Bowel parasitosis and neuroendocrine tumours of the appendix. A report from the Italian TREP project.

Five children with a neuroendocrine tumour (NET) of the appendix associated with a parasitic bowel infection are described, and the possibility of inflammation-triggered carcinogenesis is discussed. Schistosoma haematobium is linked primarily to bladder cancer but it has been reported in association with several other histotypes, including NETs of the gastrointestinal tract. Conversely, Enterobius vermicularis has not yet been claimed to participate in the onset of pre-cancerous conditions or tumours. The rare occurrence of contemporary appendiceal NETs and parasitic infection, raises the intriguing hypothesis of an inflammation-related carcinogenesis, although a cause-effect relationship cannot be established. Larger international series of childhood appendiceal NETs, which also include countries with higher prevalence of parasitic bowel infections, are needed to further clarify this possible cause-effect relationship.

Inguinal hernia in neonates and ex-preterm: complications, timing and need for routine contralateral exploration.

BACKGROUND/PURPOSE: Aim of this study was to present a series of neonates and ex-preterm babies who underwent inguinal hernia repair focusing on complications and possible indication to perform routine contralateral groin exploration. METHODS: This is a retrospective study of a series of consecutive patients weighing less than 5 kg who underwent inguinal hernia repair between January 2007 and December 2012. Only the affected side was treated. Patients have been routinely followed up postoperatively. We resorted to available outpatients' charts and admission notes to record demographic data, surgical details, complications and the occurrence of metachronous hernias. A questionnaire was administered to all patients' relatives to confirm the long-term outcome. RESULTS: One hundred fifty-four patients were operated for a total of 184 herniotomies (88 right sided, 36 left sided and 30 bilateral). Median length of follow-up was 42 months (range 6 months-7.5 years). Thirteen patients (13/124 = 10.5 %) developed metachronous hernia that proved to be significantly more frequent in patients weighing less than 1,500 g at birth (p < 0.05). We observed 10 % of complications, including 2.7 % testicular atrophy and 4.5 % recurrence. Atrophy proved to occur more frequently in patients who experienced preoperative incarceration (p < 0.05). No other risk factors were identified. CONCLUSIONS: The results of our series demonstrated that, though technically demanding, herniotomy in the neonate and ex-preterm is associated with a relatively low incidence of complications. Based on our results and in accordance with literature data, we do not advocate routine contralateral exploration in case of unilateral hernia but surgery to be performed only on the symptomatic side, as soon as possible after initial diagnosis. Very low birth weight patients should be followed with care in the early postoperative period due to the higher likelihood of developing a metachronous hernia.

Intraoperative bronchoscopy for bronchial carcinoid parenchymal-sparing resection: a pediatric case report.

Bronchial carcinoid tumors are the most common primary pulmonary neoplasm in the pediatric population. The widely accepted treatment for carcinoid tumors is surgical, specifically aiming at being as much as conservative on lung parenchyma, while the entire tumor is resected. A brief case is described, highlighting the importance and advantages of a surgical and endoscopic combined approach.

Shifting from open surgical cut down to ultrasound-guided percutaneous central venous catheterization in children: learning curve and related complications.

PURPOSE: Tunneled indwelling central venous catheters (CVC) are essential in the management of children with cancer, hematological, nephrological disorders and for parenteral nutrition. The aim of this study is to present the experience of a single center of the transition from traditional open surgical cut down procedure (OSC) to ultrasound (US)-guided percutaneous CVC insertion, focusing on learning curve and related complications. METHODS: All CVCs inserted between April 2008 and November 2009 in children at the Gaslini Children Hospital were revised, and data on methods of cannulation, intraoperative and device-related complications and re-intervention were recorded. RESULTS: 194 CVCs were positioned in 188 patients. 128 out of 194 CVCs were positioned through an OSC technique, whereas the remaining 66 CVCs were inserted percutaneously with US guidance. Of the 27 recorded complications, 15 were mechanical events, 7 cases developed infection, whereas the remaining 5 (2.6%) were classified as intraoperative complications. A second surgical procedure was described in 23 (11.8%) cases. CONCLUSION: Shifting from OSC to US-guided percutaneous CVC insertion inevitably involves a challenging learning curve which is generally associated with high complication rates. Complications progressively decrease once a good experience in US guidance and percutaneous technique has been obtained.

