right middle lobe. The pulmonary CT revealed cavitary lesion, with a diameter of about 40mm in the right lung, and with the presence of septa to the interior and air content. The infant was urgently transferred to Marie Curie Hospital in Bucharest, where the cyst formation was removed through a surgical procedure. The anatomo-pathological examination revealed a bronchogenic cyst. The evolution was favorable after the surgical procedure.

Neonatal intensive care unit on-site surgery for congenital diaphragmatic hernia.

The present study presents the experience gained in the Newborn Intensive Care Unit (NICU) of 'Maria S. Curie' Emergency Clinical Hospital for Children in Bucharest (Romania) after performing a series of bedside surgery interventions on newborns with congenital diaphragmatic hernia (CDH). We conducted a retrospective analysis of the data for all patients operated on-site between 2011 and 2020, in terms of pre- and post-operative stability, procedures performed, complications and outcomes. An analysis of a control group was used to provide a reference to the survival rate for non-operated patients. The present study is based on data from 10 cases of newborns, surgically operated on, on average, on the fifth day of life. The main reasons for operating on-site included hemodynamical instability and the need to administer inhaled nitric oxide (iNO) and high-frequency oscillatory ventilation (HFOV). There were no unforeseen events during surgery, no immediate postoperative complications and no surgery-related mortality. One noticed drawback was the unfamiliarity of the surgery team with the new operating environment. Our experience indicates that bedside surgery improves the likelihood of survival for critically ill neonates suffering from CDH. No immediate complications were associated with this practice.

Pediatric esophageal stenoses: Challenges and new surgical device promoting tension-free esophageal anastomosis.

Esophageal stenoses of childhood have a broad spectrum of underlying causes. Their treatment is usually minimally invasive by endoscopic means, but sometimes surgery is necessary in refractory cases. Techniques employed in the surgical treatment of esophageal strictures include resection of the stenotic esophageal segment or esophageal substitution procedures. Esophageal anastomosis has always been a challenge in pediatric surgery. Anastomosis complications are linked to anatomical, biological and technical aspects. Mechanical tension between esophageal ends is an important cause of complications including anastomotic leaks or dehiscence. Eleven cases of esophageal stenoses, surgically treated in the Pediatric Surgery Department of Emergency Clinical Hospital for Children 'Marie S. Curie' by a single team in 5 years, were included in the present study. The results showed that, the main causes of esophageal stenosis were represented by corrosive esophageal injury in five cases, complications of esophageal atresia repair in three cases, congenital esophageal stenosis in two cases and chemotherapy-induced esophageal necrosis in acute lymphoblastic leukemia treatment in one case. The authors also designed and presented a device facilitating esophageal anastomosis under tension. Its principle involved temporary absorption of tension at secure points of the two esophageal pouches and reallocating it in equal amounts following anastomosis while decreasing any stretch-related tissue trauma. In conclusion, this auxiliary tool is beneficial for esophageal anastomosis; however, the standard steps of the esophageal anastomosis procedure should still be considered when necessary.

Antiproliferative therapy with sirolimus and propranolol for congenital vascular anomalies in newborns (Case reports).

We present a series of four newborns diagnosed with complicated congenital vascular anomalies, with different localization: Congenital lymphatic malformation (CLM) on the left hemithorax extending on the left upper limb; congenital hepatic hemangioma (CHH) with important complications in the first 7 weeks of life; Kaposiform hemangioendothelioma (KHE) of the left lower limb complicated with Kasabach Merritt phenomenon (KMM) and most probable diffuse capillary malformation with overgrowth (DCMO). All patients were treated with combined antiproliferative therapy with sirolimus and propranolol. The initial dose of sirolimus was 0.45-0.5 mg/m2 with doses adjusted according to plasmatic levels. Therapeutic intervals of sirolimus were considered at plasmatic levels of 7-12 ng/ml. Our aim was to use the lowest therapeutic dose in order to avoid possible side effects. Propranolol was initiated in doses of 0.5-1.0 mg/kg/day and was increased up to 3.0 mg/kg/day depending on tolerability. Following two months, every patient showed a marked reduction in the size of the mass, improvement in overall appearance or even calcification in the liver vascular tumor. No patient showed life threatening side effects to the treatment. Hypertriglyceridemia was the only side effect noted in all patients. This is in accordance with several international studies, which try to demonstrate the importance of sirolimus in neonatal vascular malformations in monotherapy or combined with different drugs.

