Giovanni Cobellis

Italian multicenter survey on laparoscopic treatment of gastro-esophageal reflux disease in children

Background: Skepticism is still present today about the laparoscopic treatment of gastro-esophageal reflux (GER) in children. We present the prospective experience and short-term results of eight Italian pediatric surgical units. Methods: We included all the children with complicated GER, operated after January 1998 by single surgeons from eight different centers. Diagnostic aspects, type of fundoplication, and complications were considered. All the patients were followed for a minimum period of 6 months in order to detect complications or recurrences. Results: 288 children were prospectively included. Mean age was 4.8 years (3 m–14 y). Nissen fundoplication was done in 25%, floppy Nissen in 63%, Toupet in 1.7%, and anterior procedures (Lortat Jacob, Thal) in 10%. Gastrostomy was associated, if neurological impairment or feeding disorders were present. Mean follow-up was 15 months and reoperation was necessary in 3.8% of cases. Conclusions: This experience underlines that minimal invasive access surgery in children is safe and that the laparoscopic approach is considered in eight centers the golden standard for surgical repair of gastro-esophageal reflux disease maintaining the same indications and techniques of the open approach.

The value of laparoscopy in the management of non-palpable testis

OBJECT To retrospectively review the value of laparoscopy in the management of impalpable testis. MATERIALS AND METHODS In 1993-2006, 182 laparoscopies for impalpable testis were performed for a total of 194 testicular units. Five laparoscopic findings were considered: testicular ectopia, intra-abdominal testis, and cord structures that are blind ending, completely absent (agenesis) or entering the internal inguinal ring. RESULTS In 62 cases an intra-abdominal testis was found; 18 were classified as high and managed by a laparoscopic Fowler-Stephens procedure. Cord structures entering the inguinal ring were observed in 77 patients and 45 underwent an inguinal exploration: a testis was found in 12 cases and in 33 a remnant was excised. In 35 cases, intra-abdominal blind ending vas and vessels were observed and eight showed testicular agenesis. No major surgical complications were recorded. Follow up ranged from 1 to 3 years. CONCLUSIONS Our study confirms the value of laparoscopy in the management of non-palpable testis, providing a definitive diagnosis by the direct view of spermatic bundle and testis. Ninety-three patients were managed by laparoscopy only, and in 44 it was essential for the subsequent surgical approach. When the internal inguinal ring is patent and/or normal spermatic vessels are present an inguinal exploration is mandatory.

Spermatogenesis and cryptorchidism

Cryptorchidism represents the most common endocrine disease in boys, with infertility more frequently observed in bilateral forms. It is also known that undescended testes, if untreated, lead to an increased risk of testicular tumors, usually seminomas, arising from mutant germ cells. In normal testes, germ cell development is an active process starting in the first months of life when the neonatal gonocytes transform into adult dark (AD) spermatogonia. These cells are now thought to be the stem cells useful to support spermatogenesis. Several researches suggest that AD spermatogonia form between 3 and 9 months of age. Not all the neonatal gonocytes transform into AD spermatogonia; indeed, the residual gonocytes undergo involution by apoptosis. In the undescended testes, these transformations are inhibited leading to a deficient pool of stem cells for post pubertal spermatogenesis. Early surgical intervention in infancy may allow the normal development of stem cells for spermatogenesis. Moreover, it is very interesting to note that intra-tubular carcinoma in situ in the second and third decades have enzymatic markers similar to neonatal gonocytes suggesting that these cells fail transformation into AD spermatogonia and likely generate testicular cancer (TC) in cryptorchid men. Orchidopexy between 6 and 12 months of age is recommended to maximize the future fertility potential and decrease the TC risk in adulthood.

Role of anorectal manometry in children with severe constipation

Objective  Constipation is one of the most frequent disorders of the digestive tract in children and it can be an important problem in paediatric and surgical practice. Most of the time, the cause is psychological or because of a slowing of colonic transit, but it can be a sign of organic gastrointestinal outlet obstruction. Some patients with chronic constipation are resistant to a medical approach and they present with a severe form of constipation that needs recurrent hospital admission. Anorectal manometry (ARM) is a noninvasive procedure and it helps to explain the mechanisms of defecation disorders. The aim of the present study was to evaluate the role of ARM in children with severe constipation.