Incidence of indwelling central venous catheter-related complications using the Sri Paran technique for device fixation in children with cancer.

PURPOSE: Mechanical complications in tunneled indwelling central venous catheters (CVCs) often involve a risk of displacement. Fixation procedures are, therefore, of primary importance. We prospectively evaluated the incidence of CVC-related mechanical and infectious complications observed in devices fixated with the Sri Paran technique. METHODS: All CVCs inserted in children with cancer at our Institution from October 2005 to January 2007 were prospectively monitored for device-related mechanical and infectious complications. The Sri Paran fixation technique was used in all cases. The complication rate per 1,000 days was calculated as 1,000 times the number of complications divided by the total number of catheter days. RESULTS: Ninety-five CVCs were positioned in 84 children. The overall length of observation ranged between 41 and 482 days for a total of 18,618 catheter days. Mechanical complications occurred in 5% of the devices (specific rate 0.27); infections were observed in 6% of the devices (specific rate 0.32). No complications were observed during the first 30 days after CVC insertion. CONCLUSIONS: The results, we obtained with the Sri Paran technique are extremely encouraging. Yet, randomized studies are required to prove these preliminary data.

Short-chain fatty acids produced by anaerobic bacteria alter the physiological responses of human neutrophils to chemotactic peptide.

The effect of some short-chain fatty acids (SCFA) produced by anaerobic bacteria, namely acetic, propionic, isobutyric, butyric, isovaleric and succinic acids, on production of light and release of lysozyme by human neutrophils exposed to chemotactic peptide fMet-Leu-Phe was investigated. A short period of incubation of neutrophils with SCFA led to marked inhibition of both granulocytic chemiluminescence and degranulation (P less than 0.001). Ultrastructural studies of neutrophils, incubated with concentrations of SCFA inhibiting the chemotactic response, chemiluminescence and release of lysozyme (30 mmol/l), effected alterations in cellular morphology with formation of protrusions of varying shape. The data reported indicate that SCFA might be regarded as important pathogenicity factors. The observed effect on neutrophils could also partially explain the ability of anaerobes to inhibit their own phagocytosis and killing as well as that of the aerobic species present in mixed infections.

All mechanical low rectal anastomosis in children.

PURPOSE: The aim of this study is to demonstrate the feasibility and usefulness of mechanical suturing in children for low rectal anastomosis. METHODS: The study group includes 31 children operated on from January 1993 to July 1996 by the same senior surgeon, performing the modified Duhamel procedure for Hirschsprung's disease in 17 children, intestinal neuronal dysplasia in seven, and the Knight-Griffen procedure in seven pediatric patients with chronic ulcerative colitis. RESULTS: In all the cases the technique of "viscero-synthesis" was performed using the mechanical stapler. A circular stapler has been used for the end-to-end and the end-to-side anastomosis between the anal canal or the back wall of the rectum with the pulled viscus, while a linear endoscopic stapler (GIA) has been used for the consolidation of the rectocolic wall in the modified Duhamel technique. CONCLUSIONS: The results obtained demonstrate that the mechanical staplers in children are safe and effective in low rectal anastomosis, sparing operative time and reducing the risk of anastomotic dehiscence; however, the size of circular instruments limits its use in neonates and small infants.

Pancreatitis caused by duodenal duplication.

The authors present the investigations and surgical treatment of two cases of duodenal cystic duplication. Abdominal pain and gastroesophageal reflux were the most important symptoms and signs associated with an history of recurrent acute pancreatitis. Computed tomography scan, ultrasound examination, and cholangiography confirmed preoperatively the diagnosis, and a transduodenal surgical approach was carried out in both children. A simple marsupialization of the cyst was performed in the former, and a sphincterotomy with papillosphincteroplasty was associated in the latter. The diagnosis was confirmed by microscopy, and both the children are asymptomatic after a 14 and 18 months of follow-up. This report focuses on the importance of the cholangiopancreatography for every child presenting with recurrent, unexplained bouts of acute pancreatitis, and underlines the technical surgical aspects on the basis of the anatomic identification of the malformation.

