G. Lisi

Irreducible indirect inguinal hernia containing uterus and bilateral adnexa in a premature female infant: Report of an exceptional case and review of the literature

Indirect inguinal hernia is the most common congenital anomaly in the pediatric age group. About 15-20% of hernias in infant girls contain ovary, sometimes with a Fallopian tube. The presence of the uterus incarcerated with the adnexa is a very unusual occurrence in female infants with normal kariotype and phenotype, being commonly associated with several disorders of sex development. The surgical repair of this form of hernia is more difficult than a common herniorrhaphy because of the adhesions between the organs and the wall of the sac and the risk of damage during their freeing. We present a rare case of irreducible indirect inguinal hernia containing uterus and bilateral adnexa (fallopian tubes and ovaries) in a premature female infant, discussing the etiopathogenesis and the surgical features of this disorder.

Serum Cystatin C as a Reliable Marker of Changes in Glomerular Filtration Rate in Children With Urinary Tract Malformations

PURPOSE Cystatin C has been suggested as a simple method of estimating GFR more accurately than creatinine in children. We compared the diagnostic accuracy of cystatin C with serum creatinine and the Schwartz formula for estimating GFR in patients with UTMs. MATERIALS AND METHODS We prospectively compared 72 patients with UTMs (20 days to 36 months old, 58 males and 14 females) with a group of 72 healthy controls (10 days to 48 months old, 53 males and 19 females). All patients underwent nuclear medicine clearance investigations with (99m)Tc DTPA. RESULTS Serum concentration of cystatin C revealed a higher correlation with (99m)Tc DTPA (r = 0.62, p <0.001) than serum concentration of creatinine (r = 0.30, p <0.01) or Schwartz formula (r = 0.51, p <0.001). These results were more evident in patients with uropathy (19) with mild renal impairment. Agreement between methods was assessed using Bland Altman analysis. Mean differences between GFR calculated with (99m)Tc DTPA and cystatin C based GFR estimation or Schwartz formula were -2.6% +/- 46.7% and -73.4% +/- 53.6%, respectively. Diagnostic accuracy in identifying decreased GFR measured as AUC was always highest for cystatin C but hardly sufficient for the 3 variables. Cystatin C performed better in the 0 to 6-month-olds (0.70 +/- 0.08 for cystatin C, 0.58 +/- 0.07 for Schwartz estimate) and patients older than 12 months (0.82 +/- 0.09 for cystatin C, 0.65 +/- 0.11 for Schwartz estimate). CONCLUSIONS Cystatin C proved to be a superior marker rate over serum creatinine in estimating glomerular filtration in children younger than 3 years with UTMs and mild renal impairment, thus, offering a more specific and practical measure for monitoring GFR.

Paediatric ulcerative colitis surgery: Italian Survey

BACKGROUND AND AIMS Recent epidemiological studies showed an increase in ulcerative colitis among children, especially in its aggressive form, requiring surgical treatment. Although medical therapeutic strategies are standardized, there is still no consensus regarding indications, timing and kind of surgery. This study aimed to define the surgical management of paediatric ulcerative colitis and describe attitudes to it among paediatric surgeons. METHODS This was a retrospective cohort study. All national gastroenterology units were invited to participate. From January 2009 to December 2013, data on paediatric patients diagnosed with ulcerative colitis that required surgery were collected. RESULTS Seven units participated in the study. Seventy-one colectomies were performed (77.3% laparoscopically). Main surgical indications were a severe ulcerative colitis attack (33.8%) and no response to medical therapies (56.3%). A three-stage strategy was chosen in 71% of cases. Straight anastomosis was performed in 14% and J-pouch anastomosis in 86% of cases. A reconstructive laparoscopic approach was used in 58% of patients. Ileo-anal anastomosis was performed by the Knight-Griffen technique in 85.4% and by the pull-through technique in 9.1% of patients. Complications after colectomy, after reconstruction and after stoma closure were reported in 12.7, 19.3 and 35% of cases, respectively. CONCLUSIONS This study shows that there is general consensus regarding indications for surgery. The ideal surgical technique remains under debate. Laparoscopy is a procedure widely adopted for colectomy but its use in reconstructive surgery remains limited. Longer follow-up must be planned to define the quality of life of these patients.

