Pediatria Medica e Chirurgica最新文献

Colostrum is a source of growth factors and nutrients aiding newborns in adaptation to extrauterine life. Its clinical use has been investigated as an immunological component to protect, especially preterm newborns, from early infectious complications. This article aims to investigate the current knowledge about the value of colostrum in enhancing mechanisms of intestinal adaptation in patients affected by Short Bowel Syndrome (SBS). A MEDLINE systematic search was conducted. Inclusion criteria were English language and post-operative colostrum administration in animals and humans undergoing bowel resection. From a total of 734, 10 full-text articles were included: 5 studies on animal models, 4 on humans affected by SBS, and 1 study on animal and paediatric populations. Intestinal adaptation was investigated through diverse clinical, morphological, and functional parameters. No clear benefits of colostrum were reported in both populations. Paucity of trials, limited study duration, and heterogeneous conditions led to poorly standardized results. Colostrum tolerability is an encouraging result, but the outcome of colostrum clinical use in short bowel has still to be determined. Further investigations are required to safely promote use of colostrum in nutritional programs. Standard parameters of intestinal adaptation would be required to evaluate the possible role of colostrum in the process.

The purpose of this paper was to define the specturm of management for Parapneumonial Pleural Effusion/Pleural Empyema (PE/PPE) in children in Italy. We conducted an online survey, distributed by the SIVI committee to 54 Italian pediatric surgery centers. A total of 23/54 (43%) Italian pediatric surgery centers responded. All responders (100%) required an anteroposterior chest radiograph (CXR) as the first imaging approach to suspect PPE, and chest Ultrasound (US) was routinely used in 96% of centers. A preoperative CT scan was routinely performed in 70% of centers. An etiological diagnosis was obtained in more than 80% of patients in 13% of centers, between 40% and 80% of cases in 61% of centers and in less than 40% of patients in 26% of centers. Empirical antimicrobial therapy with 2 antibiotics is the most commonly used therapeutic scheme (78% of centers) and targeted antibiotic therapy was used in 82% of enrolled centers. The majority of centers (57%) approached advanced stage pleural empyema with pleural drain placement and fibrinolysis (PDF); 26% of centers preferred to execute upfront Video-Assisted Thoracoscopic Debridement (VATD), and in 13% of centers, both fibrinolysis and VATD were used. In all cases (100%), urokinase was the fibrinolytic agent of choice. Broncho-Pleural Fistula (BPF) was treated conservatively with prolonged Pleural Drainage (PD) and antibiotics in 82% of centers, while the remaining 18% proposed early surgical treatment. 82% of centers proposed prolonged antimicrobial therapy for the treatment of Lung Abscess (LA), while 18% of centers preferred to execute upfront ultrasound-guided or thoracoscopic positioning of a pig-tail drain. As expected, we observed a lack of homogeneity in the treatment between the different centers: most of these have a preference for fibrinolysis over the use of primary VATD, with urokinase being the only fibrinolytic agent used in all centers. It would be desirable to involve as many centers as possible for the drafting of shared national guidelines in the treatment of PPE in children in Italy.

Nutcracker Syndrome (NCS) is characterized by impeded blood flow from the Left Renal Vein (LRV) into the inferior vena cava due to an abnormally narrow angle between the abdominal aorta and superior mesenteric artery. This syndrome is usually associated with hematuria, abdominal pain and orthostatic proteinuria. We described three patients diagnosed with NCS (mean age 16.3 years). The aortomesenteric angle, LRV diameter ratio and peak velocity ratio were assessed through doppler ultrasonography and CT angiography. A kidney model was printed out for surgical planning. An extravascular stent was designed based on the LRV's structure using computer software and printed in three dimensions with a precision setting of 20μm. Patients underwent laparoscopic placement of the extravascular stent. The mean duration of surgery was 180 minutes. There were no intraoperative complications. CT examinations revealed that pre- and postoperative AMA ranged from 18.7°±4.3° to 55.0°±4.4, respectively. No side effects were observed in the follow-up period (range 12-24 months). At present, treatment guidelines for NCS are unclear, and the different therapeutic principles need to be applied in a patient-specific manner. Our results confirm previous reports in literature concerning the efficacy and safety of ES in pediatric patients.