Hanta hemorrhagic fever with renal syndrome: A pathology in whose diagnosis kidney biopsy plays a major role (Review).

Hantavirus infection belongs to a group of zoonoses rare in the Balkan Peninsula, causing two major syndromes, depending on the viral serotype involved: Hemorrhagic fever with renal syndrome (HFRS) also known as endemic nephropathy and cardiopulmonary syndrome (CPS). Because there is no specific treatment or vaccine for this condition approved in the USA or Europe, the key to minimizing the risk of adverse progression to chronic kidney disease, secondary hypertension or even death is primarily the recognition and early diagnosis of this condition with prompt therapeutic intervention. The aim of this study was to review the literature data on the epidemiology, pathogenesis and management of this disease and to identify several aspects related to the difficulties encountered in diagnosing this pathology, taking into consideration that the disease is not endemic in this geographical area.

Optimization of a GF-AAS method for lead testing in blood and urine: A useful tool in acute abdominal pain management in emergency.

Suspicion of lead poisoning is confirmed by its concentration in blood and protoporphyrin red blood cells. At low concentrations, lead influences the synthesis of the heme in the sense of lowering it. Acute and chronic lead intoxication is extremely polymorphic in regards to its clinical manifestations, with digestive, hematological, cardiovascular, renal hepatic and neurological features. The aim of the study was to evaluate the presence of lead in human whole blood and urine harvested before and during chelation treatment in the case of lead poisoning. An atomic absorption spectroscopic method for the analysis of lead was developed using graphite furnace atomic absorption spectrophotometer (GF-AAS), Varian Spectra AA-880 with a hollow cathode lead lamp and a deuterium lamp for background correction, coupled to a GTA-100 atomizer and a programmable sample dispenser. Standard calibration solutions were used for the range 10-100 µg/l. The linearity range was 10.0 to 100.0 µg/l with the correlation coefficient of 0.999. We established that the method can be applied for the determination of lead in whole blood and urine, and the results obtained are useful for monitoring chelation therapy in cases of acute lead poisoning, a neglected cause of abdominal colic pain in an emergency situation.

Lipoblastoma: Diagnosis and surgical considerations.

Lipoblastoma (LB) and lipoblastomatosis (LBS) are uncommon benign mesenchymal tumors of embryonal fat, occurring almost exclusively in infancy and early childhood. These fast-growing tumors have an excellent prognosis if properly treated. Eight consecutive children having pathologically demonstrated LB treated by the same surgical team were retrospectively reviewed. There were 5 boys and 3 girls between 7 to 36 months (median age 22 months). The localization of the tumors was on the thigh (1 case), abdomen (2 cases), axillary and pectoral region (1 case) paragluteal region (1 case), lumbar area (1 case), inguinal-scrotal (1 case), and in one case, presacral, gluteal and perirectal region (1 case). Five were focal and in 3 cases an infiltrative growth pattern was observed. One case exhibited a gross appearance resembling sacrococcygeal teratoma, with associated Dravet syndrome. No recurrence was noted in our series, after a mean follow-up of 28 months post operatory. Despite its rareness, LB must be kept in mind when diagnosing a rapidly growing fatty mass in children. Even when dealing with very large abdominal LB, complete surgical excision is possible, with an excellent prognosis. Due to the relatively high recurrence rate noted in the literature, particularly in LBS, follow-up is extremely important.

Characteristics of the pediatric patients diagnosed with SARS-CoV-2 infection in a Romanian children's hospital: a retrospective study.

