Pietro Betalli

Complications of percutaneous endoscopic gastrostomy in children: Results of an Italian multicenter observational study

BACKGROUND Percutaneous endoscopic gastrostomy is the preferred way to achieve an artificial feeding route for patients requiring long-term enteral nutrition. Although the procedure is well-standardized, it carries early and late complications. AIM To establish the mortality and morbidity of this technique in a large cohort of children. METHODS A multi-centre prospective clinical data collection from children undergoing percutaneous endoscopic gastrostomy tube implantation has been conducted from January 2004 to December 2007. Previous abdominal surgery was the only exclusion criterion. Follow-up visits were carried out at 1, 3, 6, 12, and 24 months after the procedure. RESULTS 239 children (males, 55.2%; mean age 6.05±6.1years) were enrolled from nine tertiary Italian centres. Major complications occurred in 8 patients (3.3%). The cumulative incidence of complications was 47.7% at 24 months. The presence of thoraco-abdominal deformity was an independent predictor of complications at 12 months. No risk factors were identified in association to complications during the 1st tube replacement. CONCLUSION In children undergoing percutaneous endoscopic gastrostomy placement minor complications are common, while severe morbidities are rare. Accurate follow up is essential to recognize every complication, in particular when risk factors such as thoraco-abdominal deformity exist.

Outcome Comparison Among Laparoscopic Duhamel, Laparotomic Duhamel, and Transanal Endorectal Pull-Through: A Single-Center, 18-Year Experience

PURPOSE Transanal endorectal pull-through has changed the treatment of Hirschsprungs disease (HD) in the past decade. The aim of the study was to compare outcomes, obtained in a single center, with laparotomic Duhamel (LTD), laparoscopic Duhamel (LSD), and laparoscopic-assisted transanal endorectal pull-through (LTEPT). MATERIALS AND METHODS We retrospectively reviewed the charts of all patients operated on for HD since 1992. Preoperative, operative, and postoperative data were collected to compare short- and long-term outcomes among the three groups. RESULTS From 1992 to 2010, 70 children were treated for HD. Patients were divided into three groups based on the surgical technique used: 14 LTEPT, 32 LSD, and 24 LTD. Mean ages at surgery were 4.67, 14.61, and 13.28 months, respectively. Patients in the LTEPT group had significant shorter operating times (195 versus 257 versus 291 minutes, P=.03), earlier start of feeding (1.2 versus 3.1 versus 4.7 days, P<.01), and shorter length of hospital stay (4.4 versus 6.8 versus 9.7 days, P<.011). Overall complications rate was lower in the LTEPT (14%) than in the LSD (31.2%) and LTD (29.7%) groups. Postoperative enterocolitis incidence was 3%-4% in the Duhamel groups and none in LTEPT. Long-term outcome showed less constipation and better continence for age in the LTEPT group at the 1-year follow-up (P=.033). CONCLUSIONS This study further supports technical advantages, lighter impact of the surgical procedure on infants, lower incidence of complications, and better long-term outcome of the transanal pull-through compared to the Duhamel approaches.

Update on management of caustic and foreign body ingestion in children

The following recommendations for management of caustic and foreign body ingestion in children have been developed following a multicentre study performed by the Italian Society for Paediatric Gastroenterology, Hepatology and Nutrition (SIGENP). They are principally addressed to medical professionals involved in casualty. Because there is paucity of good quality clinical trials in children on this topic, many of the recommendations are currently extrapolated from adult experiences or based on experts opinions. The document represents a level 2 to 5 degree of evidence (according to the Oxford Centre for Evidence-based Medicine Levels of Evidence), gathered from clinical experience, recent studies, and expert reports discussed during a consensus conference of the Endoscopic Section of the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition. This working group comprises paediatricians, endoscopists, paediatric surgeons, toxicologists, and ENT surgeons, who are all actively involved in the management of these children. Recommendations are intended to serve as an aid to clinical judgement, not to replace it and therefore do not provide answers to every clinical question; nor does adherence to them ensure a successful outcome in every case. The ultimate decision on the clinical management of an individual patient will always depend on the specific clinical circumstances of the patient, and on the clinical judgement of the health care team.