Diagnosis of Hirschsprung’s Disease: an age-related approach in children below or above one year

Aim  The aim of this study was to evaluate the effectiveness of a differential diagnostic approach to Hirshchsprung’s Disease (HD) on the basis of age.

Versatility of one-trocar surgery in children.

BACKGROUND/PURPOSE One-trocar surgery (OTS) includes all video-surgical techniques performed using a single 10-mm port and an operative scope. These techniques can be completely endoscopic or endoscopic assisted. Since 1997, OTS has become the approach of choice in our institution for a variety of laparoscopic, retroperitoneoscopic, and thoracoscopic operations. We report our experience with this technique. METHODS Four hundred fifty-eight patients (age range, 3 months to 17 years) underwent OTS from October 1997 to December 2008. The procedures were transumbilical laparoscopic-assisted (TULA) appendectomy (182 patients), TULA small bowel resection (14 patients), TULA intestinal biopsies (7 patients), laparoscopic adhesiolysis (6 patients), laparoscopic-assisted liver biopsies (5 patients), laparoscopic revision of peritoneal dialysis catheter (3 patients), retroperitoneoscopic varicocelectomy (202 patients), retroperitoneoscopic-assisted renal biopsies (4 patients), retroperitoneoscopic drainage of posttraumatic urinoma (1 patient), retroperitoneoscopic-assisted pyeloplasty (15 patients), and thoracoscopic pleural debridement and decortication for empyema (19 patients). RESULTS The procedure was completed using only one trocar in 399 cases (87.1%). All conversions to multitrocar or open surgery were elective and regarded the retroperitoneoscopic approach during the learning curve (28 of 222, 12.6%; 21 varicocelectomies and 7 pyeloplasties) and the TULA appendectomy because of the appendix mobilization failure (31 of 182, 17%). There were no intraoperative or postoperative complications related to OTS. Wound infection was observed after two TULA appendectomies (1.3%). CONCLUSIONS According to our experience, OTS is a feasible and versatile technique in pediatric surgery, providing a safe, effective, and the least invasive treatment for several different diseases.

Are Infants with Bronchopulmonary Dysplasia Prone to Gastroesophageal Reflux? A Prospective Observational Study with Esophageal pH-Impedance Monitoring

OBJECTIVE To perform an observational cohort study with esophageal pH-multichannel intraluminal impedance (pH-MII) monitoring in symptomatic preterm infants with and without bronchopulmonary dysplasia (BPD). STUDY DESIGN We prospectively studied 46 infants born ≤32 weeks gestational age: 12 infants with BPD and 34 infants without BPD. Each patient had symptoms consistent with gastroesophageal reflux and had 24-hour pH-MII, which were compared between BPD and non-BPD by univariate analysis and quantile regression analysis. RESULTS Demographic and clinical characteristics were similar between infants with and without BPD, except for fluid administration (145 vs 163 mL/kg/d, P = .003), length of stay (92 vs 69 days, P = .019), and time to achieve complete oral feeding (76 vs 51 days, P = .013). The analysis of 1104 hours of pH-MII tracings demonstrated that infants with BPD compared with infants without BPD had increased numbers of pH-only events (median number 21 vs 9) and a higher symptom sensitivity index for pH-only events (9% vs 4.9%); the number and characteristics of acid, weakly acid, nonacid and gas gastroesophageal reflux events, acid exposure, esophageal clearance, and recorded symptoms did not significantly differ between the 2 groups. CONCLUSIONS The increased number of (and sensitivity for) pH-only events among infants with BPD may be explained by several factors, including lower milk intake, impaired esophageal motility, and a peculiar autonomic nervous system response pattern.

Beyond the Intestinal Celiac Mucosa: Diagnostic Role of Anti-TG2 Deposits, a Systematic Review.