BACKGROUND: To date, information on COVID-19 pediatric patients is still sparse. We aimed to highlight the epidemiological and clinical data regarding SARS-CoV-2 infection in children and adolescents to improve the understanding of the disease in this age group and inform physicians during the ongoing COVID-19 pandemic. METHODS: We conducted a retrospective, observational study in "Marie Curie" Emergency Children's Hospital from Bucharest, Romania. We analyzed clinical and epidemiological characteristics of the patients confirmed with SARS-CoV-2 infection, between April 1, 2020-October 31, 2020. RESULTS: A total of 172 patients aged 0-18 years were included, 79 (45.93%) female and 93 (54.07%) male patients. 28 (16.28%) patients had co-morbidities (more often identified in asymptomatic group; p < 0.0001). 47 (27.32%) had exposure to an identified source. 30 (17.44%) patients were asymptomatic; 142 (85.56%) had mild or moderate disease. The most frequent symptoms were: pyrexia (78.87%), digestive symptoms (50%), cough (40.14%). Chest X-ray was performed in 50 patients and it was abnormal in half of them, all being symptomatic. About 2/3 of the evaluated patients had normal leukocytes. The most common hematological change was lymphopenia; monocytes tended to be higher in symptomatic patients. About 40% of the patients were admitted; none required admission to ICU. No significant differences were found between symptomatic and asymptomatic patients regarding gender, age distribution, and exposure to a source. CONCLUSIONS: All the patients had asymptomatic, mild or moderate disease. Patients with comorbidities, classically considered high risk patients, presented the same pattern of disease.

The importance of adrenal venous sampling in ACTH-independent Cushing syndrome: A case report and literature review.

Independent Cushing's adrenocorticotropic hormone (ACTH) syndrome can have several causes, including adrenal carcinoma or simple adrenal hyperplasia. Although the distinction between malignant and benign can be effectively made through imaging investigations, in the situation where there are bilateral formations, their hormonal activity is impossible to appreciate via non-invasive techniques. The present study includes the presentation of a clinical case on the basis of which a literature review was made. The clinical case pertains to a 32-year-old patient with ACTH-independent Cushing's syndrome and bilateral adrenal tumor formations leading to the utility of adrenal venous sampling to avoid bilateral adrenalectomy. A literature review was subsequently conducted focusing on articles pertaining to the PICO criteria in order to describe: The diagnosis of adrenal tumor masses, the decision on the type of surgery and most importantly, the impact of adrenal venous sampling in avoiding surgical resection. These interventions severely limit the patients' quality of life.

Clinical and therapeutic features of acute cholecystitis in diabetic patients.

The present study aimed to compare the clinical, paraclinical, intraoperative findings, and postoperative complications in acute cholecystitis in diabetic patients vs. non-diabetic patients. A 2-year retrospective study was performed on the patients who underwent emergency cholecystectomy for acute cholecystitis between 2017 and 2019 at the 4th Department of Surgery, Emergency University Hospital Bucharest. The diabetic subgroup numbered 46 eligible patients and the non-diabetic one 287 patients. Demographics, the severity of the clinical forms, biological variables (including white cell count, urea, creatinine, coagulation and liver function tests) comorbidity status, surgical approach, postoperative complications, and hospital stay were analyzed. Statistical analyses were performed to assess comparative results between the aforementioned data (SPSS V 13.0). The CCI and ASA risk classes were increased in the diabetic group, with 34.78% of patients having 3 or more associated comorbidities. No statistically significant associations were demonstrated between diabetes and the severity of the cholecystitis and risk for conversion. Postoperatively both minor complications such as surgical site infections and major cardiovascular events were more common in the diabetic subgroup (P=0.0254), well associated with the preoperative status and baseline cardiovascular comorbidities. Laparoscopic cholecystectomy is a safe procedure for diabetic patients, which can provide the best outcomes, by decreasing the risks of surgical wounds. Attentive perioperative care and good glycemic control must be provided to minimize the risk of complications.

Acute surgical abdomen during the COVID-19 pandemic: Clinical and therapeutic challenges.