Ciliated hepatic foregut cyst: from antenatal diagnosis to surgery

Ciliated hepatic foregut cyst is the only ciliated cystic lesion known to occur in the liver. It is an extremely rare, benign and solitary cyst that probably arises from remnants of the embryonic foregut in the liver. We report a 16-month-old girl who underwent surgical excision of a hepatic cyst discovered during antenatal ultrasonography. Surgical exploration and excision were performed because of the uncertain aetiology of the cyst and because on postnatal follow-up US the size of the mass had increased causing extrinsic biliary obstruction. Pathology revealed a ciliated hepatic foregut cyst. This is the fourth child affected by this lesion reported in the literature, the second undergoing surgical excision, and the second with antenatal diagnosis.

High-frequency miniprobes and 3-dimensional EUS for preoperative evaluation of the etiology of congenital esophageal stenosis in children (with video)

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Interobserver agreement on endoscopic classification of oesophageal varices in children

Objectives: Data regarding agreement on endoscopic features of oesophageal varices in children with portal hypertension (PH) are scant. The aim of this study was to evaluate endoscopic visualisation and classification of oesophageal varices in children by several European clinicians, to build a rational basis for future multicentre trials. Methods: Endoscopic pictures of the distal oesophagus of 100 children with a clinical diagnosis of PH were distributed to 10 endoscopists. Observers were requested to classify variceal size according to a 3-degree scale (small, medium, and large, class A), a 2-degree scale (small and large, class B), and to recognise red wales (presence or absence, class Red). Overall agreement was considered fair if Fleiss and Cohen &kgr; test was ≥0.30, good if ≥0.40, excellent if ≥0.60, and perfect if ≥0.80. Results: Agreement between observers was fair with class A (&kgr; = 0.34) and class B (&kgr; = 0.38), and good with class Red (&kgr; = 0.49). The agreement was good on presence versus absence of varices (class A = 0.53, class B = 0.48). The agreement among the observers was good in class A when endoscopic features of severe PH (medium and large sizes, red marks) were grouped and compared with mild features (absent and small varices) (&kgr; = 0.58). Conclusions: Experts working in different centres show a fairly good agreement on endoscopic features of PH in children, although a better training of paediatric endoscopists may improve the agreement in grading severity of varices in this setting.

A new indication for buccal mucosal graft: isolated congenital fistula of the penile urethra

Isolated congenital urethrocutaneous fistula is uncommon, and its repair has been associated with high incidence of recurrence. However, the use of buccal mucosal graft offers a satisfactory closure after previous failures. We report a new case in whom we adopted the buccal mucosal urethral replacement to treat the recurrence.

Conservative treatment of spontaneous biliary perforation.

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Autism and esophageal achalasia in childhood: a possible correlation? Report on three cases.

Chronic gastrointestinal symptoms are commonly reported in autistic patients. Dysphagia is often present, and it is generally related to behavioral eating disorders. The association between autism and esophageal achalasia has not been described in literature yet. We report our experience with three cases of autistic children we recently treated for esophageal achalasia. In the first case (a 14-year-old male), achalasia was diagnosed with barium swallow and esophageal manometry and was successfully treated with three pneumatic endoscopic dilatations (follow-up: 3 years). In the second case (a 12-year-old female), achalasia was diagnosed with barium swallow and esophageal manometry and was treated with Heller myotomy after two unsuccessful pneumatic endoscopic attempts (follow-up: 3 months). In the last case, a 15-year-old male underwent barium swallow and endoscopy that confirmed achalasia. He was treated with Heller myotomy, and he is asymptomatic at a 6-month follow-up. To our knowledge, this is the first report of a possible association between autism and esophageal achalasia. Because of the rarity of both diseases, their association in the same patient is unlikely to be casual even if speculation on their common etiology is impossible at present. This finding needs further confirmation, but it is sufficient, in our opinion, to indicate proper evaluation with barium swallow and/or manometry in any autistic children with eating difficulty.

Video-Assisted Thoracoscopy in Compromised Pediatric Patients

The use of video-assisted techniques (VATs) in the paediatric field has become increasingly more frequent, based on reports of prompter recovery following VATs in respect to standard techniques. Specific advantages have been documented, in particular for pediatric patients undergoing chemioradiotherapic treatment. We retrospectively reviewed data of severely compromised patients who underwent VAT for lung wedge resections and biopsies carried out in our center over a 7-year period. As far as the area of therapeutic tumor resection is concerned, the present data are consistent with the view that thoracoscopy is both an effective and safe tool in diagnostic procedures.