When to operate on ovarian cysts in children?

BACKGROUND: Ovarian cysts are rare conditions in the pediatric age group. They are characterized by different clinical presentations and by the need to establish adequate type and timing of treatment in order to prevent complications, such as ovarian necrosis after torsion and infertility. The diagnostic approach should differentiate benign occasional findings, such as follicular cysts, from neoplastic lesions, and functional cysts which can occur either isolated or in the context of McCune-Albright syndrome. Our aim was to review all the patients affected by ovarian pathologies seen in our department in the past 5 years, in order to establish a protocol for the correct management of these conditions. METHODS: In the past 5 years we studied 133 patients diagnosed with ovarian lesion. We subdivided the patients into three groups according to age: group A (age <6 months: 66 cases); group B (pre-pubertal patients, age 7 months to 10 years: 10 cases); and group C (pubertal patients, age 11-14 years: 57 cases). We collected historical and clinical data and assigned specific cut-off values in order to perform statistical analysis (Fisher's exact test) comparing the three groups. RESULTS: Ultrasound examination proved to be indispensable in the early detection of ovarian lesions and for identifying the correct treatment. Cyst size, and moreover appearance with ultrasound, were important considerations when selecting the most appropriate therapeutic approach. The larger lesions were found in group B, giving symptoms that required hospitalization (pelvic pain, nausea and vomiting) and leading to increased incidence of postoperative complications. Laparoscopic surgery appeared to be safe and effective for the treatment of ovarian pathologies. CONCLUSION: The management of ovarian lesions in children must be based on a minimally invasive approach, based on the patient's age and ultrasound findings. Treatment should be conservative, with ovariectomy undertaken only when essential. In adolescents, only cysts larger than 6 cm that do not resolve with estro-progestinic therapy within 6 months should be surgically approached; in infants, any signs of cyst complications must be addressed surgically.

Infantile Abdominal and Pelvic Lipoblastomas: A Case Series.

Lipoblastomas are rare benign mesenchymal tumors that arise from embryonal fat cells. They are usually discovered in infants and children under 3 years of age, and mostly occur in the trunk (from 10 to 60%, depending on the study) and extremities (from 40 to 45%), while head and neck localizations are rare, with only five cases described to date. We report on three cases of lipoblastomas in infants younger than 4 years, with unusual localizations: one intra-abdominal, discovered during a laparotomy for an intussusception; one pelvic, misdiagnosed as an ovarian mass; and one gluteal with a pelvic extension. All children underwent magnetic resonance imaging as preoperative workup. All tumors were completely resected with free surgical margins and ultrasonographic follow-up was uneventful for all patients.

Skills Comparison in Pediatric Residents Using a 2-Dimensional versus a 3-Dimensional High-Definition Camera in a Pediatric Laparoscopic Simulator.

INTRODUCTION: Advantages in 3-dimensional (3D) laparoscopy are mostly described in adults for better depth perception, precise visualization of anatomical structures, as well as for complex surgical maneuvers in small spaces. Using Visionsense III stereoscopic endoscopy system (Neuromed Spa), we performed a comparative study between surgical skills achievements using 2-dimensional (2D) and 3D laparoscopic equipment in a pediatric laparoscopic surgery simulator model. MATERIALS AND METHODS: Three skills were evaluated both in 2D and 3D modalities. Pediatric residents (n = 20) without any previous laparoscopic experience were randomly divided in 2 groups and evaluated doing the established tasks in a laparoscopic simulator validated for pediatric surgery. Switching the type of vision from 2D to 3D or vice versa, we evaluated bimanual dexterity, efficiency, and efficacy. Three tasks were proposed-task 1: transfer of objects (6 pegs transferred one-by-one on a pegboard); task 2: pattern cutting (cutting a paper, following a circular dotted line); and task 3: threading eyelet (transfer, twisting and passing through a eyelet-shaped support, a specific 3D object). Performance was measured using a scoring system rewarding precision and speed. Any physical discomfort related to the 3D vision was recorded. RESULTS: Of the 20 participants included, 10 began the skills in the 2D modality and then performed them in 3D, and the other 10 began in 3D and ended in 2D. Overall task 1 performance (time and number of errors) was significantly better using stereoscopic compared with monoscopic visualization. Both groups experienced a 35.6% decrease in the time needed to complete the peg transfer using 3D instead of 2D. In task 2, the 3D performance was superior (less time to correctly cut the paper along the dotted line), but did not reach statistical significance. In task 3, the residents experienced with 3D a 31.7% decrease in the time necessary to complete the passage of the object trough the eyelet. Most participants (65%) "subjectively" defined 3D laparoscopy easier overall; 6 participants (30%) did not experience any issue related to the use of 3D technology; and 1 person (5%) of group 1 found more difficulties using 3D compared with 2D. Headache (25%), nausea (20%), and visual disturbance (1%) were the most common issues reported by the students during 3D procedures. Finally, the results show that residents achieved significantly better results working with 3D vision rather than with 2D vision. DISCUSSION: As other studies have demonstrated, there was improvement in the overall performance using the 3D laparoscope. This was the first attempt to verify 3D skills in naive subjects, directly on a simulator conceived exclusively for pediatric surgery; therefore, bias was limited by using a population without surgical experience. CONCLUSIONS: 3D laparoscopic surgical skills showed superior to 2D, with higher percentages of tasks completion, less time in performing them, and a shorter learning curve. Our results indicate that 3D was subjectively easier than 2D in performing complex tasks in the skills laboratory setting.

