Giovanni Boroni

Reversal of severe parenteral nutrition-associated liver disease in an infant with short bowel syndrome using parenteral fish oil (Omega-3 fatty acids).

Total parenteral nutrition is an important adjunct in the care of neonates with surgical disorders. Cholestasis is at present the most worrisome complication of this technique; it is difficult to treat and may progress to eventual cirrhosis and liver failure. This article reviews the pertinent clinical and nutritional data in a surgical patient with short bowel syndrome who developed parenteral nutrition-associated liver disease successfully treated with fish-oil based lipids.

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.

Role of preoperative tracheobronchoscopy in newborns with esophageal atresia: A review

Preoperative tracheobronchoscopy (TBS) in the diagnostic assessment of newborns affected by esophageal atresia (EA) was described in 1981. Nevertheless, the value of the procedure is actually much debated; only a few studies have clearly explored the advantages of TBS and this procedure is not yet routinely included in the diagnostic and therapeutic assessment in many international pediatric surgery settings. Routine preoperative TBS is a safe procedure that enables the accurate examination of the tracheobronchial tree, the visualization of tracheoesophageal fistula and the diagnosis of tracheomalacia or associated respiratory anomalies. When a distal fistula is found, its occlusion with a Fogarty balloon catheter improves mechanical ventilation and facilitates surgical repair. This review provides a detailed overview on the use of TBS in newborns with EA, focusing on technical aspects, anesthesiological management, indications and limits. The benefits and risks of the procedure are also compared with alternative diagnostic tools, such as an esophageal contrast study, computed tomography scan and ultrasound.

The management of newborns with esophageal atresia and right aortic arch: A systematic review or still unsolved problem

AIM OF THE STUDY The management of newborns with esophageal atresia (EA) and right aortic arch (RAA) is still an unsolved problem. This study provides a systematic review of epidemiology, diagnosis, management and short-term results of children with EA and RAA. MATERIALS AND METHODS The PubMed database was searched for original studies on children with EA and RAA. In each study, data were extracted for the following outcomes: number of patients, associated anomalies, type of surgical repair, morbidity and mortality rate. RESULTS Eight studies were selected, including 54 patients with EA and RAA. RAA was encountered in 3.6% of infants. Preoperative detection of RAA was reported in 7 of them. In these patients, primary anastomosis was achieved through the right approach in 3 (thoracotomy in 2 and thoracoscopy in 1) while the left approach was the primary choice in 4 (thoracotomy in 2 and thoracoscopy in 2). No significant differences were found between the right and left approaches with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). In 47/54 patients (87%) RAA was noted during right thoracotomy, and primary anastomosis was achieved through the same approach in 29 (61.7%); conversion to other approaches (left thoracotomy or esophageal substitution) was performed in 15 children (38.3%). No significant differences were found between primary left thoracotomy (LT) and LT after RT with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). CONCLUSIONS Skills and preferences of the surgeon still guide the choice of surgical approach even when preoperatively faced with RAA. A multicenter, prospective randomized study is strongly required.

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.

Adenomyomatosis of the gallbladder in childhood: A systematic review of the literature and an additional case report

AIM To investigate the diagnostic and therapeutic assessment in children with adenomyomatosis of the gallbladder (AMG). METHODS AMG is a degenerative disease characterized by a proliferation of the mucosal epithelium which deeply invaginates and extends into the thickened muscular layer of the gallbladder, causing intramural diverticula. Although AMG is found in up to 5% of cholecystectomy specimens in adult populations, this condition in childhood is extremely uncommon. Authors provide a detailed systematic review of the pediatric literature according to PRISMA guidelines, focusing on diagnostic and therapeutic assessment. An additional case of AMG is also presented. RESULTS Five studies were finally enclosed, encompassing 5 children with AMG. Analysis was extended to our additional 11-year-old patient, who presented diffuse AMG and pancreatic acinar metaplasia of the gallbladder mucosa and was successfully managed with laparoscopic cholecystectomy. Mean age at presentation was 7.2 years. Unspecific abdominal pain was the commonest symptom. Abdominal ultrasound was performed on all patients, with a diagnostic accuracy of 100%. Five patients underwent cholecystectomy, and at follow-up were asymptomatic. In the remaining patient, completely asymptomatic at diagnosis, a conservative approach with monthly monitoring via ultrasonography was undertaken. CONCLUSION Considering the remote but possible degeneration leading to cancer and the feasibility of laparoscopic cholecystectomy even in small children, evidence suggests that elective laparoscopic cholecystectomy represent the treatment of choice. Pre-operative evaluation of the extrahepatic biliary tree anatomy with cholangio-MRI is strongly recommended.

Transverse flap duodenoplasty (TFD): a new technique in autologous bowel reconstructive surgery

BackgroundBowel dilatation is a common adaptive mechanism after intestinal resection. The symptomatic dilated dysmotile duodenum is difficult to manage, since conventional bowel tailoring and lengthening techniques are potentially hazardous because of the anatomy of the duodenal blood supply, the proximity to the pancreas, and the risk of injury to the common bile duct.MethodsA 2-month-old child with short bowel and a symptomatic massively dilated duodenum was treated with a Transverse Flap Duodenoplasty (TFD). The duodenum was opened longitudinally along its antimesenteric border preserving an intact strip of tissue overlying the pancreatic head. Three full thickness vascularized pedicle flaps were cut on both the anterior and posterior walls and were spirally rotated and sutured to create a uniform propulsive duodenum without diverticulae.ResultsHealing was complicated by a soft anastomotic duodeno-ileal stenosis that resolved after three elective balloon dilatations. Oral feeding established rapidly. The child is growing, does not vomit, and passes 1–2 semiformed motions daily.ConclusionsTFD is a safe and versatile technique that preserves all duodenal absorptive mucosa and that removes any risk to the pancreas, bile duct, and ampulla of Vater. Our experience, although limited, has been encouraging and leads us to suggest TFD for the management of the difficult symptomatic dysmotile dilated duodenum.

Laparoscopic Management of retroperitoneal cystic lymphangiomas in children: a systematic review and an additional case report

AIM: Retroperitoneal cystic lymphangiomas (RCLs) are rare vascular malformations which account for approximately 1% of all lymphangiomas in infancy. Surgical treatment of RCLs may be particularly challenging, due to their possible connection with vital structures. Laparoscopic excision has been recently described for RCLs also in pediatric patients, with only 14 published cases. METHODS: Authors provide a detailed systematic review of the pediatric literature according to PRISMA guidelines, focusing on laparoscopic treatment of RCLs in children. An additional case of a large RCL in a 4-year-old girl is also presented. RESULTS: The PubMed search yielded six relevant studies, encompassing a total of 14 children with RCLs; analysis was extended to our additional patient. Mean age at surgery was 6.6 years. Laparoscopic aspiration of the cysts before their removal was the common approach, used in 9 patients (64.3%. Conversion to open surgery was necessary in 3 cases (21.4%). Recurrence of the disease was reported only in one patient (7%). No mortality was reported. CONCLUSIONS: According to the limited available experience, accurate preoperative assessment and adequate training and skills make the laparoscopic resection of retroperitoneal lymphangioma a safe and feasible procedure, including within a pediatric context.

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.