Pilomatricoma and trichilemmal cyst are two benign tumors of hair follicles that can affect children. We performed a retrospective study to histologically differentiate the two tumors to determine if this has clinical utility. For 5 years, we conducted a retrospective study on the patients who underwent surgery and evaluated some parameters (site, recurrence and scar outcome) categorizing them based on their histological type. We treated 71 patients, with an average age of 7.6 years. Most of the lesions were localized on the scalp, head and neck. Histological examination diagnosed 55 pilomatricomas and 16 trichilemmal cysts. Five patients with pilomatricoma developed an unaesthetic scar (4 in subscapular region), while the recurrence was present in 10 cases, of which 6 were trichilemmal cysts (37,5% of 16 cases). Both types of lesions healed successfully, however trichilemmal cysts are more susceptible to recurrence.

Cushing's Disease (CD), defined as hypercortisolism caused by excess Adrenocorticotropic Hormone (ACTH) secretion by a pituitary corticotroph adenoma, rarely presents in the pediatric age range. The aim is to describe a 12-year-old Albanian boy with a challenging pathway to diagnosis and treatment process for Cushing's disease. He presented with headaches, rapid weight gain during the last three years, stunting, increased body hair growth, and a typical Cushingoid appearance. After a consultation in the Pediatric Endocrinology Unit at the University Hospital Center, "Mother Teresa," in Tirana, the boy was pre-diagnosed with Cushing Syndrome, and hypophyseal adenoma was suspected due to suggestive laboratory tests, although non-consistent imaging results. An ectopic ACTH-dependent Cushing syndrome was suspected together with neuroendocrine neoplasia (carcinoid tumor) as a thoracic CT showed a nodular lesion with regular-lobulated sharp contours in the lower lobe of the right lobe resulted in pulmonary tuberculosis granuloma. Even imaging failed to identify the ACTHsecreting microadenoma; the decisive examination was an intervention to collect samples from the inferior petrosal sinus during the CRH test, which found a left-side ACTH-secreting focus. Left hemi-hypophysectomy was performed using gamma knife therapy, resulting in effective normalization of hypercortisolism, but with the side effect of growth hormone deficiency.

Phimosis is a pathological condition in children and is easy to diagnose. In particular cases it can be associated with curious malformations of the foreskin. Four adolescents (aged from 9 to 13 years) presented at our attention because of a phimosis with hooded foreskin. Symptoms complained were: balanitis, urinary infection, preputial urinary retention, or psychological problems. One of the cases was asymptomatic. No other malformations were present. The surgical treatment was to remove the hooded foreskin and treat the ventral part of the skin of the penis to avoid abnormal curvatures. This type of malformation should be recognized and treated even if asymptomatic because it can create psychological problems in adolescence. The surgical treatment must prevent penile curvatures.

Lymphatic Malformations (LMs) are benign congenital malformations of the lymphatic system that commonly involve the abdomen in children (mesentery of the small intestine and omentum). The management of these malformations is not unique. 7 children with different ages (range: newborn to 14 years), diagnosis was incidental in some cases, while in others for abdominal pain. All patients underwent abdominal ultrasound and Magnetic Resonance Imaging (MRI). Laparoscopy for diagnosis was useful in 4 cases. Treatment was: conservative in 1 child, laparoscopic excision in 3 patients, laparotomic excision in 3 cases. At follow up we observed recurrence in a case that required integrated treatment and bowel occlusion after excision in 1 case. This benign malformations may not cause any symptoms to patient. The goal of treatment is to maintain organ function, preserve aesthetic integrity and complications control. Management of these patients could be varied: the best approach should be evaluated on the basis of the patient.