Treatment of vesico-ureteric reflux in children with neuropathic bladder: a comparison of surgical and endoscopic correction.

BACKGROUND/PURPOSE: Vesico-ureteric reflux (VUR) is a common problem in children with neuropathic bladder. Lesser-degree VUR may be manageable by intermittent catheterization or by anticholinergics, but higher grades usually require surgical treatment. If left untreated, two thirds of such patients may experience deterioration of the upper renal tracts. The aim of this study was to compare the results of the STING (Subureteric Teflon Injection) technique with surgical ureteric reimplantation as treatment for VUR in neuropathic bladder. METHODS: From January 1981 to December 1996, 58 children with NB (81 ureters) were treated for VUR. STING and Cohen ureteroneocystotomy were performed in 40 and 41 ureters, respectively. Mean age was 4.5 years (STING) and 5.1 years (Cohen). RESULTS: Twenty-nine of 40 refluxing ureters (72.5%) were cured by STING, whereas Cohen eradicated reflux in 39 of 41 ureters (95.5%). No complications were observed in either group. All the ureters in which STING failed were treated successfully by Cohen ureteroneocystostomy. The 2 ureters still refluxing after surgical reimplantation were cured successfully by a single STING. The mean follow-up was 6.8 years in the Cohen group and 4.8 years in the STING group. During follow-up, no recurrence was observed in patients cured by open reimplantation. In the STING group, 2 previously cured ureters showed recurrence of VUR: both were treated successfully by a further STING. CONCLUSIONS: Open ureteral reimplantation is more effective than STING in correcting VUR in children with neuropathic bladder dysfunction. Nevertheless, the good success rate, the relative technical simplicity, outpatient nature, and rapid recovery point to STING as a safe and effective procedure for the initial treatment of VUR. Failure of STING does not preclude a successful open operation.

Treatment and follow-up of vesico-ureteral reflux in patients with neuropathic bladder.

Vesico-ureteral reflux (VUR) is a relatively frequent and severe complication in neuropathic bladder, therefore it must be ruled out in every case, and prevented whenever possible. The Spina Bifida Center of our Institute is presently following 220 patients with neuropathic bladder, who undergo a periodical clinical and instrumental evaluation. Urodynamics has proved essential in detecting risk factors for VUR: small capacity bladders with reduced compliance, increased outlet resistance, and detrusor instability. Forty-eight cases of VUR, 38 of which were severe, were detected in a total of 166 patients reviewed for this paper. All patients with VUR were treated conservatively, attaining complete remission or improvement in 21 cases. Ten underwent surgical treatment owing to recurrent pyelonephritis or pyelo-renal reflux with severe dilatation, despite a standard pharmacological trial.

[Diabetic foot. A clinical case]. / Piede diabetico. Un caso clinico.

Diabetic neuropathy may cause an alteration of the function of the muscles of the sole of the foot. This is at the origin of the chronic dislocation of the articular heads, mainly of the little metatarsal bones (neuro diabetes arthropathy), with formation of areas of pathological pressure. The tissues below being chronically under pressure are affected by trophic lesions called "plantar perforating disease". Recovery may be obtained by not exposing the injured area of the foot to pressure and through careful local therapy. This doesn't prevent disease from appearing again, even though some specially conceived soles are being used, aiming at a correct weight redistribution on the sole of the foot. The clinical case we are describing applies to a man affected by insulin dependent diabetes mellitus, with relapsing diabetic foot ulcers, in spite of him using a specifically designed sole. Such lesion is aggravated by a serious infection which, by gradually penetrating in depth, leads to osteomyelitis, affecting the 5th Metatarsal head. The bone area, dislocated by neuroarthropathy, was presumably responsible for the persisting plantar lesion. The amputation of this infected necrotic structure, has led to the overcoming of the serious septic problem. By eliminating the bone link responsible for the transmission of the pathological pressure, the plantar lesion the patient had been suffering from for a long time, has consequently disappeared.