Cystic intra-abdominal masses in children.

Benign intra-abdominal cystic masses in infancy are fairly uncommon and their etiopathogenesis, histology and clinical presentation differ significantly. Our aim is to report our experience in their treatment in order to discuss the best diagnostic and treatment modality. The medical records of 5 children (2M, 3F) with cystic intraabdominal masses referred to our hospital between November 2012 and September 2016, were retrospectively reviewed. All patients underwent open surgery and subsequent histopathologic analysis. Different clinical presentations, localizations of the masses, diagnostic tools, surgical approaches, histological examinations and outcomes were reviewed. Patients mean age was 5.4 years (range: 8 months-9 years). Two patients presented recurrent abdominal pain and abdominal distension; 1 patient had a palpable mass discovered incidentally and 2 complained acute abdominal pain. Routine laboratory tests, tumor markers and abdominal ultrasound were immediately done in all patients. Three patients underwent MRI and 1 abdominal CT. At laparotomy 2 hepatic cysts, 2 mesenteric cyst and 1 retroperitoneal cyst were discovered. Histology reports described: 1 hepatobiliary cystadenoma, 1 benign hepatic hamartoma and 3 cystic lymphangiomas (1 retroperitoneal and 2 mesenteric). There were no major postoperative complications, deaths, or recurrences in our series (follow-up 3-24 months). Despite the rarity of these lesions, benign cystic abdominal masses in children are not so uncommon and should be considered as causes of acute abdominal pain. The differential diagnosis is not always possible preoperatively. In our series, radical excision of the lesions was possible in all cases, allowing reliable histological results and avoiding recurrences.

Intestinal Malrotation and Volvulus in Neonates: Laparoscopy Versus Open Laparotomy.

BACKGROUND: Intestinal malrotations with midgut volvulus are surgical emergencies that can lead to life-threatening intestinal necrosis. This study evaluates the feasibility and the outcomes of laparoscopic treatment of midgut volvulus compared with classic open Ladd's procedure in neonates. MATERIALS AND METHODS: The medical records of all neonates with diagnosis of malrotation and volvulus, who underwent surgery between January 1993 and January 2014, were reviewed. We considered the group of neonates laparoscopically treated (Group A, n = 20) and we compared it with an equal number of neonates treated with the classical open Ladd's procedure (Group B, n = 20). RESULTS: The median age at surgery was 8.4 days and the mean weight was 3.340 kg. The suspicion of volvulus was documented by plain abdominal radiograph, upper gastrointestinal contrast study, and/or ultrasound scanning of the mesenteric vessels. All the patients were treated according to the Ladd's procedure. Conversion to an open procedure was necessary in 25% of the patients. The mean operative time was 80 minutes (28-190 minutes) in Group A and 61 minutes (40-130 minutes) in Group B (P = .04). The median time to full diet (P = .02) and hospital stay (P = .04) was better in Group A. Rehospitalization because of recurrence of occlusive symptoms occurred in 30% of patients in Group A (n = 6) and in 40% of patients in Group B (n = 8). Among these, all the 6 patients of Group A underwent redo surgery for additional division of Ladd's bands or debridement; instead in Group B, 4 of 8 patients underwent open redo surgery. CONCLUSIONS: Laparoscopic exploration is the procedure of choice in case of suspicion of intestinal malrotation and volvulus. Laparoscopic treatment is feasible and safe even in neonatal age without additional risks compared with classical open Ladd's procedure.

Pediatric Thoracoscopy and Bronchial Blockers: The Continued Search for the Ideal One-Lung Ventilation.

INTRODUCTION: Thoracoscopic surgical procedures in small infants and children require a growing demand for lung isolation in pediatric anesthesia practice. MATERIALS AND METHODS: Between January 2006 and September 2014, 16 children underwent thoracoscopic procedures that needed one-lung ventilation using a bronchial blocker. RESULTS: The thoracoscopic procedure was performed at a mean age of 99 months (range, 6-186 months) and a mean weight of 33 kg (range, 7-68 kg) without any conversion to open surgery in any case. We were able to achieve one-lung ventilation in all patients. The quality of lung deflation was excellent in all patients except in 1 due to malposition of the bronchial blocker, whereas dislodgement of this device occurred in 2 cases. CONCLUSIONS: The use of a bronchial blocker provided a highly effective means of one-lung ventilation for children undergoing the thoracoscopic approach.

Pyogenic Granuloma of the Sigmoid Colon causing Intussusception in an Infant.

Pyogenic granuloma is a benign vascular tumor that may affect the gastrointestinal tract. This report describes a rare case of sigmoid-colon pyogenic granuloma in a 4-month-old boy causing intussusception. Resection and anastomosis were curative. The mother had history of high dose of progesterone exposure during initial weeks of conception for vaginal bleeding. This may point towards etiology of the lesion.