Fabio Torri

Further evidence on totally transanal one-stage pull-through procedure for Hirschsprung’s disease

BACKGROUND/PURPOSE Fifteen consecutive children aged 20 days to 12 years with biopsy-proven Hirschsprungs Disease (HD) underwent a transanal pull-through procedure over a 17-month period. These patients have been divided into 2 groups. The first was a series of 9 patients, which helped us gain familiarity and confidence with technical and postoperative gestational problems, and the second series was of 6 patients, which fully corroborates and adds further evidence on the minimally invasive nature of the technique. Mucosectomy of aganglionic bowel, access to the peritoneal cavity, division of rectosigmoid mesenteric vessels, pull-through of normoganglionic colon, colectomy, and coloanal anastomosis all were performed transanally. Patients underwent a program of progressive anal dilatations and were assessed for postoperative clinical course, continence, constipation, diarrhea, postoperative enterocolitis, perianal excoriations, and anal stricture. RESULTS Mucosectomy was done under direct vision. Operating time ranged from 150 to 350 minutes. The average length of bowel resected was 13.5 cm with a range of 8 cm to 25 cm. There were neither intraoperative nor significant postoperative complications. All but 2 patients accepted full oral feedings on postoperative day 2. Mean hospital stay in the first series of 9 patients was 7 days, range, 5 to 12 days; that of the second series of 6 patients was 5 days, range, 4 to 8 days. All children currently experience 1 to 6 bowel movements per day at a follow-up period of 1 to 17 months. CONCLUSIONS A one-stage pull-through procedure for HD can be performed successfully with a completely transanal approach. This technique is associated with excellent early clinical results. Many more cases and a longer follow-up period will be required to compare long-term results with other one-stage procedures for definitive treatment of HD.

Esophageal atresia: pre and post-operative management

Esophageal atresia is a relatively common congenital malformation occurring in 1:3000-4500 live births. Improvement in surgical, anesthetic and neonatal care has achieved a survival rate near 100% in infants weighing over 1500g and having no major cardiac problem. To achieve these outcomes, as well as a good surgical technique, careful preoperative management (early diagnosis, investigation of associated anomalies, suction of the upper pouch, prevention and treatment of gastric and bowel distension) and accurate postoperative care (postoperative analgesia and ventilation, management of trans-anastomotic and chest tube, prevention, early recognition and treatment of complications) are mandatory.

Heterotopic Gastric Mucosa in the Cystic Duct

Heterotopic gastric mucosa in the gallbladder is rare (with about 100 reported cases), and its occurrence is even rarer in the biliary ductal system.The authors report a pediatric case of heterotopic gastric mucosa in the cystic duct associated with cholelitiasis.

Endoscopic management of sigmoid volvulus in children

Sigmoid volvulus (SV) is extremely uncommon in children and is usually associated with a long-standing history of constipation or pseudo-obstruction. An early diagnosis and management are crucial in order to prevent the appearance of hemorrhagic infarction of the twisted loop, avoiding further complications such as necrosis, perforation and sepsis. In patients with no evidence of peritonitis or ischemic bowel, treatment starts with resuscitation and detorsion of the SV, accomplished by means of sigmoidoscopy and concomitant rectal tube placement. The bowel is then prepared and surgery is undertaken electively during the same hospitalization. We report a detailed review of the literature focusing on technical details, risks and benefits of endoscopic management of SV in childhood.

Chronic cough and eosinophilic esophagitis: an uncommon association.

An increasing number of children, usually with gastrointestinal symptoms, is diagnosed with eosinophilic esophagitis (EE), and a particular subset of these patients complains of airway manifestations. We present the case of a 2-year-old child with chronic dry cough in whom EE was found after a first diagnosis of gastroesophageal reflux disease (GERD) due to pathological 24-hour esophageal pH monitoring. Traditional allergologic tests were negative, while patch tests were diagnostic for cow’s milk allergy. We discuss the intriguing relationship between GERD and EE and the use of patch test for the allergologic screening of patients.

Minimally invasive Morgagni-Larrey hernia repair in children: a new and simple trick in suturing technique

Background: Literature is littered with descriptions of the minimally invasive repair of Morgagni-Larrey hernias in children. However, there are few reports about the diaphragmatic defect suture. The aim of this study is to describe a simplified trick to perform a simple and safe suturing technique. Methods: 2 children with left Morgagni-Larrey hernia underwent primary laparoscopic repair. The closure of diaphragmatic defect was performed by several simple interrupted sutures. An i.v. needle cannula was adopted like a track for returning back out of the suture, though the anterior abdominal wall at 3 mm distance from the site where the stitch is placed according to a U configuration. Results: No cases required open conversion. No complications and hernia recurrences were observed. Conclusions: Our suturing technique simplifies the surgical gesture, improves operative time and assure a safe, effective and nice cosmetic result. Furthermore, it is easily reproducible by every surgeons and it may be also used in similar operations.

Urgent laparoscopic mesh splenopexy for torsion of wandering spleen and distal pancreas: A case report.

Wandering spleen is a condition in which an incomplete fusion of the splenic ligaments allows the spleen to move within the abdomen, predisposing it to splenic torsion along its vascular pedicle. Torsion of a wandering spleen is an uncommon occurrence, especially in children, and associated torsion of the distal pancreas is even more unusual, with only four cases having been reported in adults. Non‐specific clinical presentation makes radiologic evaluation essential in order to obtain a diagnosis and to send the patient for early surgery before life‐threatening complications arise. Here we present a rare case of torsion of wandering spleen together with volvulus of the distal pancreas in a 13‐year‐old girl. In this case, prompt radiological assessment allowed for an early diagnosis, and the patient was successfully treated with urgent laparoscopic derotation of both the spleen and the distal pancreas as well as mesh splenopexy. To the best of our knowledge, this procedure has never been described in a pediatric setting.

Laparoscopic Treatment of Giant Abdominal Lymphangioma in a Child

Giant cystic lymphangioma (GCL) is a rare benign cystic tumor. The gold standard treatment of abdominal GCL is surgical excision. Only few series of pediatric patients managed with mini-invasive surgery are reported. We describe a case of a 2-year-old girl with a GCL who was treated with laparoscopic excision with a good outcome. She was admitted to our hospital because of acute abdominal pain associated with high temperature. At physical examination, the abdomen was distended and tender. An x-ray film and ultrasonography with Doppler of the abdomen shows the presence of large amount of corpusculated fluid into the peritoneal cavity. Computed tomography showed a very large, septated, cystic abdominopelvic lesion, with the small bowel and colon displaced in the central abdomen. At laparoscopy, GCL arising from the great omentum was identified and completely removed. Histological examination confirmed the diagnosis. At 2-year follow-up, the child is doing well.