Duct carcinoma of the minor salivary glands: a case report.

A tumour was removed from the oral vestibule of a 62-year-old woman. It showed histological features of both salivary duct carcinoma and papillary adenocarcinoma. The possibility that these entities might be but varieties of duct adenocarcinoma is suggested.

[Intraoperative cholangiography in laparoscopic cholecystectomy. Our experience]. / La colangiografia intraoperatoria nella colecistectomia per via laparoscopica. Nostra esperienza.

Cholangiography during conventional cholecystectomy has always been useful for anatomo-topographic study and for research of the stones of biliary tree. After a natural period of training the authors included the easy technique of cholangiography in laparoscopic cholecystectomy. The study was performed in 13 patients using Olsen's cannula with an internal a normal catheter for cholangiography. The catheterization of the cystic duct was performed in 85% of cases (11 patients), in the other 15% (2 patients) it was not possible to cannulate the cystic duct. Non complication. The mean duration of the study was 14 minutes. The authors describe the technique and conclude, after a brief discussion of the reports in the literature and personal experience, that peroperative cholangiography is an easy and safe procedure without risk and prevents the injuries to the biliary tract whose incidence is about 1.3%.

[Laparoscopic approach to appendiceal emergencies. Our experience. Preliminary results]. / L'approccio laparoscopico alle urgenze appendicolari. Nostra esperienza. Risultati preliminari.

Laparoscopic surgery in acute appendectomy is a very much debated subject also for skilled teams of mini-invasive surgery. The authors review 25 urgent laparoscopic interventions for acute appendicitis, treating some technical aspects of trocar introduction and Endoloops and EndoGia employment in this field. They conclude by emphasizing that the laparoscopic approach for acute appendicitis is the treatment of choice, considering the good results and the future prospects of laparoscopic versus open surgery.

[Surgical implications of familial polyposis coli]. / Implicazioni chirurgiche della poliposi familiare del colon (PFC).

Surgical treatment of familial congenital polyposis (FCP) is deemed necessary as soon as diagnosis is obtained. The goals of any surgical procedure must be: removal of all adenomatous tissue, reliable prophylaxis of cancer, good quality of life. Among the different procedures (proctocolectomy with ileostomy, total colectomy with ileo-rectal anastomosis and postoperative endoscopic surveillance, ileo-rectal pull-through) we consider Soave ileo-endorectal pull-through as the treatment of choice. Between 1974 and 1993, 14 patients, 12 to 40 years old, underwent an ileo-endorectal pull-through (in 4 cases as secondary procedure after ileo-rectal anastomosis performed elsewhere). We had only two major complications, ileal perforation in one case and breakdown of ileo-rectal anastomosis in another case that needed permanent ileostomy. Continence is good in all patients (safe for the one with ileostomy) with an average of three bowel movements per day. Prophylaxis of cancer must be considered complete and permanent without need of surveillance.

Hepatic resections through the laparoscopic approach.

Hepatic surgery has been undergoing progressive modifications in surgical approach to liver, passing through tohraco-phrenolaparotomy to bilateral subcostal incision and current Makuuchi's. Laparoscopic liver surgery should not be considered a new surgery, but simply a new surgical approach, with difficulties but advantages too. Laparoscopic hepatic resections are feasible with low morbidity and mortality; the short and medium term results are comparable to those obtained with open surgery provided that the surgeon has a significant experience in open hepatic surgery, advanced laparoscopic surgery and the availability of all and pertinent instrumentation. The aim of this paper is to show the rationales formal of hepatic resections through the laparoscopic approach, focusing on the necessary instrumentation, the surgical technique and results.

[Sepsis in children with malignant neoplasia, equipped with a Broviac-type venous catheter]. / Sepsi in bambini affetti da neoplasia maligna portatori di catetere venoso centrale tipo Broviac.

