Roberto Lo Piccolo

Adnexal torsion in children and adolescents: new trends to conservative surgical approach – Our experience and review of literature

The purpose of this study is to discuss the surgical treatment for ovarian torsion in children and adolescents with a focus on the procedures of adnexal conservation surgery and its frequency in the literature of the last 10 years. We retrospectively reviewed the medical charts of 127 operative ovarian lesions including 30 ovarian torsions (23.6%) treated in two pediatric centers over a 10-year period. Age at presentation, presenting symptoms, diagnostic studies, surgical procedure and pathological findings were analyzed. Mean age was 13.7 years. Conservative surgery has been performed in 46.7% of the cases and laparoscopic approach in 40%. Ovarian torsion occurred in 56.7% on ovaries with functional lesion, in 23.3% on normal adnexa and in 20% on ovaries with benign neoplasm. The article includes a literature review (2000–2010) and a statistical analysis which shows a slow increase in conservative surgery from 28 to 45%. Laparoscopic surgery accounts for 23.5%. Literature review shows 40.5% normal adnexa, 33.2% non-neoplastic lesions, 25.3% benign neoplasms and 1% malignant neoplasms. The surgical treatment of children and adolescents presenting adnexal torsion should be practiced as an emergency and it should be more conservative as possible in order to maximize the future reproductive potential.

The Role of Testicular Volume in Adolescents With Varicocele: The Better Way and Time of Surgical Treatment

PURPOSE We report varicocele prevalence in adolescents. Surgical treatment has been proposed in adolescents with relevant testicular disproportion to avoid fertility problems in adulthood. We prospectively analyzed the testicular volume variation in adolescents with varicocele and hypoplastic testis. MATERIALS AND METHODS In a 2-year period we selected 54 consecutive pediatric patients with a median age of 14.5 years (range 13 to 16) who had left varicocele using certain criteria, including testicular volume discrepancy greater than 20%, no previous inguinal-testicular surgery and no symptoms. Adolescents were divided into 2 groups, including 27 who underwent surgical correction with lymphatic sparing microsurgical varicocelectomy (intervention) and 27 who were only observed (control). After surgery or at first observation patients were evaluated clinically and by ultrasound at 3, 6 and 12 months. Testicular volume was estimated by the prolate ellipsoid formula. RESULTS We noted significant improvement in testicular volume with less than 20% disparity between the 2 gonads in 23 patients (85.2%) in the intervention group and in 8 controls (29.6%). Two recurrences (7.4%) were reported in the intervention group, each in an adolescent with increased testicular volume. CONCLUSIONS Our study confirms significantly increased testicular volume in many surgically treated boys and shows that physiological catch-up growth occurs in adolescents with varicocele without treatment. Considering critically results in each group, in select cases clinical and ultrasound followup is indicated before intervention due to a possible spontaneous decrease in testicular asymmetry. Further histopathological studies are needed to identify the relationship between testicular hypoplasia, irreversible damage and future fertility problems to determine which adolescents should be treated.

Chest fast MRI: an Imaging alternative on pre-operative evaluation of Pectus Excavatum

BACKGROUND Standard imaging methods in evaluating chest wall deformities, such as Pectus Excavatum (PE) in paediatric and adolescent patients, include baseline 2-view chest radiography and chest CT scan. Only few studies to date investigated the value of fast MRIin the pre operative assessment of patient affected by PE. OBJECTIVE To evaluate the efficacy of chest fast MRI in pre-operative management of patient affected by PE. To obtain the Haller Index (HI) and Asymmetry Index (AI) from chest fast MRI protecting patients from radiation exposure. MATERIALS AND METHODS We analyzed the data of 42 consecutive patients with severe PE who underwent minimally invasive repair between March 2007 and March 2010. All 42 patients received chest fast MRI, but only the first 5 in view of the results, were studied also with chest ultrafast CT scan. In both examinations, data at the deepest point of the depression were collected. RESULTS Severity indices of the deformity using HI and AI, collected from CT scan and fast MRI in the first 5 patients, were comparable. In the remaining 37 fast chest MRI offered good images of the chest wall deformities with no radiation exposure, detailing anatomical information such as displacement and rotation of the heart or great vessels anomalies. CONCLUSION This study suggests the use of chest MRI in pre operative workup for patients with PE to obtain severity indices (Haller Index and Asymmetry Index avoiding radiation exposure to paediatric patients.

