Edoardo Guida

Risk factors for renal function impairment in a series of 502 patients born with spinal dysraphisms

OBJECTIVE To evaluate the risk of renal damage in a large series of patients affected by spinal dysraphism. METHODS Renal function was studied in 502 spinal dysraphisms treated over the last 25 years in a single center: 283 meningomyelocele (MMC), 90 caudal regression syndrome (CRS) and 129 spinal lipoma (SL) cases. In patients with normal and impaired renal function, we compared congenital renal anomalies, vesicoureteric reflux, bladder voiding pattern and upper tract dilatation, analyzing the results with the Fisher test. RESULTS Neuropathic bladder was observed in 97% of MMC, 60% of CRS, and 39% of SL cases. There was some degree of renal function impairment in 19 MMC (6.7%), 11 CRS (12%, increased to 20% if considering only neuropathic bladder patients), and two SL (1.5%) cases. Renal agenesis was more frequent in CRS (13%), but was not associated with decreased renal function. Overall, vesicoureteric reflux and upper tract dilatation were more frequent in patients with renal damage. Insufficient bladder voiding was statistically associated with renal damage only in the CRS population. Intermittent catheterization did not represent a protective factor against renal damage in patients able to void without significant residual urine. CONCLUSION This study has increased our understanding of the prognostic risk factors for renal deterioration. More prospective studies are necessary to confirm these results and correlate treatment with renal outcome.

Acid and weakly acid gastroesophageal refluxes and type of respiratory symptoms in children

OBJECTIVES To evaluate the association between the frequency of acid reflux (AR) and weakly acid reflux (WAR) and specific respiratory symptoms (RS) in childhood. STUDY DESIGN We retrospectively reviewed medical records of children with difficult-to-treat RS, not under acid suppressive therapy, and with a positive multiple intraluminal esophageal impedance (pH/MII) monitoring. To discriminate children with prevalent AR and WAR events, a ROC curve was designed and the distribution of the different RS in children with prevalent AR or WAR events was analyzed. RESULTS A higher number of AR over WAR events was detected (p < 0.0001) but the WAR-to-AR events ratio progressively decreased with the age of the subjects (p < 0.01). Similar total number of reflux events was found in the three age group and in children with a more prevalent WAR or AR. The most prevalent RS, equally distributed among the three age groups, were persistent and/or nocturnal cough, wheezy bronchitis/asthma, and recurrent lower respiratory tract infections (RLRTI). Apnoea was most frequent in infants (p = 0.036). A higher frequency of RLRTI, but not of nocturnal cough or wheezy bronchitis/asthma, was shown in WAR as compared with AR patients (p = 0.040), and specifically those in the school-aged group (p = 0.013). Age and WAR were respectively identified as independent predictors of apnoea and RLRTI (p < 0.05). CONCLUSION WAR events are common in children with gastroesophageal reflux and difficult-to-treat RS and often associated with RLRTI. These findings support the role of pH/MII monitoring in the evaluation of these patients and may explain the disappointing clinical results often observed with anti-acid treatments.

Susceptibility to antibiotics of aerobic bacteria isolated from community acquired secondary peritonitis in children: therapeutic guidelines might not always fit with and everyday experience