The present study investigated the effects of the COVID-19 pandemic on the clinical presentation and therapeutic management of acute surgical abdomen. A retrospective study of emergency hospitalizations with a diagnosis of acute surgical abdomen between April and July 2020 vs. a similar period in 2019 was performed. The observation sheets and the operating protocols were analyzed. Between April and July 2020, 50 cases of acute surgical abdomen were hospitalized and treated, compared to 43 cases in the same period last year. The main types of pathology in both groups included: Occlusions (60%, respectively 44.2% in 2019) and peritonitis (32%, respectively 41.8% in 2019). There was an increased rate of patients with colorectal cancers neglected therapeutically or uninvestigated, who presented during the pandemic period with emergencies for complications such as occlusion or tumor perforation (32 vs. 6.97%, P=0.0039). One case, with gastric perforation, was COVID-positive, with no pulmonary symptoms at admission. The number of postoperative infectious complications was lower during the pandemic (2 vs. 13.95%, P=0.0461). As the COVID-19 pandemic appears to be still far from ending, we should learn to adapt our surgical protocols to the new evidence. Oncological patients are a vulnerable group, who were neglected in the first months of the pandemic. SARS-Cov-2 infection may be a cause of abdominal pain and should be taken into account in different diagnoses of acute abdomen in surgical wards. Correct wearing of adequate personal protective equipment (PPE) and respecting strict rules of asepsis and antisepsis are required for preventing in-hospital transmission of infection.

Practical safety in the diagnosis and treatment of congenital isolated tracheoesophageal fistula.

The rareness of H-type tracheoesophageal fistula in conjunction with its unspecific clinical presentation and wide range of anatomical presentation makes its diagnosis and treatment a problematic topic for both ear, nose and throat (ENT) specialists and pediatric surgeons worldwide. Symptoms and clinical signs of H-TOF are easily misleading. Diagnostic methods, most of the times, are dependent on the physician's experience; therefore, various errors may be made. We analyzed our experience in managing H-TOF cases over the last 15 years. Advice and strategies of action for health professionals directly involved in the diagnosis and treatment were identified, but also errors and mistakes while managing 6 cases. We analyzed 'red flags' but also important steps in the practical safety concerning this rare congenital malformation. Choosing the surgical access for division of the fistula throughout the cervical or thoracic approach is sometimes difficult. A scrupulous perioperative planning is mandatory. A dynamic overview of the patient's presentation never underestimating the subtlety of H-TOF presentation should be conducted for its early recognition and achieving best outcomes.

Safety of Laparoscopic Cholecystectomy for Acute Cholecystitis in the Elderly: A Multivariate Analysis of Risk Factors for Intra and Postoperative Complications.

Background and Objectives: This study investigates the impact of age upon the safety and outcomes of laparoscopic cholecystectomy performed for acute cholecystitis, by a multivariate approach. Materials and Methods: A 2-year retrospective study was performed on 333 patients admitted for acute cholecystitis who underwent emergency cholecystectomy. The patients included in the study group were divided into four age subgroups: A ≤49 years; B: 50-64 years; C: 65-79 years; D ≥80 years. Results: Surgery after 72 h from onset (p = 0.007), severe forms, and higher American Society of Anesthesiologists Physical Status Classification and Charlson comorbidity index scores (p < 0.001) are well correlated with older age. Both cardiovascular and surgical related complications were significantly higher in patients over 50 years (p = 0.045), which also proved to be a turning point for increasing the rate of conversion and open surgery. However, the comparative incidence did not differ significantly between patients aged from 50-64 years, 65-79 years and over 80 years (6.03%, 9.09% and 5.8%, respectively). Laparoscopic cholecystectomy (LC) was the most frequently used surgical approach in the treatment of acute cholecystitis in all age groups, with better outcomes than open cholecystectomy in terms of decreased overall and postoperative hospital stay, reduced surgery related complications, and the incidence of acute cardiovascular events in the early postoperative period (p < 0.001). Conclusions: The degree of systemic inflammation was the main factor that influenced the adverse outcome of LC in the elderly. Among comorbidities, diabetes was associated with increased surgical and systemic postoperative morbidity, while stroke and chronic renal insufficiency were correlated with a high risk of cardiovascular complications. With adequate perioperative care, the elderly has much to gain from the benefits of a minimally invasive approach, which allows a decreased rate of postoperative complications and a reduced hospital stay.

Alimentary tract duplications in children - a 15 years' experience.

