Angela Simona Montalto

Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula repair: review of the literature and meta-analysis.

INTRODUCTION The thoracoscopic approach to esophageal atresia (EA) with tracheoesophageal fistula (TOF) represents a challenging procedure whose real benefits remains unclear. Our purpose is to identify, through a meta-analysis, clinical evidence of the reliability of the thoracoscopic repair (TR) for EA/TOF compared with the open repair. MATERIALS AND METHODS Defined PubMed search, with analysis of intraoperative and postoperative complications after open or thoracoscopic primary anastomosis for EA/TOF. RESULTS Five articles met the criteria of meta-analysis, being comparative studies between TR and conventional open repair (COR), although they were retrospective. One article was excluded because it was available only in Japanese. We observed a slight prevalence, statistically insignificant, of the intraoperative and postoperative complication rate for TR: odds ratio (OR) 1.29. Excluding the conversion rate, the meta-analysis between the complication rate for TR and COR did not show a significant difference (OR 0.64). Anastomosiss leaks and strictures considered together did not show a significant difference between the two techniques, p = not significant and OR of 0.56. Similar results were observed analyzing the single outcome of leaks and strictures; the meta-analysis did not show any significant differences with an OR, respectively, of 1.05 and 0.43. CONCLUSIONS The effectiveness of the endoscopic technique for EA/TOF repair is indicated with outcomes not different from open surgery. A randomized controlled trial is needed in this field to indicate which procedure is superior, open or TR.

Long-term follow up of neonatally diagnosed primary megaureter: rate and predictors of spontaneous resolution

Abstract Objective. Primary megaureter (PM) represents 6–10% of all antenatal displaced urinary malformations. Spontaneous resolution of PM is a well-known event. This long-term follow-up study evaluated the incidence and rate of resolution of PM. Some predictive factors were revised, based on morphological classification and scintigraphic pattern. Material and methods. Sixty neonates with PM were followed. The diagnosis was confirmed by ultrasound examination and 99mTc-DTPA diuretic renal scan. All the observed patients underwent antibiotic prophylaxis. All conservatively treated children were followed from 6 months to 15 years. Follow-up consisted of monthly urine cultures, renal ultrasound and DTPA diuretic renography. Hydroureteronephrosis was considered to have resolved when a retrovesical cross-sectional diameter of ureter less than 6 mm was found. Results. In total, 72 PM were identified in this series. At the end of the follow-up period, 38 PM (52.8%) had resolved, in 18 PM (25%) ureteral dilatation persisted and 16 PM (22.2%) required a surgical procedure. The median age at resolution was significantly affected by presenting hydronephrosis grade and cross-sectional diameter at diagnosis, but not by gender. The 99mTc-DTPA renogram results showed no functional impairment in resolved and persisting cases, even after long-term observation. Conclusions. The data show that 22% of neonatal PM require surgical treatment. Poor drainage on 99mTc-DTPA scan, grade IV–V hydronephrosis and ureteric diameter more than 15.0 mm were statistically significant and independent predictive factors for surgery. The time to spontaneous resolution in neonatally diagnosed PM may exceed 3.6 years, after which recovery is rare.

Peroxisome Proliferator Activated Receptor β/δ Activation Prevents Extracellular Regulated Kinase 1/2 Phosphorylation and Protects the Testis From Ischemia and Reperfusion Injury

PURPOSE Testicular torsion is a medical emergency that requires immediate diagnosis and treatment to avoid subsequent testicular injury and infertility. PPARs are a family of nuclear hormone receptors belonging to the steroid receptor superfamily. Three PPAR isotypes (alpha, beta/delta and gamma) encoded by separate genes and showing different tissue distribution patterns have been identified. PPARbeta/delta is expressed in testis and its role is largely unknown. We tested whether pharmacological activation of PPARbeta/delta might protect the testis from ischemia and reperfusion injury. MATERIALS AND METHODS Adult male Sprague-Dawley rats were subjected to 1-hour testicular ischemia, followed by 24 hours of reperfusion. Sham testicular ischemia-reperfusion rats served as controls. The animals were randomized to receive immediately after detorsion 1) L-165,041 (4 mg/kg intraperitoneally), a potent agonist of PPARbeta/delta, 2) GW9662 (Calbiochem(R)) (4 mg/kg intraperitoneally), an antagonist of PPAR, 3) L-165,041 (4 mg/kg intraperitoneally) plus GW9662 (4 mg/kg intraperitoneally) concomitantly or 4) vehicle (1 ml/kg 10% dimethyl sulfoxide/NaCl solution). We evaluated testicular extracellular signal regulated kinase, tumor necrosis factor-alpha and interleukin-6 by Western blot. We also investigated PPARbeta/delta activation by Western blot, mRNA expression and organ damage. RESULTS Testicular ischemia-reperfusion injury caused a significant increase in extracellular signal regulated kinase, tumor necrosis factor-alpha and interleukin-6 expression in each testis. Furthermore, histological examination revealed marked damage. L-165,041 administration increased the PPARbeta/delta message and protein, inhibited extracellular signal regulated kinase, tumor necrosis factor-alpha and interleukin-6 expression, and decreased histological damage. Concomitant administration of GW9662 reversed the protection exerted by PPARbeta/delta agonist. CONCLUSIONS These findings indicate that PPARbeta/delta agonists might be an attractive therapeutic candidate for managing testicular torsion.