Pediatric Colorectal Diseases (PCRD), mainly Anorectal Malformations (ARM) and Hirschsprung's Disease, are a major issue in Sub-Saharan Africa (SSA). Even with advances in healthcare facilities and global health initiatives, most of children living in low resources SSA lack of specialist pediatric surgical facilities. Improved healthcare access is needed to manage PCRD in these locations, to prevent and reduce missing or delayed diagnosis, early mismanagement by inexperienced health practitioners, and barriers to corrective therapy and long-term follow-up. A retrospective analysis of data from three SSA hospitals shows that international surgical outreach visits helped increase capacity. Along one hundred twentyfour weeks of staggered surgical outreach visits 174 ARM and 64 highly suspected HSCR cases were collected. The study evaluates 152 ARM and 59 HSCR patients who had not been treated before. Those who came after an unsuccessful treatment elsewhere were not included. Management, clinical course, complications and results are reported. Focus is on context-aware adaptive surgery and sustainable solutions to improve outcomes and quality of life for those children, discussing long-term follow-up options and results. The local context has a substantial impact on epidemiology, demographics, and presentation compared to high-resource countries. Intestinal stomas done at a primary health facility level presented at referral to our Hospital with 25% complication rate. Due to social, economical, and transit issues, only 108 ARM and 41 HSCR could finally receive a corrective treatment by the outreach visiting teams. Complications (9.1%) were controlled using adaptive solutions. Only one surgical fatality occurred. A limited proportion of patients (46% ARM, 31% HSCR) attended a regular follow up schedule for one year or more, and finding those lost in wide rural areas was difficult. Successful and comprehensive PCRD management in under-resourced SSA requires better training at the primary health level on early recognition and correct, first surgical approach, together with a referral network to specialist facilities for further treatment. Surgical short-term outreach trips can boost local capability in under-resourced areas. The research of adaptive and sustainable surgical solutions to reduce hospital stay and staged treatments time for PCRD must be emphasised. Nevertheless financial and logistical constraints still challenge post-discharge monitoring and follow-up, which remain crucial for long-term outcome.

Schistosomiasis is a tropical infection endemic to developing nations that can result in chronic liver damage, renal failure, infertility, and bladder cancer. Genitourinary localization is marked by dysuria, visible hematuria, and urinary obstruction. We present the case of a 17-year-old male adolescent from a rural area of Central Africa, who arrived in Italy two years prior, exhibiting hematuria and urinary symptoms. He came to our attention with a history of terminal hematuria, dysuria, and intermittent abdominal pain since the age of ten. We conducted initial blood tests, urine analyses, and ultrasonography, all yielding negative results. Cystoscopy was conducted with biopsy of an atypical bladder lesion due to the persistence of hematuria. Histopathology revealed morphological findings indicative of Schistosoma haematobium. The patient received praziquantel treatment and was monitored through parasitological urine analyses. Bladder schistosomiasis should be considered in children exhibiting terminal hematuria from endemic regions. Diagnosis can be established through a urinary microbiological examination. An endoscopic evaluation may assist in the diagnosis if the results are negative.

In pediatric thoracic surgery, reported predictors for increased risk are symptoms and active/previous infections (RAP). We investigated the adverse events related to Video-Assisted Thoracic Surgery (VATS) in pediatric patients when considering RAP predictors. A retrospective analysis of pediatric VATS major lung resections in 2008-2021 was conducted at three institutions. We employed the pediatric surgical risk calculator to define patients' preoperative predicted risk (PredR). Postoperative complications were classified according to the Thoracic Morbidity & Mortality (TM&M) system. The observed TM&M rate (ObsR) and the PredR were compared. A subgroup analysis by RAP predictors was conducted. 37 patients (54% female) were included. Mean age and weight were 5.8 years and 22.8 kg. 56.7% had respiratory symptoms, 38.9% active infection and 59.5% history of infections (RAP subpopulations). VATS procedures were lobectomy (n=32), segmentectomy (n=3), bilobectomy (n=1) and pneumonectomy (n=1). The conversion rate was 5.4%. The mean PredR was of 4.43% (±1.8) and the overall ObsR was 45.94% with a median severity of II (I-III). This difference was significant and a higher PredR was not associated with complications development. PredR does not show association among the RAP vs non-RAP group. ObsR showed positive association with RAP, even if it reached statistical significance only for "respiratory symptoms" risk factor. ObsR reflected the number of bronchiectasis patients in our series (n=9), aligning with the hypothesis of "earlier and safer surgery". The risk calculator underestimates VATS morbidity. Multicentre studies will clarify the correlation between inflammation and surgical adverse events.