Multicenter retrospective study on management and outcome of newborns affected by surgical necrotizing enterocolitis

BACKGROUND Necrotizing enterocolitis (NEC) is the most common surgical emergency in newborns and it is still a leading cause of death despite the improvements reached in the management of the critically ill neonate. The purpose of this study was to evaluate risk factors, surgical treatments and outcome of surgical NEC. METHODS We retrospectively evaluated a multicentric group of 184 patients with surgical NEC over a period of 5 years (2008-2012). Indications to operation were modified NEC Bell stages IIIA or IIIB. The main outcome was measured in terms of survival and postsurgical complications. RESULTS Data on 184 patients who had a surgical NEC were collected. The majority of patients (153) had a primary laparotomy (83%); 10 patients had peritoneal drainage insertion alone (5%) and 21 patients had peritoneal drainage followed by laparotomy (12%). Overall mortality was 28%. Patients with lower gestational age (P=0.001), lower birth weight (P=0.001), more extensive intestinal involvement (P=0.002) and cardiac diseases (P=0.012) had a significantly higher incidence of mortality. There was no statistically significant association between free abdominal air on the X-ray and mortality (P=0.407). Mortality in the drainage group was 60%, in the laparotomy group and drainage followed by laparotomy group was of 23-24% (P=0.043). There was a high incidence of stenosis (28%) in the drainage group (P=0.002). On multivariable regression, lower birth weight, feeding, bradycardia-desaturation and extent of bowel involvement were independent predictors of mortality. CONCLUSIONS Laparotomy was the most frequent method of treatment (83%). Primary laparotomy and drainage with laparotomy groups had similar mortalities (23-24%), while the drainage alone treatment cohort was associated with the highest mortality (60%) with statistical value (P=0.043). Consequently laparotomy is highly protective in terms of survival rate. Stenosis seemed to be statistically associated with drainage. These findings could discourage the use of peritoneal drainage versus a primary laparotomy whenever the clinical conditions of patients allow this procedure.

Giant abdomino-pelvic adipose tumors of childhood

Adipose tumors are rare in pediatric age and are commonly represented by benign forms: lipoma and lipoblastoma/lipoblastomatosis. Generally localized in subcutaneous tissue of the trunk and extremities, they can exceptionally occur as giant intra-peritoneal or pelvic masses. These tumors could reach considerable size prior to diagnosis since they are asymptomatic. The authors report a case series of three giant abdomino-pelvic adipose tumors.

Gastroesophageal reflux in children with neurological impairment: a systematic review and meta-analysis

Neurologically impaired children (NIC) suffer severe gastroesophageal reflux (GER) with poor fundoplication outcome. Aims of the study were: (1) to determine the recurrence of GER after fundoplication in NIC; (2) to compare fundoplication versus gastro-jejunal tube feeding insertion (GJ) and fundoplication versus total esophagogastric dissociation (TEGD) in primarily treating GER in NIC. Using defined search strategy, two investigators identified all comparative studies reporting the mentioned procedures to primarily treat GER in NIC. The study was conducted under PRISMA guidelines. The meta-analysis was performed using RevMan 5.3. Data are mean ± SD. Of 3840 titles/abstracts screened, 14 studies on fundoplication (2716 pts.) reported a recurrence/persistence of GER higher in NIC (14.2 ± 8.3%) than in neurologically normal (9.4 ± 5.2%; p = 0.0001), with an increased incidence of re-do fundoplication (12.6 ± 7.0% versus 9.1 ± 4.5%; p < 0.01). Three studies revealed a similar risk of undergoing subsequent fundoplication after GJ (4.9 ± 2.1%) or initial fundoplication (12.0 ± 0.6%; p = ns). Four studies showed a lower recurrence of GER following TEGD (1.4 ± 1.1%) than fundoplication (24.8 ± 1.4%; p = 0.002). NIC are at risk of recurrence/persistence of GER after fundoplication or GJ. TEGD seems more effective to primarily treat GER in NIC. Prospective randomized controlled trials are necessary to establish which is the ideal treatment of GER in NIC.

Equipment in Pediatric Endoscopy

With the development of a sub-specialty focused on pediatric gastrointestinal disorders, new technologies such as pediatric endoscopy were developed for diagnostic and therapeutic aims. Current endoscopic technology permits safe visualization, tissue sampling, and therapeutic procedures. Outer tip and working channel diameters have the greatest importance in the selection of an endoscope for the smaller children. The use of a smaller endoscope could represent the limiting element for the use of accessories, which are needed primarily for therapeutic purposes. Gastroscopes with outer diameters ranging from 4.9 to 12.8 mm are at present available, and colonoscopes range from 9.8 to 13.3 mm. Working channel diameters range from 1.5 mm of the slimmest instruments up to 4.2 mm of the largest adult therapeutic endoscopes. In 2017, the European Society of Gastrointestinal Endoscopy (ESGE) and European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) published the executive summary of the Guideline on pediatric gastrointestinal endoscopy that refers to infants, children, and adolescents aged 0–18 years.