Abstract Appendicitis is a frequent clinical condition in normal children that may be complicated by community-acquired secondary peritonitis (CASP). We evaluated the potential efficacy of different drugs for initial treatment of this condition, as recommended by recent Consensus Conference and Guidelines for paediatric patients. Susceptibility to ampicillin–sulbactam, ertapenem, gentamycin, piperacillin, piperacillin–tazobactam, vancomycin, and teicoplanin was evaluated according to EUCST 2012 recommendations in aerobic bacteria isolated from peritoneal fluid in CASP diagnosed from 2005 to 2011 at ‘Istituto Giannina Gaslini’, Genoa, Italy. A total of 114 strains were analysed: 83 E. coli, 15 P. aeruginosa, 6 Enterococci, and 10 other Gram-negatives. Resistance to ampicillin–sulbactam was detected in 37% of strains, while ertapenem showed a potential resistance of 13% (all P. aeruginosa strains). However, the combination of these drugs with gentamicin would have been increased the efficacy of the treatment to 99 and 100%, respectively. Resistance to piperacillin–tazobactam was 3%, while no strain was resistant to meropenem. Our data suggest that monotherapy with ampicillin–sulbactam or ertapenem for community-acquired secondary peritonitis would present a non-negligible rate of failure, but the addition of gentamycin to these drugs could reset to zero this risk. On the contrary, monotherapy with piperacillin–tazobactam or meropenem is highly effective.

Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery

PurposeThe aim of this study was to evaluate the frequency of surgical and organizational events that occurred in the whole Department of Paediatric Surgery at Gaslini Children’s Hospital through an incident-reporting system in order to identify the vulnerabilities of this system and improve it.Materials and methodsThis is a 6-month prospective observational study (1st January–1st July 2010) of all events (including surgical and organizational events, and near misses) that occurred in our department of surgery (pediatric surgery, orthopedics and neurosurgery units).ResultsOver a 6-month study period, 3,635 children were admitted: 1,904 out of 3,635 (52.4%) children underwent a surgical procedure. A total number of 111 adverse events and 4 near misses were recorded in 100 patients. A total of 108 (97.3%) adverse events occurred following a surgical procedure. Of 111 adverse events, 34 (30.6%) required re-intervention. Eighteen of 100 patients (18%) required a re-admission, and 18 of 111 adverse events (16.2%) were classified as organizational. Infection represented the most common event.ConclusionsAn electronic physician-reported event tracking system should be incorporated into all surgery departments to report more accurately adverse events and near misses. In this system, all definitions must be standardized and near misses should be considered as important as the other events, being a rich source of learning.

Laparoscopic Proximal Roux-en-Y Gastrojejunal Diversion in Children: Preliminary Experience from a Single Center

BACKGROUND Neurologically impaired children (NIC) have a high risk of recurrence of gastroesophageal reflux (GER) following fundoplication. A postpyloric feeding tube may be useful when gastric emptying disorders occur; however, dislocation and difficulty in feeding management often require more aggressive procedures. Total esophagogastric dissociation (Bianchis TEGD) is an alternative to the classic fundoplication procedure, whereas laparoscopic gastric bypass is a frequently performed procedure in morbid obesity, improving gastric outlet. AIM The aim of this paper is to present a preliminary experience on the laparoscopic Roux-en-Y gastrojejunal bypass, associated with Nissen fundoplication and gastrostomy, to treat and prevent GER in NIC with gastric emptying disorders. MATERIALS AND METHODS Eight neurologically impaired children underwent surgical treatment because of feeding problems and pulmonary complications. The procedure included: 1) hiatoplasty, 2) Nissen fundoplication, 3) 20-cm Roux-en-Y gastrojejunal anastomosis and jejuno-jejunal anastomosis, and 4) gastrostomy. RESULTS All cases were fed on postoperative day 3 without any intraoperative complications. One case developed an obstruction of the distal anastomosis due to adhesion and needed reoperation. Outcome was clinically evaluated with serial upper gastrointestinal contrast studies and endoscopies. CONCLUSIONS Laparoscopic proximal Roux-en-Y gastrojejunal diversion, without gastric resection, is a safe, feasible procedure that improves gastric emptying and reduces the risk of GER recurrence. Yet, long-term results still have to be evaluated.