Indwelling central venous catheters obviate many problems in the care of children with malignancies, but they also are a well-known source of infection. We are reviewed the history of 584 Broviac catheters inserted from January 1984 to December 1991, in 475 children with cancer in order to assess the etiology of bacteremias, their association with neutropenia and their relationship with the presence of the catheters. The overall duration-time of the catheters, employed for blood tests, drug and blood infusions and parenteral nutrition, was 1-835 days (median 263, mean 186). Total catheter courses was 108.678 days. In this period 226 episodes of sepsis were observed in 180 patients: 157 in neutropenic patients and 69 in non neutropenic. Catheter related bacteremias were diagnosed in 65/226 episodes (29%): 23 (35%) were observed in neutropenic patients and 42 (65%) in non neutropenic (P < 0.005). Gram-positive pathogens were isolated in 28/65 (43%) episodes, Gram-negatives in 15/65 (23%), fungi in 9/65 (14%), and the remaining 13 (20%) were polymicrobial. In the last years we observed an increase of catheter related bacteremias due to Gram-negative rods no change was observed in pathogens causing catheters unrelated bacteremias. The high incidence of catheters related bacteremias in non neutropenic, non hospitalized patients, stress on the home-care of the catheters; a high level of suspicion of Gram-negative infections should be maintained in cancer patients with an indwelling central venous catheters.

[Role in mini-invasive surgery in children]. / Il ruolo della chirurgia ad approccio mini-invasivo in età pediatrica.

AIM: This paper describes our experience with minimally invasive surgery and underlines its increasingly important role in the treatment of pediatric patients. METHODS: The study included all those patients undergoing a minimally invasive surgical procedure between January 2006 and March 2012. Patient demographics, type of operation (classified according to disease and anatomic site), complications, and length of hospital stay (LOS) were recorded. RESULTS: Out of 12,596 surgeries, 1803 (14.3%) minimally invasive procedures were performed: Soave-Georgeson endorectal colon pull-through for Hirschsprung's disease (N.=82); colectomy for chronic inflammatory bowel disease (N.=37); ileal J-pouch ano-rectal Knight-Griffen anastomosis in colectomized patients with chronic ulcerative colitis (N.=35); Nissen fundoplication for gastroesophageal reflux disease (N.=148); cholecystectomy (N.=68); appendectomy (N.=341); laparoscopic or thoracoscopic tumor resection or biopsy (N.=90); reconstruction of the renal pelvi and ureters (N.=11); and Nuss thoracoplasty for pectus excavatum (N.=237). The median age was 3 years; the median LOS was 3 days; the complications rate was 0.9% (N.=18). CONCLUSION: According to our experience, minimally invasive surgery is a safe and efficacious alternative to conventional surgery (in terms of complications) also in children. It was associated with shorter LOS and improved quality of life, with less pain and better aesthetic results. It has become the preferred surgical treatment option by parents.

Abdominal wall defects: a 33-year unicentric experience.

AIM: The aim of this paper was to provide the main clinical features, surgical details, and long term outcome of patients with gastroschisis and omphalocele operated on at Giannina Gaslini Institute between 1976 and 2009. METHODS: All patients who were operated on between 1976 and 2009 for omphalocele or gastroschisis were included. Detailed informations regarding demographics, maternal history, type of delivery, associated anomalies, surgical details, complications, morbidity and mortality were collected. RESULTS: Sixty-one patients were included. Type of delivery did not interfere with outcome. Although patients with omphalocele had higher incidence of associated anomalies with their obvious impact on survival and quality of life, they showed a quicker recovery from surgery. Mortality rate was around 5%. Long-term outcome was available in 18 of them and proved to be satisfactory in all although almost 70% of them complained some gastrointestinal issues. CONCLUSION: Gastroschisis and Omphalocele showed improving survival and outcome during the last decades. Caesarean section proved not to confer advantages over vaginal delivery. Associated anomalies have the highest impact on survival being cardiac malformation the most significant risk factors. Although overall outcome is good in the majority of the patients, gastrointestinal and cosmetic issues seem to have a significant impact on quality of life and overall patients' perspectives.