Aim: To review the existing literature on the role and significance of intestinal transglutaminase 2 immunoglobulin A deposits (TG2 deposits) in patients with overt celiac disease (CD), potential celiac disease (PCD), and other autoimmune or gluten-related conditions. Methods: We conducted a systematic review of studies published in English, evaluating presence and characteristics of TG2 deposits in subjects with overt CD, PCD, gluten-related diseases [dermatitis herpetiformis (DH), gluten-ataxia (GA)], autoimmune disorders (type-1 diabetes), and other conditions. Studies were identified through a MEDLINE search (1950–2013). Results: Twenty-three studies were included in the review. Eleven studies were performed in children. Overall TG2 deposits were present in 100% of adults with overt CD, while in children prevalence ranged from 73.2 to 100%. Six studies with an established definition of PCD were considered, prevalence of deposits ranging from 64.7 to 100%. A single study followed-up PCD patients with repeated biopsies and identified presence of intestinal deposits as the best marker to reveal progression toward villous atrophy. Two studies investigated presence of deposits in DH, reporting prevalence between 63 and 79%. A single study documented TG2 deposits in 100% of patients with GA. In children with type-1 diabetes (T1D), positivity of intestinal TG2 deposits ranged from 25 to 78%. Conclusion: Transglutaminase 2 IgA deposits seem to be a constant feature in overt CD patients and are frequently detectable in other gluten-related conditions (DH and GA). The vast majority of PCD patients express TG2 deposits at the intestinal level, but no sufficient data are available to exactly define their prognostic role as a marker of evolution toward overt CD. The frequent finding of TG2 deposits in the intestinal mucosa of patients with T1D is an interesting observation deserving further evaluation.

Transumbilical Laparoscopic-Assisted Appendectomy in the Treatment of Acute Uncomplicated Appendicitis in Children

Transumbilical laparoscopic-assisted appendectomy (TULAA) is increasingly being performed worldwide. The authors report their experience in the treatment of acute uncomplicated appendicitis in children with TULAA. From January 2008 to December 2012 all types of acute appendicitis were divided, according to the clinical and ultrasonographic findings, into complicated (appendiceal mass/abscess, diffuse peritonitis) and uncomplicated. Complicated appendicitis was treated by open appendectomy (OA). All patients with the suspicion of uncomplicated appendicitis were offered TULAA by all surgeons of the team. Conversion to open or laparoscopic appendectomy (LA) was performed in case of impossibility to complete TULAA, depending on the choice of surgeon. The histopathologic examination of appendix was always performed. 444 children (252 males) with acute appendicitis were treated. The mean age was 9.2 years (range, 2 to 14 years). Primary OA was performed in 144 cases. In 300 patients a transumbilical laparoscopic-assisted approach was performed. TULAA was completed in 252 patients. Conversion to OA was performed in 45 patients and to LA in 3. Conversion was related to the impossibility to adequately expose the appendix in 47 patients and bleeding in 1. The mean operative time for TULAA was 42 minutes. Histopathologic examination of the appendix removed by TULAA showed a phlegmonous/gangrenous type in 92.8% of cases. Among the 252 TULAA there were 11 cases of umbilical wound infection. TULAA is a feasible and effective procedure for uncomplicated appendicitis in children. It combines the advantages of open and laparoscopic technique (low operative time, low complications rate, and excellent cosmetic results).

Genetics of Vesicoureteral Reflux.

Vesicoureteral reflux (VUR) is the retrograde passage of urine from the bladder to the upper urinary tract. It is the most common congenital urological anomaly affecting 1-2% of children and 30-40% of patients with urinary tract infections. VUR is a major risk factor for pyelonephritic scarring and chronic renal failure in children. It is the result of a shortened intravesical ureter with an enlarged or malpositioned ureteric orifice. An ectopic embryonal ureteric budding development is implicated in the pathogenesis of VUR, which is a complex genetic developmental disorder. Many genes are involved in the ureteric budding formation and subsequently in the urinary tract and kidney development. Previous studies demonstrate an heterogeneous genetic pattern of VUR. In fact no single major locus or gene for primary VUR has been identified. It is likely that different forms of VUR with different genetic determinantes are present. Moreover genetic studies of syndromes with associated VUR have revealed several possible candidate genes involved in the pathogenesis of VUR and related urinary tract malformations. Mutations in genes essential for urinary tract morphogenesis are linked to numerous congenital syndromes, and in most of those VUR is a feature. The Authors provide an overview of the developmental processes leading to the VUR. The different genes and signaling pathways controlling the embryonal urinary tract development are analyzed. A better understanding of VUR genetic bases could improve the management of this condition in children.