M. Rivosecchi

Prenatal diagnosis and clinical outcome of ovarian cysts

Technical refinements of ultrasound (US) have greatly affected the antenatal diagnosis and treatment of ovarian cysts. From 1985 to 1990 25 consecutive fetuses with ovarian cysts were followed-up by US both during pregnancy and postnatally. All cases were diagnosed between the 28th and 39th weeks of gestation. Deliveries were all at term; cesarean section was required only for obstetric complications. Eight fetuses (32%) showed US patterns of cyst torsion, a finding confirmed at surgery in all. In five patients US patterns suggested complications postnatally that were also confirmed at operation. In six cases cysts increased or remained unchanged in size after 15 days of life: in 50% of these surgery showed ovarian torsion. In the remaining six cases spontaneous resolution occurred within 1 to 4 months. One patient required intrauterine needle aspiration. There were two cases of intestinal obstruction. To date, more than 60% of newborns with ovarian cysts require oophorectomy; however, different treatments (cystectomy, needle aspiration, uncapping) combined with a close US follow-up are likely to reduce this percentage.

The role of transanal endorectal pull-through in the treatment of Hirschsprung's disease - a multicenter experience.

Abstract.The transanal approach (TAA) is a new technique for surgery of Hirschsprungs disease (HD) that was introduced by de la Torre in 1998. The purpose of this multicenter study, including experience from three Austrian and one Italian departments of peadiatric surgery, was to evaluate the role of this approach in HD in 18 children aged 1–72 months. In 14 children the TAA only was performed; in 3 an additional laparoscopy was performed and in 1 conversion to a laparotomy was necessary. One complication (abscess) occurred after laparoscopic-assisted pull-through. The postoperative recovery was rapid, no severe long-term problems were observed. The transanal pull-through technique is generally possible in most classic cases of HD with extension of the disease to the sigmoid colon. If necessary, it can be combined with laparoscopy. Our preliminary results show that the technique is safe, less invasive, and gives excellent cosmetic results, and allows rapid recovery. Long-term results are still pending.

Stenting for caustic strictures: Esophageal replacement replaced

METHODS From 1983 to 1996, 31 children with caustic esophageal strictures were seen at Bambino Gesù Childrens Hospital; they were all treated conservatively except for two cases complicated by tracheoesophageal fistula. The remaining 29 patients were divided into three groups depending on the treatment, which was modified over the years. Group A (1983 to 1987) consisted of seven patients treated by periodic dilatations; group B (1988 to 1992) consisted of 10 children treated by 40 days of esophageal stenting plus dexamethasone, 0.5 mg/kg/d plus ranitidine plus no oral feeding for 7 to 10 days; group C (1993 to 1996) consisted of 12 cases treated by 40 days of esophageal stenting plus dexamethasone, 1 mg/kg/d plus omeprazole plus early oral feeding resumption. RESULTS No differences were observed between the three groups of patients with regard to the mean age and to the ingested substance, whereas a significant difference (P = .007) was observed in the mean length of the stricture between group A and C (3.4+/-1.3 and 5.6+/-1.6 cm, respectively). In all but one of the patients (96.5%) complete healing of the stenosis was achieved by conservative treatment, with definitive relief of dysphagia. One patient in group C did not improve after a repeated stenting procedure and was surgically treated. However, in group A, resolution of the stricture was obtained after an average of 19.9+/-14.8 dilatations in a mean period of 25.3+/-17.2 months. In group B, a mean of 12+/-11.3 dilatations were required in a mean period of treatment of 14.1+/-10.6 months. In patients in group C, a mean of 3.5+/-3.2 dilatations were necessary in a mean of 5.8+/-4.8 months. A statistically significant difference was observed both with regard to the number of dilatations and to the duration of treatment, between group A and group C (P = .002) and group B and C (P = .03). CONCLUSION Esophageal replacement should be considered only in cases complicated by tracheoesophageal fistula or in the rare patients who do not respond to repeated esophageal stenting.

Surgery for ulcerative colitis in pediatric patients: functional results of 10-year follow-up with straight endorectal pull-through

Children and adolescents affected by ulcerative colitis (UC) frequently require colectomy because of refractory or chronic symptoms. The aim of this paper is to present our experience and 10-year follow-up results of 28 patients who underwent endorectal pull-through (ERPT) as surgical treatment for UC, with special regard to surgical complications, stooling patterns (frequency of defecation, stool consistency, urgency period), fecal incontinence, and quality of life. A retrospective chart review of these patients was performed to evaluate age at colectomy, indication for surgical treatment, operative procedures, technical details, and early or late complications. Frequency of defecation was less than twice per day in two patients, between three and five times per day in nine patients, and more than six times per day in 10 patients. Stool consistency was normal in 14 patients, loose in five, and liquid in only two cases. Urgency period was normal (minutes) in 14 patients, short (seconds) in four, and absent in three. Ten patients (47%) have perfect or good fecal continence, whereas 11 (52%) patients present moderate to total incontinence. The self-reported emotional health was good in most of the patients. A large number are progressing well at school and are coping with their operations. Studies of quality of life in UC patients who underwent surgical treatment in childhood or adolescence, comparing as well the results according to the surgical technique adopted, must be encouraged.