Multidisciplinary Surgical Approach to a Surviving Infant With Sirenomelia

Sirenomelia is an extremely complex and rare malformation with different degrees of lower-extremities fusion associated with gastrointestinal, musculoskeletal, vascular, cardiopulmonary, and central nervous system malformations. In the English literature, there are only 5 reports of infants surviving with this condition. In our case, a 2540-g female infant was born with normal vital signs, no facial dysmorphism, and a complete soft tissue fusion of the lower limbs, from perineum to ankles. Radiologic examinations revealed an intestinal atresia and a single pelvic kidney, with a unique ureter, 2 femurs, 2 tibias, 2 fibulas, and 2 feet (simpus dipus). At 7 months of age, a multidisciplinary surgical team achieved complete separation of the lower limbs, with independent vascular and nerve supplies. At the time of this writing, the infant was 28 months old and had a regular growth curve. Many future reconstructive surgeries have been planned to achieve an acceptable quality of life for this infant.

Treatment of Ovarian Lesions in Children and Adolescents: A Retrospective Study of 130 Cases

In this study, we analyze the management of ovarian masses in a total of 130 children surgically treated for 137 ovarian lesions (7 bilateral). The most frequent symptoms were chronic (52.3%) and acute (25.4%) abdominal pain. Histological examination revealed 64 (46.7%) functional lesions, 59 (43.1%) benign neoplasms, 5 (3.7%) malignant ones, and 7 (6.6%) torsed normal ovaries. Ovarian torsion occurred in 36 cases (26.27%). A conservative treatment was performed in 81 (59.1%) girls: 61 (75.3%) treated in nonemergency and 20 (24.7%) in emergency surgery; laparoscopic approach in 35 cases (43.2%); and open surgery in 46 (56.8%). The remaining 56 (40.9%) ovarian masses underwent nonconservative surgery: 40 cases (71.4%) nonemergency and 16 (28.6%) emergency; laparoscopy in 20 patients (35.7%); and open surgery in 36 (64.3%). Fertility preservation should be a goal in the surgical treatment. The management of ovarian torsion should include adnexal detorsion and recovery of the ovarian tissue. In case of benign neoplasms, laparoscopic tumorectomy should be the gold standard; in early stage malignant tumors, fertility-sparing surgery with accurate staging is preferred.

Is a Shorter Bar an Effective Solution to Avoid Bar Dislocation in a Nuss Procedure

BACKGROUND A variety of expedients to minimize bar dislocation in the Nuss procedure has been reported. The aims of this study were to create a mathematical model to define mechanical stresses acting on bars of different lengths in the Nuss procedure, and to apply this model to clinical scenarios. METHODS Finite element model analyses were used to outline the mechanical stresses and to mathematically define different cases. Data from a group of patients with procedures carried out using standard Nuss criteria (NC group; bars half an inch shorter than the distance between the mid-axillary lines) were compared with data from a second group treated by applying model-based suggestions (MS group; bars approximately 3 inches shorter than the distance between the mid-axillary lines). RESULTS Mean patient age in the NC group (48 cases) was 16.4 years old (84% males). The mean operating time was 57 minutes, and the mean bar length was 14.19 inches. There were 5 cases (10.4%) of bar dislocation. Mean patient age in the MS group (88 cases) was 16.2 years old (87% males). The mean operating time was 43 minutes and the mean bar length was 11.67 inches. There was only 1 bar dislocation, a reduction from 10.4% (NC) to 1.1% (MS) odds ratio 0.0989 (confidence interval 0.0112 to 0.8727), p = 0.0373. CONCLUSIONS A shorter Nuss bar reduces tension on the sutures applied at bar extremities. This leads to enhanced bar stability and a reduced risk that the bar will flip. The use of a shorter Nuss bar may reduce the incidence of bar dislocation.

Role of thoracoscopy in traumatic diaphragmatic hernia

Thoraco‐abdominal trauma can in rare cases involve diaphragmatic rupture and subsequent herniation of intra‐abdominal contents. We report a case of this complication in a 5‐year‐old boy who was injured in a car crash, and who manifested respiratory distress and hemodynamic instability after 48 h of being monitored in the pediatric intensive care unit. Multiple radiologic investigations were inconclusive and the definite diagnosis was established only on thoracoscopic exploration.

A Simplified Method to Pass the Bar Through the Mediastinum in the Nuss Technique

In the minimally invasive repair of pectus excavatum, as reported by Nuss, the introducer is inserted into the thoracic cavity, making its way through the mediastinum, and emerges through a left intercostal space. Then, 2 umbilical tapes are tied to the introducer tip as a guide to pass into this tunnel the curved bar with the concave side up. When fat tissue is present in the anterior mediastinum or bars with notched ends are used, passage of the umbilical tape could be challenging and eventually lead to bleeding. In this report, we describe a different and simple technique to allow this passage, from left to right, in a very safe and effective way.