Early “surgical” life events and functional gastrointestinal disorders (FGID): Pyloric stenosis vs. inguinal hernia

of the mother. Any sign/symptom was recorded weekly for the first three months of life, together with type of feeding. Statistical analysis (SPSS software): chi quadro test, Student t-test, linear regression. Results: 37 (32.7%) newborns were exclusively breast feeding. 16 (14.2%) newborns had regurgitation, 10 (9.7%) colics, 4 (3.5%) dischezia and 10 (9.7%) constipation. 60 (53.1%) mothers had postpartum depression and/or anxiety. 53.6% of infants with regurgitations had a depressed mother vs 23% of infants without regurgitations (chi quadro=10.63, p=0.003); 45.2% of infants with colics had a depressed mother vs 15.9% of infants without colics (chi quadro=10.63, p=0.001). A mother’s insecure attachment style was found in 36% of infants with persistence of regurgitations until third months of life vs 1.8% of infants with mother’s secure attachment style (p<0.001). Conclusions: Postpartum maternal depressive symptoms and anxiety are associated with infantile colic and regurgitations. Screening and early intervention in cases of postpartumdepression could be useful to avoid inappropriate nutritional and pharmacologic treatments, promoting the health of both mother and infant.

PO5 GIARDIASIS IN SUSPECTED CELIAC DISEASE

Background and Objectives: Celiac disease (CD) is an immunemediated enteropathy induced by gluten ingestion in a genetically susceptible patient. Giardia lamblia is the most common human parasite with a worldwide distribution and fecal-oral way of transmission. Giardia lamblia has a cosmopolitan distribution. Infected children may have acute or chronic diarrhea, crampy abdominal pain, anorexia, malasorption and poor weight gain and may be misdiagnosed as celiac disease. Diagnosis is usually made by finding the characteristic cysts in stool specimens or by duodenal aspiration. In most cases histology reveals a dense accumulation of the parasites on the surface of the duodenal mucosa with no or only slight inflammation. In rare cases, a dense inflammatory infiltrate with severe mucosal atrophy and increased count of intraepithelial lymphocytes may be seen. If in such cases the amount of parasites is low, the histological picture may mimic celiac disease. We report the case of a child 2 years old who presented poor growth, recurrent aphtous stomatitis, abdominal pain and recurrent diarrhea. No family history of CD. Material and Methods: In suspected CD, were assayed the IgA anti-endomysium antibodies (EmA-IgA) that resulted doubt and the IgA anti-tissue transglutaminase antibodies (TgA-IgA) that were found weakly positive (17.50UA; normal value 16UA). He was referred to our hospital for further diagnostic. We performed the search for genetic susceptibility of CD; the antibodies assay was repeated after 3 months. These investigations documented the presence of HLADQ2, positivity of EmA-IgA and an increase value of TgA-IgA (20.70UA). In the meantime symptoms worsened, so we proceeded performing the esophagogastroduodenoscopy and duodenal biopsies. The macroscopic appearance of duodenal mucosa was of villous atrophy, but microscopic examination showed a parasitic duodenitis, with the presence of microorganisms like Giardia lamblia. Then was started medical therapy with metronidazole per os for 10 days, and the child continued to eat gluten. Results: Abdominal pain and diarrhea disappeared gradually but rapidly; the parasitological examination was negative on 3 consecutive samples (at 3 weeks after eradication therapy); EmA-IgA and TgAIgA were negative at 1 month after eradication. The follow up to 1 year had confirmed that the increase in IgA was secondary to giardiasis, and that the symptoms were due to the histological damage of the parasite. Conclusions: When investigating a patient with suspected celiac disease (CD), several other conditions must be considered, including potential infection with Giardia lamblia. In doubtful cases like our patient, are of fundamental support an accurate assessment and appropriate follow up.

PA31 ESOPHAGEAL PERFORATED ULCER SECONDARY TO PROLONGED DECUBITUS OF A NOT-HARMFUL FOREIGN BODY (COIN) AT THE CERVICAL ESOPHAGUS

association of a clinical picture of gastroenteritis, we set the therapeutic process by supporting the second hypothesis, while allowing for endoscopic follow up of the evolution of the lesions. Faced with rapid resolution of the findings of EGD and gastrointestinal infection, the persistence of the painful symptoms has rekindled the suspicion of gastric disease due to malposition, probably exacerbated from the episode of infection. It was then performed radiological examination which led to diagnose gastric volvulus. The patient was then sent to the pediatric surgeon for surgical correction.