Gastroesophageal reflux in neurologically impaired children: partial or total fundoplication?

Background: It is difficult to give guidelines when approaching gastroesophageal disease in neurologically impaired children. Indication for surgery has been increasing over recent years, but there is no consensus on the surgical technique of choice. Nothing has been written specifically comparing the results of different procedures in these patients, so far. Study design: We retrospectively compare the short- and long-term results of two different types of fundoplication in a series of children operated on for documented gastroesophageal reflux disease at our institution. Results: One group (group A) of 27 patients, operated on between 1977 and 1993, underwent Nissen fundoplication, the other (group B), formed of 20 patients all of whom were operated on between 1993 and 1995, underwent Thal fundoplication. We compared the results in terms of positive outcome (recovery) and negative outcome (minor and major complication), computing the relative odds of group A versus group B in terms of risk of complication, and we compared the mean operative time and the length of hospital stay by means of a students t-test analysis. Conclusions: Our results show that there is no statistical difference between the two procedures in terms of relative risk of complication and success rate. The duration of surgery and hospital stay were significantly shorter in group B. The Thal procedure can, therefore, be proposed as first choice in the management of these patients.

Persistent cloaca: are we ready for a correct prenatal diagnosis?

Cloacal malformations are rare and can present in variable aspects. The importance of ultrasound in detecting these anomalies is well known. Sonographic features vary in accordance with the type of malformation and the gestational age. A positive diagnosis is not possible because of the lack of specific ultrasound findings, which can show similar aspects to other abnormalities. We present 3 cases of prenatal diagnosis of this malformation, emphasizing that in the presence of a plurilobed cystic pelvic fetal mass with associated malformations, such as cardiac, renal, and vertebral anomalies, a persistent cloaca can reasonably be suspected.

Surgery in disabled children: general gastroenterological aspects.

UNLABELLED Cerebral palsy (CP) is a non-progressive but not unchanging disorder of movement and/or posture, due to an insult to or anomaly of the developing brain. Gastrointestinal surgery can play a role in the treatment of pathologies frequently associated with a condition of neurological impairment such as gastro-oesophageal reflux disease (antireflux procedure), feeding difficulties (percutaneous endoscopic gastrostomy/jejunostomy) and swallowing difficulties (ligation of salivary gland ducts). Gastro-oesophageal reflux occurs in up to 70-75% of children with cerebral palsy. Children with gastro-oesophageal reflux disease (GERD) may present with feeding difficulties, recurrent vomiting and recurrent chest infection associated with poor growth and nutrition, reactive airway disease particularly nocturnal asthma, choking attacks, anaemia, and wheezing. Nutritional deprivation in children with cerebral palsy is the summation of several factors which result in reduced intake. Percutaneous endoscopic gastrostomy (PEG) has radically changed the handling of children with nutritional problems who, before the introduction of this procedure, were force fed parenterally or enterally, by nasogastric tube, conventional surgical gastrostomy or central venous access. In children with CP, PEG is the preferred technique for long-term enteral feeding. Swallowing dysfunction is the main cause of drooling in cerebral palsy, and medical treatment is often inefficient. Surgical treatment involves neurectomy, translocation of the salivary duct, salivary gland resection or salivary duct (parotid and submandibular) ligation. CONCLUSION This review focuses on the role of surgery in managing gastrointestinal aspects in children with CP and, in particular, surgical experience at our department with fundoplication, PEG placement and ligation of salivary ducts.

The impact of perinatal urinoma formation on renal function: our experience and review of the literature.

Introduction:  A urinoma is a fluid mass consisting of extravasated urine in the perirenal space. Its impact on renal function was analysed.