Use of failure modes, effects, and criticality analysis to compare the vulnerabilities of laparoscopic versus open appendectomy

Purpose To measure the feasibility of using FMECA applied to the surgery and then compare the vulnerabilities of laparoscopic versus open appendectomy by using FMECA. Methods The FMECA study was performed on each single selected phase of appendectomy and on complication-related data during the period January 1, 2009, to December 31, 2010. The risk analysis phase was completed by evaluation of the criticality index (CI) of each appendectomy-related failure mode (FM). The CI is calculated by multiplying the estimated frequency of occurrence (O) of the FM, by the expected severity of the injury to the patient (S), and the detectability (D) of the FM. Results In the first year of analysis (2009), 177 appendectomies were performed, 110 open and 67 laparoscopic. Eleven adverse events were related to the open appendectomy: 1 bleeding (CI: 8) and 10 postoperative infections (CI: 32). Three adverse events related to the laparoscopic approach were recorded: 1 postoperative infection (CI: 8) and 2 incorrect extractions of the appendix through the umbilical port (CI: 6). In the second year of analysis (2010), 158 appendectomies were performed, 69 open and 89 laparoscopic. Four adverse events were related to the open appendectomy: 1 incorrect management of the histological specimen (CI: 2), 1 dehiscence of the surgical wound (CI: 6), and 2 infections (CI: 6). No adverse events were recorded in laparoscopic approach. Conclusion FMECA helped the staff compare the 2 approaches through an accurate step-by-step analysis, highlighting that laparoscopic appendectomy is feasible and safe, associated with a lower incidence of infection and other complications, reduced length of hospital stay, and an apparent lower procedure-related risk.

Intraureteral Injection of NASHA/Dx Gel Under Direct Ureteroscopic Visualization for the Treatment of Primary High-Grade Vesicoureteral Reflux

OBJECTIVE To present a preliminary experience with the modified technique of extravesical intraureteral injection of non-animal-stabilized hyaluronic acid/dextranomer (NASHA/Dx) gel under direct ureteroscopic visualization for the treatment of primary high-grade vesicoureteral reflux (VUR). PATIENTS AND METHODS The medical records of all pediatric patients (age range, 0-14 years) who underwent intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization for the treatment of primary high-grade VUR during the period June 2006-June 2010 were reviewed. RESULTS Eighty-nine children (61 boys, 28 girls; M:F ratio, 2.1) underwent intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization for the treatment of primary high-grade VUR during the study period. VUR completely disappeared after the injection of NASHA/Dx gel into 105 (73%) of 144 ureters, with no further treatment required. Thirty-five (24.3%) required a second injection, and 2 (1.4%) required a third injection for resolution of their VUR. No intraoperative complications were observed. No ureteral obstruction during follow-up was observed using ultrasound or micturition studies. CONCLUSIONS Intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization is safe and effective in the treatment of primary high-grade VUR, including cases with ureteral duplication, if the ureteral meatus is easy to pass through without mechanical dilation. This approach represents an effective and safe alternative to antibiotic prophylaxis alone and open surgery.

Thymectomy to achieve primary closure of total sternal cleft

Total sternal cleft is a rare congenital malformation that may represent a challenge for the surgeon. In neonatal period, the primary closure is usually achievable, but at older age, this can be impossible. Moreover, the closure of the 2 sternal bars can bring to an exaggerated compression on mediastinal structures. Many different techniques for the treatment of sternal clefts have been reported in literature. We describe one case of total sternal cleft repaired at 4 months of age in which a partial thymectomy was performed to achieve the primary closure. We suggest considering this simple procedure in selected patients to reduce the risk of mediastinal compression.

Provisional unicentric experience with an electronic incident reporting form in pediatric anesthesia

Objective:  To present and compare with literature our experience with an electronic anesthesia‐related incident reporting form as a quality control measure at Gaslini Children’s Hospital over a 19‐month period.

When a lymphatic malformation determines a bowel volvulus: Are clinical status and images always reliable?

Highlights • Small-bowel volvulus could be a presentation of a cystic mesenteric LM.• Diagnosis could be intraoperative.• Complete excision including, in some selected cases, a bowel resection, should be the treatment of choice.