Paolo Schingo

Sonographic biometry of liver and spleen size long after closure of abdominal wall defects

Little is known about the fate of the liver and spleen after closure of the abdominal cavity in patients with abdominal wall defects (AWD). Therefore, counselling families for long-term follow-up and in the case of surgery for acute disease, pregnancy or trauma may be difficult. A total of 18 patients ranging in age from 7 to 18 years, with AWD closed at birth, underwent ultrasound evaluation of liver and spleen size by determination of the index of liver size (ILS) and splenic volume (SV). These values were then correlated with some anthropometric parameters such as body mass index (BMI) and weight; correlation was also sought with some clinical features such as type of defect and direct or staged closure. Nearly all subjects exhibited weight above and BMI below the 50th percentile for age. ILS and SV were significantly above normal limits in all cases and no difference was found with regard to the type of defect. Conclusion:in patients having undergone surgery for abdominal wall defects, liver and spleen usually regain their normal shape and position even though size and volume appear to be larger than in normal controls.

Clinical management of post-pyloric enteral feeding in children

Post-pyloric feeding (PF) allows the administration of enteral nutrition beyond the pylorus, either into the duodenum or, ideally, into the jejunum. The main indications of PF are: upper gastrointestinal tract obstructions, pancreatic rest (e.g., acute pancreatitis), gastric dysmotility (e.g., critically ill patients and chronic intestinal pseudo-obstruction) or severe gastroesophageal reflux with risk of aspiration (e.g., neurological disability). Physiological and clinical evidence derives from adults, but can also be pertinent to children. This review will discuss the practical management and potential clinical applications of PF in pediatric patients. Some key studies pertaining to the physiological changes during PF will also be considered because they support the strategy of PF management.

Pediatric Short Bowel Syndrome: Predicting Four-Year Outcome after Massive Neonatal Resection

Objectives The aim of this study was to ascertain predictors of survival, liver disease (LD), and enteral autonomy 48 months after resection in neonatal short bowel syndrome (SBS) patients with residual small bowel length (SBL) ≤40 cm. Patients and Methods Medical records of all SBS patients followed up between 1996 and 2016 were retrospectively reviewed. Survival rate, prevalence of LD, and of enteral autonomy were evaluated. Results Forty‐seven patients were included, and 43 were still alive at the end of the study period, with cumulative 48‐month survival of 91.5%. Twenty‐one (45%) patients developed LD, all within the first 6 months. On the final follow‐up visit, three (6%) patients were still jaundiced and progressed toward end‐stage LD. LD prevalence was higher in patients with recurrent bloodstream infections (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.5‐19.3). Of the 43 surviving patients, 22 (51%) had enteral autonomy 48 months after resection. The probability of weaning off parenteral nutrition (PN) was strongly correlated with the remaining SBL. Conclusion Survival of patients who have undergone neonatal massive small bowel resection has improved in recent years. Multidisciplinary strategies can improve the course of LD, but not the probability of weaning off PN, which seems to be strongly dependent on the anatomical profile of residual bowel. Therefore, the primary surgical approach should be as conservative as possible to gain even small amounts of intestinal length, which may be crucial in promoting intestinal adaptation.

Management of children presenting with low back pain to emergency department. A 7-year retrospective study

Objective: We aimed to describe characteristics, etiology and health care use in children with low back pain (LBP) presenting to pediatric emergency department (ED) and to develop an algorithm to design a diagnostic approach. Methods: We conducted a 7‐year cohort study of children admitted to ED with a primary complaint of LBP. They were classified into diagnostic groups: visceral LBP; traumatic LBP; non‐visceral/non‐traumatic LBP. To identify high‐risk factors (red flags) associated with severe prognosis conditions (SPCs), we analyzed the non‐visceral/non‐traumatic group comparing the SPC children with those children without SPCs. Results: Our population comprised 140 females (52.6%) and 126 males (47.4%), with a median age of 10.5 years. Eighty children (30.3%) were hospitalized, with an average length of stay of 8.53 ± 9.84 days. SPCs accounted for 28 patients (18.9%) of overall 148 with non‐traumatic/non‐visceral LBP. In this group, SPCs presented with earlier onset and longer duration of symptoms than non‐SPCs. The presence of red flags was more significant in the SPCs group, 28 vs 18; 100% vs 15% (p < 0.001); sensitivity 100%, specificity 85%. Among SPCs, 78.6% were hospitalized vs non‐SPC (16.8%) (p < 0.001); within SPC group 2 patients returned because of onset of red flags. Conclusion: Our study identified significative high‐risk factors (red flags) associated with serious outcomes (SPC group) compared to the non‐SPC group, thereby ensuring specific treatment. We developed an algorithm based on previous literature and the findings of our study, which will need to be validated by future prospective research.

Posterior Urethral Valves

Posterior urethral valves (PUVs) represent the most common cause of lower urinary tract obstruction in males, with incidence ranging from 1:5.000 to 1:8.000 live births, according to most of the series. PUVs represent a congenital phenomenon mostly occurring sporadically and consist of abnormal mucosal folds between the urethral wall and the distal end of the verumontanum, presenting with a spectrum of severity, from mild to lethal forms, depending on the degree of obstruction. Nowadays, with the widespread use of prenatal ultrasonography and increasing awareness, PUVs are most frequently detected during routine prenatal ultrasound. Newborns may present with delayed voiding or poor urinary stream, abdominal mass, urinary tract infections, poor feeding, and failure to thrive. Ultrasound is the primary imaging method and shows thickened, trabeculated bladder walls and an elongated dilated posterior urethra, with the so-called keyhole sign due to the distention of both the bladder and the posterior urethra, immediately proximal to the obstructing valves, and uni- or bilateral dilatation of the renal pelvis and dilatation and tortuosity of the ureters. Ascites and perirenal urinoma may represent spontaneous forms of urinary tract decompression. Voiding cystourethrography (VCUG) is the only direct means of diagnosing PUVs, before cystoscopic evaluation. VCUG demonstrates dilatation and elongation of the posterior urethra, thickened bladder walls with sacculations, trabeculations, and diverticula. VCUG also identifies preobstructive secondary changes in the urinary tract and detects and grades vesicoureteral reflux (VUR). Urodynamic and radionuclide studies may be helpful in the follow-up of these patients.

Hydrometrocolpos: Hematocolpos/Colpo-hematometra

Hydrometrocolpos, or hematocolpos, and hematometra can occur in patients with female genital tract malformation obstruction, presenting during two different stages in life because of the functional features of the endometrium, as in newborn-infanthood-childhood or at puberty.