Physical fitness testing in children operated on for tracheoesophageal fistula

The maximal physical activity capacity of children operated on for tracheoesophageal fistula (TEF) has not been clearly defined. Eight patients (average age, 12 years) successfully operated on for TEF at birth underwent maximal exercise stress testing on a treadmill, according to the Bruce protocol, to test physical work capacity. Heart rate (HR), oxygen consumption (VO2), and pulmonary ventilation (VE) were measured by a portable lightweight telemetric device. Nine healthy children served as controls. Exercise duration was significantly lower for TEF subjects than for controls (11.6 +/- 1.7 minutes v 15.1 +/- 2.3 minutes; P < .01). Mean HR at rest and during exercise did not differ between the groups. All children reached the maximum HR according to their age; however, for the majority of TEF patients, this occurred at an earlier stage than in the controls. No differences were seen in mean VO2 at rest and on exertion between TEF and control children. However, maximal VO2, as measured at the end of exercise, was significantly different when normalized per kilogram of body weight (VO2/kg = 52.3 +/- 5.8 v 33.3 +/- 6.6; P < .005). The physical rehabilitation of TEF children usually takes into account only respiratory and nutritional factors. However, complete assessment of their cardiac and respiratory function, at rest and on exertion, also should be performed, because this may show that some patients have reduced motor performance; evidence is now accumulating that these children can safely participate in the same physical activities of their healthy peers.

Surgery for ulcerative colitis in children

The treatment of children affected by inflammatory bowel disease—ulcerative colitis (UC) or Crohn’s disease (CD)—should seek to reduce or eliminate symptoms, optimize nutritional status, promote normal growth and development, prevent complications, and minimize the potential psychological effects of chronic illness. Because choice of treatment (nutritional, medical, or surgical) and treatment delivery (systemic or local) may depend on disease type and location, it is very important to assess the type, site, and extent of disease at diagnosis. Children with UC are reported to have more extensive disease than adults (pancolitis in 29% vs. 16%) [1]. In pediatric patients, who may face lifelong chronic disease, long-term effects of treatments are of particular concern, and noncompliance is an important problem, especially in adolescents. Children and adolescents affected by UC frequently require colectomy because of refractory or chronic symptoms; in contrast to CD, colectomy should be a curative procedure for such patients [2]. Surgical options for UC include either total proctocolectomy with rectal mucosectomy and straight ileoanal anastomosis (ERPT) with or without ileal pouch and temporary ileostomy, or colectomy with subtotal mucosectomy and ileo-rectal anastomosis with mechanical stapler, according to the Knight–Griffen technique [3]. The ERPT with some variant of pouch reservoir is considered to be the procedure of choice for UC requiring surgery because it preserves continence without the need for a permanent ileostomy. The ERPT was proposed by Ravitch and Sabiston [4], popularized by Soave [5] for treatment of Hirschsprung’s disease, and modified by Coran and Weintraub [6]. The first report on ERPT as surgical treatment for UC was presented by Martin et al. [7]. A number of different reservoir options are available in case of an ileal pouch construction that includes a ‘‘J’’-, ‘‘S’’-, or ‘‘W’’-shaped reservoir from the terminal ileum. Advantages of ERPT are a limited extrarectal dissection and a reduced risk of injury to the sphincter muscle and surrounding deep pelvic nerves. Moreover, the ERPT presents the fundamental requirements for anal continence by preserving the anorectal angle, levator muscle complex and puborectalis sling, anal sphincters, rectal ampulla, and anorectal sensation, and by maintaining reservoir capacity. The main advantages of an ileal reservoir are to increase rectal capacity and reduce bowel movements. As reported in most of the series with pouches, the median stool frequency is about four bowel movements/day (not including nighttime movements), in contrast to the ERPT, which has a stool frequency of about seven bowel movements/24 h [8–12]. However, it has been documented that these differences tend to disappear 1–2 years after the procedure [11]. Pouchitis remains a common problem. This clinical entity is characterized by variable symptoms, including increased stool frequency and fluidity, rectal bleeding, abdominal cramping, urgency and tenesmus, incontinence, fever, and extraintestinal manifestations. Although the exact etiology of pouchitis remains unclear, possible causes that have been advanced include fecal stasis, production of abnormal fatty acids, ischemia, oxygen free radical injury, deprivation of short chain fatty acids, and abnormal bile acid metabolism. The reported incidence of pouchitis is variable because of the difference in the nature and duration of follow-up and particularly because a myriad of diagnostic criteria have been used to define this syndrome. Furthermore, the risk of dysplasia of the mucosal pouch is also unknown. Morphologic changes associated with the development of dysplasia in the pouch mucosa occurred in children as well as in adults during a 5-year follow-up [13]. Nevertheless, an initial screening should be performed 5 years after the creation of a pelvic pouch in children or when the total M. Rivosecchi Department of Paediatric Surgery, Paediatric Hospital ‘‘Bambino Gesu’’, Rome, Italy