Traumatic Abdominal Wall Hernia

To the Editor: Traumatic abdominal wall hernia (TAWH) is defined as “herniation through disrupted musculature and fascia, associated with adequate trauma, without skin penetration and no evidence of a prior hernia defect at the site of injury” [1, 2]. TAWHmay occur after low-energy impacts and can be associated with intra-abdominal injuries [3]. Herein, we describe a case of TAWH occurring in a six-year-old boy who sustained an abdominal trauma due to bicycle handlebar. The first evaluation, immediately after the event, was unremarkable. Eight days later, the boy presented with an intermittent bulge at the site of the trauma (Fig. 1). An ultrasound scan confirmed a definite defect of the aponeurosis of the internal oblique muscle with intermittent herniation of intestinal loops. Surgical exploration revealed a defect of the abdominal wall involving the aponeurotic sheaths without muscular or peritoneal lesions. A layer-by-layer interrupted polyglactin closure was performed. Post-operative and outpatient follow-up were uneventful. Most TAWHs occur in the lower abdomen: the tension of the abdominal wall musculature between the bony prominences of the pelvis and the thinner rectus sheath below the arcuate line could explain the relative weakness of this area [4].

Left anterolateral emergency thoracotomy during the Nuss procedure: Lifesaving shortcut

In the present article we describe a lifesaving approach following myocardial tear that occurred during minimally invasive repair of pectus excavatum (MIRPE) in a 14-year-old girl with severe and asymmetric PE (Fig. 1a). During the intrathoracic passage a minor myocardial lesion occurred, resulting in cardiac tamponade. Three units of blood were immediately transfused, while left anterolateral emergency thoracotomy was performed by extending the incision up to 8 cm along the seventh intercostal space (Fig. 1b,c). The pericardium was then slit open with Mayo scissors, a lesion of the right auricle was identified and sutured within 3 min with interrupted Prolene 4.0 and a Nuss bar was then placed in the sixth space. After surgery the patient recovered quickly, cardiac function was deemed normal and the bar was successfully removed after 3 years (Fig. 1d). While MIRPE is currently considered a safe procedure with several large series reporting a null mortality rate, there are few reports on major complications such as liver piercing, bilateral empyema, bacterial pericarditis or thoracic outlet-like syndrome and cardiac damage. Although the incidence has not been clarified as yet, 16 cases of cardiac injury have been reported. It typically occurs when advancing the introducer while passing through the mediastinum. Other reported mechanisms are the generation of myocardial tear along with fibrotic tissue during bar removal, and myocardial injury due to deep sternal wiring used to elevate the sternum. Although no indicators of enhanced risk of cardiac injury during bar positioning or removal have been identified, some cases have been associated with considerable severe deformity prior to thoracotomy, Ravitch repair or previous pericardial tear at bar positioning (Table S1). Most cases of cardiac damage manifest in the operating room with signs of cardiac tamponade and, eventually, asystole. Immediate decompression of the heart and wound repair was carried out via median sternotomy in 10 cases, left thoracotomy in three cases and bilateral thoracotomy in one case (Table S1). Several modifications of the procedure have been suggested to improve safety. To enhance visualization (besides the use of 30° 5 mm scopes) bilateral thoracoscopy and the use of a transparent hollow tube to guide thoracoscopy, namely “tunneloscopy”, have been proposed. In addition, sternum elevation methods have been argued for widening the space corresponding to the anterior mediastinum. The Crane technique consists of sternum fixation by means of a towel clip, a bone hook or a sutured wire followed by its attachment to a body retractor; by using a vacuum bell, or by inserting either two Langenbeck retractors inside both hemithoraces or a new elevator (with the same curvature as the introducer via the existing incisions) further scarring can be avoided. Median sternotomy is the approach of choice in cardiac surgery and was preferred in most of the aforementioned cases. On the other hand, emergency surgery protocols suggest that thoracotomy in cases of thoracic trauma with cardiac tamponade should be promptly performed on the left anterolateral chest wall in the fifth intercostal space. With regards to the present case, the latter approach offers clear advantages: it is technically much more accessible because it consists of simple prolongation of the left incision, thus permitting direct damage control. When the heart is injured during the Nuss procedure, the tear is likely to be on its anterior aspect, as in the present case, given that dissection is carried out on mediastinal pleurae between the posterior side of the sternum and the anterior face of the heart. Moreover, considering that PE is associated with leftward displacement of the heart, left incision provides a satisfactory field of vision. On the same basis, orthotopic cardiac transplant in a PE patient through a left anterior thoracotomy has been reported. Besides minimizing intervention time, specific complications of conventional sternotomy such as sternum instability and pseudoarthrosis, brachial plexus injury, or higher general risk in the case of redo sternotomy, are avoided. In conclusion, left Correspondence: Marco Ghionzoli, MD PhD, Department of Pediatric Surgery, University of Florence and Children’s University Hospital A. Meyer, Florence, Italy. Email: marcoghionzoli@ hotmail.com Received 11 February 2016; revised 19 April 2016; accepted 25 April 2016. doi: 10.1111/ped.13033