Accessory spleen torsion: rare cause of acute abdomen in children and review of literature

Torsion of an accessory spleen is an extremely rare condition. We describe an unusual case of acute abdomen caused by torsion of an accessory spleen in a 12-year-old boy. The patient underwent a laparotomy with splenectomy; the course was favorable. We discuss the clinical findings and values of preoperative instrumental diagnosis. The literature is also reviewed. This is the 11th case reported in the English literature. Torsion of an accessory spleen should be considered in the differential diagnosis of acute abdomen or subacute abdominal pain.

Surgical Stress after Open and Transumbilical Laparoscopic-Assisted Appendectomy in Children

INTRODUCTION The transumbilical laparoscopic-assisted appendectomy (TULAA) effects on the surgical stress response in children have not been studied. Our aim is to investigate the stress response in TULAA. METHODS A total of 35 children underwent the appendectomy by open approach (OA) or TULAA approach. Interleukins (ILs)-6, -18, and -10 were measured before (T0), at the beginning (T1a), and at the end of surgery (T1b) and 24 hours after (T2). RESULTS An increase in IL-6 levels at T1b and T2 and in IL-18 at T2 was observed after OA. A significant increase of both IL-6 and IL-18 were observed at T2 but values were less compared with OA (11.6 ± 4.4 vs. 31.9 ± 8.9 pg/mL for IL-6, p = 0.0006; 145.6 vs. 174.9 pg/mL for IL-18, p = NS). CONCLUSIONS A significant reduction in the postoperative cytokines in TULAA group suggests that this approach causes less surgical trauma in children.

Melatonin versus midazolam premedication in children undergoing surgery: A pilot study

Melatonin has been proposed as a premedication alternative to midazolam, preceding anaesthesia induction. However, to our knowledge, data concerning interaction between melatonin and intravenous anaesthetic drugs in children are not available. The aim of this prospective, randomized, double‐blind pilot study was to investigate the possible effect of melatonin premedication, in comparison to midazolam, on the required infusion of propofol in children undergoing surgery. As a secondary outcome, the effect of oral melatonin on the preoperative sedation level and on the post anaesthesia recovery score was evaluated.

Expression of Transglutaminase in Foreskin of Children with Balanitis Xerotica Obliterans

Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder of unclear etiology. The etiology and the exact molecular mechanisms underlying the disease are still unknown. The human transglutaminase (TG) family consists of several proteins with catalytic activity essential for biological processes. In the present research we investigated the transcript levels of three TGs in patients operated on for congenital phimosis without or with histologically confirmed BXO; Thirty children with acquired phimosis were enrolled. The removed foreskins were sent both for histological diagnosis and for quantitative real-time PCR to evaluate the transcript levels of keratinocyte (TG1), tissue (TG2), and epidermal (TG3) transglutaminase; We observed a decrease in TG1 and TG3 transcripts by about 70% (p < 0.001) in foreskins from patients with BXO (n = 15) in comparison with patients without BXO (n = 15) and an increase in TG2 mRNA levels by 2.9 folds (p < 0.001); Reduced expression of both TG1 and TG3 was associated with the altered structure of the foreskin in BXO and can be a consequence of damage to keratinocytes. Increased expression of TG2 can be the result of chronic inflammation. TG2 overexpression can play a pivotal role in triggering and maintaining the inflammatory response in BXO patients.

Current status of laboratory and imaging diagnosis of neonatal necrotizing enterocolitis

Necrotizing enterocolitis continues to be a devastating disease process for very low birth weight infants in Neonatal Intensive Care Units. The aetiology and pathogenesis of necrotizing enterocolitis are not definitively understood. It is known that necrotizing enterocolitis is secondary to a complex interaction of multiple factors that results in mucosal damage, which leads to intestinal ischemia and necrosis. Advances in neonatal care, including resuscitation and ventilation support technology, have seen increased survival rates among premature neonates and a concomitant detection in the incidence of this intestinal disease.Diagnosis can be difficult, and identifying infants at the onset of disease remains a challenge. Early diagnosis, which relies on imaging findings, and initiation of prompt therapy are essential to limit morbidity and mortality. Moreover, early management is critical and life-saving.This review summarizes what is known on the laboratory and instrumental diagnostic strategies needed to improve neonatal outcomes and, possibily, to prevent the onset of an overt necrotizing enterocolitis.

CO2 Pneumoperitoneum Preserves β-Arrestin 2 Content and Reduces High Mobility Group Box-1 (HMGB-1) Expression in an Animal Model of Peritonitis

Laparoscopy (LS) has been shown to decrease the inflammatory sequelae of endotoxemia. β-arrestin 2 plays an important function in signal transduction pathway of TLR4. High mobility group box-1 (HMGB-1) is involved in the delayed systemic inflammatory response. We investigated the effects of CO2 insufflation on liver, lung, and kidney expression of both β-arrestin 2 and HMGB-1 during sepsis. Cecal ligation and puncture (CLP) was performed in male rats and 6 h later the animals were randomly assigned to receive a CO2 pneumoperitoneum or laparotomy. Animals were euthanized; liver, lung, and kidney were removed for the evaluation of β-arrestin 2 and HMGB-1 expression. Immunohistochemical detection of myeloperoxidase (MPO) was investigated in lung and liver and bacterial load was determined in the peritoneal fluid. CO2 pneumoperitoneum reduced peritoneal bacterial load, increased the expression of β-arrestin 2, and blunted the expression of the potent proinflammatory HMGB-1 in liver, lung, and kidney compared with laparotomy. Liver and lung MPO was markedly reduced in rats subjected to LS compared with laparotomy. We believe that CO2 exerts an early protective effect by reducing bacterial load and likely toll-like receptor activation which in turn leads to a preserved β-arrestin 2 expression and a reduced HMGB-1 expression.