Duplications of the alimentary tract are a diverse and complex spectrum of congenital malformations and can be found anywhere along the digestive tract. The management depends on multiple factors, such as age, location, size, macroscopic aspect, and the associated anomalies. This study reflects a 15-year single surgical team experience. We reviewed medical records of 35 consecutive patients presenting alimentary tract duplications, evaluated and managed between 2004 and 2019. The anatomical distribution included: oral structures (two cases), esophageal (three cases), gastric (three patients), jejunoileal (seven cases), ileocecal (12 cases), colonic (six cases), anorectal (one case), and one case of complex tubular duplication of the terminal ileum and entire colon with two anal openings at the perineum. Four patients had antenatal diagnosis, initially asymptomatic, were followed, after birth, with repeated ultrasound examinations for a medium period of 3.8 months. All cases were managed with open surgery. Excision of the lesion with preservation of the gut integrity could be performed in 28 of the cases, while in six cases, enterectomy followed by digestive anastomosis was required. In one complex caudal duplication syndrome, the duplicated tubular colon was left in place. The postoperative complications were gastroesophageal reflux disease (GERD) (two cases), Claude Bernard-Horner syndrome (one case), wound infection (one case), and in one case, massive tongue edema. Clinical findings may be misleading, imaging studies may be uncertain, therefore the surgeon remains to complete de picture with intraoperative findings. In complex duplication cases, a multidisciplinary approach is imperative for the best results.

Changing strategy and implementation of a new treatment protocol for cleft palate surgery in "Maria Sklodowska Curie" (MSC) Children's Hospital, Bucharest, Romania.

In "Maria Sklodowska Curie" (MSC) Children's Hospital, Bucharest, Romania, cleft palate repair has been performed according to von Langenbeck since 1984. The speech was good in most patients but wide clefts had a high percentage of fistulas, abnormal speech due to short length and limited mobility of the soft palate. In 2009, the protocol was changed to Gothenburg Delayed Hard Palate Closure, (DHPC) technique. The present evaluation was performed to study the implementation of this technique. One hundred and sixty-eight patients with cleft palate were admitted, 89 isolated cleft palate (ICP), 53 unilateral (UCLP) and 26 bilateral (BCLP). In these, 228 surgical interventions were performed. Soft Palate Repair (SPR) and Hard Palate Repair (HPR) were performed with the DHPC procedure. The transfer to this technique was successfully performed in three steps: one team visit to Gothenburg by a surgeon from MSC and two visits by surgeons from Gothenburg to the MSC. Patients with SPR and HPR were operated on without major complications and there were no differences in results between Gothenburg surgeons and MSC surgeons. The interventions with SPR and HPR technique were proven to be easy to teach and learn and successfully performed without major complications. For cleft patients at MSC hospital it has meant earlier surgery, less re-operations and complications. This report shows a successful change of strategy for palatal repair with improved outcome regarding surgery. In future, speech and growth will be followed on a regular basis and will be compared with results from the Gothenburg Cleft Team.

Gruber-Frantz tumor: a very rare pathological condition in children.

Solid pseudopapillary tumor of the pancreas or Gruber-Frantz tumor is a rare pathological entity. Its incidence is even lower in children. This neoplasm has low malignant potential and with adequate surgical treatment has a very good prognosis. We present the case of a 15-year-old girl admitted in our department for an intra-abdominal tumor, diagnosed incidentally on ultrasonography after a minor trauma. The CT scan revealed an important mass, apparently localized in the liver. Intraoperative assessment found the tumor originating from the pancreatic head (12 cm in diameter), well defined, with reddish-brown color, well-vascularized and heterogeneous consistency. It was completely removed without sacrificing other tissues. The postoperative evolution was uneventful. The microscopic feature of the tumor, using Hematoxylin and Eosin staining was characteristic. Immunohistochemistry confirmed the diagnosis. Four years postoperative follow-up showed no recurrence. Only several hundred solid pseudopapillary tumors of the pancreas are described in the literature. In children, the incidence of this tumor is extremely rare. Some investigators believe it is originated from pluripotent primordial stem cells. The clinical picture is non-specific. Despite its rarity, this type of tumor should be taken into account in the differential diagnosis of abdominal masses in children, especially in girls. The diagnosis is made only histologically. Complete surgical excision is curative.